The MKSAP Challenge
From the March ACP-ASIM Observer, copyright © 2003 by the American College of Physicians-American Society of Internal Medicine.
The feature below contains questions and answers excerpted from MKSAP 12 Update, a new enhancement to the College's popular self-assessment program. For more information on MKSAP 12 Update, contact ACP-ASIM Customer Service at 800-523-1546, ext. 2600, or 215-351-2600.
Clinical scenario
A 44-year-old woman returns from a 14-hour airplane trip and presents two days later with an episode of right-sided weakness lasting approximately two hours. The episode began shortly after she awoke, and she noted slightly slurred speech. She felt numbness in her right hand and was clumsy when she tried to write a check. On physical examination, her heart rate is 82/min and regular, and blood pressure is 125/70 mm Hg. Her neurologic and cardiovascular examinations are normal. Laboratory data are normal, as is a computed tomography scan of the head.
Which of the following tests is most likely to influence therapy?
A. Venous Doppler examination of the lower extremities
B. Magnetic resonance imaging of the head
C. Transesophageal echocardiogram
D. Measurement of serum protein C and S levels.
Answer: A
Educational Objective: Manage a patient with a cerebrovascular event and patent foramen ovale.
The clinical scenario is consistent with development of a deep venous thrombosis during her long plane ride with subsequent paradoxical embolization through a patent foramen ovale. Documentation of a deep venous thrombosis will necessitate full anticoagulation with a low-molecular-weight heparin followed by warfarin. Evidence of a patent foramen ovale should then be sought to determine long-term management with continued anticoagulation or closure.
Although magnetic resonance imaging is more sensitive for detecting a small embolic stroke, the finding will not change management at this time. It is likely that transesophageal echocardiography will reveal a patent foramen ovale, but the finding will not dictate the patient's immediate management, whereas the presence of a deep venous thrombosis will indicate the need for anticoagulation. A work-up for a hypercoagulable state may be advisable in the future if there is a positive family history or a prior history of deep venous thrombosis. However, the results will not change immediate management of this patient.
Reference
Salem DN, Daudelin HD, Levine HJ, Pauker SG, Eckman MH, Riff J. Antithrombotic therapy in valvular heart disease. Chest. 2001;119:207S-19S.
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