This week we discuss some critical pearls and teaching points from our morning report conference.
Case: November 2017
Shortness of breath and abdominal pain
62yM PMH HTN, HLD, DM2, bioprosthetic MVR p/w shortness of breath and diffuse abdominal pain for three days. He c/o generalized malaise, nausea and multiple episodes of non-bloody, non-bilious emesis. He is concerned about elevated readings on his home glucometer. He is prescribed lisinopril, metoprolol, metformin and lantus. He denies alcohol or drug use. Denies fevers, chills, chest pain, palpitations, dizziness, diarrhea, dysuria, or recent trauma.
132/91 – 94 – 40 – 100% – 97.0
Ill appearing, in moderate distress, moaning and breathing heavily, speaking in short sentences
NCAT EOMI PERRL, dry MMs
Neck supple, no JVD
Borderline tachycardic, no murmurs, rubs, gallops; distal pulses intact
Abd soft, nondistended, diffusely tender to palpation, no pulsatile mass, no rebound or guarding
Ext warm, no edema
Awake, alert, moving all extremities spontaneously
VBG: pH 6.818, pCO2 25.7, pO2 65.7, HCO3 3.9, Lactate 22
CBC: 8.8 > 8.9 / 27.5 < 167, 84% PMN BMP: 146 / 5.9 / 89 / <10 / 48 / 5.5 / 385 LFT: 27 / 13 / 80 / 0.4 / 0.2 / 6.4 / 3.5 UA: 2+ ketones, 2+ blood, 1+ protein, 0 WBC, 2-10 RBC, negative nitrite, leuk esterase, bacteria
What is your differential diagnosis?
How would you manage this patient?