I don't know how to feel about this. I recall an EM physician not too long ago posted a similar story so I wanted to share mine.
I'm in IM. I was doing some moonlighting one night when a lady comes in for hypertensive emergency. Her SBP is >200 and she has a headache. All her other vital signs are rock solid. She has elevated trops and an elevated BNP. I trend the tropes out and first they are level, and then start dropping as we get control of her pressures with a nicardipine drip (slow early decrease, aimed for no less than 160 for the night). A CT head has no bleed. Not any other end organ damage.
SpO2 98% on RA the whole time. HR comfortably in the 70s-80s, and she's on a baby dose of metop xl 25 at home. She was given an extra metop short-acting 25 in the ED for the HTN.
Never any chest pain, SOB. Had a cough she reported in the morning without sputum, or hemoptysis. She did have some palpitations, that was it. She gives me this strange history of polyuria as well over the last 24 hrs, which she makes a point to emphasize. Telemetry was rock solid normal. An EKG was identical to one done a year ago. The patient herself looks awesome. Pleasant, interactive. Nothing to suggest anything more serious going on that what's been presented.
Her exam is totally normal except for a slightly elevated JVP that I got at maybe 8 CM, and a positive hepatojugular reflex. She doesn't have any CHF history and overall I would call her exam euvolemic to slightly dry, so I was at first thrown off by that finding but I couldn't put it together with anything else I was seeing. So in my mind I'm thinking, she's older, maybe there's just some pulmonary HTN or something. I'm going to let her drink to thirst and I see no reason to diurese.
I see she has a history of thoracic descending aortic aneurysm, which was imaged about a month ago and stable but ever so slowly growing. She starts telling me she has left shoulder pain. Exacerbated by movement. I'm thinking: ok this is totally MSK pain. I pour over this for like 2-3 hours. HTN emerg. Descending aneurysm. Left shoulder pain. Trops. And the nurse is telling me she's been up all night back and forth urinating, producing small amounts but constantly doing it, consistent with the polyuria in the ROS.
So I finally pull the trigger and CTA her, just to put my mind at ease about the aneurysm. I chalk the trops to a type II NSTEMI and rationalize that she is not having an ACS so I don't need to give her anticoagulation.
A couple of times her BP drops to like normotensive levels suddenly, making the nicardipine stop. Then it gets restarted when it goes back up. I don't think much of this except to make sure she's not stroking out. It's already been much more than 6 hours since presentation so I don't get too worried about those drops.
I follow up the next day and -great- the aneurysm is stable. But BOOM PE in the right main pulmonary artery. Signs of right heart strain! Wtf!
It was just dumb luck. So now of course the right-sided heart findings on exam makes sense. But that's it. How utterly jarring and unnerving. I'm wondering if I missed this. Should I have acted on my exam? How the hell does this cause HTN emerg? Should I have started the AC on the type II NSTEMI? I feel like this could have gone VERY badly and honestly it is terrifying.
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