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New-Onset Wheezing in a 66-Year-Old Man |
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BACKGROUND
A 66-year-old man is referred to a pulmonologist for progressive shortness of breath that has lasted for the past 3 months. His symptoms began shortly after discharge from a prolonged hospital stay for a logging accident in which he sustained multiple rib fractures and a left hip fracture. At that time, the patient had an extended stay in the intensive care unit and was on mechanical ventilatory support for 21 days. A tracheostomy had not been performed. On a post-hospitalization follow-up with his primary care provider, the patient reported shortness of breath, and wheezing had been noted during the physical examination. A trial of oral glucocorticoids and levalbuterol inhalation therapy was prescribed; however, the symptoms persisted and failed to respond to the therapy. When seen by the pulmonologist, the patient states that he experiences shortness of breath even when he is at rest and loses his breath completely with mild exertion such as climbing a few stairs. He denies orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema. He also denies experiencing any chest pain, cough, fevers, weight loss, or night sweats. He has a history of cigarette smoking and degenerative joint disease. He takes acetaminophen/hydrocodone as needed for pain, but otherwise, he does not take any regular medications. On physical examination, the patient is a well-developed and well-nourished man in no apparent distress. He is afebrile with a regular heart rate of 80 beats/min, a respiratory rate of 14 breaths/min, and a blood pressure of 102/64 mm Hg. High-pitched breath sounds are detected throughout all lung fields during both inspiration and expiration. The remainder of the patient's physical examination, including the head and neck and cardiac examination, is unremarkable. Spirometry is obtained (see Image 1; patient flow-volume is loop shown as the solid blue line; a normal flow-volume loop is shown as the interrupted black line), with subsequent imaging by computed tomography (CT) of the neck (see Image 2). What is the cause of the patient's wheezing? |
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