Case #61 "The Last Cruise"
by Charlene Babcock Irvin, MD
A
spry 68 y/o female presents after syncope.
She is with her sister. The history is
peppered with comments about their last
cruise. They just arrived back today, and at
the airport, she had a brief episode of
syncope. She was waiting for the luggage
when she described feeling very dizzy,
lightheaded, and then she sat down. Her
sister said she was unconscious for only
about 15 seconds. There was no seizure
activity. The security responded, but they
declined any medical assistance at the
airport, and just decided to come directly
to the ED here as it was close to their
home.
Past Medical History: History of mild
hypertension. The patient noted she just
stopped eating any salt, and then didn’t
need any medication. Last blood pressure
check in the pharmacy was “OK”
(approximately one year ago). She hasn’t
seen a doctor for years and isn’t sure if
her previous doctor is still in practice.
(“I avoid doctors…that’s why I’m still
here!” she adds with a smile.)
Past Surgical History: She had a
hysterectomy ‘years ago’.
Medications: None
Allergies None
Social history: They were both retired
school teachers, neither was ever married.
“We just have each other”. No smoking but
they do have some wine with dinner
occasionally. They just got back from a
cruise in the Caribbean, and flew directly
from Miami to Detroit (2.5 hours) just
before the syncope episode.
ROS: No fevers, no chills, no cough, no pain
anywhere (including no chest pain). No
shortness of breath, no abdominal
complaints, she had a normal BM three days
ago, but she usually goes every day
(traveling “always binds me” so mild
constipation was not unusual). She was
slightly nauseous with the episode, but no
vomiting. She did get ‘clammy’ per her
sister, but that has resolved. No unusual
exposures while on the cruise (“We mostly
shop.”)
PE: Well developed female in no acute
distress.
BP: 100/60, RR=20, HR=100, Temp=98F, Sat=98
HEENT: Unremarkable
HEART: RRR, systolic murmur present (3/6)
New per patient: “That’s news to me, but I
haven’t been checked in a while!”
LUNGS: Clear bilaterally
ABD: Slightly obese, no tenderness, no
masses. No palpable AAA. BS present.
EXT: No rashes. No palpable cords or edema
to legs.
NEUROLOGIC: Non-focal
1.
What is the differential?
2.
What do you need to do? What tests to order?
3.
What is the San Francisco Syncope rule?
4.
She begins to vomit bright red blood. What
will save her life now?
Click here for answers and to respond
