History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnosis
Essential Immediate Steps
Test Result 1
Relevant Testing
Test Result 2
Test Interpretation
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Syncope in an 80-yr-old Woman
Physical Examination
General appearance
: Ill-appearing, confused elderly woman in respiratory distress.
Vital signs
:
Temperature: 34.6° C
Pulse: 115 beats/min, regular
BP: 70/21 mmHg
Respirations: 34/min
Skin
: Face plethoric, cyanotic, and mottled. Extremities mottled. Multiple small ecchymoses on lower abdomen compatible with history of recent anticoagulant injections. Groin incision healing well, no bleeding.
HEENT
: Significant bilateral jugular venous distention to angle of jaw.
Pulmonary
: Shallow, rapid respirations; lung sounds clear and equal bilaterally; normal to percussion bilaterally.
Cardiovascular
: Tachycardia, mid-systolic mechanical click consistent with mechanical aortic valve. Heart sounds muffled. Femoral and carotid pulses weak but symmetric. Unable to palpate more distal pulses. Chest nontender, no crepitance with palpation.
Gastrointestinal
: Unremarkable, including rectal exam showing stool brown and guaiac-negative.
Genitourinary
: Unremarkable
Musculoskeletal
: No swelling, erythema, tenderness, or deformities of extremities.
Neurologic
: Patient is unable to cooperate with detailed examination, but pupils are symmetric and react equally to light, face appears symmetric, gag reflex is normal, and all extremities move equally on command.
Mental status
: Oriented only to name. Appears confused.
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