Station 2 Case 2

Station 2 Case 2:

Follow Up Questions/Answers

Can you summary exactly what happens during one of these episodes of
collapse

o Mr Jackson presented with 3 episodes of collapse.

o 2 were in the context of recent activity and one was in the context
of being in an enclosed warm environment on the tube.
o He described feeling light headed.
o He described a change to his vision a slight blurring around the
edges.
o He was also able to tell me he was aware of the sensation of the
feeling that he was going to collapse and black out.
o He didn’t mention any aura.
o Whilst he was on the ground there was no evidence of tongue
biting or urinary incontinence nor any seizure like activity or
twitching.
o Whilst he did report that he felt shaken by the episode there was no
evidence of persistence confusion or postictal period.

Based on this description what do you think is the most likely cause of Mr
Jacksons collapses?

o The diagnosis that I most want to exclude is one of cardiogenic

syncope, given the lack of postictal symptoms completely makes
me most concerned about that.

What may be relevance his shortness of breath which has been coming on
over the last few months?

o That does make me concerned of what his cardiac function is.

o It did also make me wonder or not there may be an element of
anaemia concurrent.
o I wanted to do a simple blood test to check what his haemoglobin
level was.

Investigation wise, you mentioned some investigations just summarise the

investigations again for me, and what might be the outcomes of those
investigations and what kind of thing you’d be looking for?

o The blood test to check for anaemia,

o I mentioned doing some postural blood pressures to make sure
there wasn’t some evidence of postural instability.
o I want an ECG which might let me see if there’s any evidence of
hypertrophy or any abnormal QRS complexes.
Station 2 Case 2

o I felt an echo would be important particularly looking for any

hypertrophy.
o I felt that a 5 day ambulatory ECG would be important to see if
there are any episodes of him flipping into abnormal rhythms

Why do think a thorough family history is relevant in this case?

o It is well known there is a hereditable link between certain structural

cardiac diseases and dysrhythmias.
o It would be important to know if there were any family history
particularly in a first degree relative of any sudden death or known
diagnosis.

Do you think this could all be a non-organic cause here for these
collapses?

o Mr Jackson did mention that he was under increased stress with

coming to the completion of his PGCE.
o Whilst that could be a factor I think it’s much more important that
we fully rule out organic causes and thoroughly investigate it from
that point of view before we really considered a none organic
cause.

You mentioned your main differential diagnosis here is to do with the

heart and cardiac side of things, but if those investigations were normal
and you were possible considering other diagnoses and thinking about
epilepsy, how would you think about that, and how would you diagnose
that?

o The vast majority of epilepsy diagnoses is a clinical decision based

on the history, which in this case doesn’t quite correlate with that of
epilepsy.
o If the history did lead me to think of that the first thing I would want
to do would be to rule out any intracranial structural abnormality
via a CT scan and also consider the role of an EEG to assess what
the electrical was in the brain.
o If I was going down that path it would also be important to discuss
with Mr. Jackson that it would be inappropriate to continue driving
until further notice.
o I’d also give advice regarding not swimming and being involved in
potentially dangerous activities.
Station 2 Case 2

Station 2 Case 2:

Key Words and Phrases

This is the case of a young man with three separate episodes of syncope
or collapse. The history must include the chronology of these episodes
and any particular circumstances in which they happened.

However the most important aspect is the exact description of the actual
collapse which can be divided into the Prodrome, the episode and the
recovery. Different aetiologies will classically give a different history. It is
important to gather this information in a systematic fashion during the
history of presenting complaint before moving on to the other important
aspects of the history.

The description here is of a very sudden onset with fainting type

symptoms with an extremely brief loss of consciousness and rapid
recovery with no after effects – typical of a cardiac or vagal type
syncope. There is no prodrome or ‘post ictal’ malaise and no intra
syncopical shaking or incontinence. History from bystanders relayed to
the patient maybe important to ascertain regarding this.

Here the main differential diagnosis is quite wide between vagal

episodes, a true cardiac cause, less likely, epilepsy, possible anemia in
view of his breathlessness.
Only once you are satisfied that you have an accurate description and
understanding of the syncopical episodes can you then explore other
important aspects of the history such as family history, medications
(including over the counter meds and recreational drug use) and whether
there are any particulars stresses within the patient’s life at this time.

Exploration of what the patient thinks might be cause and whether they
are worried about anything in particular can sometimes be helpful in the
history taking station when there is usually a differential diagnosis before
any investigations have been performed
An explanation of the potential differential diagnoses, investigation plan
and future follow up following the history is helpful.

Typical investigations to consider here would be lying and standing

Blood Pressure’s, ECG, Echocardiogram, cardiac holter monitoring,
maybe a 24 hour tape or a 5 day tape and you may consider a CT Head
and EEG if all the cardiac investigations are normal, but as I say epilepsy
is less likely given the exact history.
Station 2 Case 2