The Real-World Boards: Question #15
A 47-year-old man with acute heart failure and hypoxemic respiratory failure
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A 47-year-old man is in the ED with acute hypoxemic respiratory failure. He has no prior history of significant illness. He felt well until three weeks ago when he developed a fever and mild cough. He was diagnosed and treated for influenza in a telemedicine appointment based on symptoms. He felt “100% better” after about 7 days. A few days after that, he developed bilateral wrist pain, then sharp chest pain that reoccurred throughout the day and dyspnea that worsened until he presented to the hospital today.
His blood pressure is 112/85, pulse 110/min, respirations 30/min, and SpO2 80% on arrival, now 95% with 7L/min nasal cannula oxygen. He is febrile to 38.2° C.
ECG shows nonspecific T-wave changes without ST elevations.
High-sensitivity troponin is elevated at 0.12 ng/mL (ULN 0.02 ng/mL). White blood cell count is elevated at 12,500. Renal function is normal.
Bedside ultrasound shows hypokinesis of the left ventricle with an estimated ejection fraction of 30% and regional wall motion abnormalities (hypokinesis of the LV lateral wall). The right ventricle is not well seen.
A chest radiograph is performed:
