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Clinical Case 045: Syncopal Salesman

37 yo man who works as a travelling sales rep.  He has a hectic lifestyle and is overweight.  Flies around the country a lot visiting hospitals selling medical equipment.  He presents via ambulance after having a syncopal episode in the local McD’s.

The event was witnessed by a client and staff at the restaurant – he was a bit sweaty, got up to go to the bathroom and fell, he narrowly avoided hitting his head on a chair as he collapsed to the ground. No seizure activity, incontinence or neurolgical deficit noted at the scene. He was unconscious for about a minute.  When the ambos arrived 5 minutes later he was GCS – 15, oriented, though seemed a ‘bit vague’.

Whilst in your small country town for a 3 day visit he notices that he has become increasingly “unwell” – he can’t really put a finger on it -he says he “has been hazy in the head”  and “feeling like nothing seems real”  for the last 48 hours.  No specific vertigo symptoms, headaches or pre-syncopal events have been noted.

Overweight BMI = 35

Hypertensive – was on ramipril, but stopped taking it as it interfered with his ‘performance’

Smoker – 10 -15 per day

1 episode of gout effecting MTP jt

Depression – currently on 40 mg paroxetine/day, good response to this and supportive therapy from GP

Dyslipidemia – trialing “diet and exercise”

He is a fat, slightly sweaty man, looks a good few years older than 37!

Obs: pulse = 85 reg, BP 145/90 no postural drop, SpO2 = 99% RA, RR 14/min, no clinical pallor, anaemia etc

Otherwise his heart, chest, neuro, abdo etc are all normal.

What specific negatives do you want to ensure on physical examination??  What can you exclude by looking and listening?

BSL is 6 mmol (~110 in the U.S.A)

ECG – normal, sinus rhythm, maybe borderline for LVH criteria, normal axis.

What specific features / conditions do you want exclude / or see on the resting ECG in a man with syncope?

Urninalysis is = SG 1.015, 1+protein, otherwise normal

Plum normal

pH 7.41, lactate 0.4 mmol He has a Hb of 156 g/l

Electric lights are all normal

Nothing to write home about… What were you hoping not to see ?

OK, that is it for now.  At this stage I will tell you that any further tests that you want to do are either negative or unavailable in our little ED scenario.

The diagnosis is out there…  first prize goes to the reader who asks the right questions to solve the puzzle.

Ready, set, go…. write your thoughts on the comments and I will respond

Comments

  1. Minh Le Cong says:

    Whats his medical history? Medications? Allergies?
    I suspect his physical exam will be unremarkable, right?
    ECG please. BSL. UA. Baseline bloods, including troponin, electrolytes.

    smells cardiac…or drug related.

  2. Aw shucks. I’ll have a stab

    Even in the busy ED at 3am, I’ll try and take a history encompassing bio-psycho-social factors

    Past Medical history?
    Medications and allergies? Inc illicit/recreational and OTC meds
    Family history?
    Social history?

    Push him hard n risk factors for cardiac or neuro disease.

    Explore stressors – financial & work particularly

    Exam – geenral appearance. Addisonian? Cardiac and neuro exams in detail. Carotids?

    ECG useful

    I wanna know his obs. If I’m feeling cheeky I’d like to know bloods from iStat

    What does HE think is causing it?

    Differential at this stage is huge

    Feed us some more info (and I reckon history will be the clue) and see if we need any more fancy Ix like CT head, 24hr tape etc…

  3. All the above but my top differential is PE.

    CT angio please

    • Casey Parker says:

      We have access to a CT angio in Broome. But, he is PERC negative with a low risk Wells score.
      In the absence of any chest pain, dyspnoea, cough etc this seems like a bad call.
      Remember the relatively high rate of false positive that CTPA produces means you might be condemning him to warfarin for no good reason
      So no imaging was done. Anybody out there think his is foolhardy or cavalier? Let me know
      Casey

  4. CT angio? In Dingo Creek? You’re having a laugh aren’t you?

    My ED when I arrived consisted of a few old IVs and a piece of string…the first time I asked for a chest tube I was given a urinary catheter…

    Things are a LOT better now. But I reckon a CT angio in Dingo Woop-Woop is pushing it.

    Bedside ultrasound? There’s a maybe…

  5. I’d be curious about his sleep quality – does he have apnea? Also, how’s his renal function?

    • Casey Parker says:

      Great thought. I reckon sleep apnoea is one of those common but oft-forgotten diagnoses that can turn up in a lot of scenarios.
      It should be a routine question in pre-anaesthetic clinic, but it aint!

      But, no -he had no SSS or history of sleep apnoea
      However, he had not been sleeping well – tossing and turning a lot!
      Casey

  6. Minh Le Cong says:

    Diet and exercise, year right! He collapsed in Macdonalds! Oh I forgot you can order a salad there…lol. Paroxetine..it must be something to do with that. Its not a popular antidepressant anymore due to the withdrawal syndrome.

    Questions
    Did he run out of paroxetine or forget to take it for a few days?
    Did he take any over the counter medicines that could interact with paroxetine, in particular antihistamines.

  7. Will Sargent says:

    I’m picking up some neuro notes on the nose here.
    Call Oliver Sachs.
    Ask him how many elephants there are in Belgium.
    Are things appearing small?
    Alice in wonderland syndrome?
    Tumour or bleed, somewhere……
    Full+++ exam, fields, etc.

  8. Will Sargent says:

    Don’t ask Oliver Sachs how many bloody elephants there are.

  9. Andrew Walker says:

    With HTN and LVH, I’d like to know whether he’s got the narrow pseudo Q waves in the lateral chest leads of HOCM. Is he dehydrated? If so, it will be more likely to be symptomatic.

    If that doesn’t help, even though he’ll be PERC negative, being a fat man on a plane I’d want to know what’s the CT-PA result.

  10. Casey Parker says:

    HOCM – good thought. Does the absence of a murmur make this unlikely?
    Tough to exclude in ED. If you are a keen ECHo doc you might be able to see it, but anybody happy to rule it out?

    Re: CTPA – see above reply to JB. Not going there personally

  11. Syncope me screams either neuro, cardiac or drug related

    ECG is the single best investigation to do here with no bloods or CT
    -> looking to exclude Long QT, WPW, Brugada, HOCM (See Amal Mattu’s talk on Syncope), VT, ischaemia
    -> http://www.emrap.tv/index.php?option=com_content&view=article&id=2206

    Examination you could exclude hopefully exclude a cerebrovascular cause in the neurological exam also any toxidromes such as a serotonergic or anticholinergic . CVS – rule out tachyarrythmias, acute valvular lesions

    Hmmmmm

    Fat man goes to ground. Normal ECG, normal neurological and CVS exam. Hazy in the head, could this be a metabolic or drug related issue?

    Did he stop taking his paroxetine? (Minh already asked)

  12. mat holland says:

    Causes of syncope are commonly postural hypotension, cardiovascular or cerebrovascular (rarely)

    Postural hypotension:

    History is always all important – what was he doing at the time? already standing, just stood up? eating? micturating? was he wearing a tight collar?

    Lying / standing BP would be very important

    Cardiovascular:
    Ischaemic – high pretest probability, though no ECG changes would go against this.

    Valvular – Ao sten (M sten less likely). should be picked up by clinical exam. Was the pulse slow rising? Was the aortic second heart sound easily heard? LVH would be in keeping. Atrial myxoma. (echo would be very useful.)

    Arrythmia. A completely plum normal ECG would go against this, but usually most ECGs that are reported as normal in ED are not! consider WPW, VT, Brugada, bradyarrythmia, polonged QT (paroxetine)

    Hypertensive encephlopathy – consider phaeochromocytoma with episodic hypertensive changes (LVH on ECG and possible renal involvement WTU – protein) What was on the fundi?

    Cerebrovascular:
    vertebrobasilar ischaemia (? diplopia, ataxia, vomiting, nystagmus)

    I agree PE is possible but unlikely to have such a large PE with no other features (though not impossible, so I would investigate further if nothing else showed up.)

    Great site Guys, though I trained for my FJFICM up in queensland I have a fondness for western australia and the kimberley.

    Mat

  13. CAD

  14. maren glomsrod says:

    Any palpitations, chest discomfort or dyspnea during these episodes? If so, 24 h Holter monitoring.
    CBC? Electrolytes (Na low?)?
    Does the parents or sibling have any diseases?
    He’s young, but maybe a USG of he’s carotids.
    Did he fell unhappy and took some extra doses of paroxetine?:)

  15. Alex Harris says:

    I think there are 2 keys here. He felt sweaty BEFORE standing up, following which he had what sounds like a hypotensive episode. The other is that he has been unwell for a few days.

    Withdrawal effects of SSRIs as per AMH
    – dizziness, nausea, paraesthesia, anxiety, agitation, tremor, sweating, confusion, electric shock-like sensations
    – more common with paroxetine and least likely with fluoxetine

    Cardiac causes would be my first guess in real life, but given the other comments I will punt on SSRI withdrawal.

  16. Minh Le Cong says:

    For those of us who prescribed Paroxetine in its time of popularity, will recall the acute withdrawal issues that plagued our patients on it who were trying to change to another medication or cease it. It is the hardest antidepressant to cease due to this issue.

    that is why I was immediately suspiscious of the Paroxetine being the root cause of this man’s problems. Nowadays you dont often see it prescribed so many in clinical practice may have never seen this issue.

    if you work in ED or critical care predominantly you may never have seen this syndrome.

  17. johan theunis says:

    What about PE?

  18. A bit more on social history, job situation, life stressors etc?

    The hint that tests etc will mostly be normal makes me think of usually unlikely DDx’s;
    Psychogenic syncope, dissosciative disorder, panic disorder.

    Great blog! Very difficult but enjoyable cases!

  19. Casey Parker says:

    Case 045: the Answer
    Congrats to Minh le Cong, he was first in to ask the big question that clinched the diagnosis…
    The patient was on a good dose of paroxetine, and let it home. He then went out all night drinking and ended up in a fast food restaurant having not eaten for 12 hours
    Combination of these factors I think is enough to make the diagnosis.
    The tests were all normal, the dangerous diagnoses were either not there or too unlikely to need consideration.
    A: SSRI withdrawal with too much grog, dehydration leading to transient syncope

  20. Obese hypertensive with syncope-chance of arrhythmia is high.i would opt for holter monitoring

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