|ECG during acute presentation|
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|ECG From 1 Month Prior|
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Things to think about
- What are the key features on each ECG ?
When interpreting hemodynamic studies of drugs which – potentially – alter the resistance of the pulmonary vascular tree, we often turn to the calculated pulmonary vascular resistance [cPVR] as our guide. For instance, a vasopressor determined to increase the cPVR is wholly avoided in a patient with pulmonary arterial hypertension. We envision the vascular conduits [... read more]
The post ICU Physiology in 1000 Words: The Folly of Pulmonary Vascular Resistance appeared first on PulmCCM.
As they say in the North, Winter is Coming. But what better way to stay warm than by putting on your thinking cap and trying your hand at this month’s COTM?
The patient is a 35 year-old man with a previous history of MI, OSA, CHF, HTN, and CKD, recently admitted to an outside hospital but left AMA who presents to the Janus ED with a week of abdominal distension. He endorses progressive bilateral lower extremity edema, orthopnea, and dyspnea on exertion. He denies chest pain, cough, fevers/chills, bowel or bladder complaints. He has been seen at multiple hospitals “for his kidneys and is interested in a procedure that will take the water out of his blood”.
Past surgical history: Denies
Medications: Aspirin 81 mg, Clopidogrel 75 mg, Isosorbide dinitrate, Pravastatin 20 mg nightly, Amlodipine 5 mg daily, Carvedilol 3.125 mg, Gabapentin, Hydralazine 50 mg three times a day
SH: Recreational EtOH, regular marijuana smoker, denies tobacco or intravenous drug abuse
Triage vitals: 178/126, 102, 20, 100% (oxygen by face mask)
General: Obese man sitting in stretcher, face mask in place, uncomfortable
HEENT: No scleral icterus or injection, PERRLA, EOMI, moist mucous membranes, obese neck, unable to appreciate JVD
CV: Tachycardia, regular, S1+S2; no murmurs, rubs, or gallops
Chest: Bibasilar crackles
Abdomen: Obese, soft, non-distended, non-tender to palpation, dull to percussion
Ext: 1+ bilateral lower extremity edema to the knees
Neuro: A+O x 3, no focal deficits noted
CBC: WBC 3.79, Hb 9.7, Hct 30.6, Plt 146
CMP: Na 133 K 5.6 (mild hemolysis), Cl 103, CO2 15, BUN 55, Cr 4.05, Ca 7.0 (ionized 4.6)
Protein 10.6, Albumin 2.6, AST 35 ALT 21 Alk phos 105 T. bili 0.8
UA: 2+ proteinuria
CXR: L lung nodular opacity that is likely artifact, RLL opacity that may represent consolidation vs. atelectasis
EKG: Sinus rhythm at 102, Q waves in leads II, III, aVF, QTc at 517
Bedside US: bilateral B-lines
So, the questions are:
- What is your differential diagnosis?
- What work-up would you perform?
- How do you interpret the patient’s labs?
- If you could only pick one additional test to perform on this patient for diagnostic clarification, what would it be?