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CPC Case for May 20, 2005
 
Discussant: Wyatt Rousseau, MD
Presenter: Dr. Nilam Soni, MD
CC

Shortness of breath
HPI

A 48-year-old Mexican male presented to the emergency room complaining of shortness of breath.  Two months ago he began having fever, cough, night sweats, and weight loss, and three weeks ago, he was diagnosed with pulmonary tuberculosis.  After a recent 4-day trip to Mexico, he reported progressively worsening shortness of breath.  He came to the emergency room after developing some right-sided pleuritic chest pain.  He denied sick contacts, lower extremity edema, diaphoresis, nausea, vomiting, diarrhea, or headache.
PMH
 No other significant medical problems
MEDICATIONS
  1. Isoniazid  300mg po daily
  2. Rifampin   600mg po daily
  3. Ethambutol  1600mg po daily
  4. Vit B6  50mg po daily
FH
 Unknown

SH

 He is a construction worker who is originally from Mexico.  He is married with five children, and all of his family currently live in Mexico.  He smoked 1 1⁄2 packs per day for 30 years, but quit smoking 4 years ago.  He used to drink alcohol occasionally, but quit 7 years ago.  He denies illicit drug use, transfusions, tattoos, or high risk sexual practices. 
VITAL SIGNS
 T 98.6° P 125 R 38 BP 135/96 SaO2 75% (room air)  
PHYSICAL EXAM:

Gen:  Well-developed male sitting upright in bed with non-rebreather mask in respiratory distress

HEENT:  Pupils equally round and reactive to light.  Anicteric conjunctiva.  Nasal and oral mucosa pink and moist.  Bilateral tympanic membranes normal

Lungs:  Moderate respiratory distress.  Diffuse, coarse rhonchi throughout both lung fields.

Heart:  Regular tachycardia.  Normal S1 and S2 without any murmurs, rubs, gallops.

Abd: Soft, nontender, nondistended, normal-active bowel sounds.

Ext:  Warm with 2+ distal pulses.  No lower extremity edema or calf tenderness.

Neurological:  Alert and oriented x3.  Motor strength normal, and sensation intact to touch.  Reflexes 2+ throughout, and negative Babinski reflex. Gait not tested.

Skin:  No rashes
LABS:
Na
142
K
 3.6
Cl
 102
HCO3
 27
Glucose
 158
BUN
 6
Ca
9.5
Mg
 1.7
Phos
3.3
 
 
Creatinine
 0.9
Alk Phos
 115
AST
75
ALT
76
TP
8.1
Alb
 4.3
Total Bili
0.6
GGT
 109
Glob
 3.8
 
 
 
 
Trop I
 2.4
CK
 88
CK-MB
 2.7
 
 
D-dimer
>1050
   
 
 
 
 
 
WBC
 14,100
Hgb
 17.1
Hct
 50
Plts
 154,000
MCV
 96
Differential
 (N84 L7 M6 E3)    
Blood Cultures:
x2 negative                
Imaging and Other Studies
CXR
 See image        
Hospital Course/ Outcome
He was admitted to the intensive care unit and intubated shortly thereafter.   Lower extremity venous dopplers showed extensive deep venous thromboses, and anticoagulation was started.  The three drug regimen for tuberculosis was continued, and broad spectrum antibiotic coverage was added for community-acquired pneumonia.  Despite maximal ventilatory and vasopressor support, his oxygenation and blood pressure remained marginal for the next several days.  His respiratory failure continued to worsen, and he eventually expired.  An autopsy was performed, and a diagnosis was made.