The Case

CC

Shortness of breath and abdominal pain

HPI

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.

Physical Exam

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
Tachypneic, CTAB
Abd soft, nondistended, diffusely tender to palpation, no pulsatile mass, no rebound or guarding
No CVAT
Ext warm, no edema
Skin dry
Awake, alert, moving all extremities spontaneously

Labs

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

Questions

  1. What is your differential diagnosis?

  2. How would you manage this patient?