2/19/06 Case

Chief Complaint

• Pt is a 33 y/o aa male who presents with new onset dyspnea

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• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

History of Present Illness

Pt is a 33 y/o aa male w/ hx of a murmur in childhood who presents w new onset dyspnea. Pt noticed that he became short of breath while driving today. This is the first time that he has felt this way and it lasted for about twenty minutes. It became better with time and was self limiting. The patient denies having any chest pain, palpitations, light headedness or recent URI. He also denies any recent trauma, calf tenderness, immobility, or history of clotting. He does however admit to being an anxious person and noticed some tingling down his left arm and right side of his body. He also noticed having a muscle cramp in his right arm and diffuse pain across his abdomen.

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Past Medical History

Anxiety

Hx of heart murmur

No surgical history

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Medications

None

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AllergiesNKDA

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Social History

Smokes 3 cigars a day

Drinks 24 oz beer / day

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Family Medical HistoryMother- SarcoidosisFather-

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Review of systems

General: weight change, fever, chills, weakHead: headache, nasuea, vomittingRespiratory: SOB, wheeze, no cough or URICardiac: HTN, murmurs, angina, palpitationsGI: appetite, n/v, incont., const/diarrhea,

mild abdomen painGU: frequency, hesitancy, urgency, dysuria

hematuria, incont., stones, no dyspareunia, no discharge

MSK: muscle weakness, flank pain, muscle cramps

Neuro: parasthesias, loss of sensationPsychiatric- Pt is not depressed

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological

• Diagnosis• Treatment

Physical ExamVS- BP- 146/80 T-98.8 R-15 P-120General- Pt is well nourished and AxOx3Heent- EOMI, PERRLA, no vision changesCV- RRR w/o murmurs or rubs, clicks or gallopsRESP- Clear to auscultation bilaterally, no wheezes,

rales or cracklesAbdomen- Soft, NT, ND, no masses, BS, no bruitsGU- No discharge, bleeding, nodules or masses

Positive lloyd’s testMSK- No weakness, mild tenderness in R flank

TTA T11-L-1 EXT- No edema, negative homans, pulses b/l,

negative troussau signNeuro- No neurodeficits, CN II-XII intact

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

Differential

PsychiatricAnxietyPanic attack

PulmonaryMost probably acute PEPneumothorax

Less likely chronic etiologyCOPD

CardiacArrhythmiaMIUSA

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What do we want to order?

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Labs

ChemistryCBCD-dimerEKGChest X-rayCardiac enzymes

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CBC

6.914.6 g/dl

43.2

221

Chemistry

140

3.5

104

22

15

1.0

94

D-dimer<100

Phos 1.1AST 61ALT 71Cardiac Enzymes – X3

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Chest X-rayRight hilar vascularityNo flattening of diaghram

EKGNSR

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Diagnosis

1. 33 y/o aa male presenting with hyperventilation and dyspnea with left arm tinglingMost likely panic attack; must rule out pulmonary (PE) and cardiac process (MI)

Cardiac enzymes, monitor patient for new episodes, D-dimer, out patient echo

2. HypophosphatemiaMost likely secondary to above and secondary to alcohol history0.1 mmol/ kg IBW potassium phosphate

3. Hx of sarcoid; aa raceSerum angiotensin converting enzyme

Hyperventilation

• Acid base balance maintained by kidney and lungs– Carbon dioxide is removed via lungs

• Hyperventilation can cause respiratory alkalosis

– Acid removed via kidney• Hydrogen and volatile acids like phosphate

Hyperventilation

• Respiratory alkalosis– Acute respiratory alkalosis

• Fall in partial pressure of carbon dioxide – Similar change in the cells

– Carbon dioxide readily diffuses across cell membranes.

– Rise in intracellular pH

» Stimulates phosphofructokinase

» Stimulates glycolysis

– Extreme hyperventilation

– Can lower serum phosphate concentrations to below 1.0 mg/dL

– Most common cause of marked hypophosphatemia in hospitalized patients

Hyperventilation

• Hypophosphatemia– Other causes

• Poor intake (rare)– Kidney usually will reabsorb phosphate

• Antacids• Hyperparathyrdoidism• Vitamin D deficiency• Renal wasting• Alcoholism• Hypersecretion• Hungry bone syndrome• During treatment of DKA

HyperventilationHypophosphatemia

• Signs and symptoms– CNS –

• Irritability • Paresthesias• Confusion• Seizures• Delirium• Coma

– MSK• Proximal myopathy leading to

rhabdomyolysis– May mask low phosphate

– Hematological• Hemolysis• Poor phagocytosis• Defective clotting

• Cardiopulmonary– Impaired Myocardial

contractility• ATP depletion

– Respiratory failure • Weakness of the diaphragm

– Reduction in cardiac output• Congestive heart failure• If plasma phosphate

concentration falls to 1.0 mg/dL

Thank you!

• Questions, comments, concerns?