Dyspnea in a Man Who Was Stuck in a Bathroom for 24 Hours

Joshua J. Solano, MD

Disclosures

November 04, 2020

Physical Examination and Workup

Initial vital signs in the ED are as follows:

  • Temperature: 95.7°F (35.4°C)

  • Heart rate: 125 beats/min

  • Respiration rate: 22 breaths/min

  • Blood pressure, 175/120 mm Hg

Pulse oximetry reveals an oxygen saturation of 90% on 2 L/min of oxygen by nasal cannula. The patient's weight is 231.5 lb (105 kg), height is 5 ft 9 in (175 cm), and body mass index is 34.3 kg/m2.

The patient is awake and able to converse but is in mild respiratory distress and appears uncomfortable. He has an abrasion to the right side of the head without bleeding and an underlying 2 × 2 cm hematoma. His mucous membranes are dry. Mild jugular venous distension is noted.

The cervical spine is nontender, but mild paraspinal tenderness is noted upon palpation. The patient has a regular pulse and no murmurs. In both lower extremities, 2+ pitted edema is noted. Bilateral crackles are audible throughout the lung fields. No abdominal tenderness, distension, or masses are detected. Several bullae are noted on the right side of the torso and right upper extremity. The patient has full range of motion of the extremities without pain, pulses are 2+ throughout, and sensation to light touch is diminished in a stocking and glove distribution at the level of the forearms and at the ankles.

All compartments are soft. No midline tenderness of the thoracic or lumbar spine is observed, but tenderness is noted along the right lateral thoracic and lumbar regions. The neurologic examination shows that the patient is alert and oriented × 4, cranial nerves II-XII are intact, and upper and lower extremity strength is 5/5.

Other findings include the following:

  • White blood cell (WBC) count: 8.5 × 109/L (reference range, 4-11 x 109/L)

  • Hemoglobin level: 15 g/dL (reference range, 13.5-15.5 g/dL)

  • Hematocrit: 46.2% (reference range, 45% to 52%)

  • Platelet count: 176 × 109/L (reference range, 150-400 × 109/L)

A comprehensive metabolic panel reveals the following values:

  • Sodium: 136 mEq/L (reference range, 135-145 mEq/L)

  • Potassium: 5.5 mEq/L (reference range, 3.7-5.2 mEq/L)

  • Chloride: 100 mEq/L (reference range, 96-106 mEq/L)

  • Carbon dioxide: 18 mEq/L (reference range, 23-29 mEq/L)

  • Blood urea nitrogen: 80 mg/dL (reference range, 8-24 mg/dL)

  • Creatinine: 3.5 mg/dL (reference range, 0.9-1.3 mg/dL)

  • Glucose: 465 mg/dL (reference range, < 160 mg/dL)

  • Aspartate aminotransferase: 80 IU/L (reference range, 6-34 IU/L)

  • Alanine aminotransferase: 75 IU/L (reference range, 20-60 IU/L)

  • Total bilirubin level: 1 mg/dL (reference range, 0.1-1.2 mg/dL)

  • Alkaline phosphatase: 75 IU/L (reference range, 44-147 IU/L)

  • Calcium: 10.3 mg/dL (reference range, 8.5-10.5 mg/dL)

His brain natriuretic peptide (BNP) level is 850 pg/mL (reference range, < 450 pg/mL), and his troponin level is 0.15 ng/mL (reference range, 0-0.4 ng/mL). His international normalized ratio (INR) is 2.1 (reference range, 2-3). His prothrombin time is 25 seconds (reference range, 11-12.5 s [>1.5-2 times control value for those receiving anticoagulant therapy]). His partial thromboplastin time is 29 seconds (reference range, 60-70 s [1.5-2.5 times control for those receiving anticoagulant therapy]). His creatine phosphokinase (CPK) level is 4500 IU/L (reference range, 55-170 units/L).

The urine is amber and appears hazy. Urinalysis reveals the following:

  • Specific gravity: 1.040 (reference range, 1.002-1.030)

  • pH level: 5.0 (reference range, 4.6-8)

  • Urobilinogen, leukocyte esterase, and nitrites: Negative

  • Blood: 3+

  • Protein: 3+

  • Glucose level: > 1000 mg/d (reference range, 0-15 mg/dL)

The urinalysis also revealed a trace level of ketones and no red blood cells, WBCs, bacteria, or epithelial cells.

An electrocardiogram (ECG) is obtained (Figure 1).

Figure 1.

Non-contrast CT scans of the head (Figures 2-4) and neck (Figure 5) are performed.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

A point-of-care ultrasound examination of the lungs is performed (Figure 6).

Figure 6.

Point-of-care echocardiography is performed (Figures 7 and 8).

Figure 7.

Figure 8.

A chest radiograph is obtained (Figure 9).

Figure 9.

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