Question

Ms. X is an 87 y/o Hispanic female who presented to the ED after experiencing an episode of syncope this AM. She was getting out the bed and when she stood up felt some chest pressure and fainted. She landed on her bed and did not sustain any injuries. She has not had any prior syncopal episodes. She has chronic dizziness which has not changed and has not started any new medications. She denies nausea, vomiting, diarrhea, a history of aortic stenosis, DVT, or PE. Currently she is experiencing chest pain, which is mild in severity, constant, dull and radiate to her back between her scapula. Her past medical history is positive for: Diastolic Heart failure, HTN, CAD, hypothyroidism, hyperlipidemia, and breast cancer for which she just completed chemotherapy. Prior surgeries included a hysterectomy and bilateral cataract removal.

Physical exam:

Vitals: 36.3-74-16-163/74, O2 sat is 89% on room air.

Normocephalic.

Alert & Oriented x3. Well developed.

Eyes: PERL. No nystagmus

Neck: Supple, no cervical lymphadenopathy

Cardiovascular: Normal Rate and rhythm. No murmur, gallops. 2+/4_ radial, brachial, dorsalis

Pedis pulses bilaterally. 3+ pitting edema of lower extremities.

Pulmonary: mildly dyspneic, not using accessory muscles. Lungs are clear in all lung fields.

Abdomen: Soft and nontender, active bowel sounds. No peritoneal signs.

Skin: warm, dry and pale.

EKG: no ST or T wave changes. QTc is normal.

CXR: without any acute changes, CT of Head: Negative

VQ scan: V/Q ratio is 1.3.

Lab	Result
Na+	134 mEq/L
K+	4.1 mEq/L
creatinine	0.86 mg/dL
BUN	17 mg/dL
Troponin T	<0.01 ng/ml
BNP	100 pg/ml
WBC	5,000 mm3
Hct	35.6 %
Hgb	12 g/dL
Platelet count	240,000
Calcium	9.2 mg/dL
Magnesium	2.1 mg/dL
Phosphorus	4.2 mg/dL
Glucose	122 mg/dL

Questions

1. The clinical scenario is most consistent with which diagnosis? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.

2. What data in the clinical scenario supports your diagnosis? Make sure to interpret the lab values. You may simply list your answers below using a bullet point format. This does not have to be in a complete sentence. Interpret the labs that you list as part of your answer by indicating normal, high or low.

3. What risk factor(s) led to this person’s diagnosis? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.

4. Describe the key pathophysiologic concepts of the diagnosis in question 1. To answer this question completely, you must answer all of the sub-questions below using complete sentences. Each sub-question may be answered in 1-6 sentences.
   1. What is the most common etiology for the diagnosis you identified in question 1?
   2. Describe how this disorder causes hypoxia.
   3. Describe the pulmonary ventilation to perfusion balance (V/Q)? What is the normal range for the VQ ratio?
   4. What is a V/Q mismatch? What does a low V/Q ratio indicate? What does a high V/Q ratio indicate?
   5. What type of V/Q mismatch is this patient likely experiencing and why?

5. For what actual or potential complications related to the diagnosis in question 1 does she need to be monitored? You may simply list your answer(s) below using a bullet point format. This does not have to be in a complete sentence.

Answer 1

1. In the present scenario, the patient is an old Hispanic female 87 years of age. Today morning she felt some chest pressure and fainted.

*In the lab value we can see the oxygen saturation is 89% on room air

*From the lab value and clinical findings we can notice there is a deficiency of oxygen and chest pressure results in syncope/faint

*We can confirm that there is an alteration in blood circulation or oxygen sufficiency to the heart and as well as to the lungs.

*To compensate with the mechanism the body tried to increase the sufficient oxygen-rich blood results in overstress to the vascular system and results in high B.P of 163/74

*From this results we can confirm the diagnosis as pulmonary arterial hypertension

2. The main aetiology for the present condition is:

*History of hyperlipidemia

*Hyperlipidemia

*Pulmonary Embolism

*History of aortic stenosis

Due to these etiological factors maybe results in:

Decreased blood flow and increased pressure, besides, there is an imbalance between cell proliferation and apoptosis leading to an increase in pulmonary artery smooth muscle leading to thickening and the formation of scar tissue (vast proliferation) - this causes the arteries to become narrower.
Symptoms: fatigue, dyspnea, chest pain, syncope, oedema (peripheral oedema due to backward flow)

3. Here due to pulmonary arterial hypertension, cause a reflex of "hypoxic pulmonary vasoconstriction," which can occur in one part of the lung or the entire lung. doesn't serve us well when it occurs in the entire lung results in hypoxia.

4. Ventilation-perfusion ratio (V/Q) is defined as the relationship of the overall alveolar ventilation (L/min) to the overall pulmonary blood flow (L/min).

The normal ventilation-perfusion ratio is 4:5 or 0.8, that means for the effective functioning of the lungs blood and oxygen are needed in a particular range and that means when for each minute 4 litres of oxygen is entering into the respiratory tract where 5 litres of blood goes through the capillaries in normal.

5. Here in the VQ scan shows that VQ ratio is 1:3 or 0.3, that indicates a low V/Q ratio or mismatch, where the PAO2 decreases because oxygen moves out of the alveolus and into the pulmonary capillary blood faster than it is replenished by ventilation.

6. *Heart failure

*Cor pulmonale

*Arrhythmias