So this patient has severe chronic obstructive pulmonary disease
and he’s had it for many years very likely because he has a history of smoking for many, many years.
His activity is very limited due to he gets short of breath,
he has dyspnea at rest and with minimal exertion and he mostly sits all day and watches TV.
And today he was brought to the emergency room by his family
because he had a sudden marked increase in shortness of breath.
He was sitting watching television and all of a sudden said, oh, I'm suffocating I can’t breathe.
He also noted when he takes a deep breathe that on the left side of his chest it hurts
then the chest pain is pleuritic if he doesn’t take a deep breath, it doesn’t hurt
and he’s anxious and worried that something terrible maybe happening.
He of course has a long smoking history of 70 pack years.
His physical exam shows that he’s in respiratory distress,
his respiratory rate is 33 per minute normal is under 20 and most people are 12 to 14.
His blood pressure is a little marginal for a 77-year-old man only 105/ 60.
His lips are blue and his arterial saturation from a finger oximeter is only 81%
and the normal value is usually above 90 and usually above 91 depending on what altitude you live.
If you live down here at sea level its above 91,
if you live a little bit elevated like in Denver, Colorado at 5000 feet
and then a 90 would be normal.
He has decreased lung sound over both lungs, he doesn’t get a good deep breath
because there’s so much damage to his lungs from smoking and fibrosis
and his heart sounds are hard to hear because he has a lot of air trapping
in various parts of the lung.
So the critical points in this history and physical, he has severe COPD, he has emphysema.
He suddenly becomes short of breath, there’s a possible symptom of pulmonary vascular obstruction
in others words a pulmonary embolus with a little pulmonary infarct so it hurt -
he has pleuritic chest pain when he takes a deep breath
and of course we know he's got emphysema because of his long smoking history.
So on physical exam the findings that are of interest -
first of all he has a respiratory rate of 33 per minute,
very abnormal, this could be due to his COPD, his baseline,
but it’s also possible that he’s had a pulmonary embolus
which also increases the respiratory rate. His blood pressure is a little low for a 77-year-old man
and that could be due to severe lung disease and causing failure of the right ventricle
although we didn’t see that on physical exam or it could be a pulmonary embolus
that’s dropping his blood pressure.
And of course he’s got inadequate oxygenation either
because of his severe lung disease or possibly in combination with the pulmonary embolus
and we see decreased lung sounds over both lungs and the heart sounds
are distant that’s consistent with severe lung disease.
What’s the diagnostic option? Well, we wound wanna look for pulmonary embolism
that would be a CT or a CAT scan computed tomographic scan, it’s an x-ray,
special x-ray with contrast.
And here we see it and there’s an arrow right there on the little box
showing you there’s a pulmonary embolus just beyond the left main pulmonary artery.
So the diagnosis is acute pulmonary embolism on top of severe lung disease.
Patients with severe lung disease are markedly increased risk for pulmonary embolism
and also his partly because of inactivity and partly often because of elevated right-sided filling pressures
that transmit back to the veins that cause some congestion in the veins
that makes it more likely that the patient would have deep venous thrombosis with pulmonary embolism.
The treatment would be acute and long term anticoagulation.
However, if the echocardiogram show that there was a lot of right ventricular dysfunction,
then we would give a thrombolytic agent that is we would dissolve the clot
or you could remove the clots in the interventional radiology suite with the vacuum catheter.
But that would only be done if the patient were in a lot of trouble.
He didn’t look to be in that much trouble,
I think he’d probably do very well with anticoagulation
and he needs long term anticoagulation to prevent this from happening again.