-3 times in 1 month she’s gotten up from sitting and passed out. Darkened vision each time.
-First one witnessed by sister. She woke up w/in 1m. No confusion.
-Fatigue for the past 3-6mo
-No fevers or chills but she’s had a 10 lbs weight loss this year
-DM and HTN
PSH: appy, chole
Soc: 3 drinks per week, 20ppy smoking history
FH: no malignancy, heart disease, liver disease
Patient said she has had an ammonia twice already this year.
VS: 110/60, HR 80, SpO2 99%, 37*C
Gen: pale, tired appearing
HEENT: pale conjunctiva
Cards: rrr, flow murmur at rusb
Abd: ntnd, nabs
Rectal: no blood, guiac neg
Skin: no rashes
Neuro: nl. AaOx3
You guys are awesome.
Ca 10, Alb 2.9
Orthostatics SBP 110, 95, 89; HR up by 5 only on standing.
Tongue seems big.
More thorough Neuro exam: she does have a distal polyneuropathy
And a skull x-ray (radiopaedia):
This sentiment (“This doesn’t make sense”) is perfect. Don’t search satisfice! Don’t throw away discordant data!
SPEP/UPEP confirm monoclonal protein. The skull X-ray suggests MM
The patient eventually gets a diagnosis of multiple myeloma (biopsy confirmed)
The thought here is that she had multifactorial causes of syncope:
-anemia from MM,
-low grade volume depletion from hctz and fatigue leading to poor appetite
-? Autonomic neuropathy from ? Concurrent amyloidosis given her polyneuropathy, big tongue
A shorter case this week overall, but the point is: chase down the threads.
When something doesn’t make sense, let it linger. Stop. Think. The diagnosis may be different or deeper than you think.