Mr. John Klein is a 62-year-old male from New Jersey who drives a truck long-distance for a living. While driving on his route, he begins to feel dizzy and faint, so he pulls over. He thinks he must have passed out because he woke up with his head on the steering wheel, and he has a bump on his forehead. His chest and left side of his neck were hurting, so he got off the expressway and drove to the nearest emergency room, in a rural area of Pennsylvania. In triage his blood pressure is 160/100 in his right arm, his heart rate is 126, and his oxygen saturations are 98%. He sees the ER doctor a few minutes later, and estimates that it has been about an hour since he first felt dizzy.
He is a smoker, and takes amlodipine and chlorothiazide for high blood pressure. He tells the ER doc that he is otherwise healthy, and that he has never had symptoms like this before. He is not dizzy lying down, but dizzy when he gets up to go to the bathroom. He is still having pain and rates it as 3/10 for the nurse.
The doctor records his physical exam in the chart as below:
Gen: appears anxious, talkative
HEENT: Oropharynx clear, tympanic membranes clear, no jugular venous distension at 30 degrees elevation of head of bed. 2x2 cm painful erythematous swelling on right forehead. Mucus membranes moist and pink.
CV: tachycardic, no murmurs, regular rhythm.
Pulm: clear, no crackles or wheeze. No increased work of breathing.
Abd: obese, NTND, no organomegaly.
Ext: pulses palpable in all four extremities. All four extremities are warm and well perfused without edema.
Neurologic: cranial nerves symmetric, gait not assessed due to history, strength equal BUE and BLE.
A head CT is performed due to the history of head trauma and is normal. Orthostatic blood pressure and heart rates are taken and are reported as: laying down HR 101 BP 160/100, sitting up HR 129 BP 155/05, standing HR 152 BP 150/90.
Kidney function, electrolytes, and blood counts are all normal. A D-dimer is performed and is normal. Bedside cardiac enzymes show a troponin of 0.034 ηg/mL and a CK-MB of 5.1 ηg/mL.
An EKG is performed 10 mins after coming to the ER and is shown:
A chest x-ray is taken, shown:
Mr. Klein is given sublingual nitroglycerin, aspirin, morphine, and supplemental oxygen. He is also given 2 liters of IV fluid. The pain gets better with the morphine, and he is less dizzy after getting the fluids. He is kept for observation in the ER for 8 hours, and repeat troponins and EKG’s are performed every 4 hours with no changes. After 8 hours with no changes, the next-shift ER doctor comes in and explains that they are not exactly sure what happened to cause his symptoms, but he is not having a heart attack and so he is being released to follow up with his regular doctor back home.
He continues to have the pain off and on during his 6-hour drive home, and feels dizzy again by the time he arrives home. His wife takes him to their local ER, where the same diagnostic tests that have already been performed above are repeated. The only test that has significantly changed is the chest x-ray, shown below.
A stat Chest CT is performed to confirm the suspected diagnosis, shown below. He is subsequently rushed to emergency surgery, and his wife is told he may not live through the night.
Mrs. Klein who is a retired nurse, calls Dr. Rosen, the couple’s primary care doctor and relates the whole story. With Mrs. Klein’s permission, Dr. Rosen then calls the ER doctor in Pennsylvania to discuss Mr. Klein’s care and his new diagnosis, relating that his condition was critical by the time he arrived home.
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