Dyspnea Case Study

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A 78-year-old female comes into the emergency department with increasing dyspnea. She states that she has had trouble breathing for the past month, which started on-and-offon and off, but over the past week it has become more constant throughout the day. Her dyspnea is worse when getting up out of her chair to go to the kitchen or bathroom and she notes feeling winded when halfway through her walk. She denies sleeping flat on her back, but describes sleeping on her side with two pillows under her. She also complains of tightness in her legs, which worsen at the end of the day, but the tightness feels less severe when waking up in the morning. Her records show two hospitalizations over the past two years for unstable angina
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Her current medications are aspirin 81 mg, pravastatin 20 mg, amlodipine 10 mg, and an albuterol inhaler as needed. She is a 40 40-pack-year smoker. Vital signs: 130/80 mmHg, Pulse heart rate 95 beats/min, respirations rate 26 breaths /min, oxygen saturation 92% on 2 liters nasal cannula, and temperature 36.7°C (98.0 °F). On physical exam, she is in mild distress and diaphoretic. No distended jugular veins are seen, heart sounds reveal a sinus rhythm and a III/VI holosystolic murmur, but no rubs or gallops. Lung sounds bilaterally display a combination of both inspiratory fine crackles and expiratory wheezing. She has palpable, pitting edema in the legs bilaterally. Past records only show her primary care doctor had ordered a pulmonary function test a month ago, which displayed findings consistent with mild obstructive disease. Laboratory basic metabolic panel and complete blood count are …show more content…
Based on the history and findings, this patient is most likely having a Congestive Heart Failure (CHF) exacerbation. The most common challenge people face when approaching acute dyspnea is determining whether the patient is experiencing a COPD exacerbation or CHF exacerbation. Management for either is very different. Symptoms on presentation for both can be exactly the same. If you read carefully on this vignette, the scenario falls more likely toward being CHF-related than COPD-related, because of the physical findings of rales on auscultation, bilateral pitting edema, and jugulovenous jugular venous distention. Also in the history, she complains of orthopnea and leg swelling. Regardless, the two best tests to initiate with to decipher between the two is a chest X-Ray x-ray (CXR), ideally portable and upright, and a B-Natriuretic Peptide β-natriuretic peptide (BNP). A CXR in CHF will show bilateral infiltrates which make the lung spaces fluffy and white. A CXR in COPD will show the lung spaces to be more hyperinflated and aerated (or opaque on view). BNP is one important diagnostic marker to order that also can help differentiate between CHF and COPD. BNP > 400 confers a 95% likelihood of CHF. BNP < 100 excludes CHF as a cause of

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