_ y/o _ w/ _ PMH/PSH _, presents with loss of consciousness.
_ no hx of prior
_ not exertion context
_ not sudden
_ positive prodromal symptoms
_ preceding tunnel vision
_ sitting to standing position (occurred in)
_ no new medications/drugs/etoh
_ no hx of BRBPR, nor black tarry stools, nor GI bleed
_ no history of heart failure, CAD, structure heart disease, family hx of sudden death,
_ no hx of seizures, no prolonged tonic-clonic movements, no tongue biting, no incontinence, no prolonged post event confusion
Complaint specific findings on exam:
CV: RRR, no murmur
_not symptomatic on ambulation in ED
EKG: Normal Sinus Rhythm. No arrhythmia (no PACs, no PVCs), no heart block, no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no dagger Q waves, no evidence of LVH, no epsilon wave, no evidence of ischemia.
EKG Interpretation: No arrhythmogenic etiology for syncope elucidated on EKG. Specifically, no evidence of arrhythmia, PAC, PVC, heart block, brugada syndrome, Torsades de Pointes, WPW, HOCM, arrhythmogenic right ventricular cardiomyopathy, ischemic.
(With appreciation that ED evaluation and an EKG has limited sensitivity for arryhmogenic etiologies to syncope. As such, pt advised for prompt f/u with PMD to evaluation for Holter Monitor)
_ POC pregnancy test
_ POC glucose
_ guiac. _ No hx c/f GI bleed.
_ cbc, bmp, trop
_ CT head
Diagnosis: Suspect syncope.
DDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does NOT meet our criteria for being reasonable for additional pursuit of these entities at this time (i.e. reasonable level of consistency with characteristic findings as detailed parenthetically below):
–arrhythmogenic etiology given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.
( arrhythmogenic etiologyfindings on EKG. i.e. arrhythmia, PAC, PVC, heart block, brugada syndrome, Torsades de Pointes, WPW, HOCM, arrhythmogenic right ventricular cardiomyopathy, ischemic. )
-valvular pathology given no murmur suggestive of aortic stenosis or other mechanical or obstructive process on exam.
– PE given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e.(unilateral leg swelling, hx of DVT/PE, hypercoagulable state)
– cardiac ischemia given given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. (preceding sx of chest pain, multitude of risk factors for MI)
- – Neurologic:
– seizure given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. (hx of seizure, post-ictal period, urinary/bowel incontinence, generalized shaking motion not not characteristic of hypnogogic jerking motions
– CVA given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. (nueo deficit on exam in ED, hx of CVA)
_ CT negative for acute intra-cranial process
– Temporary Hypoperfusion
– Hypovolemic, hypotensive given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. (vital signs, clinical signs, and historical signs of hypovolemia on eval in ED).
– orthostatic hypotensive given pt’s presentation NOT reasonably consistent w/ sufficient associated characteristics, i.e. (orthostatic in ED, signs of hypovolemia)
– Possible hyper-vagal response though given this is a diagnosis of exclusion, will risk stratify with ED work up and refer to outpatient evaluation for additional testing.
Sequelae of Syncope:
_ No traumatic injury from syncope requiring intervention based upon history and exam.
_Observation. Given _ , in my medical opinion, the patient warrants admission for further telemetric monitoring, and workup as deemed necessary by the inpatient treatment team. The patient remained clinically stable during care in ED.
-Given hx/exam/diagnostics above, patient though of sufficiently low likelihood based upon history, exam, and EKG that patient does not require emergent evaluation and would be appropriate for outpatient workup.
-Risk stratification by SF Syncope rule (CHESS) and clinical gestalt (FAME):
No CHF – no hx of
Hct not <30%
EKG – no abnormalities
Shortness of breath – no per pt
Systolic BP in triage >90
No Family history of sudden death
Age not > 80
No hx of MI
No exertion context
_Driving – patient advised not to drive until cleared by primary care physician.
The patient has a reassuring cardiac workup including a normal EKG, normal telemetric monitoring throughout the patient’s ED course without detonation nor evidence for dysrhythmias or other adverse cardiac events. Given the patient’s reassuring workup above, the patient is at sufficiently low risk for discharge and prompt outpatient follow up. The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate call or follow up with their primary physician or return for reevaluation. More extensive discharge instructions were given in the patient’s discharge paperwork.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).
HOCM – murmur, LVH, dagger
PHEGR – “faker” Preg,Hg,EKG,Gluc,RiskStratify
.notes: .hxSyncope, .mdmsyncope
CBC to evaluate for anemia
BMP to evaluate for electrolyte derangements
Guaiac to evaluate for occult GI bleed
Considered the following etiologies to her presyncope:
Not consistent with hypovolemia active and blood pressure within normal limits, normal by mouth intake and no diarrhea.
Not consistent with hypoglycemia given patient has normal blood sugar here in the emergency department.
Not consistent with vasovauel episode given history
Considered possible worsening anemia given her history of anemia and patient’s endorsing of bright red blood per rectum however patient is hemodynamically stable with normal stool in vault that is guaiac negative.
Considered possible arrhythmogenetic or cardiac etiology