A 38-year-old woman comes to the emergency department following an episode of loss of consciousness. She was washing the dishes when she became light-headed, weak, and developed blurry vision. The patient reportedly became limp, passed out on the kitchen floor, and had a few body jerks seconds after falling. She regained consciousness in 3-5 minutes and was not confused or disoriented afterwards. She did not have any tongue biting, headache, palpitations, shortness of breath, or chest pain.
Her medical history is significant for hypertension and diet-controlled type 2 diabetes mellitus. Her medications include lisinopril, amlodipine, and chlorthalidone.
The patient's blood pressure is 112/76 mm Hg and heart rate is 89/min. Chest auscultation reveals no abnormalities. There are no signs of trauma or neurologic deficits. Electrocardiogram is normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 38-year-old woman comes to the emergency department following an episode of loss of consciousness.  She was washing the dishes when she became light-headed, weak, and developed blurry vision.  The patient reportedly became limp, passed out on the kitchen floor, and had a few body jerks seconds after falling.  She regained consciousness in 3-5 minutes and was not confused or disoriented afterwards.  She did not have any tongue biting, headache, palpitations, shortness of breath, or chest pain.
Her medical history is significant for hypertension and diet-controlled type 2 diabetes mellitus.  Her medications include lisinopril, amlodipine, and chlorthalidone.
The patient's blood pressure is 112/76 mm Hg and heart rate is 89/min.  Chest auscultation reveals no abnormalities.  There are no signs of trauma or neurologic deficits.  Electrocardiogram is normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient is presenting with convulsive syncope. Brief myoclonic activity associated with syncope is due to cerebral hypoperfusion and can commonly be mistaken for seizure. Features that are more suggestive of seizure include a post-ictal state, tongue biting, head/eye turning to one side, and hypersalivation. seizure The evaluation of syncope should begin with a careful history, physical examination (including orthostatic vital signs), and an electrocardiogram (ECG), as this will identify a specific cause in about 60% of cases. This patient's presentation of syncope in the setting of prolonged standing (eg, washing the dishes) and use of multiple antihypertensive medications (eg, a calcium channel blocker and a diuretic) raises suspicion for orthostatic hypotension; another possibility is vasovagal syncope. The most appropriate next step in management is to check orthostatic vital signs. Additional testing should be based on the initial clinical evaluation. (Choices A and B) Brain imaging, electroencephalogram, and carotid Doppler are rarely useful unless there is concern for a non-syncopal cause of transient loss of consciousness (eg, seizure, cerebrovascular disease). This patient's lack of post-ictal confusion or tongue biting and normal neurologic examination make a non-syncopal cause of transient loss of consciousness less likely. (Choice C) An echocardiogram should be performed in patients suspected of having structural heart disease. However, it would be of limited value in this patient as her syncope did not occur in the setting of physical exertion and her ECG and cardiovascular examination were normal. (Choice E) Tilt-table testing can be useful for diagnosing vasovagal syncope (sensitivity 26%-80%, specificity 90%), but it is usually reserved for patients with atypical presentations, recurrent syncopal episodes after cardiovascular etiologies have been excluded, or after a single unexplained syncopal episode when the diagnosis must be excluded (eg, high risk of physical harm or occupational hazard). Educational objective: Convulsive syncope can be mistaken for seizure, but features such as post-ictal state, tongue biting, head/eye turning to one side, and hypersalivation are typically absent. The evaluation of syncope should begin with a careful history, physical examination (including orthostatic vital signs), and an electrocardiogram. __________ References: Syncope: Etiology and diagnostic approach. (http://www.ncbi.nlm.nih.gov/pubmed/25452354) AHA/ACCF Scientific Statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation: in collaboration with the Heart Rhythm Society: endorsed by the American Autonomic Society. (http://www.ncbi.nlm.nih.gov/pubmed/16418451)

A 38-Year-Old Woman Comes to the Emergency Department Following an Episode