One of the questions that were asked last year in that final exams to 6th graders was this one:

A final year female medical student complained fo two simillar attacks beginning with palpitations and briefly afterwards loss of consciousness, the patient was taken to the ER both times, Clinical exam was normal, ECG was normal. The patient would wake normally after each attack complaining of nothing.

[COLOR=purple]How do u manage this patient?[/COLOR]

This girl is having syncopal attacks due to anxiety ( as most other 6th graders do ! )
Reassurance of the girl is enough , I think!

DDx of syncpal and presyncopal attacks include :
1- Cardiogenic
( involving severe pallor of patient and rapid recovery)
2-Vasovagal
( with nausea and recovery lasts minutes )
3-Neurogenic
( with confusion )


am I right samer or i went far away?

Could be :
- Thyrotoxicosis ..
- Epileptic fit ( palpitation was the aura ) ..

That's all I can give ..

Ok the question doesnt give us much, but the palpitations make us think of cardiogenic syncope which is probably arrhythmia occuring in a paroxysmal manner.

I think that the patient should be put on Holter monitor [24 hour ECG recording], but should we give her an antiarrhythmic drug like amiodarone or not i dont really know, what i know is that ventricular arrhythmias are the commenest cardiogenic cause of syncope. And these are pretty serious.

any Ideas?

You went so far my friend; thing of simple causes first and remeber; don't perscribe any antiarryth dgs to asymptomatic patients. Although, the question hasn't given much information but think of Aortic stenosis especially in young patients who faint after tachycardia

I don't kno... first line of management is ABCDE; attache moniter and listen for the heart, but echo will give the final answer if we tempt to thing of AS

I don't kno........ i am ent man

Hi ali, in cases of aortic stenosis patients often develop syncope with exertion and this patient doesnt have such a history plus the physical examination of a symptomatic aortic stenosis will often be revealing.

anyhow, the doctor wanted the arrhythmia answer but the management is bothering me.

thanx doctors for this discussion... but i thing it's vasovagal shock..

transit attacks of SVT or AF due to exessive coffe intake

because now she is asymtomatic,we cant use any Antiarhythmic drugs unless we have definte Dx.
so put her on 24h ECG
otherwise do nothing unless you want to do ECHO if u suspect stractureal abnormality

i think it is TIA caused by AF
we saw a similar case, mx is by putting the patient on Holter monitor to confirm the diagnosis and then start treatment..

regards,

[SIZE=14]VASOVAGAL ATTACKs ...sure

hmmm, TIA? i dont think that it is likely, for loss of consciousness ot occur, it would have to affect the reticular formation.

as for Vasovagal attack, its not common to have palpitations with it, and the nausea, pallor and diaphoresis can differentiate between it and arrhythmia.

so i guess its the arrhythmia guys and as dr nadir said, a holter and an echo would be great i guess.

there is no history of caffiene intake nadir, thats MCQs talking, remember that we drink tea more

though the data is not sufficient to make a diagnosis and gives a wide range for interpretation....still

she is a young female with history of palpitation followed by syncope.

remember the definition of palpitation is awareness of the heart beats which doesn't necessarily mean tachycardia it could be bradycardia .

since nothing appeared on the ECG means there is no permanent damage to the electrical pathways such as Heart Block, WPW, ...etc.

we are thinking of something which is episodic, not due to structural abnormality and could be preceeded by palpitation(awareness or discmfort of heart beats).

I would put VASOVAGAL SYNCOPE as my first D.Dx. it is benign and since it is recurrent and preceeded by palpitation i would advice the patient to sit once she feels not palpitation to avoid injury from the syncope.

holter monitor, ECG during the attack (if lucky enough!),echo,elctrophysiologic study are all cool choices to investigate .


regards

hi everyone ..if the syncopal attack is due to arrythmias i think it wont resolve spontanously . ventricular outfow obstruction cause syncope after exertion so i go with anxiety or facticious syncope