A 79 year old diabetic male is brought to the ER for evaluation of shortness of breath. His symptoms began gradually after he returned from a trip to the market yesterday evening (approximately 8 hours ago). At that time, he felt unusually fatigued, and thought he had 'overdone' it by walking 2 blocks to the market and back, an activity he did regularly. Thinking his symptoms were due to the flu, he took an OTC cold preparation upon arriving home, but without relief. He remained awake all night, and starting about 2 1/2 hours ago, he became progressively more dyspneic and air-hungry. He denies fever, chills, cough, hemoptysis, chest pain, lower extremity edema, or remote history of either cardiac or pulmonary disease. He checks his blood sugars regularly, and they have been well-controlled recently.
Past medical history is notable for hypertension, well-controlled Type 2 diabetes mellitus, and osteoarthritis. Habits include a 50 pack-year history of tobacco use, but no current tobacco or alcohol.
CURRENT MEDICATIONS: Lisinopril 10 mg qd Multivitamin 1 po qd Insulin 70/30 - 45 U q am
EXAMINATION: reveals a well-developed, well-nourished man appearing fatigued but in no acute distress. VITAL SIGNS: BP 150/90 HR 104 RR 24 T 98.6F SKIN: generalized pallor. HEENT: unremarkable, no obstruction in upper airway on gross inspection. NECK: supple, without masses. CHEST: no skeletal deformities, no use of accessory muscles of respiration, no intercostal retractions. Auscultation clear without wheezing, rales or rhonchi. COR: regular rhythm, normal PMI without precordial heaves or lifts; no S3 or S4. Grade 2/6 systolic murmur at left lower sternal border without radiation; jugular venous pressure 6cm. ABD: normal bowel tones, without masses or organomegaly. EXT: symmetric, no edema, no cords palpable.
BEDSIDE DATA: O2 saturation 93% on room air; chem stick BS 100 by fingerstick. Quick-look rhythm check reveals sinus rhythm, rate 105. 12-lead EKG is pending.
Q: What is the differential diagnosis for this patient's complaints and physical findings? Do either the subjective or objective findings provide a clear indication of the diagnosis?
Q: What would be your next step in this situation?
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Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.