06-01-2009, 09:46 AM
this is another one that is tricky for me..can someone help me out this one and explain their reasoning..
A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain, heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component. Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin. Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation for cardiac decompensation and renal failure in this patient?
A) Bulimic cardiomyopathy
B) Cocaine intoxication
C) Hypothyroidism
D) Myocardial ischemia
E) Myocarditis
I am down between A and E but not sure
A 19-year-old white woman is brought to the emergency department by her mother because of intractable emesis. She has a past history of bulimia and according to her mother has been under the care of a psychiatrist. She apparently was well until 1 day ago when she developed emesis and an inability to tolerate liquid and solid foods. Although she takes no medications other than oral contraceptives, she admits to occasional use of both laxatives and ipecac. She denies the use of alcohol or of illicit drugs and says she has experienced no previous symptoms of chest pain, heartburn, hematemesis or fever. Physical examination shows a well-nourished woman with normal vital signs. No lesions are evident on inspection of the skin, but turgor is poor. The thyroid is flat, nontender and without masses. On auscultation of the lungs, moist rales are present at the bases bilaterally. The point of maximal impulse of the heart on the chest wall is 7 cm from the lower left sternal margin in the sixth intercostal space. There is no evidence of an S4 although an S3 is heard. A soft systolic murmur is heard at the apex without a diastolic component. Jugulovenous distention is present 3 cm above the suprasternal notch at 45 degrees' elevation of the chest. The abdomen is soft and a tender liver edge extends 3 cm below the right costal margin. Pitting edema is present in both legs to the mid-calf bilaterally. Laboratory studies show a serum creatinine concentration of 4.2 mg/dL and serum urea nitrogen (BUN) of 88 mg/dL. Urinalysis shows renal tubular epithelial cell casts. Chest x-ray film shows cardiomegaly, central hilar vascular congestion and cephalization of blood flow. Which of the following is the most likely explanation for cardiac decompensation and renal failure in this patient?
A) Bulimic cardiomyopathy
B) Cocaine intoxication
C) Hypothyroidism
D) Myocardial ischemia
E) Myocarditis
I am down between A and E but not sure