Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on Emergency Department Management of Acute Asthma Exacerbations right.
Case Presentation: Managing Postpartum Complications in the Emergency Department
A woman 3 weeks’ post partum presents with gradually worsening cough and severe shortness of breath.
Early on Sunday morning, a 33-year-old woman presents with gradually worsening cough and shortness of breath that is so severe that if she takes more than 4 steps, she has to sit down to catch her breath. Her blood pressure in triage is 185/115 mm Hg, she is tachycardic with a heart rate of 120 beats/min, and she is tachypneic and speaking in short phrases. Her temperature is 37°C, and her oxygen saturation is 95%.
She has no past medical history, and states she had an uncomplicated delivery of twin boys 3 weeks ago via cesarean delivery. On physical examination, there is jugular venous distension, crackles bilaterally, and lower extremity edema. Her abdomen is soft and nontender. You wonder why her blood pressure is so high and whether her high blood pressure is related to her shortness of breath.
Chest x-ray revealed that this patient had pulmonary edema. You treated her with IV nitroglycerin, and her blood pressure improved to 160/90 mm Hg. You also administered 40 mg of IV furosemide. On re-evaluation, her heart rate was sinus rhythm in the 80s, and her oxygen saturation was 97% on room air. Her blood pressure remained elevated, requiring a nitroglycerin infusion. CBC, CMP, uric acid level, urinalysis, and LDH were normal. An ECG revealed T-wave inversions in the lateral leads, and her troponin and BNP levels were significantly elevated. Bedside echocardiogram revealed moderately reduced ejection fraction of 35%, making a diagnosis of PPCM likely, and this was confirmed after she was admitted to the ICU.
USACS subscribers can log in or renew here.
Last Updated on January 26, 2023