Case Report: Congestive Heart Failure?
A 72-year-old male with a history of ESRD, CHF and DM presents to the hospital with 6 weeks of slowly progressive leg edema and 3 weeks of SOB/DOE that has become much worse over the past 24 hours and is associated with a new cough. What's your diagnosis?
CASE REPORT: Congestive Heart Failure?
History: A 72-year-old male with a history of ESRD, CHF and DM presents to the hospital with 6 weeks of slowly progressive leg edema and 3 weeks of SOB/DOE that has become much worse over the past 24 hours and is associated with a new cough. He denies syncope, palpitations, chest pain, fever, or other complaints.
Exam: Vital signs are normal except for a pulse-ox of 91% on room air and a RR of 30. Breath sounds are diminished but symmetric, and legs have symmetric pitting edema without erythema. His physical exam is otherwise normal.
Initial differential diagnosis: CHF, Pulmonary Embolism, Acute Coronary Syndrome, Pneumonia
Initial EKG:
COMPUTER EKG READ:
- Normal sinus rhythm
- Right bundle branch block
- Left anterior fascicular block
- Bifascicular block
- T wave abnormality, consider inferolaeral ischemia
Do you agree with the computer? What should you do next?
EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS:
EKG analysis (peer reviewed by Dr. Stephen W. Smith of
Case Outcome: Initial troponin was 8.0 (99% URL <0.030: troponin-i immunoassay, Abbott laboratories). Cardiology was consulted and the patient went to cath urgently. Repeat troponin a few hours after the first was 10.9. At cath, there was an 80% LAD occlusion that was stented.
aVR ST elevation from
Source:
Case Lessons
- ST elevation in aVR has many possible causes, one being reciprocal change to ST depression in left-sided leads as part of non-occlusive ACS causing subendocardial ischemia.
- Always look for a reason when someone's condition has become worse in the past 24 hours. This patient initially seemed like routine CHF but his acute worsening was due to acute ischemia.
