Case 39
Sudden collapse; alcohol use disorder (recovering)
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Brief Presenting History
The patient was a middle-aged Latino man, “recovering alcoholic” (per the family) with cirrhosis and esophageal varices (status post gastrointestinal bleed in somewhat recent past) and diabetes (diet controlled in past with recent addition of oral medication).
During the prior three days, he participated in home improvement activities requiring exertion (carpentry, lifting).
On the day of death, he began to complain of dizziness, sat down, was offered something to drink and then passed out.
A family member who was a health professional was present and noted a slow pulse.
Paramedics were called and the patient was brought to the emergency room.
There was no history of slurred speech prior to his initial collapse.
Emergency room course
The patient was intubated and chest compressions were continued.
An echocardiogram did not show any abnormality.
The family was present and noted increased abdominal girth during resuscitation.
Resuscitation was discontinued after one hour and the patient died.
Discussion Questions
1. Summarize the history.
2. What causes of death was the patient at risk for based on the history?
3. How do you interpret information from a health professional who is also a family member? When do you consider this reliable? When might you have questions about the reliability? Do you believe the patient was bradycardic at home?
4. What is the differential diagnosis of dizziness with bradycardia? With tachycardia?
5. What is the differential diagnosis of increasing abdominal girth when it occurs chronically over time? Acutely (prior to presentation)? During resuscitation? Specifically, during CPR? Specifically, during intubation?
6. Is there a scenario where the size of the abdomen could have started to increase before resuscitation, but was only noticed at the time of resuscitation? What scenario might that be? Revisit this question after viewing the videos. Decide if it’s still relevant. State what data in the history and videos support your answer.
7. What is the purpose of mentioning slurred speech?