REASON FOR CONSULTATION: Evaluation of syncope.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old woman with a history of diabetes and hypothyroidism, who presents with recurrent syncope and recent motor vehicle accident. The patient has no known prior history of cardiovascular disease and has had cardiac workup, including cardiac catheterization, which was reportedly normal.
The patient has syncope history that dates back to childhood. She recalls having frequent episodes of syncope that appeared, by description, to be postural in nature. She did not have further episodes of syncope throughout her adulthood life until about two months ago when she suffered another episode of syncope. She was shopping when she became very dizzy and asked for help. They were getting her a chair and she then found herself awakened in the chair surrounded by paramedic squad and bystanders. She believes she passed out either in or getting down to the chair but is uncertain of the duration of her loss of consciousness. She was taken to a hospital and underwent an inpatient workup, which was apparently normal and then discharged to home with a chemical stress test done in the doctor’s office soon thereafter. She believes all the test results were normal, but we do not have any records from this evaluation.
The patient was admitted yesterday after her motor vehicle accident with apparent preceding syncope. The patient was driving when she felt herself briefly nod off with apparent near syncope. She was at that point looking for a place to pull over when she then lost consciousness completely and struck a utility pole. She awoke after the airbags had deployed and was uncertain of her duration of loss of consciousness. The patient was brought to the hospital and since that time has had no further problems. She has remained in sinus rhythm with no recorded arrhythmias. Her blood sugar upon evaluation was 500. The patient said that she had eaten a good meal before the accident and had not had any alcohol.
PAST MEDICAL HISTORY: Diabetes mellitus, hypothyroidism, and questionable history of Parkinson’s disease.
MEDICATIONS AT HOME: Metformin, glipizide, Synthroid, and Pravachol.
ALLERGIES: Penicillin.
FAMILY HISTORY: Positive for cardiovascular disease.
SOCIAL HISTORY: The patient lives with her sister. She is a nonsmoker and nondrinker.
REVIEW OF SYSTEMS: Positive for syncope, diabetes, fatigue, hypothyroidism.
PHYSICAL EXAMINATION:
GENERAL: This is a pleasant Hispanic woman, in no distress.
VITAL SIGNS: Blood pressure 146/84, pulse 84, respiratory rate 18, temperature 98.6, O2 sat 93%.
HEENT: Notable for multiple facial injuries.
NECK: No jugular venous distention. Carotids 2+ bilaterally without bruits.
Sequential carotid sinus massage was performed revealing no pauses or symptoms.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm with normal S1 and S2 without murmurs, rubs or gallops.
ABDOMEN: Soft, no hepatosplenomegaly. Bowel sounds positive.
EXTREMITIES: No cyanosis, clubbing or edema. Pulses equal and brisk throughout.
NEUROLOGIC: Nonfocal.
SKIN: Warm and dry with multiple ecchymosis and bruises from her motor vehicle accident.
STUDIES: EKG shows normal sinus rhythm. There is a pattern of both inferior and anteroseptal myocardial infarctions with Q-waves in leads III, aVF and V1 through V4. The QRS duration and other intervals are normal. CT of the head was negative. Chest x-ray was negative.
LABORATORY DATA: Troponin less than 0.05. INR 1.0. Glucose 512, sodium 131, potassium 4.6, BUN 24, creatinine 1.0. TSH 1.50. BNP 21.4. Hemoglobin 12.8. White count 7.8. Platelet count 394.
IMPRESSION AND PLAN: This is a (XX)-year-old woman who presents with recurrent syncope, the most recent episode associated with a motor vehicle accident. EKG is notable for a pattern of inferior and anterior old myocardial infarctions. The patient, however, has had a cardiac workup done recently and was not told of any cardiovascular disease. She is not a terribly reliable historian. She had another syncopal episode about two months ago and the most recent episode occurred when she was driving and resulted in a motor vehicle accident. She also had a history of recurrent syncope as a child. Her physical exam was unremarkable as was carotid sinus massage and ECG monitoring. An echocardiogram has been performed but not yet interpreted.
We will follow up the results of her echocardiogram. If she has significant left ventricular dysfunction, then we certainly must assess the potential for ventricular arrhythmias and proceed accordingly if the echo is unrevealing of either myocardial or valvular heart disease. We still would like to work this up further with electrophysiologic evaluation. We have tentatively scheduled her for tilt testing, possible EP testing and possible implant of a Reveal loop recorder. We will modify these findings based on the results of her echocardiogram. The patient should refrain from driving at this point.
