Question

A 58 y/o female visits the Health center due to palpitations.

Medical background:

• H/O myocardial infarction in the past and with left ventricular failure, on the following medication:

o Valsartan 80 mg OD

o Furosemide 40 mg OD

o Spironolactone 25 mg OD

o Isosorbide dinitrate PRN

• History of Dyslipidemia since 10 yrs, on

o Atorvastatin 10 mg OD

• Non- Diabetic

History of present illness:

Present condition started few weeks now with palpitations associated with some giddiness, no associated chest pains, cold sweating nor malaise/fever.

Pertinent On Examination:

BP 105/70mmhg​PR 96/min​RR 21/min​Temp: 36.7 C

No anemia

Cardiac: mild tachycardia, irregular rhythm, no murmur

Lungs: Bibasilar crepitation

No edema

ECHO done Ejection fraction 45% with LA and LV, no clots seen

ECG: atrial fibrillation

IMPRESSION:

IHD (ischemic heart disease), CHF(congestive heart failure) , atrial fibrillation w/ normal ventricular respond

INVESTIGATIONS:

a. CBC/LFT/RFT/TFT/CRP/Lipids/Trop I/CKMB if needed

b. Chest XRAY

c. Echo after 6 months to 1 year

Question:

1- write articles for this case.

Answer 1

Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay was obtained as well.

CBC

Largely unremarkable and non-contributory to establish a diagnosis.

CMP

Showed creatinine elevation above baseline from 1.08 base to 1.81 indicating possible acute injury.

ECG

Ecg shows atrial fibrillation in which P-wave is absent, R-R interval is decreased and qRS maybe decreased to normal

Chest X-ray

Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. Small bilateral pleural effusions

Differential Diagnosis

• Acute on chronic COPD exacerbation

• Acute on chronic renal failure

• Bacterial pneumonia

• Congestive heart failure

• NSTEMI

• Pericardial effusion

• Hypothyroidism

• Influenza pneumonia

• Pulmonary edema

• Pulmonary embolism

Echo showed Heart failure with reduced ejection fraction happens when the muscle of the left ventricle is not pumping as well as normal. The ejection fraction is 40% or less.

Diagnosis

1. Myxedema coma or severe hypothyroidism

2. Pericardial effusion secondary to myxedema coma

3. COPD exacerbation

4. Acute on chronic hypoxic respiratory failure

5. Acute respiratory alkalosis

6. Bilateral community-acquired pneumonia

7. Small bilateral pleural effusions

8. Acute mild rhabdomyolysis

9. Acute chronic, stage IV, renal failure

10. Elevated troponin I levels, likely secondary to Renal failure

11. Diabetes mellitus type 2, non-insulin dependent

12. Extreme obesity

13. Hepatic dysfunction

Management

The patient was extremely ill and rapidly decompensating with multisystem organ failure including respiratory failure, altered mental status, acute on chronic renal failure, and cardiac dysfunction. The primary concerns for the stability of the patient revolved around the respiratory failure coupled with altered mental status. In the intensive care unit (ICU), she rapidly began to fail BiPAP therapy. Subsequently, the patient was emergently intubated in the ICU.