What is the Diagnosis?

[ihindash]

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a 24 year old smoker with a strong family history of ischemic heart disease, and relates an unexplained, sudden left-sided, severe chest pain, shortness of breath, and a temperature of 101.1 F . He now has a dry cough. He also smokes one pack of cigarettes a day and has done so for the past year, His cough was productive of a green and brown-streaked sputum. He denies wheezing and hemoptysis. He has no occupational exposure to dusts or fumes, has never been exposed to anyone with TB, and does not frequently suffer from respiratory infections.
along with the severe left-sided chest pain, he has a shortness of breath which has worsened over the past week to the point that speaking becomes difficult. but he denies sortness of breath with activity or exertion.
his physical had the following results:
Temp 101.1F
Resp 18, regular resp rythm
Pulse 72, regular pulse rythm
BP 118/80

his pulmonary exam revealed the following: Chest was normal to inspection with no obvious deformity. Palpation revealed mild left-sided chest tenderness. Lungs are clear to auscultation on the right side, but increased breath sounds are present on the left including rhonchi in the lower lung fields. The upper left lung is also dull to percussion.

his EKG reveals right axis deviation, an S wave in I and a Q in III, as well as inverted T wave in III.

his chest film was normal.

his pulmonary angio results were:
- right atrium: 3mmHg
- right ventricle: 26/6 mmHg
- pulmonary capillary wedge: 6 mmHg
- pulmonary artery: 13 mmHg

his labs showed the following:
white blood count (WBC) is 12,000 (normal is 3.2-9.8X10^9/L)
Polymorphonucleotide (PMN) 90% (normal is 50-70%)
Lymph 7.3% (normal 15-40%)
Eosinphils 0.5 (normal 1-4)
Prothrombin Time (PT) 13.2 (norm 10-12 secs)
Aspartate Aminotransferase (AST) 642(5-40) (normal 0-35U/L)
Alanine Aminotransferase (ALT) 229 (38-126) (normal 0-35U/L)
Total Bilirubin 76 (38-126) (normal 0-1.0 mg/dL)

Sputum Culture:
PMN 1+
Epithelial Cells 1+

Few mixed bacteria strep pneumo:
PCN Intermediate -Sensitivity
Erythromycin -Resistant
Vancomycin -Sensitive
Chloramphenicol -Sensitive
Sulfoximethasole -Sensitive
Clindamycin -Sensitive
Ampicillin -Sensitive
Rifampin -Sensitive
Levofloxacin -Sensitive

WHAT IS THE DIAGNOSIS?

 

[DropkickMurphy]

Any reason you posted this on the Premed side of SDN?

By the way, pulmonary embolism (S1,Q3,T3 right ventricular strain pattern and hemodynamic findings) with concommitant LUL pneumonia. And it's "what IS the diagnosis", just so you know. 😉

 

[p00psicleSTICK]

IMMEDIATE AND PAINFUL DEATH!!!

I fail! 😛

 

[ihindash]

Any reason you posted this on the Premed side of SDN?

By the way, pulmonary embolism (S1,Q3,T3 right ventricular strain pattern and hemodynamic findings) with concommitant LUL pneumonia. And it's "what IS the diagnosis", just so you know. 😉

Thank you for alerting me to the typo, but you are wrong, do a little research. very intelligent.

 

[jebus]

severe butt rot.

 

[DropkickMurphy]

Well, it could possibly be a restrictive lung process and that in turn is causing the strain pattern...given the multiple flora represented perhaps CF (cystic fibrosis) would be my guess if we are leaning toward a primary lung issue. But then again, I've had a few beers tonight so I'm not thinking as quick as I normally do.

 

[ihindash]

Well, it could possibly be a restrictive lung process and that in turn is causing the strain pattern...given the multiple flora represented perhaps CF (cystic fibrosis) would be my guess if we are leaning toward a primary lung issue. But then again, I've had a few beers tonight so I'm not thinking as quick as I normally do.

Always stick to your original diagnosis, you were right the first time, it is pulmonary thromboembolism. your very smart I give you that, what school do u go to?

 

[DropkickMurphy]

I was trained by the Air Force as an echocardiographer and a respiratory therapist. Currently I'm in school in Indiana working towards a license as a funeral director (I've got a full ride scholarship for it) and I'm also working on my general education requirements for bachelor's degrees in biology and chemistry.

 

[ihindash]

I was trained by the Air Force as an echocardiographer and a respiratory therapist. Currently I'm in school in Indiana working towards a license as a funeral director (I've got a full ride scholarship for it) and I'm also working on my general education requirements for bachelor's degrees in biology and chemistry.

Cool, Good Luck on everything.

 

[cardsurgguy]

I noticed the PE too (I was bored at work the other night was researching up EKG rhythms online and saw this online)

all of the symptoms fit either MI or PE, but the EKG didn't show anything like ST elevation or depression or bundle branch block, so I figured it was probably a PE and not MI even if I hadn't looked up the rhythm


I would imagine that this is not the only diagnosis

some of the labs are off, for example the aminotransferases and bilirubin are pretty high, so something could be going on with the liver
white count a little high, but with green and brown sputum and positive cultures, that would be expected

I guess I'll keep researching

let us know what other diagnoses there are

 

[crazy_cavalier]

Well, it could possibly be a restrictive lung process and that in turn is causing the strain pattern...given the multiple flora represented perhaps CF (cystic fibrosis) would be my guess if we are leaning toward a primary lung issue. But then again, I've had a few beers tonight so I'm not thinking as quick as I normally do.

Um, what is the history of the patient? Doesn't CF usually arise before adulthood?

 

[DropkickMurphy]

In most cases (>90% according to a pulmonologist I know who is involved in CF research) CF is diagnosed in childhood, but in a small percentage the diagnosis is not made until adulthood, in some cases over 30 years of age.

 

[DropkickMurphy]

I noticed the PE too (I was bored at work the other night was researching up EKG rhythms online and saw this online)

all of the symptoms fit either MI or PE, but the EKG didn't show anything like ST elevation or depression or bundle branch block, so I figured it was probably a PE and not MI even if I hadn't looked up the rhythm


I would imagine that this is not the only diagnosis

some of the labs are off, for example the aminotransferases and bilirubin are pretty high, so something could be going on with the liver
white count a little high, but with green and brown sputum and positive cultures, that would be expected

I guess I'll keep researching

let us know what other diagnoses there are

Keep in mind that the aminotransferrases are not specific for the liver, but rather are generalized markers of inflammation across several forms of tissue.

 

[Messerschmitts]

Diagnosis? Ask me in four years. 😛

 

[cardsurgguy]

Keep in mind that the aminotransferrases are not specific for the liver, but rather are generalized markers of inflammation across several forms of tissue.

good to know, thanks, wasn't aware of that

but the bilirubin is so high, so that's more so than the aminotransferases made me say somthing may be going on with the liver

my grandmother had liver failure before she died, and had a bilirubin of 50 or so

 

[Sanctuary]

a 24 year old smoker with a strong family history of ischemic heart disease, and relates an unexplained, sudden left-sided, severe chest pain, shortness of breath, and a temperature of 101.1 F . He now has a dry cough. He also smokes one pack of cigarettes a day and has done so for the past year, His cough was productive of a green and brown-streaked sputum. He denies wheezing and hemoptysis. He has no occupational exposure to dusts or fumes, has never been exposed to anyone with TB, and does not frequently suffer from respiratory infections.
along with the severe left-sided chest pain, he has a shortness of breath which has worsened over the past week to the point that speaking becomes difficult. but he denies sortness of breath with activity or exertion.
his physical had the following results:
Temp 101.1F
Resp 18, regular resp rythm
Pulse 72, regular pulse rythm
BP 118/80

his pulmonary exam revealed the following: Chest was normal to inspection with no obvious deformity. Palpation revealed mild left-sided chest tenderness. Lungs are clear to auscultation on the right side, but increased breath sounds are present on the left including rhonchi in the lower lung fields. The upper left lung is also dull to percussion.

his EKG reveals right axis deviation, an S wave in I and a Q in III, as well as inverted T wave in III.

his chest film was normal.

his pulmonary angio results were:
- right atrium: 3mmHg
- right ventricle: 26/6 mmHg
- pulmonary capillary wedge: 6 mmHg
- pulmonary artery: 13 mmHg

his labs showed the following:
white blood count (WBC) is 12,000 (normal is 3.2-9.8X10^9/L)
Polymorphonucleotide (PMN) 90% (normal is 50-70%)
Lymph 7.3% (normal 15-40%)
Eosinphils 0.5 (normal 1-4)
Prothrombin Time (PT) 13.2 (norm 10-12 secs)
Aspartate Aminotransferase (AST) 642(5-40) (normal 0-35U/L)
Alanine Aminotransferase (ALT) 229 (38-126) (normal 0-35U/L)
Total Bilirubin 76 (38-126) (normal 0-1.0 mg/dL)

Sputum Culture:
PMN 1+
Epithelial Cells 1+

Few mixed bacteria strep pneumo:
PCN Intermediate -Sensitivity
Erythromycin -Resistant
Vancomycin -Sensitive
Chloramphenicol -Sensitive
Sulfoximethasole -Sensitive
Clindamycin -Sensitive
Ampicillin -Sensitive
Rifampin -Sensitive
Levofloxacin -Sensitive

WHAT IS THE DIAGNOSIS?

*PLEASE MOVE THIS POST TO THE APPROPRIATE FORUM*

anus

 

[NapeSpikes]

*PLEASE MOVE THIS POST TO THE APPROPRIATE FORUM*

Seriously. How are these premeds so friggin' smart?

 

[tigress]

I knew it was PE because my husband had a very similar case on this simulated patient program they do at his school 😛

but yeah, what's the point of this being in this forum?

 

[UCLA2000]

a 24 year old smoker with a strong family history of ischemic heart disease, and relates an unexplained, sudden left-sided, severe chest pain, shortness of breath, and a temperature of 101.1 F . He now has a dry cough. He also smokes one pack of cigarettes a day and has done so for the past year, His cough was productive of a green and brown-streaked sputum. He denies wheezing and hemoptysis. He has no occupational exposure to dusts or fumes, has never been exposed to anyone with TB, and does not frequently suffer from respiratory infections.
along with the severe left-sided chest pain, he has a shortness of breath which has worsened over the past week to the point that speaking becomes difficult. but he denies sortness of breath with activity or exertion.
his physical had the following results:
Temp 101.1F
Resp 18, regular resp rythm
Pulse 72, regular pulse rythm
BP 118/80

his pulmonary exam revealed the following: Chest was normal to inspection with no obvious deformity. Palpation revealed mild left-sided chest tenderness. Lungs are clear to auscultation on the right side, but increased breath sounds are present on the left including rhonchi in the lower lung fields. The upper left lung is also dull to percussion.

his EKG reveals right axis deviation, an S wave in I and a Q in III, as well as inverted T wave in III.

his chest film was normal.

his pulmonary angio results were:
- right atrium: 3mmHg
- right ventricle: 26/6 mmHg
- pulmonary capillary wedge: 6 mmHg
- pulmonary artery: 13 mmHg

his labs showed the following:
white blood count (WBC) is 12,000 (normal is 3.2-9.8X10^9/L)
Polymorphonucleotide (PMN) 90% (normal is 50-70%)
Lymph 7.3% (normal 15-40%)
Eosinphils 0.5 (normal 1-4)
Prothrombin Time (PT) 13.2 (norm 10-12 secs)
Aspartate Aminotransferase (AST) 642(5-40) (normal 0-35U/L)
Alanine Aminotransferase (ALT) 229 (38-126) (normal 0-35U/L)
Total Bilirubin 76 (38-126) (normal 0-1.0 mg/dL)

Sputum Culture:
PMN 1+
Epithelial Cells 1+

Few mixed bacteria strep pneumo:
PCN Intermediate -Sensitivity
Erythromycin -Resistant
Vancomycin -Sensitive
Chloramphenicol -Sensitive
Sulfoximethasole -Sensitive
Clindamycin -Sensitive
Ampicillin -Sensitive
Rifampin -Sensitive
Levofloxacin -Sensitive

WHAT IS THE DIAGNOSIS?

Sudden onset of CP, low grade fever c an s1q3t3 is classic for PE. In most cases pts are usually tachy (but not here)

Pt also sounds as though he's got pneumonia. (smoking destroys cilia and predisposes smokers to pneumonia.)

One other thing that sticks out is the 2:1 AST/ALT ratio suggested of etoh. This could predispose the pt to aspiration and in addition to covering for the strep pneumo I'd want to cover anaerobes etc.

 

[UCLA2000]

Always stick to your original diagnosis,

Always sticking to your original diagnosis will get you into a LOT of trouble in the clinics. You must keep an open mind and a wide differential.

 

[Phil Anthropist]

No homework questions, please.