Guest Paula Posted January 10, 2015 Share Posted January 10, 2015 MI? Link to comment Share on other sites More sharing options...
REMPAC Posted January 10, 2015 Share Posted January 10, 2015 Ischemia? Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 Not a PA student yet but..... Any Hx of Blood in stool? Hx of Vaginal bleeding? What are lung Sounds? Any Peripheral Edema? What's her skin condition? No blood in stool. No vaginal bleeding. Lung sounds are clear without wheezing, stridor or crackles. No edema. Skin is warm, dry, a bit pale. GB PA-C Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 Does she look sick? ( I know you said pleasant appearing and subjective dyspnea at rest, but do you mount concern just by looking at her?) Does she have any associated GI complaints? Pertinent ROS? Is she in any pain? Any other symptoms that may have been over looked? Family history? She does not look sick at rest. No GI complaints. She is not in any pain. Her parents are deceased, both of heart disease. What pertinent ROS do you want to ask? Any symptoms you think have been overlooked? GB PA-C Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 What does her ekg show? anyone with dyspnea I would wanna rule out the high acuity of disease. PTX was good guess, what about a PE? 63 y/o female possible underlying cancer?? the peripheral cyanosis is what is tricky...only thing that comes to mind is raynauds, with crest syndrome. I guess we will move on to diagnostics. Her EKG is sinus tach, rate 102 at rest, no S-ST changes, nl axis, nl QT, no LVH, no comparisons found. PTX is not a guess, I would consider it in the Ddx of anyone with dyspnea. My last Ddx I always consider with dyspnea with exertion is cardiac tamponade. I will let everyone ponder that for a bit. Other diagnostics? Also put this patient in perspective where I am seeing her. Critical access hospital. Radiology and labs available. Hospitalist can admit. Minimal specialists available for consult in the ED. GB PA-C Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 Is that final ddx anxiety? It's a rule out dx, but an important one nonetheless. Did encounter one of these patients on my Peds rotation. Diagnosis of exclusion. I always find these not on my list of Ddx to consider first. No one dies of anxiety, they just are uncomfortable and get better with ativan or hydroxyzine. GB PA-C Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 She's a skosh tachycardic and tachypneic, nothing super scary/obvious jumping out. Pulse pressure is wide, but again not crazy. So this is new, rapid onset in the past week... What was her exercise tolerance/activity level before last week? Is she taking any prescription or OTC meds? (Also height/weight/build, please). DOES SHE SMOKE? (can't believe we all forgot that one) Does any one position make breathing better or worse; lying down, sitting up, etc. No pink, frothy sputum/hemoptysis, correct? Claudication present with the cyanosis? What is her usual diet? Eating recently? Ethnicity? Lung sounds? Heart sounds? She didn't make it 63 years with an undiagnosed ASD. If it's not the lungs or the heart, I'm going with some form of anemia. Missed a few. No claudication. Usual diet cereal in am, frozen food and meals lunch and dinner. Appetite not affected. Heart tachy, regular, no murmur. GB PA-C Link to comment Share on other sites More sharing options...
MisterIndubitably Posted January 11, 2015 Share Posted January 11, 2015 If they exist, when/what was her last CXR, PFT, echo, ABG, liver enzyme or ultrasound? Liver cirrhosis or maybe sarcoidosis? Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 11, 2015 Author Share Posted January 11, 2015 If they exist, when/what was her last CXR, PFT, echo, ABG, liver enzyme or ultrasound? Liver cirrhosis or maybe sarcoidosis? Sent from my iPad using Tapatalk None of those exist, she has dodged health care for the majority of her life. A blank canvas for you to paint pathology on. GB PA-C Link to comment Share on other sites More sharing options...
dchampigny Posted January 11, 2015 Share Posted January 11, 2015 What is her MSK exam like? (any edema, venous stasis, varicosities, Homan's sign +/-? Lung exam? (crackles, fluid overload etc?) Is she diueresing adequately? I think this was missed.....does she drink alcohol? Things I would like to get.... CBC with diff, EKG, CXR, D-Dimer, LFTs, BMP, ABG Link to comment Share on other sites More sharing options...
pmed8 Posted January 11, 2015 Share Posted January 11, 2015 Pale skin, exertional dyspnea with mild hypoxia and cyanosis. Strikes me as someone who is markedly anemic although there are other possibilities as well. You said she eats frozen meals lunch and dinner? Like TV dinners? That's a lot of Na+..... Curious for lab values esp the ones dchampigny outlined as well as cardiac markers. Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 12, 2015 Author Share Posted January 12, 2015 What is her MSK exam like? (any edema, venous stasis, varicosities, Homan's sign +/-? Lung exam? (crackles, fluid overload etc?) Is she diueresing adequately? I think this was missed.....does she drink alcohol? Things I would like to get.... CBC with diff, EKG, CXR, D-Dimer, LFTs, BMP, ABG No edema, no statis or varicosities, calfs soft and nontender, definitely not swollen. Lungs are CTAB, no wheeze, no stridor, no crackles. She does not drink alcohol on a regular basis, only a handful of times a year and then only a drink or 2. CBC and diff in normal ranges. EKG already mentioned and normal other than sinus tach at 102 or so. CXR normal, as in no cardiomegaly, no infiltrate, no PTX, no atelectasis, no ILD, no mass. LFTs nl ranges. BMP nl ranges except glucose elevated at 140s. ABG I dont remember specific #s but slight hypoxia on RA. Troponin negative. Please provide your rationale in ordering a d Dimer? GB PA-C Link to comment Share on other sites More sharing options...
pmed8 Posted January 12, 2015 Share Posted January 12, 2015 Carbon Monoxide level? Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 12, 2015 Author Share Posted January 12, 2015 Carbon Monoxide level? Good thought. But not one I was having at the time so there is no carboxyhemoglobin level to report. GB PA-C Link to comment Share on other sites More sharing options...
pmed8 Posted January 12, 2015 Share Posted January 12, 2015 It was worth a shot. You mentioned tamponade.... how are heart tones? Link to comment Share on other sites More sharing options...
pmed8 Posted January 12, 2015 Share Posted January 12, 2015 Heart tachy, regular, no murmur Nm i read above again and saw it has already been posted. Link to comment Share on other sites More sharing options...
GreatChecko Posted January 12, 2015 Share Posted January 12, 2015 Diagnosis of exclusion. I always find these not on my list of Ddx to consider first. No one dies of anxiety, they just are uncomfortable and get better with ativan or hydroxyzine. GB PA-C Thanks for correcting that, dx of exclusion... not using my words right.... I'm comfortable saying its not STEMI or anemia, PTX, pneumonia, interstitial lung disease, neoplasm, pleural effusion, asthma, etc. I'm still thinking heart here, especially with the peripheral cyanosis. BNP? Is echo a possibility? Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 12, 2015 Author Share Posted January 12, 2015 Not being a dick but it is heart sounds, never heard heart tones before. Nomenclature and pronunciation is a big thing in medicine. I got corrected as a student multiple times (and after) about saying something I thought was correct but obviously wasnt. BNP was indeterminate, meaning between 100 and 500. Echo is in on tuesday, it was not tuesday. Any bedside tests anyone wants to do? Any thought process leading to the dDimer being checked? GB PA-C Link to comment Share on other sites More sharing options...
dchampigny Posted January 12, 2015 Share Posted January 12, 2015 I wanted a D dimer for DVT/pe Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 12, 2015 Author Share Posted January 12, 2015 I wanted a D dimer for DVT/pe Sent from my iPhone using Tapatalk d dimer is normal. GB PA-C Link to comment Share on other sites More sharing options...
dchampigny Posted January 12, 2015 Share Posted January 12, 2015 hmmmm.....this certainly is an interesting case! Simple bedside blood glucose? Endocrine tests? (PTH, T3, TSH, T4, cortisol, vitamin D, other endocrine tests?) I'm starting to reach here... Link to comment Share on other sites More sharing options...
GreatChecko Posted January 12, 2015 Share Posted January 12, 2015 Are you able to do bedside ultrasound? Haven't read much about its use in dx heart failure, but do know that in the right hands (ie not mine) the heart is able to be well visualized. Link to comment Share on other sites More sharing options...
fakingpatience Posted January 13, 2015 Share Posted January 13, 2015 Not a guess, just wanted to say I'm really enjoying this thread and reading the though processes (hopefully I'll be able to think of all these possibilities next year when I'm a student!) And sorry, I'm the one who voted this thread 1 star, I accidentally clicked it and can't take it off :-( Link to comment Share on other sites More sharing options...
Derbingle Posted January 13, 2015 Share Posted January 13, 2015 I clicked on full stars but it only registered two. Enjoy watching thread. Now, back to the thread. Link to comment Share on other sites More sharing options...
dchampigny Posted January 13, 2015 Share Posted January 13, 2015 I want a BNP too Link to comment Share on other sites More sharing options...
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