It’s getting hot so cool off with another brain-crunching case, presented by the industrious COtM crew:
The patient is a 47 year-old man with PMHx of CAD s/p CABG in 2014, HTN, dyslipidemia, and hypothyroidism who presents with chest tightness and shortness of breath x 1 day. He woke up @ 4 AM, was diaphoretic and felt short of breath, but denied any chest pain at that time. Around 9 AM, the patient began to feel chest tightness in the midsternal area, 8/10, without radiation to back, neck, left arm or jaw. Pain was improved upon sitting up. He is currently having discomfort. Also reported was worsening of his chronic LE edema over the past 4-5 days, and he endorses headache and dizziness upon waking up. He denies any dyspnea on exertion prior to the onset of these symptoms and no prior orthopnea or paroxysmal nocturnal dyspnea. He denies palpitations, n/v, fevers, diarrhea, sick contacts, or recent travel.
PMHx/PSHx: as above
Meds: Non-adherent with medications for the past two months: amlodipine 5mg, aspirin 325mg, clopidogrel 75mg, synthroid 150mcg, docusate 100mg TID.
FamHx: CAD, HTN (father)
SocHx: ½ ppd cigarettes x 20+ years, cocaine and heroin use in past but none in the past 5 years, denies EtOH use
ROS: Negative aside from symptoms listed above
Vitals – BP: 129/90. HR: 51. RR: 18. O2 saturation: 95%. Temp: 96.3 F
Gen – Sitting up in bed, mild discomfort from pain
HEENT – PERRL, moist MM
CV – S1S2, bradycardic, no m/r/g, no S3 or S4
Chest – CTA b/l, no w/r/r
Abd – soft, nt, nd
Ext – 2+ non-pitting edema up to the knees b/l
Neuro – No focal deficits appreciated, A&Ox3 but with intermittent lethargy
CBC – WNL
CMP – Sodium 129, potassium 3.4, chloride 92, creat 1.50, glucose 61, ALT 90, AST 175, remainder WNL
UA: +Hgb, 0 RBCs, otherwise unremarkable
CXR: Normal heart size, no consolidations
EKG: Sinus bradycardia @ 49, no ST changes
While you ponder this case, the nurse informs you that the patient is now diaphoretic and doesn’t look well. He is lethargic but arousable. You go to check a radial pulse and find that he feels cold and clammy. His pulse is around 45 bpm.
Uh oh, better get cracking. Good thing you have time to mull this over. Answer the following questions the best to enter the COtM Hall of Fame:
1) What is your management at this time?
2) What further work up would you do?
3) What is your differential list and leading diagnosis?
Have at it and post below. Get your thoughts in before someone else steals them!
Go to ANSWER.
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