DFIB Posted December 13, 2011 Posted December 13, 2011 (edited) tniugs - I know that I ask patients with CHF to weigh daily before breakfast and record the changes as an indication of fluid retention and possible PE. I am truly couriouse if this is not done at the hospital. Muffled Heart sounds are in the EMT literature as one component of the cardiac tamponade triad but I was not aware that listening is not a common practice. Note to self, skip listening to heart. Humor fail. Ok, so returning to our obese, CHF, medicated, COPD, smurf .... What does he weigh? Is this his normal weight or has there been a sudden increase? I echo the question about urine output. I would recommend a RAST test or serum triptase as well as changing the antibiotic just to observe what happens. You mentioned his airway is patent but did you mention lung sounds? Are his legs swollen? Are his legs bilaterally equal in size and color? Is he taking any medication that could be competing with O2 and binding to hemoglobin? Do we know where his infection is? Lungs, peri cardium, endocardium, etc,,? Is anyone standing on his air hose? Edited December 13, 2011 by DFIB
mobey Posted December 13, 2011 Author Posted December 13, 2011 What does he weigh? Is this his normal weight or has there been a sudden increase? He weighs 280lb. I echo the question about urine output. The sending hospital has not put in a catheter. They have been using a lift to change his adult diapers. They say his output has remained the same since he came in, and they are changing him about every 3-4 hrs. This is not to say he is dry between changes.... I would recommend a RAST test or serum triptase as well as changing the antibiotic just to observe what happens. I do agree.... of course they were not calling me for a consult You mentioned his airway is patent but did you mention lung sounds? Bases are nearly silent, I could hear a little air movement down there at the end of the inspitory phase but hardly anything. Apicies are slightly wheezy on expiration, but again really, really quiet. There is very very little chest expansion. Are his legs swollen? Are his legs bilaterally equal in size and color? This guy carried his weight funny. Torso/neck/face/upper arms/thighs were huge, but ankles/wrists were average size. His ankles/hands had no edema and did not pit. Is he taking any medication that could be competing with O2 and binding to hemoglobin? Did I mention he is on CO pills? Haha, just joking... Do we know where his infection is? Lungs, peri cardium, endocardium, etc,,? Sending physician is suspecting pneumonia. Recieving Doc looked at x-ray and does not concurr Is anyone standing on his air hose? As in the OP, it would not matter since the simple mask is around his belly! Right after I made the original post, I got brutally slammed at work. Now that I have had a good nights rest 'll try be more thourough. appoligies for leaving things out on this one, I was not doing it on purpose. BTW Squint: I was looking for your # during this call! LOL "Squint patch" What tells me a lot with this senario is loading with Bug Juice and Roids .. again its a shotgun approach to medicine not an internist's sniper rifle . cheers Yes well... rural hospitals. I am sure you have dealt with this one before. Give you a hint, The Walmart is full of army brats
mobey Posted December 14, 2011 Author Posted December 14, 2011 What was haemoglobin again and Crit ? Sorry I do not have an exact # for you, however it was within the normal range. I WAS planning on posting this all while it was still fresh in my mind and have specific answers, so I didn't write them down, but since then I have had a few looong critical transfers, and the data has slipped away. I DO however know that PvC02 and WBC were the only abnormal lab values. I am wondering if HGB "within normal range" for the avg adult male was actually low for this chap? Hmmm
DFIB Posted December 14, 2011 Posted December 14, 2011 Sorry mate. The squiggly lines are above my pay grade.
Aussieaid Posted December 14, 2011 Posted December 14, 2011 How about some more history from before the hospitalization. Any exposure to any kind of poisons, insecticides, nitrites, etc? Did they get a methemoglobin level? Is the cyanosis still present with the SpO2 level of 96%? (Might want to increase that O2 flow level anyway).
tniuqs Posted December 14, 2011 Posted December 14, 2011 (edited) Sorry I do not have an exact # for you, however it was within the normal range. I WAS planning on posting this all while it was still fresh in my mind and have specific answers, so I didn't write them down, but since then I have had a few looong critical transfers, and the data has slipped away. I DO however know that PvC02 and WBC were the only abnormal lab values. I am wondering if HGB "within normal range" for the avg adult male was actually low for this chap? Hmmm Well that blows my opportunity at a post on polycythaemia, or anemias that can lead too what we see in the 12 lead, or the real definition of cyanosis, or ventilatory vs respiratory failure, or the use of CPAP. yeah thanks mobey ! LOL Edited December 14, 2011 by tniuqs
HellsBells Posted December 14, 2011 Posted December 14, 2011 Its a little blurry, I don't think there are any significant ST changes, the T waves in V2, V3, V4 seem to be slightly peaked, which could lead to the conculsion he may still be somewhat hyperkalemic
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