Sudden-Onset Chest Pain in an 80-Year-Old Man With COPD

Samantha Nicholson-Spence, MB BS; Frederick Williams, MD


January 08, 2019

Physical Examination and Workup

His vital signs on admission include a temperature of 98.3°F (36.8°C), heart rate of 93 bpm, blood pressure of 170/90 mm Hg, and a respiratory rate of 26 breaths/min with a pulse oximetry of 93% on room air. He does not appear distressed and, despite being tachypneic, is able to speak in full sentences.

Examination of the head, neck, central nervous system, and abdomen are all within normal limits. He has no jugular venous distention or peripheral edema. No breath sounds are noted in the right upper and mid-lung zones and diffuse rhonchi in both lung fields with bibasilar inspiratory crackles are noted. His cardiac examination reveals a grade 3/6 pansystolic murmur heard all over the precordium that is loudest at the apex. His lower extremities are symmetrical and no calf tenderness is detected.

His complete blood cell count and basic metabolic panel are within normal limits, except for a white blood cell count of 14.3 × 103/μL (the patient has chronic leukocytosis secondary to his bronchiectasis). His international normalized ratio (INR) is 2.7, and his brain natriuretic peptide (BNP) and cardiac enzyme examinations are unremarkable. The arterial blood gas shows a pO2 of 79 mm Hg on 21% FiO2, a pH of 7.47, pCO2 of 39 mm Hg, and an HCO3 of 28 mEq/L. A chest x-ray shows bilateral airspace disease, a right lower-lobe nodule, and cardiomegaly. A chest CT scan is performed (see Figure 1).

Figure 1.


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