Thursday, February 20, 2014
A morbidly obese 35 year old gentleman who is 5'5" and 260lbs with a history of obstructive sleep apnea, hypertension, and insulin resistance undergoes pre-operative evaluation for a uvulopalatopharyngoplasty. He has excessive daytime sleepiness, loud snoring, witnessed apnea during sleep followed by a loud snort, fatigue, hypersomnolence, impaired concentration and memory, and a thick neck.
However, you also notice an elevated JVP, hepatomegaly, and some pedal edema. He has dyspnea on exertion and needs to rest after half a flight of stairs. An arterial blood gas shows a PaO2 on room air of 70, a PaCO2 of 48, a bicarbonate of 28, and a Hct of 55. Thyroid studies and electrolytes are normal. Pulmonary function tests show a low FVC, a low FEV1, a low ERV, but a normal FEV1/FVC ratio. EKG suggests right atrial and right ventricular hypertrophy. CXR is normal.
Challenge: Is there something else going on here?
Image is in the public domain, from Wikipedia.