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

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