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Recurrent
Syncope in a 43 year-old Nat=
ive
American Female
Clinicopathological Conference
=
Internal Medicine Grand Rounds
June 22, 2005
Julia =
H.
Indik, MD PhD
Assist=
ant
Professor Medicine
Sarver=
Heart
Center, Dept of Internal Medicine
History
of the Present Illness
<=
span
style=3D'font-size:88%'>•43 year old Native American female bus driver
=
•Over the past eight months – recurrent
spells:
<=
span
class=3DB1B style=3D'position:absolute;left:-3.36%'>–No provo=
king
factors (at rest or activity and not associated with chan=
ge
in posture)
History
•She has had two episodes of syncope=
3;
•Most recent – driving her car and
felt chest tightness beforehand. She then blacked =
out
and awakened to the sound of her car hitting another car and =
with
herself slumped over the steering wheel
History
=
226;PMHx:
migraine headaches (headaches do not precede events)
=
;
–MRI
brain (about 6 months previously) entirely normal
=
226;Meds:
none (previously on amitriptylline, discontinued months earli=
er)
History
•Fam Hx: mother with DM,
HTN; father 90’s HTN, seven siblings in good health. =
No =
family
history of syncope or sudden death
•SocHx
–Works as bus driver
(discontinued after her MVA)
–Tohono-O’odham
tribe; married with three children
–No tobacco, alcohol or
illicit drugs
•
•<=
/span>
History
•ROS: no weight loss, occasional heartburn,
last menses two months prior and one year before that (perimenopausal),
no history of seizure disorder, no DM/thyroid disease
Physical
Exam
•BP 110/78 R, 102/72 L arm, pulse 81=
3;
•JVP 5cm, normal carotid upstroke
<=
/span>
•CV: RRR, normal S1, S2, no murmurs, normal
PMI, normal peripheral pulses
•Neuro: no abnormal findings
•Labs: essentially normal, TSH 1.59
=
;
•EKG: normal sinus rhythm, narrow QRS
A Case of Syncope
•=
Rational
approach guided principally by
the history
•=
Try to
avoid “fishing expeditions”
–=
Mostly
useless tests: carotid dopplers, head
CT, EEG, Holter monitors, cardiac enzymes
– the “rule-out”
![](3D"slide0009_image002.jpg")
Differential Diagnosis for Syncope
from Harrison’s:<=
/span>
Such a large differential
that it becomes <=
/span>practically useless