Dyspnea at Rest, Productive Cough, and Chest Tightness in an Elderly Man

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Chest radiograph shows flattening of the diaphragm with evidence of hyperinflation.
Chest radiograph shows flattening of the diaphragm with evidence of hyperinflation.

Case

An 80-year-old man with an 80 pack-year history, hypertension, diabetes mellitus, and chronic obstructive pulmonary disease (COPD) presents to the emergency department with dyspnea on exertion, which he has had for the past week. It has since progressed to dyspnea at rest, a chronic cough productive of dark green sputum, and chest tightness.

Physical examination in the emergency department reveals an irregularly irregular rhythm with otherwise normal heart sounds. Auscultation of the lungs reveals distant lung sounds and diffuse wheezing but no crackles. There is increased resonance to percussion. His lower extremities show some mild hair loss distally but no edema.

Laboratory testing shows normal brain natriuretic peptide level and negative troponins but elevated serum bicarbonate level and evidence of metabolic alkalosis. Chest radiograph shows flattening of the diaphragm with evidence of hyperinflation. Because of the patient's irregular rhythm when examined in the emergency department, an electrocardiogram is ordered (below). 

Electrocardiogram image courtesy of George Marzouka, MD.

What best describes this patient's clinical presentation?

A. Congestive heart failure exacerbation caused by atrial fibrillation with rapid ventricular response

B. Congestive heart failure exacerbation with multifocal atrial tachycardia

C. COPD exacerbation with atrial fibrillation and rapid ventricular response

D. COPD exacerbation with multifocal atrial tachycardia.

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