Question

SB is a 74 year old man who presents to the ED with his wife complaining of shortness of breath and fever. He is confused about what to use when, so you are not sure which medications he actually takes. No known allergies.

Past Medical/Surgical History

o   Heart failure following myocardial infarction at age 68 years

o   COPD (on 2 L home oxygen)

o   Hypertension

o   Appendectomy

JS Past Record Review  (brought by wife)

-      Echocardiogram with EF of 25%

-      Spirometry with FEV1 35% predicted that does not change significantly after inhaled bronchodilator

Records Review

Unable to determine when last pneumoccal vaccine was given

-      Patient and wife don't recall "a pneumonia shot"

-      Does know he got his "flu shot" last month at a grocery store

JS current symptoms include the following:

-      Unable to speak in full sentences for the past several hours per wife

-      Cough productive but unknown color of sputum

-      Audible wheezing since last night per wife

-      Mild chest tightness

-      Dyspnea

•       His wife has noted no change in his alertness or mental status

•       When you inquire, the wife states that JS usually has a cough, worse in the morning, productive of gray sputum, gets short of breath if he walks more then 10 feet, and has episodes of wheezing if he gets sick (e.g. with an upper respiratory infection).

•       He usually is able to help around the house with light work and fixing things.  

•       Physical examination

-      Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral

-      Unable to speak in full sentences, audible wheezing, alert and oriented

-      Pertinent positives:

•       General:  audible wheezing, no accessory muscle use

•       Nails: tar stains, clubbing

•       Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation

•       Heart: regular, no murmurs

•       Study results

-      Pulse oximetry 86%

-      Chest x-ray shows hyperinflation and right lower lobe pneumonia

-      You continue his heart failure medications as per his home regimen

•       No need to discontinue the cardioselective beta-blocker

is the admitting diagnosis CHF, Pneumonia, or could it be either one? please explain, thanks!

What would be some medications that he should take?

Also, based on the symptoms - what would his labs look like? any specific diagnostics or tests needed.

Answer 1

DIAGNOSIS- The patient is already suffering from heart failure and along with it he has pneumonia.

He have positive heart failure symptoms like dyspnoea and unable to do normal day to day works . He also have pneumonia symptoms like fever , productive cough , chest tightness and wheezing and x- ray findings.

He should continue on heart failure medications . Along with it he should take drugs for pneumonia like Amoxicillin / amoxyclav/ levofloxacin / cephalosporin etc .

The laboratory tests shows positive for CHF and pneumonia. Additional DIAGNOSTIC tests like ECG, blood tests and urine tests can be done for prognosis of heart failure .