A 50s M is brought in by EMS for dehydration and a febrile illness. His nasal swab is positive for Covid. His labs, CXR, and EKG are shown. The patient’s room air oxygen saturation is 90; he does well with supplemental O2. What are his treatment and disposition?
Answer to Blurry Vision/”Un Papel Malo”:
The EKG shows undiagnosed bad CAD; it is typical of Wellen’s syndrome. If the patient is here for chest pain, the answer is easy – cath / CCU. What should we do if the patient is here for an unrelated problem?
To me, the answer is relatively straightforward. What do you do when you find a ticking time bomb in a patient? They are not medical emergencies, but they require serious attention. It’s similar to finding cancer, type B aortic dissection, or a serious murmur. These are chronic conditions that may kill the patient, but they don’t need fixing in the next hour. My dispo plans generally depend on (1) patient preference (and understanding), and (2) if the patient has a good doctor (someone that’s available to talk and see). I admit most of my patients because few patients have PMD availability where I work, esp in the age of Covid.
For the teachers-in-training, this case is an illustration of my approach of “give the resident a chance to kill the patient”. When the resident got the EKG, he was apologetic. He immediately recognized the seriousness of the EKG but he felt a little bad about getting the EKG. I shrugged and asked him if he wanted to admit the patient or send him home. He was mildly flustered, but he ultimately decided that it was best to admit the patient. If you don’t give the residents a chance to kill the patient, you’re not giving them a chance to be the hero. Good job JY :^).
Not surprisingly, the patient had disease in all his cors, most notably a 95% LAD lesion. Surprisingly, the patient had a clot in his LV, which could have explained his vision complaint (although his story was not amaurosis). Hopefully, this incidental finding will save the patient from having a cardiac event in the future.