This is my case tomorrow:

Pt is in mid 60's, accidentally shot in the leg a few days ago causing a "highly comminuted" distal femur fracture. The bullet fortunately missed significant vasculature and an ex-fix was placed.

History:
Ex-smoker.
Mechanical MVR.
A-fib, s/p ablation.
CHF.
V-pacer.
Non-ischemic cardiomyopathy. 2d echo shows
-dyskinetic septum & apex, akinetic inferior & posterior walls, severely hypokinetic in all other segments
-markedly enlarged LV and dilated RV with reduced systolic function
-moderate pulmonary HTN
-large apical LV thrombus
-EF ~15%
Most recent CXR shows stable vascular & interstitial congestion consistent with CHF.

Pt is currently on neo gtt after becoming severely hypotensive after the ex-fix placement (which was uncomplicated intra-op). H/H about 9/29, plts 170, pt 1.8, ptt 102. Also on heparin gtt because of the valve & thrombus.

Students - what's your plan?