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55 yo male
heavy smoker (20 cigs/day for 20 yrs),
chronic stable angina,
Come to you with moderate abdominal pain of recent onset, severe dizziness and shortness of breath and blood in the stools.
the pt. is very agitated.
BP = 95/65 supine, 70/50 orthostatism
HR = 180
RR = 30
systolic murmur best heard at the apex
distended neck veins
bilateral lung rales
generalized palor; cool extremities
diffuse abdominal tenderness, voluntary guarding, mildly distended abdomen
DRE: blood-streaked stools
pH = 7.12,
SaO2 = 88%
ECG: supradenivelated ST segment in precordial leads, irregular rhythm
CXR: enlarged heart silhouette, blunted costovertebral angles, bilateral upper lobe infiltrates
The next logical investigation is 8) :
The most probable dx is : (be very careful)
The patient is a NIDDM - so he had a silent myocardial infarction (probably anterior) some hour before, then he developed atrial fibrillation or an intraventricular thrombus - the trombus embolised into a mesenteric artery producing a intestinal infarction (thus the blood in his stool)
The next investigation (this is always my weak point :roll: ) - probably some cardiac enzymes to confirm the AMI and/or abdominal XR
WELL DONE Deea!!!!!!!!!!!!!!
Yes, the pt has MI and intestinal ischemia, probably secondary to chronic AF
There is still one aspect you did not notice - the patient is in shock - so the pt. has cardiogenic shock
The next investigation is ECHO - to see the ejection fraction
Also try to get the cardiac enzymes. Although not very useful right now.
Then ask an angigraphy = gold standard dx for ischemia
Treatment: O2, Morphine (also for pulmonary edema - present in this pt.), vasopressor drugs / Digoxin, depending on what you fing on ECHO
Ganz catheter - monitor fluid status
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