A 68 year old male presents to the emergency room with his wife complaining of falling at his home. The patient is currently hemodynamically stable and has no other complaints. The patient takes hydrochlorothiazide and metoprolol for high blood pressure and atorvastatin for hypercholesterolemia. A head CT reveals no intracranial bleeding or skull fractures and the patient is free of any noticeable injuries. The patient says he feels fine and wonders if it is okay to go home. What is the next best step in the management of this patient?

Question

A 68 year old male presents to the emergency room with his wife complaining of falling at his home.  The patient is currently hemodynamically stable and has no other complaints.  The patient takes hydrochlorothiazide and metoprolol for high blood pressure and atorvastatin for hypercholesterolemia.  A head CT reveals no intracranial bleeding or skull fractures and the patient is free of any noticeable injuries.  The patient says he feels fine and wonders if it is okay to go home.  What is the next best step in the management of this patient?

Quizplus · Accepted Answer

Explanation: This patient describes a fall at home, but it is unclear in the given history if it was a mechanical fall (i.e. the patient tripped) or a syncopal episode (transient loss of consciousness with rapid recovery). Syncope can be divided into two broad categories: cardiovascular and noncardiovascular. Cardiovascular causes include arrhythmia and blood flow obstruction (i.e. aortic stenosis). Noncardiovascular causes are extensive including: vasovagal, carotid sinus hypersensitivity, orthostasis, seizures, TIA, etc. Approximately 25% of patients have no known etiology of their syncopal event. The most important part of a syncope work up is the history. Thorough history taking, physical examination (including orthostatics), and EKG will reveal the cause of syncope in about 50% of patients. A high number of episodes in a short time span points towards a more serious etiology, such as arrhythmia. Vasovagal syncope is often associated with a prodrome of tunnel vision, diaphoresis, nausea, and pallor. Associated symptoms may help to point towards the diagnosis as well. (Choice A) It would be inappropriate to discharge this patient without a thorough history and physical with follow up testing if indicated. The patient's age along with his history of hypertension and hyperlipidemia raise the likelihood of an arrhythmia, therefore an inpatient admission may be warranted. (Choice B) An MRI of the brain is not likely to show any abnormalities associated with true syncope, but could be helpful in seizure or stroke. (Choice C)An EEG is also unlikely to reveal a cause for syncope unless suggested by history. Only if there is sufficient evidence for seizures (postictal confusion, tongue biting etc.) is an EEG indicated. (Choice E)An echo would be an appropriate diagnostic test in this patient, but further history should be obtained first. Educational objective: Thorough history taking in a patient with a fall is crucial in order to determine if the underlying cause is syncope, mechanical, or seizure. Additional history taking should clarify number of episodes, presence of a prodrome, surrounding events, associated symptoms, duration of the episode, time until full recovery, witnesses to the event, other medical problems, drug use, and history of seizures.

A 68 Year Old Male Presents to the Emergency Room