FL_Medic Posted July 27, 2006 Share Posted July 27, 2006 Use this post to test the diagnostic skills of your fellow posters. Give us a quick Assessment including S/S, and patient presentation. We aren't to ask you any questions just give you are top 5 reasons for this presentation. Please be sure to try and give us enough information to Dx without giving it away. Points should be awarded to the victors, using the honor system. Link to comment Share on other sites More sharing options...
hammerpcp Posted August 9, 2006 Share Posted August 9, 2006 Why don't you start us off. Link to comment Share on other sites More sharing options...
chbare Posted August 9, 2006 Share Posted August 9, 2006 Ok, here goes. Let us start with an easy one. You are dispatched to the residence of a 52 year old male who complains of dyspnea. Upon arrival you find a safe scene without any noticeable hazards. S: 52 Y/O male complains of frequent productive coughing over the past week with generalized malaise and states "I am having a hard time catching my breath." States coughing up green sputum. A-NKDA, M-Tylenol po prn, PMHX-Appy 1990, T&A 1960, Smoker 1PPD/30 years, Occasional drinker, Denies drug use, L- a power bar this am, E- "started with productive cough 7 days ago, slowly been feeling worse with more coughing, unable to catch my breath, and generalized weakness." O-7 days ago, P-Activity, Q-"Weak, tired, and cannot catch my breath." R- N/A, S- "I have never been short of breath like this" T- "Started 7 days ago." Height~5'7" Weight~215# O: General Impression, AO*4, Ambulatory with MAE and steady gait. Frequent cough noted, coughing up greenish sputum. V/S: P-117 Strong & Regular, RR- 24 Moderate Dyspnea with Productive Coughing, SA02-88% R/A, B/P- 146/092, Temp- 101.2 F. Neuro: No deficits noted, unremarkable. Psych: Anxious. HEENT: Unremarkable exam with the exception of the patient coughing up greenish sputum. CV: Regular apical pulse equal to radial without any deficits or abnormalities noted. Sinus tachycardia noted on the monitor in lead II. CX: Wheezing noted throughout all lobes with fremitus to the bases during the palpation exam. ABD: Unremarkable, normal bowel habits noted. GU: Unremarkable. Back: Unremarkable. EXT: Unremarkable. Integ: Pale skin noted with flushing around the face and neck. A: ????? P: ????? E: ????? Take care, chbare. Link to comment Share on other sites More sharing options...
MrSpykes Posted August 9, 2006 Share Posted August 9, 2006 The coughing up of green sputum, the fever, the wheezes, and last but definitely not least the dyspnea leads me to believe pneumonia and probably the onset of COPD, more specifically emphysema. Link to comment Share on other sites More sharing options...
chbare Posted August 9, 2006 Share Posted August 9, 2006 MrSpykes, the diagnosis of pneumonia is correct. The findings of a productive green cough, fever, abnormal lung sounds, malaise, dyspnea, and fremitus are highly suggestive of pneumonia. Lets take it a step further? How would we treat this guy enroute to the hospital? Then, what tests do you expect to be ordered while at the hospital? Next, how will we help this guy get better? Finally, let us back our responses up with a rationale. Take care, chbare. Link to comment Share on other sites More sharing options...
MrSpykes Posted August 9, 2006 Share Posted August 9, 2006 Put him on some high flow O2, call the doc and see what he says about if an albuterol updraft would help. I am not sure that it help that much because the problem is not bronchial constriction, but it would dry up some of the productive cough. I am not sure though. Give him an IV and run some fluids in a little quicker than TKO because he is probably losing some fluids to the fever. In the ER i would guess a Chest X-ray to look for infiltrates and a CBC to look at white count to check for infection. Start him on some antibiotics. And finally make sure his take home msg is quit smoking. Thats all I can think of. Link to comment Share on other sites More sharing options...
chbare Posted August 9, 2006 Share Posted August 9, 2006 MRSpykes, good thinking. Oxygen to increase tissue perfusion. Isotonic IV fluids will help with hydration, thinning out resp secretions, and can be used for meds. A bronchodilator may help open this guy up and may even help him cough and prevent further atelectasis. In addition it, may help him cough up a sputum sample for C & S testing. Need to get an X-ray to see where the pneumonia is located. From the history we suspect is is bilat lower lobe pneumonia. CBC will help us identify infection by looking at the WBC and the breakdown of the different white cells. A manual diff may be ordered as well. In addition, blood cultures may be ordered as well. This guy will be put on ABO's. Depending on his status in the ER, he may be admitted and receive IV ABO's. The docs down here like the shot gun approach until the C&S comes back. IV Levaquin and Rocephin. Tylenol could be given for the fever. A cardiac profile and 12 lead may be ordered as well. (Age, risk factors, and a pulmonary C/O.) Take care, chbare. Link to comment Share on other sites More sharing options...
CoyoteMedic Posted August 29, 2006 Share Posted August 29, 2006 Well... based off my counties protocols... Baseline Field Findings: pneumonia * Lung sounds * Fever * Productive cough & color sputum * Increased pulse rate and resp rate * Skin signs Treatment; -Monitor -Albuterol, 2.5mg in 3cc pillow nebulized w/ O2 *Many reasons why the O2 sat could be low, cold hands due to poor circulation, new onset of COPD due to the smoking. Field diagnoses of cardiac vs Resp wheezes is almost impossible, could be new onset CHF (BP & increased pulse rate), but unlikely (sputum color & other signs). -IV, *Will most likely be reciving IV antibiotics uppon arrivel at the ER Reassess during transport after alubterol treatment. Repeat if V/S's are within limits (pulse was elivated to begin with) Keep pt on high flow O2 & monitor pulse ox and mental status Link to comment Share on other sites More sharing options...
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