Case 2: A birthday celebration

On a Sunday afternoon, a 72 year old woman comes in after a syncopal event. She was at a birthday party, when she suddenly felt lightheaded and her vision went dark for a minute or so. She tried to get up but felt too weak, and she vomited once after drinking the glass of water her relatives brought her. They then decided to call an ambulance and she was brought to you.

The patient is not good at recounting her medical history, but does know she is taking a pill for high blood pressure, another one for the heart, and then another two or three. No allergies.

Her vital signs are:

GCS	15
BP	110/72	mmHg
HR	70	/min, somewhat irregular
RR	22	/min
SpO2	97%	on room air
Temp	37.2	°C
BGL	6.1	mmol/l

Please describe and interpret.

List your most important differential diagnoses.

Outline key elements in your further history and examination.

The nurse brings you the patient’s ECG.

Source: Dr Amal Mattu (with permission).

Please describe and interpret.

While you were away, a helpful nurse has inserted an IV cannula and drawn blood.

He presents you with three vials of blood and a lab request form (on which he has ticked quite a few boxes), and is now asking for your signature. You suddenly remember a memo you saw last week about cutting unnecessary lab tests due to increasing costs.

Which tests do you consider essential?

Are there any local, national or international guidelines to help justify your choices?

What evidence supports these guidelines?

After a while, you get the patient's blood results back:

			Reference range
WBC	12.6	× 109/l	(4.0−11.0)
Hb	102	g/l	(135−180)
Platelets	302	× 109/l	(150−450)
Urea	12.4	mmol/l	(2.5−7.5)
Creat	184	µmol/l	(50−100)
Na+	129	mmol/l	(135−145)
K+	4.7	mmol/l	(3.5−5.0)
hsTnI	6	ng/l	(<26)
Digoxin	1.8	nmol/l	(0.6−1.3)

Please describe and interpret.

The patient’s dipstick urinalysis reveals 2+ leukocytes and 2+ nitrites.
How does this affect your assessment and management?

Your junior doctor, who has just finished a rotation to the neurology department, wants to order a contrast CT-scan of the brain. You decide to first supervise her doing a targeted neurological examination.

What are you looking for in your examination?

What are your indications for ordering the CT scan in syncope, and what would you be looking for?

What patient characteristics determine your disposition, i.e. how do you risk stratify this patient?

Do you use any particular decision instruments, such as the San Francisco Syncope Rule? Are there any institutional guidelines where you work? What evidence are they based on?