First Aid Step 2 Casebook
A 70-year-old man presents to the emergency department complaining of increased shortness of breath with minimal exercise, cough, and fatigue. These symptoms began 2 weeks ago and have progressed gradually. He reports he used to feel this way “all the time” years ago, but that this has not happened much since he began using his inhalers and his “water pill.” He also has a history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), diabetes mellitus, hypertension, and 30-pack-years of smoking. He denies swelling of the extremities, fever or chills, productive cough, chest pain, or palpitations. He cannot remember the names of his medications, but says he has not missed any doses. When asked about his diet, he says he has been eating more hot soup since the weather has gotten colder. His temperature is 37.5°C (99.5°F), blood pressure is 135/90 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and oxygen saturation is 94% on room air. Examination of the neck reveals mild jugular venous distension. Examination of the lungs reveals loud crackles throughout the lung fields bilaterally. Examination of the heart reveals a laterally displaced point of maximum impulse with no murmurs, rubs, or gallops. There is mild clubbing of the extremities, as well as pitting edema of the lower extremities to the knee, bilaterally. His plasma brain natriuretic peptide level on rapid bedside assay is 500 pg/mL, and an x-ray of the chest reveals perivascular haziness, interstitial edema, and an enlarged cardiac silhouette.