1. 2/19/06 Case

2. Chief Complaint Pt is a 33 y/o aa male who presents with new onset dyspnea

3. What questions do we want to ask this patient?

4. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment History of Present Illness Pt is a 33 y/o aa male w/ hx of a murmur in childhood who presents w new onset dyspnea. Pt noticed that he became short of breath while driving today. This is the first time that he has felt this way and it lasted for about twenty minutes. It became better with time and was self limiting. The patient denies having any chest pain, palpitations, light headedness or recent URI. He also denies any recent trauma, calf tenderness, immobility, or history of clotting. He does however admit to being an anxious person and noticed some tingling down his left arm and right side of his body. He also noticed having a muscle cramp in his right arm and diffuse pain across his abdomen.

5. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Past Medical History Anxiety Hx of heart murmur No surgical history

6. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Medications None

7. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Allergies NKDA

8. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Social History Smokes 3 cigars a day Drinks 24 oz beer / day

9. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Family Medical History Mother- Sarcoidosis Father-

10. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Review of systems General: weight change, fever, chills, weak Head: headache, nasuea, vomitting Respiratory: SOB, wheeze, no cough or URI Cardiac: HTN, murmurs, angina, palpitations GI: appetite, n/v, incont., const/diarrhea, mild abdomen pain GU: frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no dyspareunia, no discharge MSK: muscle weakness, flank pain, muscle cramps Neuro: parasthesias, loss of sensation Psychiatric- Pt is not depressed

11. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Physical Exam VS- BP- 146/80 T-98.8 R-15 P-120 General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes CV- RRR w/o murmurs or rubs, clicks or gallops RESP- Clear to auscultation bilaterally, no wheezes, rales or crackles Abdomen- Soft, NT, ND, no masses, BS, no bruits GU- No discharge, bleeding, nodules or masses Positive lloyd’s test MSK- No weakness, mild tenderness in R flank TTA T11-L-1 EXT- No edema, negative homans, pulses b/l, negative troussau sign Neuro-No neurodeficits, CN II-XII intact

12. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Differential Psychiatric Anxiety Panic attack Pulmonary Most probably acute PE Pneumothorax Less likely chronic etiology COPD Cardiac Arrhythmia MI USA

13. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment What do we want to order?

14. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Labs Chemistry CBC D-dimer EKG Chest X-ray Cardiac enzymes

15. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment CBC 6.9 14.6 g/dl 43.2 221 Chemistry 140 3.5 104 22 15 1.0 94 D-dimer <100 Phos 1.1 AST 61 ALT 71 Cardiac Enzymes – X3

16. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Chest X-ray Right hilar vascularity No flattening of diaghram EKG NSR

17. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Diagnosis 1.33 y/o aa male presenting with hyperventilation and dyspnea with left arm tingling Most likely panic attack; must rule out pulmonary (PE) and cardiac process (MI) Cardiac enzymes, monitor patient for new episodes, D-dimer, out patient echo 2.Hypophosphatemia Most likely secondary to above and secondary to alcohol history 0.1 mmol/ kg IBW potassium phosphate 3.Hx of sarcoid; aa race Serum angiotensin converting enzyme

18. Hyperventilation Acid base balance maintained by kidney and lungs –Carbon dioxide is removed via lungs Hyperventilation can cause respiratory alkalosis –Acid removed via kidney Hydrogen and volatile acids like phosphate

19. Hyperventilation Respiratory alkalosis –Acute respiratory alkalosis Fall in partial pressure of carbon dioxide –Similar change in the cells –Carbon dioxide readily diffuses across cell membranes. –Rise in intracellular pH »Stimulates phosphofructokinase »Stimulates glycolysis –Extreme hyperventilation –Can lower serum phosphate concentrations to below 1.0 mg/dL –Most common cause of marked hypophosphatemia in hospitalized patients

20. Hyperventilation Hypophosphatemia –Other causes Poor intake (rare) –Kidney usually will reabsorb phosphate Antacids Hyperparathyrdoidism Vitamin D deficiency Renal wasting Alcoholism Hypersecretion Hungry bone syndrome During treatment of DKA

21. Hyperventilation Hypophosphatemia Signs and symptoms –CNS – Irritability Paresthesias Confusion Seizures Delirium Coma –MSK Proximal myopathy leading to rhabdomyolysis –May mask low phosphate –Hematological Hemolysis Poor phagocytosis Defective clotting Cardiopulmonary –Impaired Myocardial contractility ATP depletion –Respiratory failure Weakness of the diaphragm –Reduction in cardiac output Congestive heart failure If plasma phosphate concentration falls to 1.0 mg/dL

22. Thank you! Questions, comments, concerns?