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ODULE # 8 CASE STUDIES
THE CARDIOVASCULAR DISEASE
A 58 year old African-American woman, with Sickle cell trait is complaining of what she describes as “migraine” on the left side that has been getting worse over the last 10 days. She is obese (you notice she has trouble getting out of her chair), diabetic and she’s been taking Glucophage, she is also hypertensive and she’s taking Norvasc.
She states that she used to have regular migraines earlier in her life but “they stopped” right before she reached menopause. This time the “migraines are back” and they are so severe that she must stop whatever she’s doing even eating is painful. (she’s a tax preparer and she can not look at the computer screen anymore). No nausea or vomiting, examination reveals BP 155/90, and tenderness over the left side of scalp. Her father died from a stroke at 65 and her mother is 82 with a bypass surgery at 67.
1. You pick up your prescription book and you write Rx___________________________? (all I need is a drug name)
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ID/CC A 57 year old man of Ashkenazi Jewish descent complains of severe, cramping pains in his calves that prevent him from walking, esp. the left side.
HPI The patient states that the pain comes mainly after walking to work – which he does daily – but nowadays he can not walk the whole distance anymore before stopping for rest midway. More recently it has appeared, accompanied by numbness, following mild exertion and at rest. Hx of smoking two packs of cigarettes per day for many years.
PE Pallor; cyanosis; coldness on the affected leg. Tips of toes of affected leg are shown in the picture.
1. What is the Diagnosis?
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ID/CC A 79 year old white woman complains of a throbbing, unilateral headache that is most severe around her forehead and temples.
HPI She has had recurrent bouts of fever over the past year and also complains of malaise and muscle aches. She reports some weight loss and occasional vision problems in her right eye. She also reports pain in her mandible when she is eating.
PE VS: fever. PE: tenderness to palpation over the jaw and the left temples
Labs CBC: normal white blood cell (WBC) count; mild anemia. Markedly elevated erythrocyte sedimentation rate (ESR).
1. What is the diagnosis?
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ID/CC A 48 year old male with a history of hypertension is brought by ambulance to the emergency room because of the development of sudden sharp, tearing, intractable left chest pain with radiation to the back.
HPI When he first arrives, he shows a declining level of consciousness, becomes pale, dyspneic, and oliguric, and is unable to move his left arm and leg; subsequently he faints.
PE VS: marked hypotension (BP 90/50) in left arm, with significantly different reading in right arm (170/80). PE: pallor; cyanosis; diaphoresis; indistinct heart sounds; aortic murmur; reduced breath sounds; anuria; left-sided hemiplegia.
Labs ECG: no evidence of myocardial infarct.
1. What is the Diagnosis?
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ID/CC A 24 year old man complains of easy fatigability, dyspnea on mild exertion, and pain in the chest (angina pectoris).
HPI He also admits to having occasional spells of lightheadedness and fainting while playing basketball.
PE Systolic ejection murmur to right of sternum
Labs ECG: left ventricular hypertrophy
1. What is the Diagnosis?
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ID/CC A 25 year old female complains of low-grade fever and myalgia of three weeks’ duration
HPI She has a history of rheumatic heart disease (RHD). One month ago, she underwent a colonoscopy to rule out polyposis.
VS: fever. PE: pallor; small peripheral hemorrhages with slight nodular character; small, tender nodules on finger (look the pic) and toe pads; petechial hemorrhages on conjunctiva, oral mucosa, mild splenomegaly; apical diastolic murmur on cardiovascular exam.
1. What is the Diagnosis?
Solution:
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CASE STUDY # 1:
A 58 year old African-American woman, with Sickle cell trait is complaining of what she describes as “migraine” on the left side that has been getting worse over the last 10 days. She is obese (you notice she has trouble getting out of her chair), diabetic and she’s been taking Glucophage, she is also hypertensive and she’s taking Norvasc.
She states that she used to have regular migraines earlier in her life but “they stopped” right before she reached menopause. This time the “migraines are back” and they are so severe that she must stop whatever she’s doing even eating is painful. (she’s a tax preparer and she can not look at the computer screen anymore). No nausea or vomiting, examination reveals BP 155/90, and tenderness over the left side of scalp. Her father died from a stroke at 65 and her mother is 82 with a bypass surgery at 67.
You pick up your prescription book and you write Rx___________________________? (all I need is a drug name)
ANSWER
If you prescribed anything other than steroids (and must be in high doses & for a long time too) then the scenario would go something like this; after 4 weeks or so you hear from the woman’s lawyer as she lost vision in her left eye, you have a multimillion dollar malpractice suit against you, the board called to inform you that your license has been revoked pending investigation…it’s dark, it’s raining & your car wouldn’t start…..ok ok, so I got carried away a little:-)
Failure to recognize this condition would result in a permanent loss of vision.(and hence the drama). This is a case of Temporal (Giant cell) Arteritis which should be on your mind for any “new” onset headache in a person over 50 and with visual symptoms (the computer). Don’t you ever forget that condition! The sickle cell trait part is just a “throw off” to think other pathology, and that actually happens quite frequently in clinical practice.
Classic story, a woman in a long term care facility (yes it’s most commonly seen around 60-65, but can occur at a younger age and could be in a man too) complains with a “new” onset of one sided (could be bilateral too) headache over the temples with tenderness over the course of the temporal artery (that’s the scalp part).
The headache episodes are accompanied by blurring of vision or temporarily loss of vision – the computer part. These are your key Sx. Rx like we said is high dose Steroids, then refer to a surgeon for Temporal Artery Biopsy, but STEROIDS FIRST. Without waiting for biopsy results or even MRI. A dramatic relief from the steroids.
The other thing that we can learn from this case is the constellation of symptoms, and esp. at this age group. You would wish to see “isolated” pathologies like the way we study them but that does not happen in real life. And this age population is famous for having plastic bags filled with amber vials!
So you must differentiate between their existing conditions, complications of those conditions, side effects of the drugs, compliance taking the meds, and then the onset of a totally ‘new’ pathology, like this one.
The same case is listed later in the case studies with the same Sx only written out like it is in a textbook, and indeed almost all of you, if not all, got it right then.
The part in this case where she has trouble getting out of the chair is NOT because she is obese, but because this condition is commonly associated with Polymyalgia Rheumatica (PMR), a condition of weakness of “proximal” muscles (like glutes and shoulders), a topic to be discussed when we get to the musculoskeletal week. And the part of eating is because of Jaw claudication (ischemia to mastication muscles) common with the same pathology. Hope we made an important clinical point here, and I hope you will never forget this case….. To purchse full solution click below