History:

83 yr old Female presents after loss of consciousness walking up stairs. Patient

recalls feeling dizzy, experiencing difficulty breathing, and burning feeling in
chest before loss of consciousness. Husband reports that the episode of
unconsciousness lasted between 1 to 2 minutes. Patient reports recently over the
last few months being "tired all the time". No abdominal pain or weight loss is
reported.
ROS: no headaches, no visual or audio disturbances, no palpable lymph nodes, no
joint pain, no urinary problems
PMHx: HTN diagnosed 15 years prior, compliant with medication
Meds: HCTZ, amlodipine, statin, 80mg aspirin daily (compliant with all
medications).
Allergies: NKDA
FHx: N/A
SHx: no smoking

PE:
-General: older aged female, well kept and in no apparent distress. AAOx3
-Vitals: PP-72, BP 115/75 standing without orthostatic decline, BMI 28
-HEENT: no nystagmus, no retinopathy
-Neck: Carotid pulses decreased with bilateral carotid bruits. No JVD
-Chest: No abnormalities in size, shape, or symmetry noted
-Cardio: S1 heard and S2 faintly heard, S4 sound heard, 2/6 crescendo-decrescendo
systolic murmur
-PVS: No edema seen
-ABD: No bruits
-Lab testing shows an Hb level of 11 g/dL. Chest X-ray shows mild cardiomegaly and
clear lungs.
-EKG testing shows LVH

Assessment:
DDX1: Aortic Stenosis----> age, history of HTN, syncope, carotid bruits, crescendo-
decrescendo systolic murmur, LVH
DDX2: CHF----> angina, history of HTN, syncope, fatigue

Plan:
Surgery to replace valve

To rule out stroke in this patient the first test done would be a CT of her head
without contrast. This will atleast rule out a hemorrhagic stroke before starting
other therapies. However, because this patient has been taking aspirin daily, her
risk for stroke should be lowered since the aspirin is preventative for stroke.

In handing this patient off I would suggest surgery to replace her valve. She may
also need to come off of her diuretics as they can become hazardous to the filling
pressures she will require from volume depletion. She should also be evaluated for
enteric angiodysplasia as a result of her Aortic Stenosis (Heyde's Syndrome)