Gradual onset, worsening dyspnea (includes IV/EKG placement)


• Duoneb

• Solumedrol IV

• Oxygen

• IV access


• Dyspnea improved after nebs, solumedrol

• Discharged


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center


• Dyspnea
• Shortness of breath
• COPD exacerbation

Differential Diagnosis

• Myocardial infarction

• COPD exacerbation

• Asthma exacerbation

• Pulmonary embolus

• Rib fracture

• Pneumonia

Patient Workup

• History

• Physical exam

• CBC/CMP/troponin/UA – all normal

Editor’s Notes

This patient case includes two common nursing procedures: IV insertion and 12-lead ECG placement (see “Supporting Materials” section). This particular patient was noted to have wheezing on exam. It was reasonable to treat this patient with a DUONEB and IV steroids because of his known COPD and multi-year pack history of tobacco smoke. Please note the oxygen saturations were low at triage. There was also a subjective relief of dyspnea after nebulizer treatment. Due to the history of chest pain (likely related to cough) it was also reasonable to exclude myocardial infarction.

-Dr. David Spiro

Standard Approach Key points

• Note IV access procedure – preparation is key!

• Presence of wheeze makes pneumonia less likely.

• Patient reported he stopped smoking for 4 days – this provides a potential window for smoking cessation education.

Suggested references

Chronic Obstructive Pulmonary Disease and Emphysema in Emergency Medicine

Intravenous Cannulation


• Gender: Male

• Age: 64 years

• Height: Not Available

• Weight: Not Available


• Temperature: 98.1 F/36.7 C

• Blood Pressure: 103/69

• Heart Rate: 88

• Respiratory Rate: 18

• Pulse Oximetry: 94% RA

Signs and Symptoms

5 days worsening dyspnea, SOB

History Medical

• PMH: COPD, HTN, chronic back pain – s/p laminectomy

• NKDA Social

• Tobacco use, Occ EtOH use


• Venlafaxine, Combivent, Metoprolol, clonazepam, trazadone, Vicodin, diuretics

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