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DwayneEMTP

65 year old male, difficulty breathing...

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It might seem obvious after you already know the answer, but to me, it's giving me fits and I don't have much more to add other than some form of anemia. Not seeing any bruising anywhere? It could be that this nice fellow has just adjusted to living with whatever hypoxemia he normally has at sea level, and has become symptomatic simply because he came up to altitude where there is even less oxygen available...

If all you got is your ears, time to bone up on heart sounds brother... you don't need to be a rocket scientist to start practicing listening to tickers. You'd scoff at any normal medic who said "ya know, I'm not real good at the lung sounds thing..." Well, you chose to be Mr. Superman In Da Boonies, so you better fine tune your capability accordingly! You told us to let you know when you were being a bonehead... *poke*...

Wendy

CO EMT-B

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If all you got is your ears, time to bone up on heart sounds brother... you don't need to be a rocket scientist to start practicing listening to tickers. You'd scoff at any normal medic who said "ya know, I'm not real good at the lung sounds thing..." Well, you chose to be Mr. Superman In Da Boonies, so you better fine tune your capability accordingly! You told us to let you know when you were being a bonehead... *poke*...

Wendy

CO EMT-B

Great to have you back. We need you to keep Dwayne honest.

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Chris, blood sugar is within normal limits.

Biebs, good summation.

You may be at a loss, but you're not without the skills. There is one part of this presentation, from the beginning, that didn't make sense to me, though Chris may say that he sees it all the time. I didn't really get it until I'd trialed him on room air several times though and then it finally clicked.

I came up with only one theory that made any real sense to me, I consulted with some Aussie docs in Sydney who agreed, and then it was 'verified' though I've no idea how, at the hospital in Lae.

You're thinking possible altitude sickness, possible P/E, both of which come with significant hypoxia, right?

Currently, yeah. By the way, did he have any cyanosis when his sats dropped?

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He didn't Biebs, though it would have been difficult to tell I guess as he's really black, almost purple black. But I did check his nails and didn't notice anything, though they were mostly stained with Betelnut...

Yeah, see, I'm not nearly as good at scenarios as Biebs...

The ultimate diagnosis was long standing COPD exacerbated by altitude with relative dehydration from the altitude masking his pathologic lung sounds. Not sure the flavor.

It made me pretty crazy because I was medicating and trying to create some improvement on room air, even just a few points of SPO2 but I just couldn't. (In case you'd never heard this, there appears to be no acute treatment that cures COPD, so you might want to save your time.)

I'd assuuuuuumed that he's had a prehire physical, which cause me to assuuuuumme that the issue was acute, which cause me, of course, to try everything that I knew to do for an acute issue...

Then it occurred to me that he wasn't really altered with an SPO2 of 72%. Upon his initial presentation he was somewhat diaphoretic, showing air hunger, SPO2 72%, so he kind of presented as I expected and I didn't consider his mentation right away.

It wasn't until I'd gotten baseline vitals, then put him on an O2 neb of albuterol that it kind of struck me that something was weird, and not until I'd trialed him on r/a again a few times that I noticed that neither his mentation nor resp effort changed regardless of treatment when he was at rest..

Now, to some of you COPD might seem obvious, but I'd never had one that presented like this. In fact most if not all (assuming I've missed some) have presented, even if in extremus, I've been able to manage them in some way, and I guess that I've always assumed that someone smart made them better. That if I'd seen them later that night that I'd have seen a completely different presentation and vital set. Know what I mean?

His lungs sounds were full and clear, but I'm guessing, and the doc's agreed that relative dehydration from the altitude might have masked pathologic lung sounds...

Anyway, I thought it was a pretty interesting case that took me about 6hrs to figure out. It wasn't until I thought, "Shit, I might as well save the O2, he's just as good without it..." Then, "yeah...he is...why is that?"

I guess I'm not aware of ever seeing an asymptomatic though significantly ill COPDer...It never really occurred to me that people might be walking next to me with SATs in the 70's yet look more or less normal when not exerting themselves.

So the bottom line is long standing undiagnosed COPD exacerbated by the altitude. We sent him to the hospital in Lae by road, about 5-6 hrs depending on road conditions, and before he got there he felt fine and didn't want to go to the hospital...

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COPD eh? He probably was barrel chested and had clubbed fingers as well.

Relative dehydration from altitude and 600 ml of water per 12 hour shift.

You are "the stick" my ninja friend.

Edited by DFIB
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Heh...He DID have clubbed fingers, but I had remembered that being attributed to heart disease and didn't give it much thought after the XII lead. And he wasn't significantly barrel chested, but then the Papuans tend to be pretty deep in the chest naturally so I may have missed it in him..

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Heh...He DID have clubbed fingers, but I had remembered that being attributed to heart disease and didn't give it much thought after the XII lead. And he wasn't significantly barrel chested, but then the Papuans tend to be pretty deep in the chest naturally so I may have missed it in him..

Wish i had mentioned it earlier but then we would have missed the fun of trying to show how smart we think we are!

Great scenario, Brother!

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The ultimate diagnosis was long standing COPD exacerbated by altitude with relative dehydration from the altitude masking his pathologic lung sounds.[...] Then it occurred to me that he wasn't really altered with an SPO2 of 72%.

A very good scenario! Remembers of using things we DON'T expect or DON'T see as diagnostic instruments. Great work on this patient to get him a diagnose, Dwayne, respect!

BTW; maybe a little lung function test device (spirometer) as used by asthmatic patients would have helped on your site?! They're cheap (~10-20 EUR/$, multiple use) and a real simple test for lung capacity on a complying patient:

320px-Peak_flow_meter_horiz.jpg

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