Case 36 – History


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Case 36



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Brief History

The patient was a middle-aged Caucasian woman with past medical history of hiatal hernia, gastric ulcer (on Protonix for approximately 5 years and Mylanta) and deep venous thrombosis.

She did not visit the doctor often.

She had recent weight gain and knee pain; decreased activity and shortness of breath on exertion; and required elevation on pillows to sleep (for reflux, but possibly also for shortness of breath).

The patient also had multiple episodes of unwitnessed syncope recently where she said she woke up after passing out in the bathroom.

She was found dead after a family member could not enter her apartment and called police for a wellness check.

She was found on a couch lying on her right side.


Next: External exam

Discussion Questions

1. What are some possible causes of death based on the history?