Case #84 "Not a Simple Cough!"
by Charlene Babcock Irvin, MD, FACEP
On a busy Saturday night shift, I finally
get around to a chart that was sitting in my
‘to see’ box for about 45 min. As the vital
signs were normal, and the chief complaint
was ‘cough’ in a 27 y/o with ‘none’ past
medical problems, she had been bumped back a
bit in order to see some patients with more
serious complaints. As it has been a busy
night, I was looking forward to a quick and
simple case I could evaluate and discharge.
The ‘cough’ patient is a 27 y/o female, resting comfortably on the stretcher,
watching TV with her husband sitting in the chair.
She has had the cough for
about 1 week, but it’s getting worse, and
she has a hard time sleeping because of the
cough. It always gets worse at night. She
does feel short of breath, especially when
she is coughing a lot. She denies any runny
nose or post nasal drip. Tonight she was
coughing so much, her husband just decided
to bring her in to get checked out. He noted
that both hadn’t gotten much sleep.
ROS: No fevers, she does note some
sweats. No nausea, vomiting, abdominal pain.
She does have a ‘chest ache’ which has been
constant for the past week, slightly worse
today. The pain has a slight pleuritic
component to it, and she definitely notes
more discomfort with the coughing. The cough
is dry. No significant sputum production.
PHM: Unremarkable, only hospitalizations for
childbirth (G2P2). No history of HTN, DM,
increased cholesterol, smoking, or family
history of CAD. No history of asthma.
VS: HR=98, RR=20, BP=135/80 Sat 95% (RA),
Temp: afeb.
PE: Pleasant female in NAD, but I did note
she really was slightly tachypnic. (In my
experience, most patients with RR=20 at
triage have a real RR of 12-16 after sitting
in the room). For me, her RR was 24 (so much
for the “treat and street” case).
HEENT: Unremarkable, no sinus tenderness, no
post nasal drip.
Heart: RRR, Faint S3 is present.
Lungs: Decreased breath sounds at both bases
with some mild expiratory wheezing.
Abd: Soft, non-tender. No masses.
Neurologic Exam: Normal
Ext: Some +2 edema is noted in the pre-tibial
area. When questioned about this, she noted
that it had been present for the past 6
months, and started during her pregnancy
with her second daughter, who is now 6 wks
old.
(I hate it when I feel I didn’t get
all of the pertinent info in my history
questions, usually it’s my fault for not
asking the right questions: Any
hospitalizations besides your babies? Any
surgeries? Any medical problems? She
answered ‘no’ to all these, but it was my
fault for not asking about recent
deliveries.)
AN EKG done prior to my evaluation (per
protocol at our institution if any patient
complains of CP, they are very liberal at
obtaining an EKG) revealed NSSTT changes
(flipped T waves in inferior and lateral
leads with 0.5 mm ST depression in V5 and
V6).
CXR revealed cephalization, borderline
cardiomegally, and mild congestion.
LABS: Hbg=12.5 Troponin was 0.08 (upper
limits of normal at our institution are
0.03). NT-pro BNP = 400 pg/ml (normal <300).
Other labs normal.
Questions:
1. What are the causes of elevated troponin besides ischemic cardiac disease?
2. What are the other causes of elevated BNP besides Congestive Heart Failure?
3. What is her prognosis? Can she get pregnant again?
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