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What’s the Diagnosis #21?

intensive care unit monitorA patient presented for evaluation of dyspnea. Her trouble breathing had been going on for a few days and kept getting worse. No coughing. No fevers. No other symptoms. No medical history. She smoked a couple packs of cigarettes per week.

Her physical exam was entirely normal. Lungs were clear. Heart sounds normal. Labs (including CBC, CMP, d-dimer, and cardiac enzymes) and chest x-ray normal. EKG normal.

Intermittently, her pulse oximeter readings would dip down into the low 80s. Then she’d ring the call bell, stating that she couldn’t catch her breath. When staff went in the room to check on her, the saturations would go back up to the mid to high 90s.

We ordered an ABG on room air which was normal. Then we had her walk up and down the hallway with the pulse oximeter attached. Her saturation stayed above 95% the whole time.

The patient was getting more anxious and showed us multiple pictures of the oximeter on her iPhone with readings as low as 82%. She even began crying when we talked about sending her home with some steroids and a metered dose inhaler. “I’m afraid I’m going to die,” she said.

Anyone have a diagnosis yet?

 

Lots of good guesses.
Rest of the story and diagnosis posted in the comments section.

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14 comments

  1. Psychogenic/ munchausen’s:
    (Taking the pulse ox off her finger when nobody in room)

  2. Malingering of some sort — breath holding, messing with the sensor…

  3. PLant a tech next to her for an hour or so. If it happens, admit her for a bronch/pulm consult – otherwise, what the other two said.

  4. Oximeter on iPhone?????

    I often have the reported symptoms less oximeter readings.

    Seems to come and go which leads to a personal diagnoses of “going crazy”.

    Pneumenology study and cardiology visit next month.

  5. bp cuff on same arm as pulse ox

  6. Aside from what everyone else said, does it happen when lying flat? Could be a venous/arterial shunt.

  7. Initial thoughts…panic attack….

  8. Disconnecting or taking off the oximeter won’t get you a reading of 82. It takes either holding your breath (long!) or limiting blood circulation to the finger. I can tell you from experience that holding your breath long enough to drive down to 82% sat isn’t easy. Maybe clenching your fist hard would keep the finger from getting fresh blood.

    My guess would be that she is huffing away at something when nobody is present, and getting some kind of asthma result. Either that, or she has some kind of really weird sleep apnea that lets her wake up fast enough to take a picture of the oximeter screen. Perhaps something positional that when she lies down on one side, she’s blocking one of her bronchia?

  9. Transient PE resolving with position changes?

  10. I am with DefendUSA . . . Panic Attack

  11. She was imitating me from my last surgery when I stopped breathing 2x and my sats were at dead level. What a copy cat.

  12. So we went back and reviewed the computer history of her oximeter readings. The strips showed that pretty much every time her oxygen levels decreased, there was a poor oximeter reading.
    A tech then snuck into the room next to hers and watched her from behind the curtains. Interesting finding.

    The patient was taking the pulse oximeter off of her finger, waiting for the oxygen levels to drop on the monitor, taking a picture of the screen, then ringing the call bell and complaining of trouble breathing.

    The second time that she did so, the nurse came into the room and pointed to the tech behind the curtain who waved at her and smiled.

    Here’s a prescription for albuterol just in case.

    Then her significant other came to pick her up and asked the money question. “Will she still be able to go to her court date tomorrow morning if she’s breathing like this?”

    Yes. Yes she will.

    And as a side note … dang you guys are good.

  13. OK, interesting case. But there are some missing info: patient’s age and past medical/surgical histories are relevant here.

  14. Something else to consider with this presentation is pulmonary HTN with patent PFO. Ok when hypertensive; when systemic pressure drops (patient relaxes, or is sick, or gets meds) you get a right-to-left shunt with hypoxia.

    I’ve seen one. Which I made worse with antihypertensives, given to “tune him up” for the hospitalist. Mistake….

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