I apologize for the short summary. However, I feel this is an important learning point. 62 y/o male hospitalized for a fall due to weakness in his legs.
Pt with hx of difficult to control HTN. PMHx is significant for atherosclerotic disease (2 previous strokes 2009 and 2011 and carotid stenosis 90% L side and 70% R side).
While in hospital pt is found to have a difference in BP in upper extremities L>R. The difference in systolic BP varies between 20-40 mmHg. No symptoms associated. No chest pain, H/A, dizziness, SOB or ischemic changes in R arm.
CT chest shows stenosis (likely atherosclerosis) of the R subclavian artery, which explain the difference in BP.
Learning point: In elderly pts with significant atherosclerotic disease, think about atherosclerosis as a possible cause of discrepancy between upper extremity BP readings. Other causes: dissection, coarctation of aorta.
80 yo male brought by EMS as pt unable to cope at home due to dementia. Found by home care lying in bed confused. PMHx: NSTEMI, AFib on ASA due to compliance issues (CHF EF 50%, NYHA III), CKD creat 120, HTN, dyslipidemia, DM2, Depression, VAscular dementia MOCA 6. On admission patient presents with tachycardia and cheyne stokes respiration. Pt is put on DVT profilaxis. 1d after admission pt presents episode of desaturation with low BP that last for approx 30 min and goes back to baseline 2d of admission pt develops similar episode of desaturation requiring 2L O2 by NC and continues tachycardic. CXR: atelectasis. EKG: sinus tachycardia, BNP:200, CBC and lytes Normal Tachycardia is attributed to Afib, however pt is at moderate risk for PE (base on wells score:3). D-dimer is done >7000. CT chest is done showing an extensive PE mostly R pulmonary artery. Which med to start now taking in account pt has dementia?? Is heparin protocol the first choice in this case? Pts eGFR >30 for which dalteparin is a better option taking in account due to dementia, most likely pt would not allow heparin IV infusion. Instead dalteparin SC od is started at the same time with warfarin (for Afib and PE) Learning point: PE is always a differential in any pt with sudden onset of tachycardia or SOB. In good renal function or at least >30 eGFR, dalteparin is a great option. Warfarin and dalteparin are started at the same time, once INR 2-3 for at least 2 days, LMWH can be discontinued and continue warfarin. If reversible cause for PE anticoagulation for 3m. If unknown cause for PE anticoagulation 6m-indeterminate If irreversible cause: indeterminate
I apologize for the short summary. However, I feel this is an important learning point. 62 y/o male hospitalized for a fall due to weakness in his legs.
ReplyDeletePt with hx of difficult to control HTN. PMHx is significant for atherosclerotic disease (2 previous strokes 2009 and 2011 and carotid stenosis 90% L side and 70% R side).
While in hospital pt is found to have a difference in BP in upper extremities L>R. The difference in systolic BP varies between 20-40 mmHg. No symptoms associated. No chest pain, H/A, dizziness, SOB or ischemic changes in R arm.
CT chest shows stenosis (likely atherosclerosis) of the R subclavian artery, which explain the difference in BP.
Learning point: In elderly pts with significant atherosclerotic disease, think about atherosclerosis as a possible cause of discrepancy between upper extremity BP readings. Other causes: dissection, coarctation of aorta.
By: Marcela Gil
80 yo male brought by EMS as pt unable to cope at home due to dementia. Found by home care lying in bed confused.
ReplyDeletePMHx: NSTEMI, AFib on ASA due to compliance issues (CHF EF 50%, NYHA III), CKD creat 120, HTN, dyslipidemia, DM2, Depression, VAscular dementia MOCA 6.
On admission patient presents with tachycardia and cheyne stokes respiration.
Pt is put on DVT profilaxis.
1d after admission pt presents episode of desaturation with low BP that last for approx 30 min and goes back to baseline
2d of admission pt develops similar episode of desaturation requiring 2L O2 by NC and continues tachycardic.
CXR: atelectasis. EKG: sinus tachycardia, BNP:200, CBC and lytes Normal
Tachycardia is attributed to Afib, however pt is at moderate risk for PE (base on wells score:3).
D-dimer is done >7000. CT chest is done showing an extensive PE mostly R pulmonary artery.
Which med to start now taking in account pt has dementia?? Is heparin protocol the first choice in this case?
Pts eGFR >30 for which dalteparin is a better option taking in account due to dementia, most likely pt would not allow heparin IV infusion. Instead dalteparin SC od is started at the same time with warfarin (for Afib and PE)
Learning point: PE is always a differential in any pt with sudden onset of tachycardia or SOB. In good renal function or at least >30 eGFR, dalteparin is a great option. Warfarin and dalteparin are started at the same time, once INR 2-3 for at least 2 days, LMWH can be discontinued and continue warfarin.
If reversible cause for PE anticoagulation for 3m.
If unknown cause for PE anticoagulation 6m-indeterminate
If irreversible cause: indeterminate