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COPD vs CHF vs MI vs PE ????????


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This is not your typical scenario, as it really isnt a scenario, but instead a common EMS call that may be difficult to diagnose (yes I said the D word). What I am looking for, is what criteria you use to decide what treatment you provide for this patient. Please base your decision on the info provided. This is not a trick scenario, the patient has one of the four conditions listed above. So which direction do you go with the info provided, and why ?

You respond to a 50 year old male with onset of dyspnea in the last few hours. The patient has no history other than he has smoked about 2 packs per day over the past 20 years, and he is about 40lbs overweight. He states he was short of breath when he woke up, and it has progressively gotten worse over the past few hours.

You find:

Meds : None, but pt has not been to a doctor in years.

Allergies None

Pain: None

LOC / head / neck: Alert and oriented x 4, PEARL, NO JVD

Skin: warm and dry - no cyanosis.

Neuro: No neuro deficits

Breathing: He is in obvious distress with insp/exp wheezing noted bilaterally. He is using acc muscles.

Pulse Ox: 88% room air

B/P: 210/98

Pulse: 94

Monitor: Sinus no ectopy / 12-Lead negative for MI.

Extremities: Moves all well, no edema, no pain, no tingling.

D-Stick: 102

No cough / No fever

No drug or alcohol use

No exposure to chemicals or signs of anaphylaxiis.

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theres really no 'criteria' i would follow for treating this patient. Hes presenting with about every s/s of CHF. id expect to see LVH on the 12 lead though depending on how far along the disease process is. no meds or allergies leads me to believe this is a new onset though. we could also throw an MI in the mix but hes not experiencing any pain and he doesnt have diabtetes or any other condition that would mask the pain and our 12 lead is non diagnostic. anyways...

Tx Plan:

CPAP

Monitor

IV access with a saline lock

.4mg SL nitro spray

re-assess

consider MS

id like to go farther with this but have questions about the patient.

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I'm only a student don't shoot me :P

If unable to obtain more information which I think is unfair, I would treat nothing specifically just the generic respiratory distress. Oxygen, IV, Monitor, vitals and attempt to obtain more information while giving supportive care during my 5 minute transport time, and I would follow up in the ED and learn what I forgot to ask that would have lead me to an appropriate diagnosis. There are parts to the exam you list that can indicate, everything you listed, without being able to do a more focused exam and obtain more history I don't see a systemic way to narrow it down further.

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Would never shoot a rookie, it is for you that I am putting this out there. Go ahead, ask any other question you like, that would help you in your efforts.

P.S. and you dont have a 5 minute transport time, so you have to treat the patient, one way or another. And for the sake of arguement all phones and radios are inoperable, you can not seek guidance from Medical Control.

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Not suggesting you are wrong or right, which specific symptoms or thoughts led you to CHF versus the other possibilities, if you wouldnt mind painting the picture. Thanks.

the picture is in your presentation.

HTN

Nocturnal dyspnea

no CP

no meds

warm and dry

in and out wheezing

clean 12 lead

Hx of smoking

i dont think its an MI (although possible) because hes not in any pain and has nothing to mask it, 12 lead is good, dyspnea has worsened over the last couple hours and hes been supine for those couple of hours, acc muscle usage. no sympathetic response and hes on no meds.

as for not being COPD. this is an acute onset and a pretty significant one at that. COPD is a progressive disease. is he pursed lip breathing? clubbed fingers? barrel chest?

A PE? Possibly. Acute onset, sats in the crapper, sedentary smoker but hes using accessory muscles. a PE doesnt increase the work of breathing, it decreases the ability to exchange oxygen and CO2. also hes not cyanotic even though his sats are in the 80's.

i chose the treatment i did because it knocks off the most possibilities. nitro is indicated for an MI. hes hypertensive so im comfortable with not believing its a RVI, if it is i have IV access. CPAP will take care of the breathing issue, nitrates will also help with the CHF part of the equation and possibly with the PE part depending on the embolus.

is this what youre looking for?

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Im not thinking so much that this is a CHF pt, #1 no history of CHF, no crackles or rhonchi. correct?

Possibly a PE. however like it was said before he's not having any CP, is he experiencing any calf tenderness?

I would treat him like any other respiratory pt, presenting with SOB and wheezing. O2, Monitor, IV, Neb treatment. possibly NTG for the pressure. but would give the neb first and re-assess after that as far as breathing and maybe the use of NTG.

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Since you said anything could be asked..

Ever had wheezes/sob before?

Does (and how much) activity make him SOB and/or dizzy?

Headache? Anxious?

Family history?

What does the patient do for work?

I'm leaning toward COPD (although that BP and possibility of masked rales bothers me), but want to know a bit more history. Good LOC/skins with sats of 88% suggest chronically low PaO2.

Initial Tx:

O2, IV TKO,

Albuterol (wary of BP and want to know more history)

Standing by with nitro and getting answers to questions..

Reassess lungs throughout treatment looking for anything besides wheezes.

I would kinda go from there after reassessment..

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