Mr. Farmer is your first patient on your next midnight shift. He is 82 years old living at home with his wife, retired on the farm. He drives, and is still cutting wood though he says he has “slowed down a bit lately”.
- Medications: Hydrochlorothiazide, atorvastatin, ASA, tamsulosin, metoprolol
- On examination: BP: 135/70, HR 90, T 37.6; Sat 96%
- No focal findings on any system. Hematology/chemistry/urine – all within normal limits.
- Watch the video below and answer the questions that follow.
Re-Examine the Evidence
- What else would you like to know?
Or does it mean “over the past two days.” This would mean an acute change consistent with delirium or an acute illness or injury.
- “What has changed? This allows you to narrow in on what is new and different.
- “What made you decide to come to the ED now (Wednesday at midnight)” The answer may be “well it wasn’t till this evening that he fell down!” Or “That’s when he couldn’t talk for ten minutes.”
It is essential when exploring Atypical Presentations to establish what is new and when did it happen.
- Has he taken some extra anti-hypertensives (because he remembers that’s what happened “the last time I had a heart problem.”)
- Has he taken some extra of alpha-blocker (because “I thought it was my prostate.”)
- Is there a new OTC (Gravol? “Because I was feeling nauseous”)”
- Was a new medication (donepezil, nitrofurantoin) added last week that they’ve both forgotten to mention?
- But isn’t 135/70 a bit unusual for an elderly hypertensive? Is this actually hypotension for him?
- And his normal HR of 90? But if he’s beta and alpha-blocked what are the chances it would get higher?
- Afebrile and not hypoxic? Could he have pneumonia? Only a chest x-ray will tell.
- So what could this man have?