Intern Report Case 4.3

Case Presentation by Dr. Dan Helzer

HPI
36 year old AA female presents to the emergency department complaining of “passing out.”  Pt states that she was sitting down watching TV when she stood up, became very dizzy and lightheaded but no vertigo and fell to the ground.  She stated that she remembers almost everything but could not stay standing up for some reason.  Family members stated that she was not arousable for a few seconds and then came too.  She felt uneasy as family members helped her up and needed assistance getting into the car to be brought to the ED.  She has felt a little weak over the last few days but has experienced nothing like this recently.  Pt also states that she has had heavy vaginal bleeding for the last 10 days, it began with her normal menses but never stopped.  Her last normal menstruation was a month and a half ago.  Typically she has heavy menses but it only lasts 3-4 days.  She says that currently she is passing large clots and goes through multiple pads daily.  She denies headaches, abdominal pain, chest pain, palpitations, and SOB.  She denies ever being told that she has an abnormal heart beat or problems with her heart.  Her family denies any bladder or bowel incontinence during the event.
Past medical history is significant for anemia and fibroid uterus.  Pt is G3P3 and is sexually active.  Her medications include Fe pills.
Past surgical history positive for C-section x 2.
Social Hx includes a 30 pack/year smoking history.
PE
Vitals:  108/55, HR 104, RR 16, Pulse Ox 99 % on RA, Temp 37.7
General:  Pt is in no acute respiratory distress, appears pale.
HEENT: Normocephalic/atraumatic, PERRLA, EOMI, no nystagmus, conjunctiva pale and non-icteric, mucous membranes moist and pale. Fundoscopy demonstrated no pappiledema.
Neck: No lymphadenopathy, no JVD, no masses
Respiratory and Lungs: Equal excursion bilaterally, CTAB, no wheezes, rales, rhonchi, or stridor.
Cardiovascular and Heart: Tachycardic rate and rhythm, S1/S2 auscultated, no murmurs, gallops, rubs, or thrills.  Pulses palpated in all 4 extremities.
Gastrointestinal and Abdomen: BS +, Abdomen soft, non-tender, non-distended.  No masses.  No CVA tenderness.
Neurological: Patient is alert and oriented to person place and time, CN II-XII intact, sensation to pinprick intact in all 4 extremities, strength 5/5 in all extremities.  No pronator drift was present. Reflexes are 2+.  Heal to shin was normal.  Upon standing pt became lightheaded and dizzy and felt the need to sit back down, therefore gait and Romberg were not properly evaluated. Dix-Hallpike test was normal.
Genitourinary:  External genitalia were normal. Examination of the pelvis and vagina revealed active bleeding from the closed cervical os with pooling of blood and blood clots in the vaginal vault, no tissue like material was present.  The uterus was not enlarged.  CMT was absent.  The adnexa were non-tender and no masses were palpated.
Orthostatic Vital Signs:
-Supine BP 109/60, HR 103
-Sitting BP 100/59, HR 111
-Standing BP 88/52, HR 127  
Lab Results:
Urine pregnancy negative
WBC 11.3, Hemoglobin 2.9, Hematocrit 11.7, Platelets 35
Electrolytes all WNL 
Diagnostic Studies:
12 Lead ECG:  Sinus Tachycardia at 107 BPM.
Ultrasound showed?
SourceURL:file://localhost/Users/adamrosh/Desktop/Syncope%20Case.doc
Pelvic US with Duplex:
Findings suspicious for adenomyosis.
Nabothian cyst in the cervix largest measuring 0.7 x 0.5 x 0.8 cm
Paraovarian cyst adjacent to left ovary.
Questions: 
1.     What is the most common cause of syncope in adults aged 18-65 who present to the ED?
A.   Postmicturation
B.    Orthostatic
C.    Psychogenic
D.   Unknown or Idiopathic
E.    Cardiac
2.     The same pt is brought in by family members who tell you that when she fell down after standing up her whole body started shaking for at least one minute and she was completely unresponsive during this time. They said it looked just like a seizure that the patient’s cousin with epilepsy has all the time.  Which clue in the HPI can often be the only distinguishing feature between syncope and seizure?
A.   The patient has never had a seizure before
B.    The patient remembers everything
C.    The patient has an abrupt and complete recovery to baseline
D.   The patient has generalized tonic/clonic movements during the episode.
E.    The patient ate 10 tacos from taco bell and drank a liter of cola earlier in the afternoon.
3.     Of the following, which pt with syncope should be discharged from the ED with follow up by PCP and not be admitted.
A.   A 17 year old male with exertional syncope and crushing chest pain.
B.    A previously healthy 37 year old male with 5 seconds of asystole on carotid sinus massage.
C.    Our patient with a hematocrit of 11 and orthostatic hypotension
D.   A 90 year old female with an EF of 22% and enlarged heart borders on CXR
E.    A 52 year old male with SOB on initial presentation.

Answers:  1. D, 2. C, 3. B 

 

 

Discussion:

 

Syncope is the sudden transient loss of consciousness with a loss of postural tone.  The most important defining feature being transient, in that it resolves spontaneously within a small time frame.  It is a common complaint in the ED and presents at a national rate of 2.8 visits per 1000.  Most cases are benign and have a very low morbidity/mortality outcome, although serious underlying disease and trauma following syncope often complicates the clinical picture.

The causes of syncope are numerous, but all causes eventually lead to a final common pathway of dysfunction of either both cerebral hemispheres or the brain stem/reticular activating system.  A 35% reduction in blood flow to the CNS usually results in LOC and can be attributed to changes in CO, SVR, and/or intravascular volume.  Etiologies behind these changes often define the type of syncope that occurs.  With such a large differential the goal of an ED physician handling a patient with syncope is identifying those patients with serious pathology that would result in increased morbidity and mortality if left untreated.  Life threatening causes of syncope that need to be identified include cardiac ischemia, dysrhythmias, cardiac valve lesions, cerebrovascular disease, metabolic and toxicologic derangements, severe hypovolemia, and anemia.

Clearly, syncope is often just a symptom of another disease and often when a patient presents following a syncopal episode they will have no other complaints.  That is why a thorough HPI, PMH, and medication list must be obtained.  It is invaluable in separating benign syncopal events from the more serious.  Combined with a proper physical exam and a few ancillary tests including EKG a serious case of syncope will never be missed.

In our case a middle aged female with past medical hx of anemia and fibroid uterus presented with a case of apparent orthostatic syncope.  The patient reported standing up from a sitting position becoming faint and loosing consciousness.  Family provided details of the actual syncopal event and described the fast return to baseline.  In further questioning she admits to vaginal bleeding for multiple days and feeling weak days leading up to presentation.  Pertinent negatives included the patient not exerting herself before the event, she had no chest pain, SOB, and no history of cardiac arrhythmias or CHF.  Also, no seizure like activity was described.  The patient’s medication list showed no drugs with cardiac effects.

Physical exam also helped narrow the diagnosis.  Vital signs including orthostatics were consistent with anemia or volume depletion.  CV demonstrated no murmurs or thrills and lungs were clear to auscultation leading one away from a diagnosis of valvular disease, MI, of CHF that could be underlying her syncope.  A thorough neuro exam helped rule out stroke and seizure.

Ancillary tests including EKG, CBC, and electrolytes helped clinch the diagnosis. With hemoglobin of 2.9, a hx of sig bleeding and syncope on standing this was most likely a case of volume depletion combined with chronic anemia leading to hypoperfusion of the CNS and syncope.  The patient autocorrected the hypoperfusion on her own by losing postural tone and falling to the ground.  In doing this she was able to increase venous return to the heart, increase CO, and subsequently return proper perfusion to the CNS thereby regaining consciousness and postural tone.

The first question is general epidemiology.  The correct answer is D, unknown or idiopathic.  Most cases of syncope in the age group are related to benign etiologies.  These patients will have a completely negative ED workup and further testing to make a definitive diagnosis like a tilt table test are not within the realm of an ED workup.

The second question brings to light the problem of distinguishing syncope from a seizure which at times can be difficult.  The correct answer is C.  It is not uncommon for generalized tonic/clonic movements to present during syncope.  It is also not completely rare to see new onset seizures in the patients in this age group.  If a patient remembers feeling faint and loosing tone they could have had a “presyncopal” event or a simple/complex partial seizure among other things. If on the other hand, there is no post ictal state with loss of postural tone and a quick return to baseline status no matter what happens in between, this is most likely to be syncope and not a seizure.

The third question brings up disposition of a syncopal pt.  The correct answer is B.  Using the San Francisco Syncope Rule as guidelines, pts with the absence of abnormal ECG findings, SOB, Hypotension (systolic less then 90), anemia (Hematocrit less then 30%), or hx of CHF are low risk and can be followed up outpatient. Furthermore any patients with exertional syncope, chest pain, or valvular disease need hospitalization.   In this question, the correct answer B whom has none of these findings. He does however qualify for carotid sinus sensitivity and carotid sinus syncope which is usually benign and can be followed up as an outpatient.

Rosen’s Emergency Medicine, seventh edition, 2010, pages 142-147, Marx

Syncope: E-Medicine.   emedicine.medscape.com/article/811669

Carotid Sinus Hypersensitivity: E-Medicine. emedicine.medscape.com/article/153312

Approach to adult patient with syncope:  UpToDate.  www.uptodate.com

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