Chest Pain, Shortness of Breath, Cyanosis & Cough [Case #2]

“A 38 year old man has presented to the Emergency Department with a chronic history of shortness of breath. He states that it has been gradually getting worse over 6 months and has been to see his GP with this complaint several times.”

According to the patient, the dyspnea is worse on exertion and is associated with decreased exercise tolerance. There are no associated chest pains, palpitations, dizziness, or syncope. The patient denies any associated cough, haemoptysis, fever, or weight loss. At his initial presentation to his GP at the time of symptom onset, a cardiac stress test and pulmonary function testing were within normal limits; however, his symptoms have persisted and have actually worsening over the prior two weeks.

He has been prescribed zopliclone (sleeping medication), as needed, by his GP, who labeled his condition secondary to anxiety. The shortness of breath has progressively gotten worse, so much so that the patient can no longer exercise, or even walk, without becoming short of breath. The patient is an active tennis player and has no family history of heart disease.

He does not take any medications or herbal supplements, and he has no known drug or food allergies. There is no history of smoking, alcohol abuse, or illicit drug use.

On arrival to Majors area in ED he has RR 20 at rest, saturations of 94% on room air, BP 110/78 mmHg and apyrexial.

Q1. What top 5 diagnoses would be in your differential diagnosis?

His ECG was taken in Majors:

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Q2.What ECG changes are present and what could the possible diagnosis be?

Q3. How would you investigate and treat this patient?

The patient had a normal CXR seen by the junior doctor and the ECG was considered to be normal at the time. His symptoms seemed to be minimal at rest and he was reassured and sent home with advise to see his GP in a few days.

The following day the patient is on his way to work but as he is walking to the car he collapses. This is witnessed by his wife who calls for an ambulance and starts CPR as instructed. The paramedics arrive at the scene and continue CPR and intubate the patient. He is found to be in PEA throughout and arrives to the Resus room within 25 minutes of collapsing at home. He is still in PEA.

Q4. As the team leader how would you manage this patient?

Q5. How long would you continue CPR for in this case?

After appropriate resuscitative care he has a ROSC. He is still intubated and is starting to make a respiratory effort.

Q6. Where will he be transferred and what specific treatments should be initiated?

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case: