Author: Ahmad Saqer, Umer Uqaili / Editor: Steve Corry-Bass / Codes: EC2, EP6, ResC7, ResP2, SLO1, SLO3 / Published: 25/11/2022
A previously fit and well 79-year-old presents with a past medical history of a STEMI 10 years ago. He is complaining of sudden onset difficulty in breathing that started 3 hours ago whilst sitting down.
He denies having any previous respiratory problems. He complains of having a sore throat as well as feeling like ‘’something is stuck in my throat’’.
He denies eating anything earlier that he has not eaten before or starting any new medications. He has not travelled anywhere recently. He is not on any ACE inhibitors.
He is a non-smoker and his COVID PCR test has come back as negative. He denies any chest pain.
On examination, you do not see any obvious neck or facial swelling. The tongue is not swollen, and the throat including tonsils looks normal with a pen torch. On auscultation, you hear widespread wheezes bilaterally, accompanied by an inspiratory stridor. He has a fast but regular heartbeat with no murmurs. He has no evidence of an urticarial rash.
Observations:
- SpO2 96% on room air
- HR 109
- BP 182/86
- RR 25
- T 38.6°C
His initial ABG:
- PH 7.39 (N: 7.34-7.45)
- PO2 10.4 (N: 10.5-13.0)
- PCO2 4.4 (N: 4.5-6.0)
- HCO3 23.8 (N: 22-28)
- Lac 1.10 (N:0-0.9)
His blood results:
- WBC 23.1 (4.0-11.0)
- Neu 18.0 (2.0-7.5)
- D-Dimer 420 (0-225)
- CRP 161 (0-5)
- Troponin 19 (0-15)
A CXR is performed & is shown below.
6 responses
good review of acute epiglottitis
Excellent module
This is a very refreshing topic, and a lot was learned especially in differential diagnoses of acute shortness of breath and tachycardia and management options
good case
Not sure I would be giving the LMWH early on as it appears there are many other things that could be the diagnosis.
Nice module, definitely tricky to see a similar patient in real life. Don’t think I’d start Rx for PE (although it’d be in my differentials) or give IV magnesium from the get go tbh, & stridor immediately worries me of upper airway disease. What I’d give is IV Abx, IV steroids, Combi nebs and Adrenaline nebs, take him to resus and think upper airway pathologies given the super acute onset and stridor (so ASAP involvement of ENT/anesthesia/ITU). D-DIM is notoriously nonspecific, but I admit the CXR findings & the rarity of epiglottitis can throw us off. Thank you for this case.