It's 10pm and the resident comes to me having seen a 61 year old lady who presents with a sudden onset of dizziness on standing.
She is hypertensive, and not in any distress but describes a feeling of significant unsteadiness while standing from a sitting position at home.
She describes a tremor and tingling down her left hand with no complaints of headache or vomiting despite feeling nauseous.
The resident reports a 15mm Hg drop in blood pressure on standing. Other vital signs remain normal and she has a normal ECG with a normal neurological exam.
She says she had a similar episode a month back but thought nothing of it. It was transient at that time and remained transient today but tonight her symptoms persisted a bit longer, making her seek help.
Her FBC/U&E returns within the normal range and after being treated with 500ml of normal saline with 12.5mg of prochlorperazine she appeared well.
Prior to discharge I go to see her and for a sense of completeness decide to use POCUS [point of Care Ultrasound] on her carotids.
After visualising normal vasculature on the right side, it became obvious that there was a significant stenosis in the left carotid artery just distal to its origin after the bifurcation.
Having found this on my unaccredited scan, it then begs the question whether it is just a coincidental finding or the cause of her symptoms. I organised a CT angiogram which confirmed the stenosis without any other pathology.
The options were to then discharge her with an outpatient formal US request and a outpatient vascular appointment after starting her on Aspirin, Statin and an antihypertensive, or admitting her for further investigation.
After discussion with the vascular team it was decided to admit her for a formal Duplex study of her carotids as an inpatient and after quantifying the degree of stenosis a multidisciplinary team discussion can occur in the cold light of day.
She went on to have the Duplex US study the next day and was discharged remaining asymptomatic and is awaiting an outpatient clinic review by the vascular team.
Dr Ashes Mukherjee
MBBS FRCS FRCEM FACEM CFEU CCPU
Armadale Hospital, Western Australia