Thank you to our PD emeritus Dr. Marshall Wolf & @tmmeade1 for kicking off the week with a case of syncope yesterday!
The 💰 is in the 🗣️! 1. Is this true syncope? Transient LOC + spontaneous and rapid recovery 2. How worried 😱 are you for 💔 etiology? Any ❤️ disease, new chest pain/palpitations, exertional or supine syncope, FHx sudden cardiac death, abnormal VS or ECG should set off 🚨
...May be reassured by syncope stable x years, with clear prodrome & trigger, in a younger individual (<40 y/o)
🤔 In thinking about worrisome etiologies, recurrent syncope less likely to be tamponade, dissection, ACS, PE but arrhythmia🔌💓 still on the table!
#TheBrighamFamily looooooooves a good TTE!
But consider ROMEO score (shout out to @tony_breu and @thecurbsiders) - a score of zero 99.5% sensitive for a normal TTE, so may not be needed in all comers with syncope!
In this case, our patient had recurrent syncope and recent event monitor:
Dropped beats concerning for Mobitz I vs. II - 2:1 block makes it challenging to distinguish!
While Mobitz II confers worse prognosis and ⬆️ progression to CHB, symptoms/syncope + 2nd degree block = class 1 PPM indication!
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Thanks to Dr. Carolyn Becker for a great discussion of ⭐️surprise!⭐️ osteoporosis 2/2 asymptomatic primary hyperparathyroidism!
There are MANY 2ndary causes of osteoporosis- use hx 🔎 to tailor work up. All comers get:
🧑🔬 BMP - Cr (CKD), Ca/Phos (⬆️⬇️parathyroid)
🧑🔬 LFTs - AST/ALT/bili (cirrhosis), ALP (bone turnover), albumin (nutrit. status)
🩸CBC - anemia ➡️ inflam, malabsorb
🦴 25 OH Vit D
In evaluation of hypercalcemia, PTH shapes your ddx!
🦴Inappropriately nl or ⬆️, ➡️ use urine Ca to distinguish from Fam Hypocalciuric Hypercalcemia
🦴Low PTH then can move on to more extensive work up - problems with AB or REsorption of Ca++