Learner Version
Module #7
Created by Dr. Merideth Prevost
3/2014
Objectives:
See facilitator version
References:
See facilitator version
Case
A 71 yo male with history of CAD, hypertension, hyperlipidemia, diabetes, BPH, chronic back pain and PTSD presents after a fall while walking his dog. He complains of maxillary and nose pain. He has no chest pain or shortness of breath. He cannot remember any symptoms leading up to the fall. He simply woke up on the ground. A neighbor saw him fall, then called 911 and he was brought to the hospital via ambulance.
Outpatient medications include: ASA, Clopidogrel, Isosorbide Mononitrate, Metoprolol, Lisinopril, Simvastatin, Furosemide, Terazosin, Glargine, Metformin, Gabapentin, Oxycodone, and Fluoxetine
What other information would you like to obtain in the history?
What are the general categories of syncope and how does the history help you to narrow the differential diagnosis?
You talk to the patient more about the events surrounding his fall. You also interview the neighbor.
The patient states that 2 weeks ago he saw his PCP for increased swelling in his legs and some shortness of breath with exertion. His PCP prescribed furosemide for him. He was also having to get up a lot at night to urinate, so his terazosin dose was increased. His swelling and urination got better with these medication changes. The patient reports he had no chest pain or palpitations when he was walking his dog, but he felt very fatigued and a little lightheaded before the event. He had no diaphoresis, N/V. The neighbor reports that the patient was just walking along, then paused slightly and fell forward onto his knees, then his face. He had no incontinence and no jerking movements. He was pale and his nose was bleeding. His LOC lasted about 30 seconds and when he woke up, the patient behaved normally. He was confused about how he got to the ground, but was otherwise oriented.
On physical examination, his temperature is 36.5 °C, blood pressure is 116/68 mm Hg, heart rate is 64/min, and respiratory rate is 16/min. The patient is alert and oriented. He has bilateral periorbital ecchymosis and facial abrasions, with edematous nose and blood crusted at nares. RRR, 3/6 late peaking systolic murmur best heard at the right upper sternal border with radiation to carotids and delayed upstroke of carotid pulse. He has JVD, scant bibasilar crackles, 1-2+ pitting edema to mid-calf. Neuro exam is normal.
Labs:
CBC: WBC 4.9, Hgb 12, Hct 36, Plt 231.
Chem 10: Na 137, K 3.4, Cl 98, HCO3 29, BUN 31, Cr 1.5, Glc 163, Ca 8.3, PO4 2.8, Mg 1.7
LFTs: Normal
What are the leading diagnoses on your differential for this man’s syncope?
What physical exam findings suggest aortic stenosis as a possible cause?
What are some of the medications that may have contributed to this episode of syncope?
You order an ECG. What are you looking for?
What other studies do you want to get?
You get the test results:
Orthostatics: Supine—BP 116/68 HR 64 Sitting—BP 110/62 HR 68 Standing—BP 94/56 HR 74
ECG: NSR, old Q waves in inferior leads, T wave flattening anterolateral leads, QTc 435 ms
Trop: 0.018
NT-ProBNP: 2348
TTE: EF 35-40%, LV dilation, inferior akinesis, anterolateral and septal hypokinesis, mild MR and TR, severe AS with AVA 0.9 cm2, aortic jet velocity 5.1 m/sec, mean gradient 43 mmHg.
CXR: Cardiomegaly, increased vascular congestion with cephalization and Kerley B lines, small bilateral effusions
What are his diagnoses?
What medications do you order? Fluids?
Does the patient qualify for Aortic Valve Replacement?
What other tests does this patient require prior to surgery?
MKSAP 16 Questions
Gen IM Question 21
Gen IM Question 86
Gen IM Question 31
Gen IM Question 156
CV Med Question 90
CV Med Question 35
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111) or Dr. Patrick Rendon, UNM Hospital.
1) Topic of module:______
2) On a scale of 1-5, how effective was this module for learning this topic? ______
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:
6) Please circle one:
Attending Resident (R2/R3) Intern Medical student