Case of the Month 16

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

Allergies: NKDA

SH: Recreational EtOH, regular marijuana smoker, denies tobacco or intravenous drug abuse

Physical Exam:

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

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Labs:

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

Trops 0.135

BNP: 2935

UA: 2+ proteinuria

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Imaging:

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?

Good luck.