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CC: “I think I passed out”
HPI:
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.
Continuation of HPI
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. He estimates that it has been about an hour since he first felt dizzy.
ROS: 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. He denies headache, new cough or difficulty breathing, nausea/vomiting/diarrhea.
PMH:
HTN
Medications:
Amlodipine
Hydrochlorothiazide
Family History:
Unknown as he was adopted.
SH:
Smokes 2 packs per day. Rare alcohol use. Mr. Klein has worked as a truck driver for 17 years, with routes limited to the Midwest states. His diet is primarily from fast food chains or restaurants near his usual stops. He exercises very little though he does take half-mile walks with his wife 3-4 times per month.
VS: T 36.5º, HR 126, BP 160/100 in his right arm, RR 18, oxygen saturations are 95%
Gen: appears anxious, talkative
HEENT: Oropharynx clear, tympanic membranes clear. 2x2 cm painful erythematous swelling on right forehead. Mucus membranes moist and pink.
CV: tachycardic, no murmurs, regular rhythm, no carotid bruit and no jugular venous distension at 30 degrees elevation of head of bed
Pulm: diminished but clear bilaterally, no crackles or wheeze. No increased work of breathing.
Abd: obese, non-tender, non-distended, 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, strength equal in bilateral upper and lower extremities.
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 155/95
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-I of 34 ηg/L 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 fluids. 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 EKGs 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. A stat consult is placed to Dr. Singh, the cardiothoracic surgeon on call. He explains the CT findings and recommends emergency surgery, without which he will likely die. He also informs Mr. Klein and his wife of the significant risk of stroke and renal failure after surgery. They agree to surgery, and he is taken directly to the operating room.
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 ED in Pennsylvania to discuss Mr. Klein’s care and his new diagnosis, relating that his condition was critical by the time he arrived home. The ED physician flags Mr. Klein’s record to be discussed at their next group meeting.
