Presented by Michael Fernandes, MD
Chief Complaint: “I’m having trouble breathing.”
History of Present Illness:
This is a 46 year-old female presents to the emergency department as a medical code. Her primary complaint is severe shortness of breath. She is fully alert, complaining that her breathing has been getting progressively worse, as well as feeling her heart beating inside her chest. She has also been experiencing progressive swelling of her extremities and abdomen, and significant weakness and fatigue causing her to have difficulty “getting around”. The duration of these symptoms has been for the past 4-5 months with progressive worsening; today being the worst that she has felt. She had her family call the ambulence to bring her to the emergency department. In the ED, she denies any chest pain or chills. She does admit to having a nonproductive cough with no hemoptysis, and state she is feeling warm, but with no distinct fever. She has no other acute complaints at this time.
Past Medical History: Negative for hypertension, diabetes, or coronar artery disease
Past Surgical History: Laparoscopic cholecystectomy in 2002
Social History: She denies any drug use. She does admit to smoking ½ pack of cigarettes every 2 days, and consumes alcohol socially.
OB/GYN History: G3P3003. Her last menstrual period was 4/22/09.
Family History: Significant for unspecified heart disease; however, she is not aware of any MI, strokes, or diabetes.
Vital Signs: BP: 161/94, P: 192, RR: 32, T 38.3, SpO2: 93% on RA
General: Pt appears her stated age. She is propped up on the stretcher in moderate respiratory distress
HEENT: Head is Normocephalic, atraumatic.
Eyes: Appear to be slightly proptotic, PERRLA, EOMI, sclerae is anicteric, no conjunctival pallor.
Ears: TM are clear, no hemotympanum bilaterally.
Nose: MMM, no erythema, no swollen turbinates, no rhinorrhea or discharge.
Mouth and Throat: MMM, no erythema, no tonsillar exudates, no intraoral lesions.
Neck: Supple, no lymphadenopathy, trachea is midline, carotids are 2+, however, there is significant JVD with the patient sitting upright with the head of the bed at an angle of approximately 85 degrees.
Lungs: Decreased breath sounds on the right, clear on the left. No wheezing, rhonchi, or rales. She had significant use of her accessory muscles. She appears to be acutely dyspneic, however, no cyanosis, no diaphoresis. She also has dullness to percussion on the right lung base posteriorly.
Cardiovascular: Irregularly, irregular rhythm with a tachycardic rate, unable to appreciate any murmurs, rubs or gallops due to the rapid rate, peripheral pulses are 2+ and symmetric in all 4 extremities.
Abdomen: Firm, markedly proturberant. Normoactive bowel sounds. Non-tender, with shifting dullness. No discernable organomegaly, guarding, or rebound.
Extremities: FROM, strength is 5/5 proximately and distally in both upper and lower extremities. She has marked dependent pitting edema bilaterally in her lower extremities.
u Feels warm and moist to the touch. No rashes, no lesions.
Neurological: AAO x3, normal speech and hearing, face is symmetrical. Sensation is equal and intact throughout. She has no gross focal motor deficits.
Lytes: Na:142 K:4.2 Cl:101 CO2:26 BUN:18 Cr:0.8 Glu:123
Ca:9.1 Mg:2.1 Phos:3.5
CBC: WBC:13,200 Hgb:13.9 Plt:372,000
Coags: PT:11.6 INR:1.04 PTT:24.2
LFTs: WNL Albumin:2.8
ABG: pH:7.46 PCO2:34 PO2:61 O2 sat:87.2%
Tropnin I: <0.02
1. What is the primary medical problem with this patient?
a. cardiac tamponade
b. congestive heart failure
c. hypertensive crisis
d. pulmonary embolism
2. Which agent will block the release of stored thyroid hormone?
d. propylthiouracil (PTU)
e. saturated solution of potassium iodide (SSKI)
3. Which of the following groupings of medications represents the proper treatment sequence?
a. propanolol, PTU or methimazole, SSKI
b. propanolol, PTU, SSKI, methimazole
c. propanolol, SSKI, PTU, methimazole
d. propanolol, SSKI, PTU or methimazole
e. SSKI, PTU or methimazole, propanolol
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