Level 3: Dyspnea – Contrasting Case #2: Patient Information

Given these changes from the original case, what is your diagnosis?

As compared to the long case, this patient is a 60-year-old man who presents to the ED complaining of 3 days of progressively worsening shortness of breath.

HPI: One week ago, the patient reports he developed a “cold” consisting of productive cough, fever, and fatigue after which his shortness of breath gradually increased. Currently, he has a productive cough that produces a small amount of white/yellow sputum. He does not currently report fever, chills, hemoptysis, chest pain, loss of appetite, weight loss/gain, or excessive fatigue.

Physical Exam:
VS- BP 140/92, P 78, RR 28, T 99.8 F, O2 sat 89%
Resp- Decreased breath sounds with diffuse crackles bilaterally, LLL dullness to percussion
Rest of exam noncontributory

Arterial Blood Gas-
pH 7.23
PaO2 88 mmHg
PaCO2 40 mmHg
Serum HCO3- 16 mEq/L