Case part 2

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Case presentations are so different in real life.  When this patient came in, everyone said to treat his chf and put him on bipap, whereas when people look at this case on the website, there was quite a bit of disagreement.  The patient was hypercapneic.

The patient was placed on bipap, and his ms actually got worse, leading to intubation.  After intubation, his ms slowly became normal (wide awake), but his sBP went down to 80.

Some labs come back…

bnp 522
wbc = 16, hct = 52
na = 144
k = h
cl = 100
bicarb = 40
gluc = 171
bun / cr = 44 / 2.3

trop = 0.8

ekg is normal


What do we do with the chf cxr and a bnp of 522?

What do we do about the BP?

What do we do about the trop?

What do we do with an awake patient gagging on the tube but his BP is 80?

What do we do about his abd wall cellulitis?

One Comment

  • BC

    Looking at the first part of this case, I was not entirely convinced this is primarily CHF. Lungs were clear-ish but then he’s fat. In my opinion he wasn’t tachycardic or hypertensive enough to make this overwhelmingly CHF.

    Hypercapneic resp failure would explain his sat and his mental status.

    His bnp is not that high but I don’t know how high is too high? Some lasix could help but this guy could be septic from his cellulitis and if he’s tanking after intubation I would hold off on diuresis.

    Put him on pressors, abx for cellulitis/copd (and maybe even for pna on cxr?), give asa for demand ischemia (unless ekg says otherwise), sedate him, start with fentanyl

    Now the real question is what to do about the cellulitis? Like McG said, this could very well be nec fasc. If it looks bad enough, I would call surgery to take a look.

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