Case Of the Month 10 – Presentation

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. 
Allergies: NKDA
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
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
Laboratory results:
CMP – Sodium 129, potassium 3.4, chloride 92, creat 1.50, glucose 61, ALT 90, AST 175, remainder WNL
BNP: 20
Top: <0.02
CK: 5320
CK-MB: 32
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!
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James Hassel

4th Year EM-IM Resident at SUNY Downstate/Kings County Hospital

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1 comment for “Case Of the Month 10 – Presentation

  1. ablumenberg
    April 25, 2016 at 1:34 pm

    1. Acute management: hypoperfusion with AMS presumably secondary to bradycardia.
    – ABC assessment, IV/O2/Monitor
    – Protect airway, intubation equipment at bedside
    – Transcutaneous pacing pads on, if rapidly feasible provide atropine else begin pacing. Consider epinephrine, dopamine.
    – 50g of dextrose
    – Rapid infusion 1 liter NS
    – Prepare for central access / trans venous pacing
    – Continual reassessment of vitals, cardiac rhythm, perfusion
    – Repeat EKG
    – Evaluate and treat underlying cause which leads to #2/3

    2 & 3
    1. Myxedema coma: provide 400mcg levothyroxine, 20mcg triiodothyronine, 100mg hydrocortisone, warming blanket. Send TSH, T4, cortisol. Consult MICU and endocrinology. Admit to MICU.
    2. Overdose of medications that the patient is probably on but are not listed: hyponatremia, hypokalemia, hypochlormia, mild rhabdo, and bradycardia sound like taking too much thiazide, statin, and beta blocker. Replete electrolytes, provide NS, give 1mg glucagon.
    3. Addissonian crisis: treatment will overlap with treating myxedema coma. If this were only diagnosis being considered dexamethasone would be preferred treatment because it does not interfere with diagnostic testing down the line. In this case give hydrocortisone 100mg.
    4. Right sided NSTMI: Aspirin
    5. Infection. UTI and PNA less likely. Will not treat empirically at this time but will consider encephalitis/meningitis and other infections in mind.
    6. Intracranial mass leading to increased ICP with partial Cushing’s triad and salt wasting. Supportive measures, CT head when stable enough for transport.
    Less likely:
    – Substance abuse / intoxication. MDMA, benzodiazepine, heroin mixtures may explain AMS/rhabdo/CP/electrolyte disturbances
    – Zebra infections like Lyme, Coxsackie, Chagas

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