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  #1  
Old 06-03-2012
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Question Sudden Collapse

A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and became diaphoretic and lightheaded. She sat on the ground and then lost consciousness. According to her son, she was unconscious for less than a minute, exhibited some twitching movements when she first lost consciousness, but had no incontinence or symptoms of confusion upon awakening. She had no further symptoms upon regaining consciousness. She has a history of hypertension and hyperlipidemia. Current medications are lisinopril and lovastatin. On physical examination, temperature is normal, blood pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine) and 92/min (standing), and respiration rate is 14/min. BMI is 35. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?

A Echocardiogram
B Electroencephalogram
C Exercise stress test
D Tilt-table testing
E No further testing
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Old 06-03-2012
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Originally Posted by Novobiocin View Post
A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and became diaphoretic and lightheaded. She sat on the ground and then lost consciousness. According to her son, she was unconscious for less than a minute, exhibited some twitching movements when she first lost consciousness, but had no incontinence or symptoms of confusion upon awakening. She had no further symptoms upon regaining consciousness. She has a history of hypertension and hyperlipidemia. Current medications are lisinopril and lovastatin. On physical examination, temperature is normal, blood pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine) and 92/min (standing), and respiration rate is 14/min. BMI is 35. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?

A Echocardiogram
B Electroencephalogram
C Exercise stress test
D Tilt-table testing
E No further testing
E............?????
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  #3  
Old 06-03-2012
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E............?????
Please post your explanation as to how you arrived at the answer.
We are here to learn and the whole idea is to have a discussion on a particular topic so that our concepts are clearer and they burned/welded into our memory.
Thanks
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Old 06-03-2012
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Please post your explanation as to how you arrived at the answer.
We are here to learn and the whole idea is to have a discussion on a particular topic so that our concepts are clearer and they burned/welded into our memory.
Thanks

m not sure ........
I thot this is her first seizure (may be) and no testing is necessary.......

actually I have gone very superficially thru IM notes so whatever partial info i retained , i apply / guess the answer......thats why i dont explain my answers.......may be after 2nd read,i will be ready for explanations......
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Old 06-04-2012
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E No further testing

The pt collapsed on a HOT summer day.
Did not lose continence, and had no confusion upon waking up.
No postural hypotension and normal ECG
No other abnormality seen, so i am thinking its just vaso-vagal syncope.
We can do tilt table test but not sure if this is needed in this pt.
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Old 06-04-2012
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Originally Posted by Novobiocin View Post
A 36-year-old woman is evaluated in the emergency department after collapsing suddenly while waiting in line at a county fair on a hot summer day. The patient states she felt nauseated and became diaphoretic and lightheaded. She sat on the ground and then lost consciousness. According to her son, she was unconscious for less than a minute, exhibited some twitching movements when she first lost consciousness, but had no incontinence or symptoms of confusion upon awakening. She had no further symptoms upon regaining consciousness. She has a history of hypertension and hyperlipidemia. Current medications are lisinopril and lovastatin. On physical examination, temperature is normal, blood pressure is 142/80 mm Hg (supine) and 138/78 mm Hg (standing), pulse rate is 84/min (supine) and 92/min (standing), and respiration rate is 14/min. BMI is 35. Cardiac and neurologic examinations are normal. An electrocardiogram is normal. Which of the following is the most appropriate management option for this patient?

A Echocardiogram
B Electroencephalogram
C Exercise stress test
D Tilt-table testing
E No further testing
the rule is
• No further testing is indicated in young patients after a single episode of syncope with no obvious cause on history, physical exam, or EKG
• The initial test in a young patient with recurrent syncope and no cardiac risk factors is head-up tilt-table test (HUTT) to evaluate for vasovagal syncope.
• Consider cardiac testing in patients with cardiac risk factors (e.g., older age) or cardiac symptoms (e.g., palpitations). Like echocardiography, stress test, and Holter monitoring

in the hx there's SUDDEN & Pre-syncope sx, also there's a hot day,there's no palpitation that can point to arrhythmia. so best shoot is vasovagal, also Prolonged standing or heat exposure is a predisposing factor
and since its the first time the dx is relatively clear i think no further testing is needed. if the episodes recur then i will go with tilt table test.
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  #7  
Old 06-04-2012
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The patient’s history is consistent with vasovagal (neurocardiogenic) syncope based on the history of prolonged standing and prodromal symptoms of nausea, lightheadedness, and diaphoresis. These presyncopal warning symptoms are highly sensitive for the diagnosis of vasovagal syncope if lasting for more than 10 seconds. Brief myoclonic jerking after losing consciousness is not unusual with syncope, especially vasovagal syncope. In addition, the normal physical examination, electrocardiogram, and lack of orthostasis on vital sign assessment all point toward vasovagal syncope.

Advanced cardiovascular diagnostic testing, such as an echocardiogram or exercise stress test, is not needed after a first episode of syncope when symptoms are characteristic for vasovagal syncope.

In suspected vasovagal syncope, a tilt-table test can be useful, providing a diagnosis in up to 60% of patients when done with pharmacologic stimulation. This test is indicated in patients with recurrent syncope as well as those with one episode who are at high risk based upon their occupation. However, this test has poor sensitivity, specificity, and reproducibility, and it is not indicated in most patients with suspected vasovagal syncope.

An electroencephalogram might be indicated to evaluate a first, unprovoked seizure, but despite this patient’s few myoclonic jerks, there is no evidence of seizure activity, such as tongue biting, incontinence, or postictal confusion.
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