Clinical-Pathological Conference

Presented by

Bradford L. Walters, M.D., FACEP

William Beaumont Hospital

Department of Emergency Medicine

Royal Oak, Michigan

Case 1

CC: Fever, chest pain, shortness of breath

HPI: A 22 y/o white female presents with a two day history of fever, cough productive of white-yellow sputum, difficulty breathing, and chest pain with a deep breath and cough. Symptoms have been getting worse over the past two days. She has not measured her temperature at home but has felt warm and sweaty. She has coughed up some sputum of a yellow/white color, not particularly thick, and she denies any blood in the sputum. The shortness of breath has gotten significantly worse today to the point where even walking out to the car left her breathless. She also denies any recent travel, sick contacts, weight loss, or night sweats. (explain why those are pertinent negatives).

PMH/PSH: negative, no history of hospitalizations or surgery, no history of blood clots. She gets bronchitis about once a year and this is similar but worse.

Allergies: none.

SH: smokes about 1 pack-per-day.

FH: negative for inherited diseases including DM, CAD, DVT/PE.

Medications: none, however on repeat questioning she says she is on birth control pills but she did not consider that a medication as it is not treating a disease (a common belief so watch how you ask questions).

PE: Vitals – BP = 110/55, Pulse = 125, RR = 22, T = 38.7oC, Pox = 89% on room air, 92-94% on 4L oxygen by nasal cannula, Wt = 60kg.

HEENT: neg

Neck: no JVD, modest use of accessory muscles of inspiration, no masses

Lungs: diffuse crackles throughout both lung fields, tachypnic, pleuritic pain with deep breath

Ht: tachycardic, no murmur, no gallop, no friction rub

Abd: neg

Genital/Pelvic: deferred

Ext: no pre-tibial edema, no cords, no calf/thigh tenderness, full pulses all four extremities

Skin: warm to the touch, no rash/petechia, no cyanosis

CNS: neg

What is your differential at this point?

What labs do you want and justify your choices?

What do you do while you wait for all this to come back?

You guys can get back to me by the end of the break and I'll send you the answers and results. I'll also give you one clue...

CXR = atalectasis both bases, no pruning or Westermark's sign or Hamptom's hump, no cardiomegaly, no infiltrate. (look up Westermark's and Hamptom's hump and tell me what they are)

Good luck and have a good break!!

Erica