A 51 years old attending physicians is found lying on the floor of the medical record department ,after signing more than 100 charts in less than an hour. One of the residents found him and transferred him to the ER and admitted him to the ICU. On admission, he was hyponatremic, bradycardiac, with cold extremities. ECG shows ST elevation in the anterior leads with sinus Bradycardia
Laboratory studies showed
Sodium 132 meq/L
Bicarbonate 12 meq/L
Potassium 5.3 meq/L
Blood urea nitrogen 20 mg/dL
Chloride 103 meq/L
Plasma glucose130 mg/dL
1-What is the most likely clinical diagnosis?
2- How would you confirm your diagnosis? (Name two)
3-what is the best next step in management
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3 comments:
CO poisoning
get an ABG to check HbCO
normal pulse oximetry
CT head to assess for cerebral edema
first step in management:100% oxygen
1) Most likely Acute anteriorinferior wall MI also involvng the SA node which could have caused bradycardia. Decreased cardiac output might have triggered for inceased renin angiotensin causing hyponatremia.
2) Troponins, CK-MB
3) IV fluids, coronary angiography.
1- Based on the biochemical picture this patient has a high anion gap metabolic acidosis, most likely secondary to lactic acidosis secondary to anterior myocardial infarction and shock.
2-Obviousely this patient has ACS, but to investigate and confirm the underlying cause of the hig anion gap:
a- Check plasma lactate
b- Arterial blood gases including pH
3- Treat the underlying cause ,in this case the best next step Transfer patient stat to the cardiac cath lab for cardiac angioplasty
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