On arrival the patient is found sitting in a dining room chair that his spouse brought to the foyer. A grocery bag is up-ended with groceries all over the floor.
The patient has vomited but he does not appear to be incontinent of urine.
He appears to be acutely ill.
The patient is awake and oriented to person, place, and time but not event.
Skin is cool, pale, and diaphoretic.
The patient's baseline SpO2 is 96. He is placed on oxygen via NRB mask @ 15 LPM.
He denies chest discomfort, palpitations, or shortness of breath.
Past medical history is significant for hypertension and congestive heart failure.
Medications include aspirin, spironolactone, and carvedilol.
Vital signs are assessed.
RR: 20
HR: 64 R
BP: 102/58
The cardiac monitor is attached.
A 12-lead ECG is captured.
What's next?
Tom, we could use some extra data here. Anything out of the ordinary on ausculation? How low is his LVEF/FC? Is his CHF ischemic or otherwise? Any recent drug/dosage modifications?
ReplyDeleteRecent illness with fever?
I probably should reserve judgement until you give us the information. However, for the time being I think this fella has an intra ventricular conduction delay, which means his EF is probably low enough to put him in jeopardy of ventricular arrhythmia. His current hypotension could indeed be due to his medications, but K-sparing diuretics do not usually lower BP as much as loop diuretics, and we must not forget that he has HTN to begin with! In short, I'd suppose there's something in the way of cardiogenic shock coming up, with electrical instability and intermittent tachyarrhythmia, causing short-lived syncope (also in accordance with retrograde amnesia). If there's no respiratory distress or evidence of significant pul congestion, I'd see that he gets IV fluids (slow drip), continuous monitoring and get him to the nearest ER ASAP.
I'm very sorry, Anonymous. I don't have any extra data on this case!
ReplyDeletejust a student passing by here heh..so show mercy...
ReplyDelete12 lead ECG:
ST-T changes (elevation with mildly tented T waves--early signs of MI and hyperkalemia ) on V1-V4 with QRS abnormality (block?conduction disturbance?) on V4,V3, aVL and III leads..
interpretation: anterior MI causing slow conduction
regular sinus rhythm on first ECG, and normal axis frontally and zone of transmission located on V4 from 12 lead ECG.