Thursday, June 22, 2006

Case Study - CL part 2

Recall, the case of the pleasant, anxious 73 yrs Chinese lady with vague aches and pains and chest pains. Remember.
The next day after admission, the CXR done was essentially normal. The echocardiogram shows a very dilated RV and RA. The LVEF is 70% and there is no evidence of any segmental wall motion abnormality. There was significant TR and PA systolic estimated was about 70mmHg. The Hb was 13 gms%, PCV 31, serum Na+ 130mMols/L, and the urea and creatinine were both mildly elevated ( about 2x normal ). On the third hospital day, she was noted to have a swollen left leg. The right leg was normal. The Lt leg swelling was not tense and Homan's sign was negative. The BP was 90mmHg, HR 100/ min. An interview with her son reveal that he had a history of Lt calf swelling and was on oral warfarin. She started on subcut. injections. Thereafter, she made an uneventful recovery and was discharged well on 10th hospital day.

1. What is your provisional diagnosis now?
2. How would you manage this patient, acutely and in the longterm?
3. What was the cause of the chest pains and hypotension, on admission?

1 comment:

Jan said...

Is her "chest pain" due to pulmonary hypertension due to prior pulmonary emboli with ongoing PEs? If she had acute PE with sudden rise in RV pressures to 70 that could explain her chest pain and hypotension. However the comment that the RA and RV were very dilated suggests this is a chronic process.
It is not clear if she was on coumadin at the time of admission or just on it in the past. She needs chronic anticoagulation and to be treated with heparin until her INR is therapeutic.
If she had already been on coumadin at the time of admission, then would want to consider a filter as well.