TCAs and hypotension

[Solideliquid]

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BTW Sazi,

How common is this anyway? What I mean is, most of the time people throw clots into the lung, but the clots don't get to the brain unless there is a heart/septal wall defect right?

Snap snap snap I is on my way!

EDIT: This case is like stuff on the show HOUSE.

 

[worriedwell]

Test: Echocardiogram (2D and M Mode)
Result: Normal left atrium size, left ventricle size, left ventricular wall thickness, right atrium and right ventricular size. Inferior vena cava not well seen; Intra-atrial septum show definite patent foramen ovale; no pericardial effusion; normal valves, left ventricular function normal; ejection fraction 56%



Worriedwell, every time I read a post of yours, my respect for you increases. When the coags came back normal, I was stuck. I would like to blame that on my MS1 infopenia. You have breathed new life into me.

Thanks for the kind words...and the hole in the heart makes me think that now we can have a mechanism for the clots to get to the brain (Solid is patting himself on the back as we all can see) especially with the crackles at the lung base (maybe PE related, although you might expect tachycardia and/or some tachypnea if the PE were big enough to cause crackles). Might want to doppler the legs.

 

[worriedwell]

oh yeah, one more thing...interestingly enough, I believe a PFO (patent foramen ovale) has some association with migraine headaches.

food for thought.

still don't get the muscle wasting diffusely though?

or the poor dentition, but that may just be evidence that this lady smokes more than she leads the doctor to believe (very common for people to underestimate/lie about their substance use)

By Achems razor though, something is unfulfilling...and saying somebody has migraines, plus strokes, plus something causing muscle wasting is not wholly satisfying.

 

[i61164]

Here's an interesting idea. We may not have been totally wrong about the DVT's. With a PFO, theoretically an embolism could start in the venous system and bypass the lungs via the PFO which would allow it to get to the brain.

However, at this point I am not going to order any more tests because I have a 12:15 deadline and I have to draw the line somewhere. They do not expect us to figure everything out. Actually they will probably be surprized that I got as far as I did (thanks to a little help from you guys). If I find out any more info about the case during my presentation/evaluation I'll let you all know.

 

[Doc Samson]

oh yeah, one more thing...interestingly enough, I believe a PFO (patent foramen ovale) has some association with migraine headaches.

food for thought.

still don't get the muscle wasting diffusely though?

or the poor dentition, but that may just be evidence that this lady smokes more than she leads the doctor to believe (very common for people to underestimate/lie about their substance use)

By Achems razor though, something is unfulfilling...and saying somebody has migraines, plus strokes, plus something causing muscle wasting is not wholly satisfying.

When I hear poor dentition and muscle wasting, I think of bulimia (already mentioned) and methamphetamine abuse. IV methamphetamine could also lead to venous emboli... but she'd have to be smoking it too to get the meth mouth (though her teeth could just be messed up b/c of bruxism from IV meth).

Too late, I know, but it seems like you've got your bases pretty well covered.

 

[i61164]

I found out that once everyone is done with their presentations and faculty evaluations, the "solution" to this case will be e-mailed to us. I'll post it when I get it so stay tuned.

 

[Surg Path]

Test: Echocardiogram (2D and M Mode)
Result: Normal left atrium size, left ventricle size, left ventricular wall thickness, right atrium and right ventricular size. Inferior vena cava not well seen; Intra-atrial septum show definite patent foramen ovale; no pericardial effusion; normal valves, left ventricular function normal; ejection fraction 56%



Worriedwell, every time I read a post of yours, my respect for you increases. When the coags came back normal, I was stuck. I would like to blame that on my MS1 infopenia. You have breathed new life into me.

MR findings make sense, as the speech problems make me think associative auditory cortex, i.e. anterior temporal lobe, and the speech delay could be something parietal.

I haven't a clue as to the etiology. Headaches are not common in MS, and I don't know how the poor dentition and decreased muscle bulk fit into the story.

One thought is a mood disorder secondary to the brain lesions. That might explain the poor hygiene, and decreased muscle bulk due to poor appetite.

Something theoretically possible, but not probable: if there is DVT, and patent foramen ovale, you could have a small embolism go to the left side of the heart and to the brain. Seems like a long shot though.

 

[i61164]

Well I am done with with my presentation and I passed. I haven't received the "solution" yet but one of my faculty evaluators did mention that the patient's asthma is not really asthma but a symptom of the PFO. It makes sense, but I would not have figured that out on my own. Interesting...

 

[i61164]

During my evaluation they told me that a CMP was done and they don't know why I couldn't get the results to come back, but that all results were normal. Also, in the write-up below, they say that an LP was done, but I coudn't get the results from that either. Weird. BTW, this was a real patient.


The patient initially presented to her primary care practice and had the MRI scheduled ASAP. Since the problems she was presenting with were not acute, it was felt the MRI would give more information. CT is the appropriate test for an acute presentation particularly if bleeding is in the differential (stroke, subarachnoid hemorrhage, etc) with the disclaimer given on report that strokes may not be manifested on CT until 48-72 hours have elapsed.
Once the CT report was obtained, the patient was sent to the ED and admitted to neurology for further workup. The multitude of labs were done while she was an inpatient. During the SPA, some of the labs raised questions as to why they were done. For example, a drug screen was done probably because of the appearance of the patient (thin, poor dentition, etc) and possibly due to her socioeconomic status. Pregnancy test was done (not a bad idea on any potentially fertile woman regardless of hx of taking oral contraceptives).
In essence, basically all he labs with the exception of the MRI, were normal or negative. She did have a lumbar puncture to rule out an infectious etiology of the MRI findings. All studies on the spinal fluid including cultures and other tests for viral (herpes), fungal and bacterial were negative. SHe had an extensive work up for a clotting disorder with all tests (thrombophilia screening) normal/negaitive.
The cardiac ECHO reported a patent foramen ovale and the mechanism for her probable embolic stroke(s) was found. This was a surface ECHO (done with transducer on the chest wall). She was started on anticoagulation with coumadin and discharged with referral to interventional cardiology for further evaluation and closure of the PFO. Interestingly, on follow up ECHO (this time done transesophageal = probe swallowed and images obtained without interference of chest wall), NO patent foramen ovale was found despite multiple injections of agitated saline, valsalva, etc. The cardiologist concluded that no PFO was present. The patient remains on anticoagulation.
Was there a PFO that somehow sealed, was the original ECHO interpretation correct, would doing the ECHO by surface instead of transesophageal create artifact that looks like a PFO?????? To the best that I can ascertain, the plans are to continue on the anticoagulation for a period of some months and redo the ECHO.
It is conceivable that her infarcts were related to migraine headaches. This phenomenon can occur (discussion with Pat Reynolds).
But, given the likelihood that there was some type on embolic event, there is no concrete answer as to why she would develop the emboli. In my opinion, most likely source of them would be pelvic vein thrombosis that otherwise was asymptomatic. She had no leg findings and negative dopplers looking for deep vein thrombosis in legs. She certainly was at some increased risk for thrombosis with her smoking history and use of oral contraceptives.

 

[Solideliquid]

During my evaluation they told me that a CMP was done and they don't know why I couldn't get the results to come back, but that all results were normal. Also, in the write-up below, they say that an LP was done, but I coudn't get the results from that either. Weird. BTW, this was a real patient.


The patient initially presented to her primary care practice and had the MRI scheduled ASAP. Since the problems she was presenting with were not acute, it was felt the MRI would give more information. CT is the appropriate test for an acute presentation particularly if bleeding is in the differential (stroke, subarachnoid hemorrhage, etc) with the disclaimer given on report that strokes may not be manifested on CT until 48-72 hours have elapsed.
Once the CT report was obtained, the patient was sent to the ED and admitted to neurology for further workup. The multitude of labs were done while she was an inpatient. During the SPA, some of the labs raised questions as to why they were done. For example, a drug screen was done probably because of the appearance of the patient (thin, poor dentition, etc) and possibly due to her socioeconomic status. Pregnancy test was done (not a bad idea on any potentially fertile woman regardless of hx of taking oral contraceptives).
In essence, basically all he labs with the exception of the MRI, were normal or negative. She did have a lumbar puncture to rule out an infectious etiology of the MRI findings. All studies on the spinal fluid including cultures and other tests for viral (herpes), fungal and bacterial were negative. SHe had an extensive work up for a clotting disorder with all tests (thrombophilia screening) normal/negaitive.
The cardiac ECHO reported a patent foramen ovale and the mechanism for her probable embolic stroke(s) was found. This was a surface ECHO (done with transducer on the chest wall). She was started on anticoagulation with coumadin and discharged with referral to interventional cardiology for further evaluation and closure of the PFO. Interestingly, on follow up ECHO (this time done transesophageal = probe swallowed and images obtained without interference of chest wall), NO patent foramen ovale was found despite multiple injections of agitated saline, valsalva, etc. The cardiologist concluded that no PFO was present. The patient remains on anticoagulation.
Was there a PFO that somehow sealed, was the original ECHO interpretation correct, would doing the ECHO by surface instead of transesophageal create artifact that looks like a PFO?????? To the best that I can ascertain, the plans are to continue on the anticoagulation for a period of some months and redo the ECHO.
It is conceivable that her infarcts were related to migraine headaches. This phenomenon can occur (discussion with Pat Reynolds).
But, given the likelihood that there was some type on embolic event, there is no concrete answer as to why she would develop the emboli. In my opinion, most likely source of them would be pelvic vein thrombosis that otherwise was asymptomatic. She had no leg findings and negative dopplers looking for deep vein thrombosis in legs. She certainly was at some increased risk for thrombosis with her smoking history and use of oral contraceptives.

LOL that is just beyond...

 

[Anasazi23]

But, given the likelihood that there was some type on embolic event, there is no concrete answer as to why she would develop the emboli. In my opinion, most likely source of them would be pelvic vein thrombosis that otherwise was asymptomatic. She had no leg findings and negative dopplers looking for deep vein thrombosis in legs. She certainly was at some increased risk for thrombosis with her smoking history and use of oral contraceptives.

OCP + possible PFO + smoker = possible embolic event

 

[Anasazi23]

BTW Sazi,

How common is this anyway? What I mean is, most of the time people throw clots into the lung, but the clots don't get to the brain unless there is a heart/septal wall defect right?

Yeah, it's not common, at least in my experience, but this is medical school, where they thrive on zebra meat.
🙂

 

[Anasazi23]

Darn..forgot about the spiral CT chest. Hopefully I won't make TOO much of a fool out of myself during intern year. Although I guess intern year would be the best time to make a fool out of yourself, because at least you are learning...

MRI for stroke, CT for masses..

Yes, but if you want an answer in 20 mins, get the CT to rule out big bleed. Though, due to test resolution, many infarcts won't show up until a day or two later.