Presented by Claire Jensen, MD
CC: “She passed out,” per EMS.
HPI: A 63 year-old African-American female presents to the emergency department by ambulance following a witnessed syncopal episode at a casino. Upon her arrival in the ED, the majority of the history is obtained from EMS as the patient is actively vomiting. She was seated at a slot machine with friends when she suddenly slumped to the floor unconscious. She did not complain of feeling ill and was acting normally prior to the syncopal episode. Within seconds of landing on the floor, she regained consciousness. Initially she was somewhat slow to respond, but was alert and oriented, responding normally by the time the paramedics arrived. She vomited once, and was transported to the ED. A blood sugar was obtained in the field, 130 mg/dL. Upon arrival, she complains of “just not feeling well” and continues to vomit. She also complains of severe headache “all over” and some blurred vision. She denies vertigo, chest pain, shortness of breath or abdominal pain.
ROS: Negative except as mentioned in the HPI.
Allergies: None known.
SH: Life-long non-smoker, non-drinker, and does not use illicit drugs.
VITAL SIGNS: BP 200/104, P 102, R 16, T 36.3, SpO2 99% on room air.
GENERAL: Alert and oriented x3, initially answers questions appropriately, diaphoretic, moderate distress from vomiting.
HEENT: Head is atraumatic, normocephalic. Pupils are 2 mm bilaterally and minimally reactive to light. Mild disconjugate gaze is noted, with slight temporal deviation of the left eye. No nystagmus. No conjunctival injection or pallor. No scleral icterus. Funduscopic exam attempted but unable to perform due to the patient’s continued vomiting. Tympanic membranes are normal. No nasal drainage. Moist mucous membranes, no tonsillar enlargement.
NECK: Supple without lymphadenolpathy. There is no nuchal rigidity, no carotid bruits.
CARDIOVASCULAR: Tachycardic, normal S1, S2, without murmurs, rubs or gallops.
RESPIRATORY: Lungs are clear to auscultation bilaterally.
GASTROINTESTINAL: Abdomen obese, soft, non-tender, non-distended, without masses or organomegaly. Bowel sounds present.
MUSCULOSKELETAL: Normal muscle bulk and tone. No deformities. Unable to perform muscle strength testing due to patient’s decreasing ability to follow commands. She moves all extremities spontaneously. Peripheral pulses are 2+ and symmetric in all four extremities.
NEUROLOGIC: Unable to assess orientation due to patient’s continued vomiting, The patient is noted to have increasing difficulty following commands. Disconjugate gaze as noted above. The face is symmetric. DTRs were not assessed. Babinski is down-going bilaterally.
Near the completion of the physical exam, the patient suddenly became unresponsive with snoring respirations and minimal gag reflex. IV access was obtained, and the decision was made to intubate the patient so that emergent CT scan of the head could be obtained.
1. This is the patient’s CT (without contrast). What is the diagnosis?
A. Brain tumom
B. Epidural hematoma
C. Interparenchymal hemorrhage
D. Subarachnoid hemorrhage
E. Subdural hemorrhage
2. Which medication should be considered for use as an adjunct to rapid sequence induction in this patient?
B. Defasciculating dose of vecurionium
3. A 49 year-old man presents after he fainted while running on his treadmill at home. He has been having exertional dyspnea and angina for the past several months. Which of the following cardiac diseases is most likely to cause these symptoms.
A. Aortic stenosis
B. Atrial septal defect
C. Mitral incompetence
D. Pulmonary stenosis
E. Tricuspid incompetence
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