Thread by @RosenelliEM

Time for some #SpacedRepetition: @CPSolvers @DxRxEdu @rabihmgeha
Chat recap of the #ClinicalPearls #VirtualMorningReport

August 10th Episode 113: clinicalproblemsolving.com/morning-report…
w/ @kiaracamacho96 @RizwanDania & Maria Jose Vides
Teaching points illustration by Sukriti Banthiya

Let's start with an initial problem representation:

A 73 y/o M w/ a pmh of DM2, depression, hypoTh, BPH presents w/ a few days of nocturia & LE pain & brought in bc he was found lying on the floor of his bathroom disoriented after experiencing dizziness, blurry vision & falling

Was this fall a syncope or seizure?

Sounds like reflex vs orthostatic syncope but keeping all buckets open.

Foresee an EEG & MRI to check for seizures...

A hx of any cardiac disease will be helpful. also thinking about syncope mimics - stroke, seizure, hypoglycemia

Also, check a CK for possible Rhabdo and a lactic acid (makes seizure more likely)

is this disorientation post-ictal?

Check out this graphic illustration for transient confusion by @JoshMedPeds

https://twitter.com/JoshMedPeds/status/1258141961283874816

Always concerned about possible internal bleeding in anybody above 60-70s. But more concerned with the dizziness and blurry visión.

What else can cause postural dizziness? Check his med list specifically for anticholinergic, muscle relaxers, pain meds, etc

His blood pressure is normal at 120/85 with a pulse of 95 but would likely check orthostatics

Also, check for systolic murmurs - Aortic Stenosis or MR??

His exam shows loss of sensation in both LE, normal strength and reflexes

Make sure he doesn't have cauda equina or conus

Loss of sensation in both legs points more peripheral than central

How late can rheumatic fever present?

usually in childhood - but MS/AS present much later usually

Apparently, it can present past 60...jamanetwork.com/journals/jama/…

It usually presents at an average age of 6.5-17 depending on the study. This one from JAMA found that among 3,741 patients with rheumatic fever entering Bellevue Hospital from 1911 to 1919, Lambert found 91 over the age of 60.

What about an atrial myxoma? What type of murmur would one have?

The murmur of a left & right atrial myxoma can have similar auscultatory findings as mitral and tricuspid stenosis, respectively.

It is typically a mid-diastolic, crescendo diastolic murmur.

The diastolic murmur occurs as the atrial myxoma causes atrioventricular valve obstruction.

A Case Report of a Left Atrial Mass: The Importance of a Detailed Physical Exam, ncbi.nlm.nih.gov/pmc/articles/P…

I would get a CBC, CMP, CK, Lactic acid, CT head, CT lumbar spine, ECG, and a UA to start.

Hyponatremia (125), otherwise normal renal function, normal WBC, mild anemia, nml plts.

b12 low at 110 which could be causing the neuropathy

Labs cont.

mildly elevated TSH at 14 (no free t4 or total t3 given)

An abnormal UA with 40 wbc/hpf that grew ecoli

Lets tackle the hyponatremia, activate schema

Next we need serum osm. his is 266. Great that makes it true hypo-osmolar

Next we need urine osm. his was 138. This rules out primary polydipsia, tea and toast diet or beer potomania

Always ask about diet and water intake. Patients always note being told to drink a lot of H20

Next check urine Na. His was 26 which puts it in the bucket of decreased arterial blood volume vs SIADH.

Next step is to give an NS challenge. If the Na improves it is decreased arterial blood volume. If it gets worse it is SIADH.

clinicalproblemsolving.com/dx-schema-hypo…

He is on an SSRI and we know that SSRIs cause SIADH

Hyponatremia as a fall predictor in geriatric trauma population. pubmed.ncbi.nlm.nih.gov/25065652/

Of the 2370 geriatric trauma admissions during the study period, there were 1841 (77.7%) falls admissions & 293 (12.4%) pts were hypoNA

He is on an SGLT2, and they can also predispose people to limb ischemia as well as euglycemic DKA

Here is a list of side effects. pubmed.ncbi.nlm.nih.gov/29485006/

Why does he have a b12 deficiency? Is he vegan?

He is on metformin though

Long-term Metformin Use and Vitamin B12 Deficiency

Long-term use of metformin in DPPOS was associated with biochemical B12 deficiency and anemia. Routine testing of vitamin B12 levels in metformin-treated patients should be considered. ncbi.nlm.nih.gov/pmc/articles/P…

His EMG showed neuropathy likely from his B12 def and his fall was considered multifactorial from the low sodium UTI, paresthesias causing LE pain and multiple medication interactions including a new herbal supplement.

Remember to check a list in the elderly pt w/ falls

@GurleyGuy @AndreaAnampaG @AnthonyPensa @lakh_malla @PGuptaMD @YihanYangMD @DanielCLiauw @ASanchez_PS @AbelJosephMD @BrentChamMD @this_is_svenka @SurajNagaraj @dminter89 @Doc_Fomin @AnnKumfer @DoubleDawgMD @Anand_88_Patel @MikeRoseMDMPH @haematognomist

@Sharminzi @ArsalanMedEd @ecvasti @JonathanRyderMD @RezidentMD @GurleyGuy @appyjumpindaze @justalisongrace @DavidTHLam @BethGay45 @BrandonKinneman @rongejman @BryanCUlrich @victorekuta @danaamara1 @NishaSunkuMD @pri_athavale @BhavyaVarma12 @sargsyanz @StephVSherman

@noahrosenberg @JFBirnbaum @chioma_ndukweau @andressa__k @PeytonNesmith @blairgolden @BP76104 @Gurpreet2015 @mBohlega @INizamuddinMD @AlexHorneMD @EricaLCrosley @AJ_Kurtzman @miniisms @dsouzl @AaronLTroy @danielgauvin07 @AdamLongMD @d_dressler92 @Chris_Lees_

@tmodarressi @DanielleEngskow @AnneArnason @AmandaGarfinkel @mBohlega @Tapatio117 @DoctorVig @travishughes @activist_doc @franklybryan @_HarryPaul_ @Baker_C23 @FZghyer @RamlaKasoziMD @_blake_smith @LizzyHastie @AzeemRathore_ @AchantaAditya @Jcortesizaguirr @ShrutiKoti

@Azooz_Asbeutah @saipeeps @JordanSell22 @RizwanDania @Kaitlyn_Rogers9 @LawrenceWuMD @buckeye_sanjay @dmottacalderon @vikramagn @maheen_ihsan @efloyd14 @cobbnotgrey @Azooz_Asbeutah @onsarigo93 @Dayyan95 @tarheel_doctor @Anouf14 @VCU_IMRes @coyefish379 @amrmousa96 @Elizabe19893579

@Gurleen_Kaur96 @AshleyGWallace @Vandylism @RWBonner91 @abhiappukutty @PeguyTelusma @3owllearning @arturohdez_i @PaulKunnath @medrachel @sukritibanthiya @abdallah_tom @OpsBug @fernandbteich @LindseyShipley8 @OpsBug @smalltownOMS @sathya27024741 @SwainNordstrom @INizamuddinMD

@tonlajr @RobWeberMDPhD @ABRezMed @hraza222 @Rafameed @settinger_ @medrachel @Flower_freeland @amrmousa96 @TheRealDSrini @kiaracamacho96 @RizwanDania