Category Archives: #fridayimagechallenge

#FridayCaseChallenge

A case challenge for you on this rainy Thursday.

I will present the case step by step with additional information provided  every ~24-72h. Please leave your thoughts in the comments, or can submit to the anonymous link.

CASE: A 59yo with severe ischemic CM (most recent EF <20%) presents to CUH ED with DOE, orthopnea, bendopnea, and PND. He has had 3 hospitalizations in the last 4 months for heart failure exacerbations. His initial lab work is notable for normal K, CO2, AG, and creatinine, CBC is wnl, normal lactate, TSH. He is afebrile, BP 140/75, HR paced at 70, and satting well on RA. he has 2+ pitting edema b/l, JVP 15cm, +HJR, his extremities are moderately cool to touch. Overall he appears chronically ill but stable for the floor.

his EKG is belowADHF

His home medications are as follows

amiodarone 400 qday, furosemide 40mg BID, carvedilol 25mg BID, clopidogrel 75mg, pravastatin 10mg, diltiazem 30mg q6h, ranolazine 1000mg BID, ISMN 30mg BID, digoxin 125mcg qday, pradaxa 150mg BID

He is taken to RHC on HD1 with numbers below.

Hemodynamics:

Right atrium: 14 mmHg
Right Ventricle: 40/8 mmHg
Pulmonary Artery: 39/18/26 mmHg
PCWP: 20 mmHg

NIBP: 114/ 75/ 88 mmHg
Heart Rate: 60
PA sat: 47 %
Pulse Ox: 96%
Hgb: 14.6 g/dL

Assumed Fick: cardiac output 2.8 L/min, index 1.37 L/min/m2
Thermodilution: cardiac output 2.8 L/min, index 1.36 L/min/m2

Day 1 questions- What Stevenson profile is this patient? What are your treatment options and how do his RHC numbers inform your decisions? What would you do with his home medicines? What conditions make thermodilution less accurate? What kind of device does have in place?

If you have further questions of the patient’s history or initial presentation please ask as well

 

#FRIDAYIMAGECHALLENGE (with answer)

Case: 55yo homeless man presents to the hospital altered and febrile to 39, seen two weeks ago at OSH for cough where EKG was documented as “normal sinus rhythm”

This EKG was obtained in the ED

(click image to enlarge)

What is the EKG finding and what underlying diagnosis should be at the top of your differential?

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Continue reading #FRIDAYIMAGECHALLENGE (with answer)

#fridayimagechallenge(with answers)

From the (excellent) August Parkland MICU team and Tri we have a CXR for today’s image challenge.

We had one correct answer which I think came from Arjun… Nitin’s answer of ‘get this man some steroids!’ will also be accepted.

Hit “read more” for the case and answer.

 

photonegative-pulm-edema-1

Continue reading #fridayimagechallenge(with answers)