One of the golden girls (don’t worry, not Blanche) presents to your ER after a near syncopal episode. She reports generalized weakness, but denies all other complaints.
VS (scary): HR 136, RR 25, BP 70/30. The pulse ox won’t pick up.
She has clear lungs, normal heart sounds, no leg swelling, BUT LARGE JVD.
As usual most accurate/first answer to the following questions wins a special prize…
1. What are your top three differential diagnoses?
2. How are you going to work-up and treat this patient?
By Dr. Andrew Grock
The following two tabs change content below.
andygrock
Latest posts by andygrock (see all)
- Levamisole Toxicity - May 26, 2015
- Of Course, US Only for Kidney Stones… - May 18, 2015
- Case of the Month 11: Answer - May 12, 2015
1 Comment
L.Rolston · January 2, 2015 at 4:17 pm
Top 3 on my differential:
1. Tamponade due to the presence of Beck’s Triad
2. Massive PE
3. Inferior MI with RV infarction
My workup for this patient would start with IV w/500ml fluid bolus, O2, monitor, 12 lead EKG and a full set of labs. If STEMI, call code H, if alterans present consider tamponade. The next thing I would do is a STAT bedside echo, looking for one of 3 things: Effusion with tamponade, D-sign or any akinetic segment of the myocardium. If effusion with evidence of tamponade present an emergent pericardiocentesis is indicated. If D-sign present I would consider thrombolytics given hemodynamic instability and presumed hypoxia given that we can’t get a reading on out pulse ox. If there was any significant segment of abnormal wall motion I would be more likely to think the patient was having an acute MI, in which case I would give 162 mg of aspirin and call a STAT cards consult.