Duncan III: It's Complicated

Cardiovascular System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M32_F3.jpg"}},{"insert":"\n\nAround 3 months ago, you met 56-year-old Duncan, who presented with signs and symptoms of heart failure. He had an inferior NSTEMI one year before, which was treated with percutaneous coronary intervention and placement of a stent. He was also found to have hypertension and dyslipidemia at that time. Unfortunately, he defaulted of treatment soon afterwards.\n\nFollowing careful investigation, you found Duncan to have NYHA class II heart failure with reduced ejection fraction (HFrEF). After educating and counseling him, you started him on the combination of furosemide, digoxin and spironolactone for the heart failure, and nitroglycerin, aspirin, valsartan, and lovastatin for the ischemic heart disease. You also intended to start him on beta-blockers, following compensation of the heart failure.\n\nUnfortunately, Duncan defaulted on follow-up once more, appearing only after a month had passed. While the symptoms of heart failure had resolved, he was experiencing palpitations \u2013 and following futher investigation you found out that he had developed non-valvular atrial fibrillation. Subsequently, you started him on atenolol for rate control and warfarin for anticoagulation. Duncan responded well to your therapy. Since he was stable on rate control alone, you opted against rhythm control.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M32_F38.jpg"}},{"insert":"\n\nJust two weeks after his last visit, Duncan is (unexpectedly) in front of you once more. He complains of vague lower abdominal pain and a weird tingling sensation in his left leg, both of which started around 4 days ago. No other symptoms are present.\n\nOn examination, his pulse is 64 bpm and blood pressure is 125\/75 mmHg. The general examination is unremarkable. Cardiorespiratory examination is as earlier: cardiomegaly and fourth heart sound. His lungs are clear. Abdominal examination is only significant for mild lower abdominal tenderness. Musculoskeletal examination reveals pain on active and passive extension of the left hip. \n"}]}


{"ops":[{"insert":"You order several urgent laboratory studies. Not too long afterwards, the results come in.\n\nDuncan\u0027s full blood count shows that his hemoglobin level is 11 .6 g\/dL (normal:11-18). This is as opposed to his full blood count just one week ago, in which his hemglobin level was 12.2 g\/dL. His INR is 2.9, which is within the expected range of 2.0 to 3.0. His serum electrolytes and renal functions are within normal parameters.\n"}]}


{"ops":[{"insert":"You ponder what the cause of Duncan\u0027s symptoms might be.\n\nWhich of the following are you thinking of?\n"}]}
1. A retroperitoneal hematoma
2. A dissecting abdominal aortic aneurysm
3. Mesenteric ischemia