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He demonstrates Beck's Triad, raising the flag for cardiac tamponade. Are his heart sounds muffled?
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Good one, Doc, but I'm betting that the neck vein distention resolves when the patient is raised to semi-reclining position.
DDX: After thinking about it and looking at the medical history, the patient is Type II diabetic (Glyburide) but blood glucose is normal therefore no keto-acidosis. He is on anti-coagulant (Plavix) prophylactic for a patient with CHF (Vasotec and Procardia) and isorbide dinitrate to treat angina.
The ECG leads me to think of hyperkalemia (small or absent P waves and a wide QRS complex with wide (tented) T-waves.
Order blood chems to measure K+ level, kidney function markers.
Rx Plan: withdraw isosorbide dinitrate and Vasotec (ACE inhibitor) both of which are contraindicated and can induce (probably did in this case) hyperkalemia. Admin Na Bicarb and titrate to blood pH. Calcium chloride (1 ampoule IV) titrate to ECG response, Ventolin nebulizer (10 mg) to follow as needed (monitor ECG). The treatment goal is to reduce K+ level. Re-evaluate meds for long term maintenance. This patient dodged a bullet. Discharge when stable.