A 65-Year-Old Man With a Cough and Worsening Dyspnea

Joshua M. Kosowsky, MD

Disclosures

April 09, 2020

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 65-year-old man presents to the emergency department with difficulty breathing. He describes worsening dyspnea on exertion that is associated with chest tightness, wheezing, and coughing. The patient's dyspnea has worsened to the point that he can hardly walk from his couch to the bathroom without becoming extremely short of breath. He recently recovered from a cold, with several days of nasal congestion, clear rhinorrhea, and a nonproductive cough.

The patient reports having been healthy his whole life and has not been to see a physician in at least two decades; however, he does admit that he has gradually curtailed his physical activities, such as gardening, shoveling snow, and walking in the mall, because he has been increasingly "getting winded." He smokes two packs of cigarettes daily, a habit he has been trying to break for at least 30 years.

Physical Examination and Work-up

Upon physical examination, the patient is alert but appears to be in mild respiratory distress, with moderate retractions and pursed-lipped breathing. He is afebrile. His blood pressure is 140/85 mm Hg; his pulse is 103 beats/min and mostly regular. His respiratory rate is 28 breaths/min, and a pulse oximetry reading shows 85% while the patient is breathing room air. His breath sounds are diminished throughout, with a markedly prolonged expiratory phase and faint expiratory wheezes in the upper lung fields.

The cardiac examination reveals distant heart sounds, with a somewhat prominent P2. He has no murmur, gallop, or pericardial rub. His skin is cool and dry. He has trace edema at his ankles, but no cyanosis or clubbing. An ECG is performed (Figures 1 and 2).

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