Clinical Case 146: Heady Heart

Welcome back to the first Clinical Case for 2019. I have been having a great break over the summer doing a bit of travel and spending a lot of time in the ocean. For a look at my latest photographic adventures check out the pics here

The case today starts in a small community clinic several hours drive away. This one is an exercise in risk and uncertainty.

A 55 yo man was driving between a few remote communities in an un-air-conditioned car in January (in the Kimberley that means 100 F and 100% humidity) for half a day. He began to feel unwell about 50 km from the clinic and stopped on the side of the road as he felt like he was going to pass out. He developed a headache which came on over a few minutes and peaked within 10. The headache was initially quite severe but faded over another 10 minutes to be more of a “dull ache”

When he stood beside his car he felt “weird” and had subjective weakness in his right arm and was unable to speak properly. He tried to use his mobile phone to call for help but was unable to make any words. Being a stoic Aussie bloke he decided to get back into the car and drive into town. The weakness and speech disturbance resolved in the 30 minutes he took to drive to the clinic.

On arrival to the clinic the remote-area nurse has done observations and placed an IV. His BP is 160/80, pulse regular at 75, other all in normal range. BSL 6.6 mmol/l. She could not detect any clinical weakness, facial droop or dysphasia. But….

… as you were discussing the plan our man started complaining of anterior chest pain. The pain was abrupt in onset and radiated up from his chest to his neck. You ask for an ECG and a call back!

The ECG is normal. The clinic does not have any ability to do POC troponin. The pain did settle with a single dose of SL GTN.

FIRST QUESTIONS:

  • What do you think is going on?
  • Would you prescribe anti-platelet or anti-coagulation at this stage? If so, what?

The Royal Flying Doctors are alerted and they estimate that they can retrieve this chap within an hour or two.

… 3 hours later. Our patient has arrived in your rural hospital and has a mild headache. The chest pain has not returned and several more ECGs have been normal. He is neurologically normal to examine. A fresh blood sample is collected… the troponin is mildly elevated at 0.12 [ <0.04 ng ]

SECOND QUESTIONS:

  • What tests would you like to do and in which order?
  • Will you change your anti-coagulation plan at this stage?
  • What do you think is going on now?

A CT of the brain is performed and this is reported as normal approximately 7 hours after the initial headache symptoms. An LP is subsequently performed around the 12 hour mark and this was essentially clear – with 2, 1 and ZERO red cells in the 3 tubes… xanthochromia will be unavailable for at least 24 hours.

THIRD QUESTIONS

  • Where to from here?
  • Does he require any more investigation? Your small hospital cannot perform advance angiography or MRIs!
  • What is the disposition plan?

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