Interesting day ...
40-ish male presents to the ER c/o constant, diffuse upper chest pain & productive cough x 2 weeks. Lungs sound tight, but pretty clear. Trace pedal edema noted. Hypertensive - initial BP was 180s/110s ... SBP dropped to 150s after NTG & other meds, but DBP remained > 105. This is a walkie-talkie patient - appears in relatively good physical condition, works at a job involving some physical exertion, no exertional dyspnea, no diaphoresis, dizziness, or nausea. Neb tx improved his aeration. EKG shows a junctional rhythm.
Pt. denies any history, states he hasn't been to a doctor in "many years." The beginnings of CHF?
Then we started to get some lab results ... I'm approximating these for this public posting so that I'm not essentially posting the patient's chart, but these are very close to the actual values ...
Yikes. Rectal exam ... heme negative. Where's the bleeding? Liver enzymes sent ... WNL. Bedside ultrasound shows no free fluid in the abdomen.
Cardiac enzymes significantly elevated. BNP > 3000.
My shift ended shortly after that ... too crazy busy to discuss much with the docs.
I feel like I understand the pieces of the puzzle but not the whole. What's going on with this guy?
Oct 24, '06
Is this not Chronic Renal failure that has gone undiagnosed? With CRF, a pt's Hgb/Hct do drop due to erythropoetin deficiency, the BUN and creat. are textbook and his HTN is probably b/c of an out of control renin-angiotensin system. CRF patients also can present fluid in the lungs and breathing problems and also can present with pericarditis or pericardial effusions which can cause chest pain symptoms. Can you recall any of his other labwork ie..K+, HCO3, Ca++ levels?
Let us know what you find out.
Oct 24, '06
Forgot about the electrolytes ... amazingly, they were all WNL, including K+. Previously undiagnosed/untreated renal failure ... and a normal K+. Go figure.
Venous blood gases & lactic acid were also OK.
Thanks for your response ... didn't think about the erythropoetin. You're right.