53-year-old female with Hx of hyperthyroidism At 15.20 น . 4/8/52 Case discussion
CC:fever with dyspnea
Vital signs : T 37.2, BP 80/50, PR 100, RR 24 Oxygen Sat. 100% (RA)
IV access with NSS starting with 1000 ml loading in 15 minutes
On cardiac monitoring
Collecting blood samples for laboratory studies include : CBC, BUN, Cr, electrolytes, BS, lactate
Hemoculture x 2, TFT, cardiac markers
She has had low grade fever (unmeasured) with dry cough for 2 weeks prior to presentation. The cough became worse when she laid down during the night. She walked up the stairs at home and developed very short of breath which made her come to our ED.
PMHx : Hyperthyroid
[PTU(50)2x2 + Propranolol]
She has skipped the medication
for nearly 2 weeks.
ALL : NKDA
FHx : 2 Sisters with diabetes.
SHx : Occasional alcohol
Regular use of over-the-counter drugs
(for relieving pain, fatigue and muscle strain)
General : Alert, middle-aged woman with moderate discomfort,shortness of breath and sweating.
HEENT : Mild pallor, anicteric sclera, no exopthalmos, no lid retraction, mild pharyngeal erythema.
CVS : mildly tachycardic, regular rhythm, no heart murmurs or gallops, no heaving.
RS : Clear bilaterally
Abdomen : Soft, not tender, liver and spleen not palpable.
Ext : No leg edema or tenderness
Skin : No abnormal skin rash
CBC : Hb 13.9, Hct 40, WBC 12000 (N64/L26)
PLT 417000, Band 0
Electrolyte : Na 123 , K 5.6 , Cl 87, CO 2 21
Cal 9.7, Mg 2.9, PO 4 6.6
BUN 23, Cr 0.8, BS 751
CPK 984 , Trop-T 4.28 , CK-MB 179
LFT AST 3164 ALT 2016 ALP 223 TB 0.6 DB 0.3 TP 5.3 Alb 2.3
Urinalysis : Glu 4+
Echo bedside : EF 40% IVC 1.4
Global hypokinesia with mild MR, mild TR RV not enlarge
Fluid Challenge Test Initial CVP <8 8-15 >15 cm H 2 O PAOP <12 12-16 >16 mm Hg Volume & Rate 200 mL/10 min 100 mL/10 min 50 mL/10 min During infusion, CVP rises >5 cm H 2 O or PAOP rises >7 mm Hg Yes No Stop challenge Complete the volume Wait 10 min Wait 10 min CVP change >5 3-5 < 2 3-5 < 2 PAOP change >7 4-7 < 3 4-7 < 3
CVP and Blood Volume (BV)
- Hypovolemia c venoconstriction, ventricular dysfunction
- Hypervolemia c hyperdynamic heart function
- Absolute or relative hypovolemia (vasodilatation)
- Hyper-, hypo-, or normovolemia c hyperdynamic heart or negative ITP
- Hypo- or normovolemia c positive ITP, ventricular dysfunction, obstruction of blood flow (TS, PS, cardial tamponade)