| View previous topic :: View next topic |
| What is your most likely diagnosis? |
| Psychosomatic disorder |
|
0% |
[ 0 ] |
| Cervical radiculopathy |
|
0% |
[ 0 ] |
| Stroke |
|
0% |
[ 0 ] |
| TIA |
|
80% |
[ 8 ] |
| Pancoast tumor |
|
0% |
[ 0 ] |
| Malingering |
|
10% |
[ 1 ] |
| Diabetes mellitus neuropathy |
|
10% |
[ 1 ] |
|
| Total Votes : 10 |
|
| Author |
Message |
CCS Master
Joined: 06 Apr 2007
Posts: 14
|
 Posted: Wed May 16, 2007 11:00 pm Post subject: Intermittent right-sided weakness |
 |
|
Okay, let's go to the next round:
Setting: Office
Vitals: BP 150/98 P 90 RR 16 T 37.4 C
72 year old caucasian male who presents in your office for "weird" sensations in his right arm. This happened 2 times in the last 2 weeks and disappeared after about 10 minutes. During these episodes, he couldn't really do "anything" with his hand - such as holding a glass or turning a key. This never has happened before in his life. He never has been in a hospital or at a doctor's office (except in childhood for the flu) because he was never "really sick".
Meds: He does not take any medication.
FH: His father died at age 60 suddenly - nobody knew what was the cause. Mother died at age 85 "of old age".
SH: He smoked about 5 cigarettes a day for about 30 years but quit ten years ago. He does not drink alcohol. He is a retired office worker and lives alone.
What would you do next?
_________________
*** There is no case too hard! ***
By the way:
Print your own CCS cases for free on http://www.usmlehelp.com/?usmle=print3 |
|
| Back to top |
|
 |
TobiBobi
Joined: 16 Sep 2006
Posts: 74
|
| Posted: Thu May 17, 2007 9:04 pm Post subject: |
|
|
Alright...
I'd do Vitals, and a focused physical exam (cardiovascular, neuro).
Then, regardless of the outcome, I'd transfer him to the ward.
Not sure, but I would probably do some ABGs, but not sure how it works in an Office setting. Definitely PulseOx, though. |
|
| Back to top |
|
|
Usmilie
Joined: 18 Sep 2006
Posts: 30
|
| Posted: Tue May 22, 2007 4:29 pm Post subject: |
|
|
In would also do a neuro exam and check the heart for arrhytmia and the carotids for bruits...
_________________
------------------------
Keep always smiling!
 |
|
| Back to top |
|
|
CCS Master
Joined: 06 Apr 2007
Posts: 14
|
| Posted: Tue May 29, 2007 6:23 pm Post subject: |
|
|
Okay, you would redo the vitals and do a neuro and cardiovascular exam!
Good - these are the pertinent exams you should at least do.
The new vitals are: BP 153/99 P 89 RR 15 T 37.3 C
Neuro exam: WNL (No deficits, normal motoric and sensory)
Cardiovascular exam: Tachycard but regular rhythm. S1 and S2 normal. No murmur but distant bruits audible. If you listen to the carotids, you hear bruits bilaterally - more on the left.
What would you do next?
_________________
*** There is no case too hard! ***
By the way:
Print your own CCS cases for free on http://www.usmlehelp.com/?usmle=print3 |
|
| Back to top |
|
|
drpsycho
Joined: 16 Feb 2007
Posts: 16
|
| Posted: Wed May 30, 2007 10:26 pm Post subject: |
|
|
| Doppler sonography of the carotids. BMP (glucose)... EKG, Perhaps a dobutamine stress test (don't want the guy to throw an embolism, so I'm not sure)... |
|
| Back to top |
|
|
CCS Master
Joined: 06 Apr 2007
Posts: 14
|
| Posted: Fri Jun 22, 2007 12:31 am Post subject: |
|
|
| drpsycho wrote: | | Doppler sonography of the carotids. BMP (glucose)... EKG, Perhaps a dobutamine stress test (don't want the guy to throw an embolism, so I'm not sure)... |
Doppler of the carotids: Non-free floating plaques with 75% stenosis in the left internal carotid artery. 25% stenosis in the right internal carotid artery.
Glucose: 105
EKG: essentially normal
I would not do a Dobutamine stress test. If you are concerned about a cardiac ischemic event then yes. But this does not seem to be the case. However, before doing such an (expensive - you have to be also cost effective) exam and you would be concerned about a cardiac ischemic issue, the first things to do would be EKG and cardiac enzymes. These are quick exams and based on these findings you should go further with your diagnostic workup and treatment.
What do next?
_________________
*** There is no case too hard! ***
By the way:
Print your own CCS cases for free on http://www.usmlehelp.com/?usmle=print3 |
|
| Back to top |
|
|
SpeBeeTo
Joined: 16 Sep 2006
Posts: 44
|
| Posted: Mon Jul 30, 2007 11:30 pm Post subject: |
|
|
Well, I think Doc Psycho thought that it might be an embolic event in the heart, and you wouldn't want to do a stress test for the guy if he's going to throw an embolism.
At least that is my opinion.
Anyone else?
_________________
If you can't win somebody over................ then at least confuse them! (My dad) |
|
| Back to top |
|
|
Usmilie
Joined: 18 Sep 2006
Posts: 30
|
| Posted: Fri Aug 31, 2007 3:28 pm Post subject: Call the surgeon! |
|
|
Well, since the Doppler of the carotids shows non-free floating plaques with 75% stenosis, I would consult a vascular surgeon to do an endarterectomy.
_________________
------------------------
Keep always smiling!
|
|
| Back to top |
|
|
Alienbrain
Joined: 21 Sep 2006
Posts: 22
|
| Posted: Sat Sep 01, 2007 3:06 am Post subject: Endarterectomy |
|
|
Yep, absolutely agree - he needs vascular surgery!
(...and I am a poet and don't even know it!  ) |
|
| Back to top |
|
|
CCS Master
Joined: 06 Apr 2007
Posts: 14
|
| Posted: Sun Sep 02, 2007 2:55 pm Post subject: TIA - Transient ischemic attack secondary to microemboli |
|
|
Excellent! That was the final step. The patient finally needs a surgical consult for endarterectomy because of significant/symptomatic carotid artery stenosis and showered microemboli.
We are done with this case. - ENCOUNTER CLOSED!
_________________
*** There is no case too hard! ***
By the way:
Print your own CCS cases for free on http://www.usmlehelp.com/?usmle=print3 |
|
| Back to top |
|
|
|
FAQ
Search
Memberlist
Usergroups
Register
Profile
Log in to check your private messages
Log in
