case2

[pbruss]

this is a patient i just saw in cambridge. i would like ONLY the first years to contribute to this case. i want EVERY first year to add something, i promise you will lear a whole lot more if you do. dont be afraid of being wrong.

22 yo femal with syncope. aaox3, VSS, no distress, no abnormalities on exam. she states that she has 1-2 syncopal episodes a month since she was 13. however, over past 3 days she has 2-3 syncopal episodes a day. the recent episodes are no different the her previous ones, just more frequent. she states that she was worked up by here PCP and "they didnt find anything". attached is her EKG and CXR in the ER as well as her last CXR from 2009.

what do you think of her ekg and cxr's? what would be your next step in diagnosis and or treatment?

i

Attachments:

[Bjs04f]

What is the context of the syncope? Exertion, non exertional? Any change in medications recently? Just looking at EKG I see some PR prolongation looking like 1st degree heart block, the concave looking ST in V2-3 look a bit like BER. CXR looks unremarkable. I think  a further workup involving a continuous monitor would be valuable, to see what rhythm shes in during these syncopal events, maybe and ECHO to evaluate structural malformation. 

[kemple]

Also dysautonomia should be considered. I think a tilt table would be nice. Off the EKG I agree I see 1st degree block, but no evidence of Brugada or HOCM. CXR shows more prominent markings than I woudl expect for her age but overall no acute processes.

[pbruss]

Good points but you are missing something on the EKG that gives you diagnosis. Take a closer look,

[Bjs04f]

QTC looks to be about 600ms. This could be hereditary prolonged QT syndrome ie.jervell lange neilson or romano ward. Start her on metoprolol and have cardiology follow up.

[kemple]

Brandon answering questions on his day off. I'm so proud *tear

[Bjs04f]

what else am I supposed to do on my day off. All my friends and family are working.....The life of EM