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Describe the patient's lab findings and their relevance.
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CBC: Leukocytosis (20k). CMP: Anion gap 14, bicarbonate 16 (low). ABG: pH 7.25 (acidotic), pO2 84 (normal), pCO2 46 (slightly elevated), HCO3 15 (low). Elevated lactate 5.8. Lipase & amylase normal. Troponins negative. Fecal occult blood test negative. Blood cultures negative. These findings indicate an underlying metabolic acidosis and systemic inflammatory response.
What treatment plan was initiated for the patient's acute mesenteric ischemia?
IV fluids (prefer Lactated Ringers), NG tube to decompress bowel, antiemetics, analgesia, antibiotics, anticoagulation with Heparin, and evaluation for embolectomy or thrombolysis.
When is thrombolysis considered in the management of acute mesenteric ischemia?
Thrombolysis is considered if the patient is not a candidate for embolectomy, to dissolve the clot causing the ischemia.
What physical examination findings would lead clinicians to consider non-abdominal causes for the patient's symptoms?
Cardiovascular findings like irregular rhythm and bi-basilar pulmonary crackles suggest heart failure exacerbation or a systemic process such as sepsis, warranting a broader differential.
Why was the patient tachycardic and febrile upon presentation?
Tachycardia (150 bpm) could be related to atrial fibrillation exacerbated by the ischemic event. Fever (101.4°F) suggests an underlying systemic response or inflammatory process, possibly due to mesenteric ischemia leading to bacterial translocation and septic response.
What are the vital signs of the patient upon initial examination?
Heart rate: 150 bpm (tachycardic), Respiratory rate: 32 breaths/minute (tachypinic), BP: 110/70 mmHg, Temperature: 101.4°F (febrile), SpO2: 94%
What imaging findings support the diagnosis of acute mesenteric ischemia?
CTA of the Abdomen confirmed an occlusion of the superior mesenteric artery.
What clinical indicators suggest that this patient's abdominal pain is out of proportion to physical exam findings?
The patient's severe pain, despite a relatively benign abdominal exam showing no significant tenderness or rebound tenderness, suggests mesenteric ischemia.
What were the significant findings in the patient's EKG?
Rate: ~150 bpm, irregular. Rhythm: Atrial fibrillation. No ST segment elevation or depression.
Why is acute mesenteric ischemia a critical differential to consider in this patient?
Due to the patient's history of atrial fibrillation and the presentation of constant, non-radiating diffuse abdominal pain, acute mesenteric ischemia should be highly suspected, especially given the decreased flow in the SMA observed on imaging.
How does atrial fibrillation contribute to the development of acute mesenteric ischemia?
Atrial fibrillation can lead to the formation of emboli, which can travel and occlude the superior mesenteric artery, resulting in ischemia of the bowel.
Explain the significance of the patient's elevated lactate level in the context of their condition.
Elevated lactate level (5.8) indicates lactic acidosis, which is consistent with tissue hypoperfusion and ischemia, supporting the diagnosis of acute mesenteric ischemia.
Identify key physical exam findings for this patient.
Cardiovascular: Tachycardic, irregular rhythm. Pulmonary: Tachypnic, bi-basilar crackles. Abdominal: Grimacing in pain, soft, non-tender, normal active bowel sounds.
What are some other differential diagnoses considered for this patient's abdominal pain?
Small bowel obstruction, diverticulitis, bowel perforation, pancreatitis, appendicitis, pyelonephritis, cholecystitis, peptic ulcer disease (PUD), nephrolithiasis, abdominal aortic aneurysm (AAA), sepsis, inferior MI.
Why might vasopressors be used cautiously in this patient?
Vasopressors can potentially worsen mesenteric ischemia by decreasing blood flow to the intestines. Inodilators like dobutamine or milrinone may be preferred if needed.
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