Case 10

Pt is a 77 y/o female with history of HTN, HLD, R hip pinning s/p fall and fracture in Dec from golden gate nursing home coming in for hypotension and SOB since last night. Pt states she was short of breath and was sent in because her blood pressure was lower than normal. Denies CP, back pain, fevers, chills, cough, leg swelling/pan, edema or erythema of the LE, smoking history, previous thrombotic events or other associated findings.

ROS:

Constitutional: No fever, no chills, unexplained weight change or malaise.
Eyes: No visual changes, eye pain or discharge.
ENMT: No hearing changes, pain, discharge or infections. No neck pain or stiffness.
Cardiac: SOB and hypotension.
Respiratory: No cough or respiratory distress. No hemoptysis. No history of asthma or RAD.
GI: + nausea. No vomiting, diarrhea or abdominal pain.
GU: No dysuria, frequency or burning.
MS: No myalgia, muscle weakness, joint pain or back pain.
Neuro: No headache or weakness. No LOC.
Skin: No skin rash.
Endocrine: No history of thyroid disease or diabetes.

PHYSICAL:

Vitals T 98.2 HR122 RR 18 BP 74/53 99% on 4LNC

CONSTITUTIONAL: Diaphoretic female in no acute distress
HEAD: Normocephalic; atraumatic
EYES: PERRL; EOM intact
ENT: Normal nose; no rhinorrhea; normal pharynx with no tonsillar hypertrophy
NECK: Supple; non-tender; no cervical lymphadenopathy, no JVD
RESP: Decreased chest excursion with respiration; breath sounds clear and equal bilaterally; no wheezes, rhonchi, or rales
CV: Tachycardic, S1/S2, RRR, no murmurs, rubs or gallops
ABD: Normal bowel sounds; non-distended; non-tender; no palpable organomegaly
EXT: BL DP 2+. Normal range of motion in all four extremities; non-tender to palpation; distal pulses are normal
SKIN: No erythema over LE. Normal for age and race; warm; dry; good turgor; no apparent lesions or exudate

LABS:

SODIUM L 129 mEq/L
POTASSIUM 3.6 mEq/L
IONIZED CALICUM L 0.96 mmol/L

BLOOD PH L 7.37
PA CO2 H 50 MM/HG
PA O2 *L 33 MM/HG  VBG
O2 SATURATION *L 61 % VBG
HCO3 H 28.9 M/L
BASE EXCESS H 2.6
LACTIC ACID *H 4.1 mmol/L

1. What cardiac view are we looking at?  What is abnormal about this image?

2. What cardiac view are we looking at?  What two things about this study can be changed to optimize the image?

3. In the apical view what do you see?  What can you do to optimize this view?  What is the next step/treatment for this diagnosis?