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.
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
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
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
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
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
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
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