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A Morbidly Obese 26-Year-Old Man With Respiratory Failure and Bilateral Lower Extremity Swelling

      A 26-year-old morbidly obese man with OSA on CPAP presented with fatigue, dyspnea on exertion, and bilateral leg swelling for 2 weeks. While in the ED, he was started on bi-level noninvasive mechanical ventilation. Laboratory results were significant for d-dimer of 6,110 DDU ng/mL, brain natriuretic peptide of 1,183 pg/mL, and troponin I of <0.3 ng/mL. ECG showed indeterminate axis, minimal ST depressions in III, arteriovenous fistula; inverted T waves in III, arteriovenous fistula, V1-6; and incomplete right bundle branch block (Fig 1). Chest radiograph showed an enlarged cardiac silhouette with clear lung fields (Fig 2). CT and nuclear scans could not be performed because of his weight and body habitus.
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      Figure 1ECG shows indeterminate axis, minimal ST depressions in III, arteriovenous fistula; inverted T waves in III, arteriovenous fistula, V1-6; and incomplete right bundle branch block.
      Figure thumbnail gr2
      Figure 2Chest radiograph shows an enlarged cardiac silhouette with clear lung fields.
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