Compile

Mr. M is a 23-year-old medical student who had an episode of syncope this morning after entering his anatomy lab for the first time. He is quite alarmed (and embarrassed).

Mr. M reports that he was in his usual state of health and felt perfectly well prior to entering the anatomy dissection room. Upon viewing the cadaver, he felt queasy and warm. He became diaphoretic and collapsed to the floor. When he regained consciousness, he was very embarrassed but not confused. The instructor told him that he was unconscious for only a few seconds.

Mr. M reports no diarrhea or vomiting, and he is not taking any medications. He has no known heart disease and exercises vigorously without symptoms. There is no family history of sudden cardiac death. There is no history of confusion following the syncope, tonic-clonic activity, or incontinence. On physical exam, his BP and pulse are normal and do not change with standing. Cardiac exam reveals a regular rate and rhythm without a significant murmur, JVD, or S3 gallop. His ECG is normal.

Mr. M is reassured, and although embarrassed, he feels much better. After explaining the pathophysiology of his disorder, you initiate standard recommendations for the prevention of further episodes.

SOAP NOTE

S: 23 y/o male. Chief complain of an episode of syncope this morning.  Abrupt onset with nausea, warmth. Unconscious last a few seconds. Denies confusion following the syncope, tonic-clonic activity, incontinence, diarrhea, or vomiting.

PMH-Denies any signification PMH.

Med- Denies taking any meds.

FHx – Denies sudden cardiac death.

O (vital signs first, general, other positive): normal BP/pulse, no change with standing. Regular heart rate and rhythm without a significant murmur, JVD, or S3 gallop. Normal ECG.

A: Vasovagal syncope – appears transient alarmed and embarrassed with a typical history, normal physical exam and ECG

R/O orthostatic syncope, cardiac syncope, HCM

P: Avoid triggers, lie down if notices the premonitory signs of an impending faint

Tensing leg muscles when standing

Avoid prolonged standing and drink plenty of fluids.

Case Summary:

Vasovagal syncope occurs when the part of the nervous system that regulates heart rate and blood pressure malfunctions in response to a trigger. The common triggers include, standing for long periods of time, heat exposure, having blood drawn, fear, straining, or other extreme emotional distress. Even the reflex syncope may not always be able to avoid, it can be prevented by lie down when we notices the premonitory signs of an impending faint. Because this allows gravity to keep blood flowing to the brain.

Vasovagal syncope typically occurs in young patients while standing. For this case, Mr. M’s history clearly suggests reflex syncope. The typical premonitory symptoms, such as brief nausea, or diaphoresis are present precede syncope. However, it is also important to consider other potentially life-threatening causes of syncope, for example the hypertrophic cardiomyopathy (HCM). HCM is the most common cause of cardiovascular death in young people and among young athletes and can affects 1/500 adults in the general population. Most patients are asymptomatic or mildly symptomatic. It can be discovered due to a family history of sudden cardiac death, during the evaluation of an asymptomatic systolic murmur, or when symptoms occur, which including syncope, arterial fibrillation, heart failure, or cardiac arrest.