Ya'll's thoughts on a PBL case

[Mr. Freeze]

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I don't know where else I could put this.

Elderly male presents at clinic approx. 1.5 hrs. after noticing R weakness and loss of functional motor control. Normally mobile and agile. He calls his daughter and they both come to the clinic.

We weren't given any neuro exam results, but there was R weakness. No CP or ShOB. He did have cardiac hx though, having had a bypass 2 years ago. He had returned via airplane from Boston the day before, and did have a mild bout of CP that abated with seated rest. This was at the airport. I think that covers what we were given, aside from these, or what I can remember:

Little tachy at 100 beats, nerves probably
Probably normotensive for him, 160/90
platelet count of 350
Normal BG
NSR
fixed split S2, systolic eject murmur
Had atrial septal defect with regurg into the LA by the colored US
RV hypertrophy

Only med he was on daily was ASA, they didn't say how much.

I don't know if we get closure in the sense that we find out what the problem is, or if we use it to learn more about the method of forming differentials. At any rate, I have my thoughts about the mechanism of what has happened which I'll reserve, but our moderator seemed to think I may be off. At the least, further imaging is needed/warranted...

 

[colbgw02]

the point of the exercise is most likely to go through the differential, but it sounds like they're going for a thromboembolus that crossed the ASD and caused a stroke.

first step is to get a non-con head CT to see if the stroke is hemorrhagic or not.

his underlying cardiopulmonary disease is most likely a red herring for his acute issue designed to spur discussion for the differential.

hope this helps.

oh, and it's y'all, not ya'll.

 

[glp]

I don't know where else I could put this.

Elderly male presents at clinic approx. 1.5 hrs. after noticing R weakness and loss of functional motor control. Normally mobile and agile. He calls his daughter and they both come to the clinic.

We weren't given any neuro exam results, but there was R weakness. No CP or ShOB. He did have cardiac hx though, having had a bypass 2 years ago. He had returned via airplane from Boston the day before, and did have a mild bout of CP that abated with seated rest. This was at the airport. I think that covers what we were given, aside from these, or what I can remember:

Little tachy at 100 beats, nerves probably
Probably normotensive for him, 160/90
platelet count of 350
Normal BG
NSR
fixed split S2, systolic eject murmur
Had atrial septal defect with regurg into the LA by the colored US
RV hypertrophy

Only med he was on daily was ASA, they didn't say how much.

I don't know if we get closure in the sense that we find out what the problem is, or if we use it to learn more about the method of forming differentials. At any rate, I have my thoughts about the mechanism of what has happened which I'll reserve, but our moderator seemed to think I may be off. At the least, further imaging is needed/warranted...

the main problem of the septal defect was flow from LA to RA which was shown on the echo and the cause of the RV hypertrophy but the above post hit the nail on the head as far as the diagnosis and cause.

 

[glp]

oh, and it's y'all, not ya'll.

and where i come from, it's ya'll.

 

[colbgw02]

and where i come from, it's ya'll.

http://en.wikipedia.org/wiki/Y'all

"Y'all is the Southern American English" - considering i'm from alabama, i'm gonna claim dibs on correct spelling when speaking with someone in oklahoma

from the above website:

Confusion with other Southern words
Though formerly another spelling of y'all, the word ya'll has changed pronunciation (from /y-all/ to /yull/) and meaning (from "you all" to "you will") for most Southerners. Because of this, it is generally considered by them to be ignorant or foolish to continue to use ya'll as a replacement for y'all. Y'all is also commonly misspelled as yall (a Southern pronuciation of yowl, pronounced /yahl/). Like ya'll, this is looked down upon and generally discouraged by Southerners, though some insist on yall in order to emphasize its role as a regular pronoun. These usage differences are generally cited in the same manner as how people often confuse their, there, and they're.

 

[Mr. Freeze]

Depending on how well I'm typing, sometimes its ya'll, sometimes its y'all...gig me for spelling y'all's, when "your" fits better 😀

When I heard the plane trip part, I thought thrombosis. But that would explain him coming in with PE, not a head clot; until they uncovered the ASD. Which in my mind, however small the chance, provides an opportunity for a venous clot to break loose and reach the head, even with the periodic flow from LA to RA.

I definitely agree it was more for the process.

And that he should get a CT. Now.

 

[Bad-Obsession]

the point of the exercise is most likely to go through the differential, but it sounds like they're going for a thromboembolus that crossed the ASD and caused a stroke.

first step is to get a non-con head CT to see if the stroke is hemorrhagic or not.

his underlying cardiopulmonary disease is most likely a red herring for his acute issue designed to spur discussion for the differential.

I think this is right on the money. Additionally the most likely place for small clots to lodge is the brain. The moment I hear Elderly + Plane Ride the first thing I start to think about is Deep Vein Thrombosis. 🙂

 

[Igor]

Weakness, shortness of breath, and chest pain have long, complicated differential diagnoses.

Look up the differential DDX for an S2 with a fixed split.

When you get a complex case like this, focus on the most unusual fact you've got (at least when it's not a real patient, any way).

Hope this helps.

 

[beastmaster]

I don't know if we get closure in the sense that we find out what the problem is, or if we use it to learn more about the method of forming differentials.

as everyone has said, the diagnosis is "paradoxical emoblism" unless new information suggests otherwise.

 

[deleted109597]

as everyone has said, the diagnosis is "paradoxical emoblism" unless new information suggests otherwise.

I think he also has a PE, from the previously diagnosed DVT. Chest pain and tachy and all.

 

[beastmaster]

I think he also has a PE, from the previously diagnosed DVT. Chest pain and tachy and all.

Yea, the PE causes right ventricular overload, increasing right heart pressure hence precipitating the PDE.

 

[Gut Shot]

Don't worry. We'll sort it out at autopsy.