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Morning Report
May 7, 2012
Holly Shillington, MD, PGY-2
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The Case
CC: Passed out
HPI: 17 yo male, watching a movie at
school at 0830, the next thing I knew, I
was on the floor and felt tingly. A
classmate told him he had passed out.
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HPI Cont: Total of 5 episodes of passing
out in his life: 2 month ago when hepassed out during a blood draw when sick
with mono, 2 other times also while ill, and
1 time when was well and sitting down in
school like todays episode.
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ROS
Positive for headache.
Denies head trauma, chest pain,
coughing, loss of bladder/bowel,
tonic/clonic movements, and any other
concerns.
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PMH: EBV with hepatitis and pancreatitis inFebruary, asthma, seasonal allergies, T&A
Meds: Allegra, albuterol prn NKDA IMMS: UTD
Family Hx: No seizures or sudden death. Dadhas a history of passing out a lot. Great-grandfather reportedly had an early heart attack,but lived to an old age.
Social:
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Any Other Questions?
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Any Other Questions?
Food?
- Yes. Ate breakfast. Drinking normally.
Pokeman cartoon or The Miracle of Life?
- No, watching a documentary about makingdocumentaries. (Did he pass out fromboredom?)
Any ingestions?
- Only whey protein.
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Objective
VS: T 36, HR 85, RR 18, BP 111/71,sat 94% RA, wt 100 kg
PE: Lying on the bed, texting. No acute distress.Exam, including full neuro exam, is normal.
Orthostatics:
Lying: HR 62, BP 109/62Sitting: HR 64, BP 110/43
Standing: HR 85, BP 75/51 passed out
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Differential Diagnosis ofSyncope
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Differential Diagnosis of Syncope
Neurocardiogenic(Vasovagal) Micturition, defecation
Deglutition, Cough Post-Tussive Carotid Sinus (Tight Collar) Hair Grooming
Orthostatic Hypotension
Metabolic Hypoglycemic
Neuropsychiatric Breath holding Hyperventilation
Neurologic Seizure Disorder Syncopal Migraine
Cardiac LVOT obstruction Myocardial dysfunction Arrythmias
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ED Course
BMP showed met acidosis: K 5, Cl 111,
bicarb 11, AG 17
Blood tox neg for ethanol, acetaminophen,salicylates, tricyclics.
EKG: sinus brady with normal PR, QTc
CXR: normal heart size
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ED Course
After 2 liters of fluids: Repeat BMP was normal Repeat orthostatics were normal
DX: Syncope, orthostatic hypotension
Dispo: Discharged home with cardiology follow up and
instructions to increase fluid and salt intake.
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Vasovagal Syncope
Accounts for about 75% of pediatric cases of syncope
Syncope triggered by emotional or orthostatic stress(pain, fear, heat, prolonged standing), or reflexes(micturition, defecation, swallowing, coughing, vomiting,tight collar, hair grooming)
Associated with a prodrome (nausea, pallor, diaphoresis,vertigo, visual changes tunnel vision, decreased acuity)
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Vasovagal Syncope
Mechanism: transient autonomic dysfunction which leads to acutepostural hypotension (and thus cerebral hypoperfusion)
No further testing necessary if classic presentation and absence of
red flags (syncope during exertion, personal or family hx of heartdisease)
Testing: The Tilt Table Test will show postural hypotension and thus
predisposition for vasovagal syncope. Positive: > 20 mmHg fall in systolic blood pressure or > 10 mmHg fall in
diastolic or fainting within 2-5 minutes of standing EKG to screen for cardiac causes
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Vasovagal Syncope
Management: Lie down when prodrome is recognized to prevent LOC Wear support hose to prevent venous pooling
Increase water and salt intake Eat regularly Avoid noxious stimuli Avoid alcohol, beta-blockers, tricyclics Contract leg muscles while standing to increase venous return
Medications for severe cases
Prognosis: recurs in 2/3 of cases
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References
Causes of Syncope in Children and Adolescents Up To Date. 6May 2012
Marcdante, et al. Syncope. Nelson Essentials of Pediatrics, SixthEdition. (pp. 531-533). Philadelphia: Saunders Elsevier.
Narchi, Hassib. The Child Who Passes Out. Pediatrics in Review2000; 21;384.
Reflex Syncope Up To Date. 6 May 2012 Upright Tilt Table Testing in the Evaluation of Syncope Up To
Date. 6 May 2012. Willis, John. Syncope. Pediatrics in Review2000; 21;201.
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