Case History

Personal Details:
Mr. Rajesh Verma, 65-year-old male, retired accountant

Presenting Complaint:

• Sudden loss of consciousness (syncope) for 1 minute, occurred yesterday

History of Presenting Illness:
Mr. Rajesh was standing in a queue at the bank when he suddenly felt dizzy and lightheaded, followed by brief loss of consciousness. He reports that he regained consciousness spontaneously within about a minute, feeling weak but alert, and did not experience confusion or drowsiness after the episode. He had no warning symptoms such as chest pain, palpitations, visual changes, or sweating. There was no tongue biting, involuntary movements, or incontinence. He did not sustain any injury during the fall.

He recalls a similar episode six months ago while standing for a long time in a crowded bus. He denies any recent fever, cough, or breathlessness. There is no history of recent medication changes, dehydration, or excessive heat exposure.

Past Medical History:

• Hypertension for 10 years, on regular medication

• No history of diabetes, heart disease, stroke, or epilepsy

• No previous hospitalizations for similar complaints

Drug History:

• Amlodipine 5 mg once daily

• No recent changes in medication

• No use of diuretics, antiarrhythmics, or sedatives

Personal History:

• Diet: Vegetarian, regular meals

• Appetite: Normal

• Sleep: Normal

• Alcohol: Does not consume

• Smoking: Non-smoker

• Physical activity: Walks daily

Family History:

• No family history of sudden cardiac death, arrhythmias, or epilepsy

Socioeconomic History:

• Retired, lives with spouse in an urban apartment

• Middle-class socioeconomic status

• Good access to healthcare

Systemic Enquiry:

• No chest pain, palpitations, breathlessness, or leg swelling

• No neurological symptoms such as headache, seizures, or weakness

• No urinary or bowel complaints

Case Summary

Mr. Rajesh Verma, a 65-year-old hypertensive male, presented with a brief episode of syncope while standing in a queue, preceded by dizziness and followed by complete recovery without confusion or focal neurological symptoms. He has had a similar episode in the past under similar circumstances, with no significant cardiac, neurological, or metabolic history.

Differential Diagnosis

1. Vasovagal (Neurocardiogenic) Syncope:

   • Most likely, given the prodrome (dizziness), occurrence while standing, brief loss of consciousness, and rapid, complete recovery578.

2. Orthostatic Hypotension:

   • Possible, especially in elderly or those on antihypertensive medication, but there was no history of postural change or dehydration7.

3. Cardiac Syncope (Arrhythmia, Structural Heart Disease):

   • Needs to be considered, especially with age and hypertension, but absence of palpitations, chest pain, or exertional onset makes this less likely234.

4. Situational Syncope:

   • Less likely, as there was no trigger such as coughing, urination, or defecation7.

5. Seizure:

   • Unlikely, as there was no tonic-clonic activity, tongue biting, incontinence, or post-ictal confusion78.

6. Other Causes (Metabolic, Hypoglycemia):

   • No supporting symptoms or risk factors in this history.

Viva Questions and Answers on Syncope

1. What is syncope?
Syncope is a transient, self-limited loss of consciousness due to acute global impairment of cerebral blood flow, characterized by rapid onset, short duration, and spontaneous complete recovery469.

2. What are the main causes of syncope?

• Reflex (neurally mediated) syncope: vasovagal, situational, carotid sinus hypersensitivity

• Orthostatic hypotension

• Cardiac causes: arrhythmias, structural heart disease

• Cerebrovascular causes: vertebrobasilar insufficiency

• Other: psychogenic, metabolic (hypoglycemia), and neurologic (seizure)4689.

3. What is vasovagal syncope and what are its typical triggers?
Vasovagal syncope is the most common type, caused by a sudden drop in heart rate and blood pressure, often triggered by prolonged standing, emotional stress, pain, or the sight of blood269. Prodromal symptoms may include dizziness, weakness, nausea, and vision changes.

4. How do you differentiate syncope from a seizure?

• Syncope: brief loss of consciousness, rapid recovery, may have prodrome (lightheadedness, nausea), rarely associated with tongue biting or incontinence

• Seizure: often has tonic-clonic movements, tongue biting, incontinence, post-ictal confusion or drowsiness47.

5. What are the high-risk features in a patient with syncope?

• Syncope during exertion or while supine

• Absence of prodrome

• Family history of sudden cardiac death

• Known structural heart disease

• Palpitations before syncope

• Abnormal ECG findings46.

6. What are the common cardiac causes of syncope?

• Arrhythmias (bradyarrhythmias, tachyarrhythmias)

• Structural heart disease (aortic stenosis, hypertrophic cardiomyopathy, pulmonary embolism, cardiac tamponade, atrial myxoma)4569.

7. What is orthostatic hypotension and how is it diagnosed?
Orthostatic hypotension is a drop in systolic blood pressure of at least 20 mmHg or diastolic blood pressure of at least 10 mmHg upon standing, often causing syncope or near-syncope69.

8. What is situational syncope?
Situational syncope occurs in specific situations that affect the autonomic nervous system, such as micturition, coughing, swallowing, or defecation69.

9. What initial investigations are recommended for syncope?

• Detailed history (including witness account if possible)

• Physical examination (including orthostatic vital signs)

• ECG

• Blood tests (hemoglobin, electrolytes, glucose)
  Further tests may include echocardiography, Holter monitoring, or tilt-table testing if indicated68.

10. Why is history from a witness important in syncope?
A witness can provide details about the event, such as the presence of convulsive movements, duration of unconsciousness, color changes, and recovery, which help differentiate syncope from other causes like seizures or psychogenic events