An Elderly Man with Dyspnea Background
A 65-year-old man presents to the emergency department (ED) complaining of difficulty breathing.
Figure 1.
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Click to enlarge) He describes worsening dyspnea on exertion that is associated with chest tightness, wheezing, and coughing. The patient's dyspnea has worsened to the point that he can hardly walk from his couch to the bathroom without becoming extremely short of breath. He recently recovered from a cold, with several days of nasal congestion, clear rhinorrhea, and a nonproductive cough. He reports having been healthy his whole life and has not been to see a physician in at least 2 decades; however, he does admit that he has gradually curtailed his physical activities, such as gardening, shoveling snow, and walking in the mall, because he has been increasingly "getting winded." He smokes 2 packs of cigarettes daily, a habit he has been trying to break for at least 30 years.
On physical examination, the patient is alert but appears to be in mild respiratory distress, with moderate retractions and pursed-lipped breathing. He is afebrile. His blood pressure is 140/85 mm Hg, and his pulse rate is 103 bpm and mostly regular. His respiratory rate is 28 breaths/min, and a pulse oximetry reading shows 85% while the patient is breathing room air. His breath sounds are diminished throughout, with a markedly prolonged expiratory phase and faint expiratory wheezes in the upper lung fields. The cardiac examination reveals distant heart sounds with a somewhat prominent P2. He has no murmur, gallop, or pericardial rub. His skin is cool and dry. He has trace edema at his ankles but no cyanosis or clubbing. An electrocardiogram (ECG) is performed (see Figure 1).
What is the diagnosis?
Hint: The ECG results suggest a chronic condition.
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