winterallsummer Posted November 21, 2014 Share Posted November 21, 2014 66 year old CM presents with SOB x 2 wks, known severe CHF, 40 pack yr hx and still smokes, and 2 wks of 3+ pitting edema b/l despite 40 lasix tid. Copd and DM are not managed. Suspect PAD without formal dx. LE u/s neg. EKG/trop neg x2. ICD/pacer x 3 yrs. Compliant w meds but hasn't seen a doctor for about a year. CXR relatively good no obvious effusions no opacities. Lungs CTA. Unmanaged DM and chronic back pain. Cannot walk half a block due to pain in legs (which likely stops him before CP and DOE occur). Satting 98% on 2L. 80/50 is BP so gets 1 or 1,5L NS. After that stable at 120/80. Admitted to obs. Gets nebs x2 and steroids. But no improvement in dyspnea. Old echo is 20-25%. BNP relatively Unimpressive. Good UOP and pt looks ok. What to do now? Hold lasix or give? Continue copd tx? Admit to inpt or send home? I will know what really happened next shift. Curious how others would've handled this. He had other issues but this is the part I'm curious about. And other things were done etc but am posting from my phone. Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 21, 2014 Share Posted November 21, 2014 You need a new echo. What is the BNP? Is there a murmur? I would be soooooo cautious about fluid loading this guy. What's his renal function like? I predict it sucks. I had a guy like this in ICU a couple weekends back. Had a loud blowing holo systolic murmur and BP 80/50s HR 100s. Trace edema. Significant JVD and rales to the scapular borders. I knew he had severe mitral regurg with an EF 15% thanks to the day resident who got it on admission. I had to start a dobutamine drip so I could maintain his pressure enough to diurese him. Didn't help he was agitated in alcohol withdrawal too...and the nurses were very afraid to give Ativan because of his pressures. My desperate move worked and he was weaned off the dobutamine a couple days later. And yes you need to treat the COPD exacerbation too. This combo is one of my frequent fliers here in the south lol. Link to comment Share on other sites More sharing options...
andersenpa Posted November 21, 2014 Share Posted November 21, 2014 other questions are RV failure, ventricular dyssynchrony (is his pacer a Bi-V?), constrictive pericarditis looks like you have r/o ACS, DVT CT PA? if renal function may permits. neg LE US does not r/o PE. you suspect PAD- does his pain seem like claudication then? too acute for DM neuropathy? peripheral pulses? LV failure sounds surprising given clear lungs and CXR Link to comment Share on other sites More sharing options...
KMD16 Posted November 22, 2014 Share Posted November 22, 2014 Sounds more so like PAD >> Decomp CHF. Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 22, 2014 Share Posted November 22, 2014 I missed the part where you said BNP relatively unimpressive with fairly clear CXR. So diuresis is unlikely to make this much better. Agree with Andersen about PE. I would scan the chest. This is will also give you valuable info about lung parenchyma. The echo will give you an estimate of pulmonary artery pressure. At this point you're looking at admission to sort all of this out. This patient wouldn't be obs at my hospital--he would be admitted--but granted my ED guys try to admit everybody lol Link to comment Share on other sites More sharing options...
KMD16 Posted November 22, 2014 Share Posted November 22, 2014 Metolazone + lasix? Pt renal status? Pt need new/repeat echo if old echo over 6mo. A comprehensive review of meds list necessary. Consider CTA extremity (? Renal status). Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 23, 2014 Moderator Share Posted November 23, 2014 HJR? sounds wet - no labs don't support him being wet (nor does exam by the sounds) and he was hypotensive.... so he is not in CHF But still DOE and SOB PE, COPD, early pneumonia, decreased cardiac output not caused by CHF LIGHT hydration, GREAT exam skills, look at weights every shift, HJR every shift - find out why he is DOE! It is not CHF by the sound - but if you hydrate him it will be ;-) PE #1 R/O Early PNA COPD Obesity hypoventilation syndrome Link to comment Share on other sites More sharing options...
winterallsummer Posted November 23, 2014 Author Share Posted November 23, 2014 So in the am the pt had syncope after heavy coughing fit which apparently has happened few times in past yr after coughing or laughing hard, although he denied syncope in initial h an p. pt was admitted. No change in repeat cxr or echo (25% EF) and no valvulopathy. So far no CT. Cards put him back on lasix and he improved some. Abg relatively normal. They restarted his bblocker also. And continuing copd tx. Pt subjectively better. SBP still running low. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 23, 2014 Moderator Share Posted November 23, 2014 what is his rate? any block present on EKG arrhythmia?' tele showing anything? i have seen cardio throw lasix at patients when they didn't know what to do - and against my exam findings..... as I am a house call clinician I have learned to go with what I am seeing and feeling and not what some specialist on the phone wants me to do..... ABG - show any retaining? zebra, pulse pressures, any pericardial effusion, carotid bruits, Why synocpal episode? vagal tone? \ CT would be helpful at this point Link to comment Share on other sites More sharing options...
KMD16 Posted November 23, 2014 Share Posted November 23, 2014 One would question the indication getting CT given the non sudden onset of pt's SOB. If there's need to r/o PE, V/Q scan instead of CT chest b/c of pt probable poor renal function. Furthermore, If cardiologist are on board w/ care of pt; I would let them proceed with care of the pt and I would sign off. Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 23, 2014 Share Posted November 23, 2014 I can see the danger of having cardiologists run a chest pain obs unit. It's easy to get tunnel vision and think only heart. Now of course I am also concerns about the heart...but let's think clinically. Ddx of dyspnea: the list is looonnnnnggggg Primary respiratory: obstructive dz (asthma, COPD etc), restrictive dz (pulm fibrosis, interstitial lung dz, etc), mixed obstructive and restrictive (think advanced sarcoid...I have a few of these pts), pneumonia, pneumonitis, bronchitis, PE (acute vs chronic--many PEs are NOT acute!) and other things that affect gas exchange at the pulmonary level.... A myriad of cardiac causes as we've discussed above (a stable echo without significant valvular dz is helpful information here).... Don't forget the common things: severe symptomatic anemia, acute decompensated renal failure, liver failure, advanced ascites with right heart failure...the list goes on and on and on. These are just the obvious things that occur to me off the top of my head. In cases like this I think it's best to step back and look at the big picture. Don't focus on details like labs at first. A focused clinical exam is worth a lot but many clinicians skip this step. OP, any other helpful info you can provide? Specifically: HR, temp, ABG at presentation (probably wasn't done), etc. And p.s. A patient who hasn't seen a health care provider in a year is most likely not compliant with meds. I rarely write more than a 6-mos script (and I think I'm pretty generous there) to ensure patients come back, especially those with chronic conditions that need to be seen quarterly at least. Link to comment Share on other sites More sharing options...
KMD16 Posted November 23, 2014 Share Posted November 23, 2014 Agreed w above....short response here due in part for insufficient time to draft a lengthy reply. Plus I think the OP did not provide enough data about pt. Link to comment Share on other sites More sharing options...
primadonna22274 Posted November 23, 2014 Share Posted November 23, 2014 I used to tell my students to think anatomically when formulating a differential. Think of what's there--every structure--and what's in the neighborhood. Think of interdependent systems (heart and lungs, heart and kidneys, etc etc). Think of structure and function...then structural dysfunction (what happens as a mediastinal mass enlarges and compresses the trachea? In what ways (name a few) does a bronchogenic mass cause dyspnea? How does pericardial effusion, then tamponade, cause chronic then acute dyspnea? Then when you know more you can start to expand to think physiologically...biochemically...etc. Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 24, 2014 Moderator Share Posted November 24, 2014 some of the best advice I ever got was to always come up with a Ddx of atleast 5 things to explain the presentation.... if you can not think of five, you need to think more! also, my own little mnemonic to develop a working Ddx------MIT (no not Massachusetts Institute of Technology - but that is what makes it easy to remember) Medical Infectious Traumatic I thought of this while coming up with an easy way to remember the commons causes of common things, as well as trying to always come up with a Ddx of atleast 5....... It honestly has gotten me to slow down and think about Ddx - and I think this is the ONE DETERMINING THING between an average provider and a great provider! As Yogi Bear would say...... "if it aint on your differential you will never Dx it!" (okay that was a stretch.....) I still think a chest CT is needed Also, it is amazing what they are getting for images with a low dose CT screening Chest CT WITH OUT contrast these days - amazing detail and would really help this case IMHO Might well be cardiac and just needing a tune up, but not sure we are there yet..... Link to comment Share on other sites More sharing options...
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