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 Case
#31 "You Made Him Worse…."
During sign-out rounds, an empty bay is
reported to you as an ICU admission with a
probable PE, already heparanized, currently
getting a V/Q scan (severe allergy to CT
dye), and waiting for an ICU bed. About 45
min later, the medicine ICU resident
approaches you and tells you the patient
doesn’t need ICU care because the V/Q scan
was completely normal and that you need to
admit him to the floor.
Feeling frustrated about the situation (a
negative test must mean the patient is fine,
right?), you go and check out the patient
yourself.
You note an obese male, age 38, sitting
upright on the cot, diaphoretic, with a
labored respiratory rate of 30. The monitor
is showing sinus tachycardia (rate 120), and
the most recent blood pressure recorded on
the monitor is 91/40. He is on 6 L nasal
canula and his Sat =93%.
As you introduce yourself, the wife at the
bedside complains to you, “What ever you did
has made him a lot worse, now he can’t even
talk! What did you do to him anyway!”
Thinking about your dropping patient
satisfaction scores, and feeling like you
really need to get a handle on the situation
before this patient crashes, you apologize
for the situation and get more history.
The patient works on the loading dock at the
river, has had cold symptoms for about 2
weeks. For the past 2 days, he has been
short of breath to work, and today, he was
short of breath just sitting there.
ROS: No fevers, chills, N/V/D. He does have
a dry cough intermittently, but worst for
the past 2 weeks (he also smokes 1 pack/day
for 12 years). He does have chest pain, on
and off for 1 week, comes when he takes a
deep breath in, centrally located without
radiation. The chest pain lasts a few
seconds, resolves when he stops his deep
breathing. He has chest pain now with his
labored breathing.
FH: Noncontributory
SH: Drinks on weekends, smokes 1 pack/day,
no illicit drug use
PMH: No history of heart problems, no
previously diagnosed COPD, takes no
medications, hasn’t seen a doctor in years.
No surgeries.
PE: Ill appearing, diaphoretic in
respiratory distress.
HEENT: HEENT remarkable for facial
diaphoresis, and a thick neck, you do
appreciate JVD.
Heart: RRR, Tachy, no M, R, or gallops.
Lungs: Absolutely clear bilaterally.
ABD: Obese, non-tender
Ext: +1 Edema to both pretibial areas.
You review the labs:
WBC 13K, normal HBG,HCT. Renal panel normal,
cardiac enzymes normal.
CXR: Radiologist read: Cardiomegally, no
infiltrate, no CHF.
EKG: Sinus Tach, no ST elevation. T wave
inversions are present in the inferior
leads. No old EKG for comparison.
You can clearly see why the previous doc was
concerned about PE: (hypoxemia, dyspnea,
pleuritic chest pain, clear lung fields),
but with a ‘normal’ V/Q scan, this drops in
the differential diagnosis.
1. What other entity should you consider?
2. What bedside test will help?
3. Who can save this patient (i.e. who
needs to be called?)
4. What do you need to do now to treat
the patient (relative hypotensive, what can
you do to increase blood pressure)?
Click here for answers and to respond
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Previous Articles
Medical (05/19/08)
Neurologic (05/12/08)
Cardiovascular (05/05/08)
Renal (04/30/08)
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Medical Emergency (04/14/08)
Pulmonary (04/08/08)
Neurologic (04/01/08)
Medical Emergency (03/23/08)
Cardiovascular (03/19/08)
Renal (03/12/08)
Pediatric (03/04/08)
Cardiovascular (02/26/08)
Gastrointestinal (02/19/08)
Pediatric (02/11/08)
Trauma (02/06/08)
Pulmonary (01/29/08)
Pediatric (01/22/08)
Neurologic (01/014/08)
Cardiovascular (01/07/08)
Cardiovascular (01/01/08)
Renal (12/26/07)
Cardiovascular (12/19/07)
Pediatric (12/12/07)
Neurologic (12/05/07)
Trauma (11/27/07)
Trauma (11/20/07)
Neurologic (11/13/07)
Pediatric (11/12/07)
Cardiovascular (10/29/07)
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