A 67-Year-Old Man With Chest Pain and Wheezing

Carla R. Sterling, MD; Niccole Bart, MD

Disclosures

July 15, 2015

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 you would like to suggest for a future Case Challenge, please contact us.

Background

A 67-year-old man presents to the emergency department at the behest of his home health aide because she noticed he was wheezing. The aide is not sure when the wheezing started, but first noticed it while she was preparing his breakfast. She comes in the mornings, and another home health aide stays overnight. The overnight aide did not report any events to the morning aide.

The patient received two albuterol (Proventil®) treatments and 10 mg of dexamethasone (Ozurdex®) intramuscularly in the ambulance on the way to the hospital, with no improvement. The emergency medical service (EMS) performed an ECG that revealed no ST elevations.

His medical history includes hypertension; emphysema; myocardial infarction (two stents); and a cerebrovascular accident 5 years ago, with residual deficits involving left-sided hemiparesis, speech difficulty, and an inability to perform activities of daily living on his own. He takes enalapril (Vasotec®), hydrochlorothiazide (Esidrix®), aspirin (Ecotrin®), tiotropium bromide (Spiriva®), quetiapine (Seroquel®), and sertraline (Zoloft®). He also uses continuous positive airway pressure ventilation at night.

The patient is nonverbal at baseline. His aide explains that she has been working with him for 8 months and thinks that today he has increased work of breathing. He has also been rubbing the left side of his chest, which is not normal.

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