Ok guys, I'll gratiously accept positive criticism as I'm a relatively new medic in a rural area and I don't see a lot but try to refrain from ripping me up too bad.
My thoughts on this pt. are that both COPD and CHF are relatively chronic problems and if this is truly the first time the pt has experienced dyspnea then I have to question both of them.
It's the "first time this has happened" that throws me. At least I'm reading this as being the first time anyway.
I'm not sure how "new onset" CHF presents, yes we have HTN, nocturnal dyspnea (presumably the first time though), negative for CP, and possibly cardiac asthma and he does smoke. But we have no hypertrophy on the 12 lead, we have dry lung sounds, we have no pedal edema.
I have doubts about this being "new onset" COPD also. As someone said no pursed lip breathing, no barrel chest, etc. Really the only thing pointing that way is the hx of smoking and once again it's an acute attack.
Now, someone stated that a PE doesn't increase the work of breathing. Based on a pt I ran recently I will respectfully disagree. Of course my guy had recent surgery and was SOB on scene and only wanted help from his car to the house. The guy appeared to be in distress but not overly so initially, color was good, able to talk in full sentences, no CP, in/out wheezes but diffuse. Within a few minutes - sats in the 80's, hypertensive and breathing like a freight train. This guy was using every acc muscle he had. Granted it turned out to be a massive PE - he later died before our little local hosp could get him flown out. But I no longer believe a PE doesn't cause acc muscle use. And the few PE's I've ran have usually been tachycardic.
It could always be an MI although we don't have much, if anything, at this time to confirm it. He has several contributing factors, smokes, overweight, HTN (we have no idea it this chronic HTN or related to the current problem - but it's likely to be chronic)
I agree with the theory that most of the tx I've read won't hurt the pt and some can be used to rule things out I suppose.
My tx:
O2, Monitor, IV, VS - Depending on time out/distance/other factors I want 12 leads every 5-10 minutes if possible.
CPAP is new here and I can only use it on "confirmed" CHF with pulmonary edema but I would have it ready in case things change.
Neb. bronchodilator - like some said it shouldn't hurt too much and if it doesn't help I can lean away from COPD and more toward cardiac issues.
Nitro (if we don't get significant relief from the neb tx) - Negative JVD, dry lung sounds and hypertension don't signal a RVI.
Any relief from the nitro I head down the MI/PE/CHF route. And if this guy has convinced me that this is truly a first time problem by now I'm really thinking MI/PE - in that order.
Have MS ready and play the MONA game...
So, did I kill the guy?