An Elderly Man with Chest Pain, Shortness of Breath, and Constipation

180 SELF ASSESSMENT QUESTIONS

Geriatric medicine ...... Postgrad Med J: first published as 10.1136/pmj.79.929.180 on 1 March 2003. Downloaded from ...... Authors’ affiliations A A Fisher, M W Davis, Department of Geriatric Medicine, Canberra Hospital and An elderly man with chest pain, Canberra Clinical School of the University of Sydney, Australia shortness of breath, and constipation Correspondence to: Dr Michael W Davis, Department of Geriatric Medicine, Canberra A A Fisher, M W Davis Hospital, PO Box 11 Woden ACT 2606, Australia; [email protected] ...... Submitted 19 June 2002 Answers on p 183. Accepted 25 November 2002 n 81 year old man was admitted to 88% on air and 94%–96% on 2–4 litres of hospital with fractured neck of his oxygen. There were no heart murmurs Aright femur. From the 11th day nor signs of peripheral oedema. The after surgery he developed recurrent epi- breath sounds were decreased at the sodes of retrosternal and right lower right base compared with the left, and chest pain associated with shortness of there were a few bibasal inspiratory breath, sweating, nausea, and hiccup; crackles but no pleural rub detected. The the pain was aggravated by deep breath- abdomen was mildly distended, tympa- ing. He had four such episodes in three nitic with mild to moderate tenderness days while walking with a frame. On and increased bowel sounds over the each occasion he was given glyceryl right upper quadrant, but no guarding trinitrate (600 µg sublingually). The pain nor rebound tenderness were noted. lasted from 30 minutes to two hours and There was no hepatosplenomegaly. Serial was relieved in the supine position. He electrocardiograms (ECGs) showed was constipated for ﬁve days. His past sinus rhythm, right bundle branch block, medical history included ischaemic and left anterior hemiblock. Repeated heart disease with coronary artery by- studies of cardiac enzymes (creatinine Figure 1 Chest radiograph: posteroanterior pass three years earlier but no angina kinase, troponin I), arterial blood gas view. since, stomach surgery for bleeding pep- measurements, D-dimer screen, serum tic ulcer (10 years previously), bilateral electrolytes, urea, creatinine, and glucose total knee replacements (two years pre- as well as full blood count were within viously), bladder cancer, and a long normal limits. Chest (see ﬁgs 1 and 2) history of constipation. He never smoked and abdominal radiographs and a com- and used alcohol only occasionally. His puted tomographic pulmonary angio- regular medications included trandol- gram were performed. april (1 mg daily), metoprolol (50 mg http://pmj.bmj.com/ daily), ranitidine (150 mg twice a day), calcitriol (0.25 µg twice a day), coloxyl QUESTIONS with senna (two tablets daily), and (1) What do the chest radiographs enoxaparin sodium (40 mg daily). For show? pain control he was taking paracetamol (1 g four times a day) and oxycodone (2) What important physical sign may hydrochloride (2.5–5 mg 3–6 times a day have been missed? as needed) since surgery. (3) What is the differential diagnosis? on September 28, 2021 by guest. Protected copyright. On physical examination (during (4) What were the predisposing factors these four episodes) he was afebrile with to this condition? a respiratory rate of 16–20 breaths/min, heart rate of 90–100 beats/min, blood (5) What is the management of this pressure ranging from 126/80 to 140/84 condition? mm Hg, and oxygen saturation of 83%– Postgrad Med J 2003;79:180 Figure 2 Chest radiograph: lateral view.