# 65yrs Female, Syncope & SOB



## Melclin (Jul 6, 2011)

Nobody seems to have been too interested in my last scenario so maybe people will be more interested in ones I got wrong rather than my successes.

Its a cool afternoon and you are called to a doctors surgery for a 65 year old female, Gwen, who has collapsed out front.

You find a skinny looking lady sitting on an exam table with a em bag looking a bit pale. 

*Characteristically abysmal handover:* Gwen came to see him for the first time yesterday complaining of SOBOE and came back in for some blood tests today. While walking into the surgery, she was seen to collapse to the ground with a minimal period of LOC. He has no idea what's wrong.

*Illness hx:* Pt first noticed SOB on exertion two weeks ago and feels it has steadily worsened since then. She notes that it is particularly bad in the cold weather. Upon waking this morning she has experienced worsening nausea but feels that this is normal for her when she hasn't eaten after taking her bp medication. She complains that she felt dizzy walking into the doctors office, and remembers feeling like she was going to fall and waking up on the ground. She reports no warmth in the face or nausea prior to fainting.  

*Hx*
Hypertension - she states usually well controlled.

2008 - GP apparently found blood in her stool (why he was looking in the first place was unclear) and ordered a colonoscopy which showed no lower GI abnormalities and apparently it was left at that. 

Recently in good health (other than SOBOE), regular exercise, non-smoker, no surgeries or hospital admissions, vegetarian, no recent O/S travel/flights, eating, drinking, opening bowels and urinating as normal. 

*O/E:* BP: 140/90, Pulse: 86 (strong, regular), Tympanic temp: 36.3, Resps: 24, GCS: 15. BSL: 5.7 (about 110 in mg/dl I think). Monitored in a SR of 86. I lost her strip, which annoys me because I wanted to post it. From memory rS wave and inverted T wave in II but otherwise normal. No 12 lead available.

PEARL, sclera are white, distal pulses and all present and normal, chest is clear and equal, no accessory muscle use, mild anxiety is evident, abdomen soft and happy, nil c-spine tenderness, distal neuro obs are good. 

There is a small abrasion on her forehead and complains of pain in both knees which are red (presumably from falling foward onto them). Pt is no longer dizzy.

Shoot.


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## mycrofft (Jul 6, 2011)

*Any orthostatic BP's?*

How are CBC and red cell distribution width? HgB? Does she get lightheaded immediately upon changing posture, or is it delayed?
Your guiac positive stool sounds important too.


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## Melclin (Jul 6, 2011)

HR increase of 10BPM, nil change in BP.

Ambulance Victoria are a stingy bunch and have yet to approve my requests for a complete path lab in the drug bag, so not too sure about the bloods.


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## mycrofft (Jul 6, 2011)

*Mucosae pale?*

I'm lost. More guessers needed.


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## foxfire (Jul 6, 2011)

Anemia is the first thing that comes to mind.
 Blood found in stool, but nothing found in lower track, possible slow upper GI bleed? 
Skin turger? Possible dehydration?
Any other medications being taken? ( other than the hypertention )


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## Melclin (Jul 6, 2011)

mycrofft said:


> I'm lost. More guessers needed.





foxfire said:


> Anemia is the first thing that comes to mind.
> Blood found in stool, but nothing found in lower track, possible slow upper GI bleed?
> Skin turger? Possible dehydration?
> Any other medications being taken? ( other than the hypertention )



No pale muscosae.
Turgor is good. No hx consistent with dehydration. 
No other medications, per pt and GP.


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## foxfire (Jul 7, 2011)

ok.....
this was the only episode of snycope in the last two weeks?
How about pupils? 
What is her normal BP?
does she take her medications as directed? 
any abdominal pain? now or recently? 
is there shortness of breath while lying down or only at exertion? 
Any aches and pain that are not normal in the last two weeks? 



 ask doc "what in the heck is wrong with this pt?"
I am wondering about a possible silent MI. Kinda shooting in the dark.   
could be a isolated episode of snycope, but then why would you post?^_^


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## Melclin (Jul 7, 2011)

foxfire said:


> ok.....
> this was the only episode of snycope in the last two weeks?
> *yes, first ever*
> How about pupils?
> ...



10chara


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## foxfire (Jul 7, 2011)

Well, I have no stinking clue what is going on with the pt. And in light of that, I would establish an IV /ns /tko, apply monitor, vitals, and monitor the pt while transporting. 
When are we going to find out what is going on with Gwen?


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## Handsome Robb (Jul 8, 2011)

Orthostatic vitals at all?

I'm sleepy from school all day so thats about all I can come up with right now.


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## Melclin (Jul 8, 2011)

Melclin said:


> HR increase of 10BPM, nil change in BP.





NVRob said:


> Orthostatic vitals at all?
> 
> I'm sleepy from school all day so thats about all I can come up with right now.



I'm glad to see others haven't immediately jumped on the answer. I sure didn't get it straight up. Nor did the doc I handed over too. It was his consultant's first guess though. 

I'll give it another day or so...see if anyone chimes in further. No one has any love for my scenarios lately :wacko:


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## MrBrown (Jul 8, 2011)

Melclin said:


> No one has any love for my scenarios lately :wacko:



That is because you're a bloody rotten scrote 

... and Brown thought Brown's scenarios were hard :wacko:


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## Melclin (Jul 8, 2011)

MrBrown said:


> That is because you're a bloody rotten scrote
> 
> ... and Brown thought Brown's scenarios were hard :wacko:



But I don't even have a healthcare card h34r:


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## Aidey (Jul 8, 2011)

SpO2? CO2?


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## foxfire (Jul 8, 2011)

OK, I am going to throw a thought out there, 
Really wish I could see the ecg strip. But what you described is a possible LBB. Inverted T waves indicates ichemia.  
That would explain the soboe and sudden syncopal episode. 
But that is about as far as I have gotten in figuring this out.


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## Melclin (Jul 10, 2011)

Fox, it wasn't a LBBB. I'm pretty annoyed I lost the strip, because there was a bit more on it other than what I described and I was interested to see what people thought. You can never get the same thing from describing it.



Aidey said:


> SpO2? CO2?



Neither I'm afraid.


Vegetarian, hx of slow GI bleeds, SOBOE worsening over time. She was quite adamant the O2 didn't help. I thought it was anaemia.

It was a PE. A few of them in fact. 

Her doc came and found me in the ambulance bay a few hours later after another job to tell me about it, which I thought was jolly good of him. As I said, he didn't pick it either but the consultant did. 

The theory goes that she'd had the first a while at the start and then as each new clot appeared over the few weeks, the SOB got worse. She was thrombolysed in the ED.

I thought it a strange presentation.


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## MrBrown (Jul 10, 2011)

The temp of 36.3 and history of HTN fit with a PE Brown saw in 2009, patient had a temp of 36 and he had a bloody huge PE ... he also had massive sepsis and DIC from nessiera meningoccus (or equivalent in actual medical words) ... he also died :unsure:


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## foxfire (Jul 10, 2011)

Wow, that was a strange presentation. Kinda makes sense now that we have the answer. They teach us in class that the pulse ox is the key point for a possible pe.  If you give o2 and do everything else and still no improvement in numbers, then good chance of a pe. 
Thanks for challenging us.


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## Melclin (Jul 11, 2011)

foxfire said:


> Wow, that was a strange presentation. Kinda makes sense now that we have the answer. They teach us in class that the pulse ox is the key point for a possible pe.  If you give o2 and do everything else and still no improvement in numbers, then good chance of a pe.
> Thanks for challenging us.



I think most of what we typically talk about in emerg stuff is about massive PEs. All that right heart strain, obstructive shock, hypoxia refractory to O2 etc. 

This woman was mildly hypoxic (87%)when we got to the ED and I went and nicked a pulse ox from ...elsewhere. I had put her on sup o2 initially when we were minus the SpO2, but she was quite sure it didn't help and it was making her claustrophobic so I ditched it. Interestingly, I put her back on a bit of O2 and she popped right up to 98, quick as you like, with me feeling like a wang because it wasn't anaemia.   

As with any SOB, PE made a passing appearance in the ddx, but I really didn't give it much more than a few seconds.


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