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

Carla R. Sterling, MD; Niccole Bart, MD


July 15, 2015

Physical Examination and Workup

On initial assessment, the patient is an elderly, frail-appearing man with no acute respiratory distress. His vitals include a heart rate of 106 beats/min, blood pressure of 137/87 mm Hg, respiratory rate of 23 breaths/min, and oxygen saturation of 94% on a 2-L nasal cannula.

His ECG is unchanged from the ECG obtained by the EMS. Physical examination reveals S1 and S2 with crescendo/decrescendo systolic murmur, bilateral basilar crackles in his posterior lungs higher on the left side than the right, and wheezing heard in the left lung fields, with a slightly prolonged expiratory phase. He has bilateral and symmetrical pitting edema of the lower extremities to the mid-shin.

The patient's laboratory findings are unremarkable, including complete blood cell count, comprehensive medical panel, B-type natriuretic peptide, and cardiac enzymes. A shock panel shows an increased CO2 level and lactate level of 2.6 mg/dL. Another round of albuterol and ipratropium (DuoNeb®) is administered to treat a potential exacerbation of chronic obstructive pulmonary disease (COPD); however, no improvement in symptoms is noted.

At this point, the patient has received three doses of ipratropium and dexamethasone without improvement. His tachycardia resolves when he is resting comfortably, but any activity increases his heart rate. CT of the pulmonary vessels is considered, as is bedside echocardiography, bilevel positive airway pressure, and intubation.

Chest radiography reveals nonspecific atelectasis changes in the left lung (Figures 1 and 2).


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