Acute Dyspnea and Tachycardia in a Cigarette Smoker

Abstract

A 75-year-old woman presented to the emergency department with exacerbation of dyspnea, wheezing, and swelling of the legs that had begun 24 hours earlier. The patient had been treated for lung disease for many years and her usual symptoms were dyspnea on very little exertion, a chronic nonproductive cough, and episodic wheezing. She had smoked cigarettes for 55 years but had stopped five years ago. Her medications included meprobamate, chlorothiazide- triamterene, loratadine, clonazepam, oxaprozin, montelukast, ipratropium, and home oxygen.The patient appeared thin and dyspneic. Her temperature was 37.2°C; radial pulse, 125 bpm; respirations, 36 per min; blood pressure, 105/55 mm Hg; and oxygen saturation, 98% while receiving 3 L per minute by nasal canula. Jugular venous pressure was slightly elevated. Breath sounds were diffusely faint, with prolonged expiration but no crackles or wheezes. Cardiac rhythm was irregular at 135 beats per minute with normal heart sounds. Mild edema of the ankles was present.Serum electrolyte, blood urea nitrogen, creatinine, and glucose levels were normal. White blood cell count was 15,000/mm3; hematocrit was 44%. An arterial blood sample taken while the patient was on nasal oxygen had a pH of 7.46; Po2, 80 mm Hg; and Pco2, 31 mm Hg. The chest x-ray showed overinflated lungs and normal heart size. The ECG is shown.