case

[Painter1]

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this is a 45yo with a hx of large uterine fibroids, htn, dm appendectomy who is referred by pmd for sinus tachycardia. the patient notes two day hx of chest pressure worse on breathing associated dyspnea on exertion. on triage, she notes neck soarness. denies falling. on review of symptoms she notes polyuria and polydipsia and some nausea. however she denies subjective fever/chills. no cough. no abdominal pain. no dysuria or hematuria. no headache. no hx of malignancy, no recent surgeries, no hx of dvt, no immbolity.

her HR is 140, normaltensive, with an oral temp of 100.1. 02 sat 96%

exam, mild distress but not toxic looking. physical exam is relatively normal other than dry oral mucosa. about her neck, she had paraspinal tenderness, no midline tenderness.

EKG sinus tach at 140. Accucheck 500.

what do you do next. what's your differential and how would it have changed if you didn't have an accucheck of 500 OR would it have changed?

 

[Enrico81]

arterial blood gases?

 

[Hard24Get]

still having heavy periods?
I would prioritize this exertional pleuritic dyspnea over the neck tenderness and so my differential would include hypergly/DKA (with or w/o BS), PE, MI, PNA, etc. Would give fluid bolus, check UA (ketones, leuks), ABG/VBG (pH, CO2), electrolytes (anion gap), cardiac panel, cbc (leukocytosis), cxr. Prob beyond D-Dimer in terms of suspicion but would still send, maybe V/Q scan if it is middle of the day vs CT if Cr great. My primary concern would be that the BS and neck tenderness is the result of another process, such as PE or PNA (less likely MI), so that is where I would start. I like when people teach on this forum 🙂

this is a 45yo with a hx of large uterine fibroids, htn, dm appendectomy who is referred by pmd for sinus tachycardia. the patient notes two day hx of chest pressure worse on breathing associated dyspnea on exertion. on triage, she notes neck soarness. denies falling. on review of symptoms she notes polyuria and polydipsia and some nausea. however she denies subjective fever/chills. no cough. no abdominal pain. no dysuria or hematuria. no headache. no hx of malignancy, no recent surgeries, no hx of dvt, no immbolity.

her HR is 140, normaltensive, with an oral temp of 100.1. 02 sat 96%

exam, mild distress but not toxic looking. physical exam is relatively normal other than dry oral mucosa. about her neck, she had paraspinal tenderness, no midline tenderness.

EKG sinus tach at 140. Accucheck 500.

what do you do next. what's your differential and how would it have changed if you didn't have an accucheck of 500 OR would it have changed?