Differential Diagnosis

[OVeractiveBrain]

I had an interesting case today:

50 yo female with history of MS and pneumonia in January. She is a caucasian female coming from home, where she is wheel chair bound, and has VNA (visiting nurse) assistance. She is normally concious alert and oriented, able to speak and move upper extremities (MS has paralyzed her legs) without much complaint at all. Last night, the VNA noticed that she had some difficulty speaking. It was not slurred speech, its just that she couldnt get the words out right to make a whole sentence. This is most likely from a change in MS medication in order to stop the pain in her face (i imagine some medication that focuses on injured nerves of the face, deadening sensation and also the ability to speak).

Now heres where we are now. This morning the patient is unresponsive, found in her wheelchair, with rapid labored respirations. After some 02 she opens her eyes spontaneously and is able to communicate through head nods that "she aint good."

Right now she is GCS:15, but sluggish, unable to speak, but making obvious attempts at communication. PMS present where they should be, PEARL. Lung sounds are wet (lets just go with crackles) without wheeze, has a global sound with diminished bases, and you can hear a gurgling sound as she breaths (even before when she was unresponsive). Shes a little pale, bu ther numbers are WNL, SpO2 98 on 15LPM NRB.. Right off the bat im thinking CHF. She is unable to lift her tongue to the roof of her mouth (either through communication, nerve damage or the fact that she is hypoxic) so NTG is out, we dont have CPAP nor PEEP, so thats out too. I could have tried using a BVM as a PEEP, but i went for more benign treatment since at this point she was awake and aware.

I gave her 40mg of Lasix, dropped her pressure from 132/p to 114/p, right side clear, left side still junky, all throughout.

ED Nurse says "Aspiration Pneumonia" no doubt.

Ok, that was long, but heres the question:

Was it CHF or pneumonia?

The presentation I saw sounded like pulmonary edema. Lasix diuresed her well and cleared the right the side, but the LEFT side still had full-on fluid sounds. 12-Lead revealed no ACS, no LVH nor axis deviation, she has no cardiac history other than HTN and she takes no diuertic nor rate control medication. You would think, if a person were in pulmonary edema, there would be a problem that led to it. For example, ventricular failure, rate for filling time, an infarct, a hx of, something. This woman had no history and overnight she flashes to full up. She sleeps laying down, one or two pillows, and its not because of diff breathing, its because of pain in her neck.

AFTER the lasix, it sounded wet, yet I had a unilateral rales, still without wheezing. There was nothing to indicate a reason for pulmonary edema, and, while the lasix helped her, it certainly did not fix the problem (transport time of about 20 minutes). I myself was unsure whether to go down the route of pneumonia or pulmonary edema. I chose Pulmonary Edema, and the ER nurse hinted that i was wrong for doing so. Talking to my partner who said a pulmonologist onc told him that a paramedic in the field will be unable to differentiate a pneumonia from edema due to resonance and a generally untrained ear. While early pneumonia may be localized and audible in one field, the chances are slim. Now i think thats crap, because pneumonia should sound different, but its still something I consider.

So is it pneumonia or CHF? Have you ever had a patient in pulmonary edema with no predisposing factors, and that did not worsen over time but just shot up almost over night? Have you had an aspiration pneumonia (or any pneumonia) that presented like CHF? I suppose a great way to find out would have been to look at her chest xray, but since I dont have access to such things, Im just going to assume I was right in what I did.

Overactive

[chbare]

I have seen many aspiration pneumonia patients. This patient's history puts her at very high risk for this condition. Yes, it can present with CHF like signs and symptoms. In addition, it can involve both lungs and involve upper and lower lobes. Think of the cause and physiology in this case. This may contrast from your generic lower lobe pneumonia presentation. If at all possible, follow up information would be very helpful.

Take care,

chbare

[AZCEP]

The fact that this patient had a neuro-muscular disorder gives here the predisposition you are looking for. A bit generalized, but it is there.

How was she positioned following the lasix? Was she on one side?

Your description raises some questions as well. Did you have an ECG? It might show something also.

If in fact this was an aspiration pneumonia, your treatment was not going to change things much. NTG/Lasix might dilate the vessels a bit, but the aspirated material would, typically, have a tough time moving into the vascular space. CPAP might have been quite useful, or some tracheal suctioning.

On a side note, this is pretty common in some assisted living facilities. The nursing assistants know they need to provide nutrition, and will do so when the patient should not be given anything by mouth.

[tniuqs]

Differential Diagnosis ?

Ok, now don't take this as a personal attack, just constructive criticism is all.

The case presentations I have seen lately on this board smacks of "did I do the right thing" and I believe attempts for others to empathize this its getting silly....Your asking for Diff Dx... when your not using a presentation that is logical. PERIOD.

I will quote your own words.....which scare me a bit frankly:

Right off the bat im thinking CHF.

Your jumping to conclusions.....not Physical examinations and findings. Listen to the PMHX (when you hear the HOOF BEATS think horses not Zebras!) What leads you to believe that Pulmonary Oedeama is present when the pathophysiology of this disease (and your knowledge base) needs some serious reading, Excacerbations with Neuro Muscular disorders and Aspiration Pneumonias are not only "common" but the factual "top of the Hit Parade" statistically.

but i went for more benign treatment since at this point she was awake and aware.

Seriously flawed thinking, Lasix is NOT benign! You may have complicated electrolye balance "Nutrition for the MS patient is always a concern" for what reason would you diurese a patient with your stated BP findings?

dropped her pressure from 132/p to 114/p,

while the lasix helped her,

AFTER the lasix, it sounded wet,

Am I just confused here or is your presentation?

Ok justify why you think this helped her? PLEASE.

she has no cardiac history other than HTN and she takes no diuertic nor rate control medication

132 systolic is NOT HTN.....@ 50 years of age! So why no Diastolic.....this is very important and palp is notoriously 10 mmhg lower than auscultated?

You have not included what meds this patient is on...BGL would be an idea too, perhaps a TEMPERATURE?

OXYGENATION

SpO2 98 on 15LPM NRB..

GREAT but what were SATs prior? Was there an O2 deficit, you state Laboured Breathing what was the rate?

(i imagine some medication that focuses on injured nerves of the face, deadening sensation and also the ability to speak)

If you don't know your assuming? What medications again?

she has no cardiac history other than HTN and she takes no diuertic nor rate control medication

LOC...? You state GCS of 15, with aphasia...very confusing.

LUNG SOUNDS

right side clear, left side still junky, all throughout.

Pulmonary Edema, and the ER nurse hinted that i was wrong for doing so. Talking to my partner who said a pulmonologist onc told him that a paramedic in the field will be unable to differentiate a pneumonia from edema due to resonance and a generally untrained ear. While early pneumonia may be localized and audible in one field, the chances are slim. Now i think thats crap, because pneumonia should sound different, but its still something I consider.

Lasix diuresed her well and cleared the right the side, but the LEFT side still had full-on fluid sounds.

HUH?

The most common aspiration problems are (LLL) when supine or the infirm patient.

She sleeps laying down, one or two pillows, and its not because of diff breathing, its because of pain in her neck

You would think, if a person were in pulmonary edema, there would be a problem that led to it. For example, ventricular failure, rate for filling time, an infarct, a hx of, something.

I would! But you have no positive findings......sooo:

Im just going to assume I was right in what I did.

Ok, that was long, but heres the question:

Was it CHF or pneumonia?

ED Nurse says "Aspiration Pneumonia" no doubt.

and the ER nurse hinted that i was wrong for doing so.

AGREED TOTALLY...... based on this presentation you should LISTEN TO THE RN she/he is telling you something here.

[tniuqs]

This is a PCR format that I use, not that its the best, I have lots to learn myself, but a logical case presentation should be followed:

C/F- Dispatch info Code's

O/A- scene/mech/RN/MD

Pmhx- SAMPLE bgl

C/C- PQRST& assco.c/o

CNS- APVU-A+O M+S function losses?

CVS- perfusion, pressures, central /perf.- Heart sounds.

ENT eyes edema reflex+consentual .neck

CVS B/P perf.pulse cap refill

PULM o/a, a/e , adventica

ABDO tender/non-masses/rebound

G/I G/U lbm / output urine bowel sounds.

DERM -temp. color' moisture, edema. petechiae

ORDERS M.D.

RX prior/ RX HX

Noted changes enroute.

CXR,ABDO,CT,LABs,U/S

TX V/S Urine output monitor,Sa02,ETCO2,ABG,12- lead

Totals ins/outs-drains

VENT-settings, IV rate/RX/totals # Bags I Vs & Type of fluids.

Papers,belongings,

INCIDENTs

Police #

Follow up findings.

[ERDoc]

tniuqs,

I agree with all of your points. However, aspiration pneumonia most commonly occurs in the RLL. The reason being is that the left mainstem has a sharper angle off the trachea than the right, so it is a more direct path to the RLL. This is also why most inhaled objects end up in the RLL. Then again, those north of the border may have a different anatomy.

Giving lasix to a pt with pneumonia is bad. You want to keep them hydrated as dehydration can only make them worse. A problem I have with this scenario is that there was such a great improvement in her pulmonary status in less than 20 minutes after lasix. My guess is that there was some mucous plugging or just some excess mucous that was hanging around causing some rhochorus sounds that cleared in the 20 minutes via coughing or movement. This osunds like a case of aspiration pn to me. A good rule of thumb is that if you are not sure what the right answer is, it may be best to do nothing but monitor and transport.

The way cases are generally presented in the hospitals:

History of present illness : 54 y/o male with h/o MI presents with sharp substernal chest pain that radiates to his left arm. Started 20 minutes ago while the pt was running on a treadmill. Nothing makes it worse, but nitro makes it better. It is associated with diaphoresis, nausea and vomiting. He has never had pain like this before.

Other pertinent history: Review of systems, PMH, PSH, fam Hx, soc Hx

Physicial Exam: Vitals and head to toe

Once this is done, the differential is usually discussed. Once a ddx has been made, you discuss the work up and treatment. After that you discuss work up results and response to treatment and then try to come up with your diagnosis.

I have no problems playing Monday morning quarterback for any call that someone has a question about, but, as tnuiqs stated, be honest with what you are thinking and hoping to accomplish. Say straight out, "I had this call and got a major attitude from the nurse. I think I'm right, but let me know what you think." Just be prepared to hear that you might be wrong. If you are looking for opinions on what happened and what the diagnosis is, you've come to the right place. If you are looking for someone to make you feel better and tell you that you were right when you might have been wrong, you have come to the wrong place.

[fiznat]

Heya dude.

Honestly I dont think I would have done what you did. I wasnt there and I didnt see the patient or hear those lung sounds, but what you've written really doesnt seem to point towards CHF.

She seems to be predisposed to the pneumonia, and even you admit that the lung sounds could possibly have gone either way. Without a cardiac history or Rx diuretics, and also a seemingly slow onset and normotension I'd like to think that I'd be looking elsewhere. All of this seems to point more towards pneumonia than CHF, although again I wasnt there. Did the patient have a temperature?

It stands out to me that this patient may not have even had a respriatory problem. You say you heard air movement throughout the lungs, so even if it is indeed CHF it doesnt seem as if she is completely full. ...Probably not full enough to cause a hypoxic change in mental status, anyways. The SPO2 of 98 seems to also confirm this, although like another poster said you didnt mention the original SPO2. ETCO2 would be really helpful here as well. Was there any other possible source for the change in mental status? You mentioned a recent medication change-- what about BGL and a stroke scale? Pupils PEARRL but were they normal in size? How different was she when you saw her from her baseline?

If you're convinced that this was a respiratory problem, and are even the least bit unsure about CHF vs Pneumonia, you should split the treatments a little differently. Our protocols specifically say that if we're unsure which it is, skip the lasix and do NTG only. Routine ALS also of course. The NTG apparently has less potential to damage a possible pneumonia patient than the lasix. I dont believe inability to lift the tongue is a contraindication for NTG. Just grab a 4x4 and lift it for her, right? ...Or paste, I suppose.

Still, a good call dude. I wish I was out there learning these lessons.

[JCicco345]

Fiznat, i'm guessing you are giving the NTG for the pulmonary edema correct ??? How much does the NTG usually help with pulmonary edema ?

Overactive, can we get some more info on the breathing, how labored was it, what was her respiratory rate and were there any o2 SATs from before your arrival ?

[fiznat]

Fiznat, i'm guessing you are giving the NTG for the pulmonary edema correct ??? How much does the NTG usually help with pulmonary edema ?

Assuming this patient had pulmonary edema, yes. NTG is the first line treatment for that condition, and it makes a huge difference. ...Better than lasix, I'd say.

Just 2 seconds of google searching:

http://www.circ.ahajournals.org/cgi/conten...stract/46/5/839

http://www.chestjournal.org/cgi/content/abstract/92/4/586

http://www.ncbi.nlm.nih.gov/entrez/query.f...l=pubmed_docsum

A quote from that last one:

...Correct diagnosis and treatment for pulmonary edema, the most common acute manifestation of CHF, are of primary importance as misdiagnosis can result in deleterious consequences to patients. The pathogenesis of acute pulmonary edema (APE) is currently believed to arise primarily from the redistribution of intravascular fluid to the lungs secondary to acutely elevated left ventricular (LV) filling pressures. This understanding has provided a basis for the management of acute APE, which entails reduction of LV preload, reduction of LV afterload, ventilatory support, inotropic support as needed, and identification and treatment of other underlying factors contributing to elevated LV filling pressures. The agent most applicable and effective for field treatment is nitroglycerin. Diuretics and morphine should be used with caution, as they carry higher risks, especially in misdiagnosed patients.

I've been to a couple conferences on the subject, and read some research on it: diuretics are getting phased out for treatment of pulm. edema. It's old and busted. NTG is the new hotness.

[CBEMT]

OVB I feel your pain. The first SOB patient I ever had as an ALS provider was much like this, with a similar result.

The only differences were his pressure was much lower but he had the classic CHF rales that you could hear down the hall. I had seen many CHF patients as a Basic, and this one was screaming CHF at me. No history that would've normally pointed me towards failure, but I went there anyway.

To my credit though, so did the ER MD. I had given and 40mg lasix enroute and the doc ordered another 80 before he was even off our stretcher, followed later by CPAP, which the patient was less than compliant with. I followed up several days later (with the ER MD), and found out that the DX was in fact pneumonia.

ERDoc- in my case, with an assessment seems most likely pneumonia with a low pressure (90's) would a fluid bolus be something to consider, or do we want to avoid that and just try to maintain him as is? I ask because many of the pneumonia patients I tend to see are on their way downhill towards fullblown sepsis, and once I'm satisfied that it's not CHF I'd like to be able to do something for them, but I've been hesitant with fluids do to everything they've already got going on. Plus, on occasion, there is still the nagging doubt of whether it IS CHF or not. I have gotten 200x better at differentiating though.