Posted by Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The patient is a 61 year old man with a history of diabetes, chronic kidney disease, and poorly controlled hypertension on five medications who was in his usual state of health until three days prior to admission when he noted increasing exertional dyspnea associated with chest pain, abdominal distention, bilateral lower extremity edema (left greater than right).
Exam notable for BP 105/54 (lower than all other prior measurements), HR 74, O2 Saturation 90%. PaO2 57mmHg, bibasilar rales and bilateral lower extremity edema. Labs were significant for BNP 218 (ref range: 0-100), d-dimer 537 (ref range to 230), WBC 11.2 (82% polys), Hgb 9.3 (baseline 10-12), creatinine 4.2 (baseline mid 2), troponin negative x 2. EKG without ischemic changes.
Echocardiogram six months prior to admission notable for hyperdynamic LV, increased EF (70-75%) and mild concentric LV hypertrophy.