Intern Report Case 1.9


Presented by Mondeep Narewal, MD

A 55-year-old man presents to the ED for progressive shortness of breath. His past medical history is significant for congestive heart failure, chronic obstructive pulmonary disease, diabetes hypothyroidism, and kidney failure.   Only a limited history could be obtained as the patient is short of breath.  He states that he has been getting short of breath for the past week.  He also states that he has had some increased swelling in his feet and hands.  He usually is on  home oxygen  however has noted he needs more now.
Pt states he has had a cough and sputum production but no changes from baseline.
He has three pillow orthopnea and PND.  Patient states he has been compliant with all medications.

A review of his medical record shows that the patient was admitted 2 weeks prior for progressive shortness of breath secondary to CHF and it is noted that he has a dilated cardiomyopathy.  His ecocardiogram during this admission revealed an ejection fraction of 45%.

ROS: (limited secondary to shortness of breath)

He states he is fatigue and feels cold over his body.  Denies any chest pain, diaphrosis, palpitations.  No vomiting, no dizziness.  He states that he has been slightly more constipated than usual.  No blood per rectum.  No diarrhea.

CHF, COPD, DM, hypothyroidism and chronic renal insufficiency

Carvedilol, levothyroxine, , insulin, albuterol, sprivia, ASA


Positive for smoking history, no crack or cocaine or drug use.  Denies any ETOH.

Physical Exam:

VS:  T=35.1 Oral, HR=67, RR=28 BP=138/94 O2 Sat=87% on 2 L
General:  Pt  has a significant conversational dyspnea and appears in mild to moderate respiratory distress
Face:  Symmetrical simile no focal deficits has some non-pitting edema around the eyes.
Eyes: Conjunctiva pale, PERRLA, EOMI,
Ears: Clear TM
Mouth:  Slightly enlarged tongue no erythema no exudates.
Neck: Supple, enlarged thyroid gland that is non tender, no bruits heard, there is a JVD 7cm, trachea midline
Cardiac:  normal S1 and S2, has an S3,no murmurs, no rubs, regular rhythm
Lungs: Rales at both bases, wheezing diffusely throughout both lung fields.
Abd: Obese, soft, NTND, no rebound no guarding.
Extremities: Pulses symmetrical 2+ throughout, 2+ edema pitting in lower legs.
Neuro Exam:  Patient has no focal deficits, CN II-X12 (8 not tested) grossly intact.
Patient’s strength is 5/5 moving all extremities, has decreased reflexes at both patella and biceps but symmetrically decreased no clonus.
Skin Exam:  Dry cool skin, patient feels cool to the touch, cap refill is slightly prolonged, there is no erythema or lesions.

Lab Results:
CBC:  H/H 13/39, WBC: 12, Plt 190
Lytes:  132/4.4/107/26/2.5  Glucose=140
UA:  Negative
Troponin <0.02
Mg 2.1
TSH:  50 uIU/ml

EKG: NSR, Slightly flattened T waves, no ST depression or elevation,  prolonged QTc interval

CXR: Pulmonary congestion with b/l pleural effusions no cardiomegaly.


1.  Taking the patient’s presenation into consideration, which of the following is the most likely diagnosis?
a)    Sepsis
b)    Congestive heart failure
c)    COPD exacerbation
d)    Hypothermia
e)    MI

2.  Given the patients clinical presentation and lab results what would be the most likely reason that this patients underlying condition has worsened?
a)    MI
b)    Uncontrolled Diabetes
c)    Pneumonia
d)    Noncomplaince with medications
e)    Thyroid function

3.  Given this patient’s clinical presentation, what is the most appropriate immediate management?

a)    Supplement O2, furosemide, nitroglycerin
b)    Supplement O2, steroids, albuterol atrovent
c)    Supplement O2, beta-blockers, furosemide
d)    Supplement O2, furosemide, nitroglycerin, start low dose levothyroxine
e)    Supplement O2, furosemide, nitroglycerin, start high dose IV levothyroxine replacement

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at Thank you for participating in Receiving’s: Intern Report.

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