, 11 tweets, 10 min read Read on Twitter
It’s #TwitterReport time!

We give you a case. You ask us questions. Everybody learns.

A 77yoF presents after passing out. This is the 3rd time it has happened. Most recently, she stood up, got dark vision, and woke up on the floor.

What else do you want to know?

1/ #TwitterReport

-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
2/ #TwitterReport

-DM and HTN

-metformin, hctz

PSH: appy, chole
Soc: 3 drinks per week, 20ppy smoking history
FH: no malignancy, heart disease, liver disease
3/ #TwitterReport

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
4/ #TwitterReport

Basic labs:
WBC 7, Hb 9, Plt 185

Na 134, K 4, HCO3 24, BUN 24, Cr 2.0, gluc 200

TSH 1.5

You’ve seen the history, exam, labs. What else do you want to know?
@Ndouthit @mgsimonson1 et al.
5/ #TwitterReport

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):
6/ #TwitterReport

@mgsimonson1 brings up a good point (No, he doesn’t know what this case is 😉): the anemia doesn’t seem severe enough to cause this much orthostasis. Many others suggested an autonomic neuropathy— @cmallarino connects this with ?MM or Waldenstrom with amyloid
7/ #TwitterReport

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)
8/ #TwitterReport

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
9/x #TwitterReport

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.
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