Chief Complaint:
Dizziness
HISTORY OF PRESENT ILLNESS: A 67-year-old woman presents with a 6 months
history of 12/07 nausea, vomiting and epigastric gnawing discomfort related to newly
diagnosed gastroparesis for which GI started her on metaclopramide. This has helped
though she still reports, "Feeling bad". Her oral intake has definitely decreased resulting
in gradual loss of weight. Four months ago, she started having symptoms of dizziness
upon standing, which has progressively worsened.
One week ago she noted a right axillary lump though to be an enlarged lymph node
though excisional biopsy revealed the mass to be a hematoma.
At this point she is essentially bed bound getting up to go to the bedside toilet due to her
substantial fear of falling.
Past Medical & Surgical History:
1. Status post hysterectomy in 1986.
Allergies/Reactions: None known.
MEDICATIONS:
1. Nexium 40 mg before meals.
2. Reglan 10 mg before meals.
3. Multivitamin once daily.
Social History: Married and lives with husband. No tobacco, alcohol, or recreational
drug abuse history.
Family History:
Father had aplastic anemia
Daughter ITP as a child, in remission
Brother died of lung cancer.
REVIEW OF SYSTEMS:
Constitutional: No fevers, chills or sweats. Appetite marginal with gradual weight loss
as per HPI
Head: No headaches.
Eyes: No visual acuity change, blurred vision, diplopia or ocular pain.
ENT: No reduced hearing, tinnitus, or ear drainage. No nasal congestion or discharge.
No epistaxis. Mouth/throat: No oral lesions, odynophagia, dysphagia.
Heme/Lymph: Bruises easily. No enlarged lymph nodes noted except as per HPI.
Cardiovascular: No chest pain but severe dizziness as noted above. No orthopnea or
paroxysmal nocturnal dyspnea. No lower extremity swelling.
Respiratory: No shortness of breath, cough, sputum productivity.
Gastrointestinal: Negative except as per HPI.
Genitourinary: No dysuria, urgency or frequency. No hematuria.
Musculoskeletal: No muscular pains or weakness. No focal bone or back pain.
Neuro: No focal motor or sensory deficits. No seizures. No stroke.
PHYSICAL EXAMINATION
BP: 129/69 P: 86 (supine)
BP: 95/53 P: 81 (sitting)
BP: 50/34 P: 86 (standing)
O2 sat: 95% on room air
Constitutional: Chronically ill-appearing female in NARD. Appears dizzy on standing.
HEENT: Eyes: PERRL. EOMi. Nonicteric sclerae. Pink conjunctivae. Oropharynx:
Oral mucosa is moist and pink without lesions, erythema, or exudates, drainage or
tonsillar enlargement.
Neck: No thyromegaly or masses.
Lymphatics: NO LAD all areas
Respiratory: CTA bilaterally. Normal chest excursion
Cardiovascular: Regular S1, S2 with a 2/6 SEM. No rub or gallop.
Abdomen: BS+. Soft NTND. No HSMY or masses.
Extremities: No CCE
Skin: Bruising over the forearms and legs bilaterally. Left axillary bruise at sire of
recent biopsy—incision healing well.
CURRENT LABORATORY & RADIOLOGY STUDIES
Chemistries:
Na 133, K 3.8, Cl 99, Bicarb 30, BUN 13, Cr 0.7, Glu 120, Ca 8.2
AST 52, ALT 61, Alk phos 161, Total bili 0.4, Prot 6.1, Alb 3.1, Prealbumin 27.2
CK is 31, CKMB 4, Troponin-I 0.07, with BNP 682.
CBC:
Hgb 11.1, Hct 34, MCV 89.7, WBC 8 with a normal differential, and Plts 272
Coags:
PT 14.9 sec, INR 1.5, PTT 52 sec. Thrombin Time 17 sec
PTT 1:1 mixing study 34 sec
Factor VIII 94%
Factor IX 87%
Factor XI 63%
Urine analysis:
Trace blood (5 RBC/HPF), Protein >300, $+ hyaline casts, 1+ bacteria otherwise negative
Transthoracic ECHO
Concentric left ventricular hypertrophy with normal cavity size and systolic function.
There is mild ventricular hypertrophy. Right ventricular systolic function is normal. The
filling pattern of the ventricles is not suggestive of restrictive physiology. The left atrium
is mildly dilated. Small pericardial effusion.