archer Q - sundna

[ArchivalUser]

243) A 65 year old man with a long history of COPD and history of metastatic colon cancer presents with complaints of increasingly severe shortness of breath that occurred at rest today. He reports that his symptoms are much more severe than his usual baseline. On examination , he is afebrile and tachypneic. Blood pressure is normal. Chest exam reveals occassional rhonchii. EKG shows sinus tachycardia. Arterial blood gases are obtained on the room air and show Ph : 7.45 Po2 40 PCo2 50 and Bicarbonate of 36. Chest X-ray shows changes of emphysema. His home medications include ipratropium and albuterol inhalers. He is placed on 4 liters oxygen by nasal cannula.

Which of the following is the most appropriate next step?

A) Intravenos corticosteroids

B) Intubation

C) Spiral CT scan and empiric Low molecular weight heparin

D) Non invasive positive pressure ventilation

E) Bed-side Spirometry

[ArchivalUser]

AAA

[ArchivalUser]

B- intubate the pt.

[ArchivalUser]

Good question! Are the blood tests done before he was placed on O2? If yes then I think we'll wait with intubation, and probably would go for steroids - A
If we have Po2 40 on 4 liters of O2 by nasal canula then we need to intubate.
At the same time it could be PE due to hypercoagulation bacause of cancer. Then we need to go for C.

What is the answer?

[ArchivalUser]

he has PE
anweeer C

[ArchivalUser]

my intuition is C.
There is post hypercapnic alkalosis and increased A-a gradient

[ArchivalUser]

my guess is C
PE-metabolic alkalosis ,increased A-a GRADIENT, tachycardia ,h/o cancer

somehow BP normal --it would be straight forward if BP low

i dont think its CoPd exacerbation

[ArchivalUser]

thats a PE if we we can cinfirm it with CT scan and empiric treatment with heparin . we dont need to waste time in managment of PE rather doing other tests . clarify me please.

[ArchivalUser]

in options ,they said empiric right

so i believe they are starting heparin first and then sending to spiral CT chest

[ArchivalUser]

you r right krithikanan