5. You are a physician working in a busy ED and a 62 year old gentleman is broug

Question

5. You are a physician working in a busy ED and a 62 year old gentleman is brought in via EMS after a syncopal episode that occurred while he was playing tennis. Upon review of his EMR, you see he has multiple visits to the ED for c/o CP over the past 6 months, but cardiac enzymes were always WNL and he was discharged to follow-up with his PCP.

On review of his systems, patient is alert, oriented, excellent historian. He works full time as an attorney and is very active. He confirms he has had recurrent chest pain and SOB with exertion over the past 6 mo, but this is his first syncopal episode. No other complaints, no significant past medical history, no allergies.

Initial ED Workup:

No trauma from the fall, head CT Negative, EKG normal, Troponins x3 sets normal, CBC, blood chemistry normal.

Physical Exam:

Auscultation of carotids NEGATIVE for bruit, Auscultation of heart tones reveals harsh systolic murmur heard best at 2nd ICS, R sternal border, radiates to neck.

c) What additional information (clinical test information or physical assessment findings) would you want to obtain to further evaluate this ddx?

d) With regard to optimizing cardiac function in a patient with this diagnosis, how would you want to manage his preload and afterload status?

Explanation / Answer

C. We would recommend to get echo cardiogram and stress test to be done to evaluate and rule out other differential diagnosis. Echo and stress test both gives information about the anatomy, blood flow, functioning of heart when increased demand is there.

D. In this condition preload had to be improved for better cardiac performance by giving inotropes. After load has to be maintained in normal limits since it requires energy to pump blood against systemic vascular resistance.

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