Note from Jerome Ruskin, MD at 1991-11-18 18:30

HISTORY OF PRESENT ILLNESS: Mr. Crawford is a 74-year-old white man seen in consultation upon referral of Dr. Barry James. Mr. Crawford has been in the hospital some time now with peripheral vascular disease. He was seen in consultation by Dr. Tilley on 10-14-91 preoperatively. There was no prior history of cardiac problems, according to Dr. Tilley, and no previous history of MI, angina or heart failure, or arrhythmias. It is noted that he may have had a small stroke in the past. He has had a nonhealing ulcer and history of amputation as well. The patient has been diabetic, has glaucoma, diabetic retinopathy and has had retinal laser procedures. He has been a smoker. 

Preoperatively the patient was noted to have an EKG which showed ST segment changes that were nonspecific. Chest X-ray was normal heart size. EKG showed a mild apical hypokineses, calcified thickened aortic valve with adequate opening. It was thought that the patient could go ahead with surgery, which was accomplished. The patient apparently did relatively well. He was about a day or so from discharge when today he was placed on the bedside commode and he passed out. According to the nurse, the nurses aid was with the patient at this time, his head rolled back, his eyes went upward and he became unresponsive. The nurse put him back in the bed as he was coming about. When she checked his P and BP they were normal. Accuchek was said to be 76 shortly thereafter.

The patient, in the hospital, presently is taking insulin eyedrops, which include Timoptic, Metoclopramide. He was also taking Naptazine and Lasix during this admission but apparently not at the present. These are diuretics in the form they usually use for glaucoma. 

PHYSICAL EXAMINATION: His P was 76 and radial, BP right arm lying was 120/80. There were decreased breath sounds. Lungs were clear. Heart revealed a RRR without significant murmurs or gallops. 

LABORATORY DATA: Preoperatively noted as above. I could not find a recent CBC or renal profile, but the last one done approximately two weeks earlier was within normal limits. 

IMPRESSION: Loss of conciousness of unknown type. Consider pulmonary embolus. This is suggested only because of the location event, i.e., on the commode. Against the diagnosis was no increased heart rate, no new cough, pain, etc. Nevertheless, it was felt important enough to check a VQ scan and blood gasses. The second possiblity is arrhythmia, for which the patient has already been scheduled to be transferred for monitoring. The third possibility could be postural hypotension. A CBC and CHEM-24 was requested to look especially for evidence of hypovolemia and renal azotemia to see if this could contribute to possible postural hypotension. A fourth possibility was infarction, although this is considered unlikely. Will check serial CKs. Lastly, I think the possibility of hypoglycemia has been ruled out because of the Accuchek of 76 shortly after the event. 

This dictation was done at 18:30. The patient has already had ABGs which revealed pO2 to be in the low 60s, compatible with COPD. VQ scan was low probablilty. CBC and CHEM-24 were essentially normal, including renal functions, and the first CK-MB is negative. 

There is nothing at this point to suggest volume depletion, and the BUN and crea are not elevated to account for the postural hypotension, which was reported by the nursing service. The nurse at my request obtained a BP of lying at 2:15 p.m. of 144/62, and sitting was 110/52, and standing 80/48. She said it was very difficult to get a BP standing. I did not ask to have P recorded at that time, however.

RECOMMENDATIONS: I will ask that the P and BP be rechecked. If the heart rate does not go up with the postural hypotension, than this would suggest autonomic retinopathy as the most likely cause. The medication the patient currently uses might effect BP. The one I can identify is the Timoptic eye drops. Perhaps his ophthalmologist would be willing to change to another agent such as Betagan. I don't believe metoclopramide has been associated with postural hypotension, but this will be checked. 

I will follow the patient with you. I appreciate the opportunity to assist in his care. 

Jerome Ruskin, M.D.
Cardiology

Signed by Jerome Ruskin, MD at 1991-11-18 18:30