Thread by @CPSolvers

Friends, it’s time for another case, tweetorial style. #medtwitter #FOAMed #clinicalreasoning

An 85M with ischemic cardiomyopathy (EF 20%) with an AICD for primary prevention presents with a syncopal episode. Pause and think of your schema for syncope, and then check out this approach by @StephVSherman from @BCM_InternalMed
clinicalproblemsolving.com/dx-schema-sync…

He reports feeling lightheaded with standing and exertion for the last few weeks. His partner witnessed him lose consciousness for about one minute after getting out of bed this morning. Pause and think of your 4 common syncope mimics...

The four most common causes of transient LOC are: seizure, syncope, TIA, and hypoglycemia.

The patient also described dyspnea on exertion for the last two weeks. He did not have orthopnea, PND, chest pain, cough or fevers. Pause and think about your schema for dyspnea, and then check this one out from @BBroderickMD from @JohnsHopkinsDOM
clinicalproblemsolving.com/%20dx-schema-d…

Challenge yourself and think about what diagnoses live here…

Before you obtain a detailed history, you notice this as soon as you walk in the room.

AF, HR 88, BP 112/72, SpO2 98%RA, hR 12 breaths min.
RRR. S1, S2. No m/r/g. JVP @ mandible @ 90 degrees. Lungs clear. Abdomen nl. Face plethoric. Upper extremities w/ 2+ edema. Dilated veins over the anterior chest wall above the nipple line which flow towards the umbilicus.

What is your leading diagnosis?

A CT chest with contrast revealed a patient distal SVC (left) but there was a lack of opacification of the SVC above the level of the azygous arch secondary to a catheter-associated SVC thrombosis (right).

Impaired venous drainage accounts for the majority of symptoms from SVC syndrome. Facial, neck and upper extremity edema are the most common.

A low cardiac output state from impaired venous return can result in pre-syncope, syncope, and dyspnea on exertion. Airway compromise and stroke can result from laryngeal and cerebral edema, respectively.

Malignancy (lung, lymphoma, germ cell) account for up to 60% of cases. Intravascular devices are the second most common cause. Rare etiologies include fibrosing mediastinitis and compression by a thoracic aortic aneurysm. Check out this awesome reference

The patient was diagnosed with catheter-associated SVC thrombosis. Balloon angiography of the SVC was performed along with anticoagulation. His symptoms have improved; discussions regarding the management of his AICD are ongoing.

SVC syndrome wasn't in either of our syncope or dyspnea schemas. Where do you think this Dx belongs in these two approaches? #crowdsourcing