A Syncope Mystery
Anna Burkhead -- This month, I am working at a Family Medicine clinic, my last core rotation of third year. It’s been a great opportunity for me to work on my basic diagnosis and treatment plan skills.
Last week, a middle-aged man came to the clinic for a hospital follow-up visit. He had recently been hospitalized after an episode of syncope in his bathroom at home and a subsequent loss of consciousness while driving later that day. In the hospital, a CT showed a small subdural hemorrhage, probably produced when he hit his head on the sink after fainting in the bathroom.
During his hospital stay, the man had an extensive workup, including several CTs, an MRI, echo, EEG, carotid doppler studies, tilt table test, and an EP study. All of the test results were within normal limits.
At the man’s clinic visit, we reviewed the results of his tests, including a follow-up CT that showed no residual subdural blood. The neurologist had cleared him to drive with caution. The patient had had no further episodes of syncope since being discharged from the hospital.
The doctor and I explained to him that no apparent etiology for his syncope had been found in his medical workup. He was surprised to learn that this was not uncommon; isolated episodes of syncope are very often followed by negative workups, and the episodes remain unexplained.
As the visit progressed, I observed the initially calm and friendly man become more and more agitated, desperate, and frantic as he realized that we weren’t able to provide an explanation for his fainting. He stuttered questions, produced a few beads of sweat, and after we left the clinic room, he called me back for more questions.
This man’s anxiety was palpable. For a brief moment, I wished that the workup had provided a reason for his syncopal episode. Then I realized that wishing such a thought meant wishing that this man had something structurally or metabolically wrong with his brain or heart. I tried my hardest to explain that isolated episodes of syncope were often just that: single (non-recurrent) incidents, without significant associated pathology.
The man eventually ran out of questions and left the clinic. He had arrived expecting an explanation, something to make the scary events he had suffered make sense. He left with little more than a copy of his hospital test results.
There was little else to do in this situation. Every reasonable test and study had been done. There was nothing left to do but reassure the patient that no significant pathology had been found. Sometimes doctors and medicine cannot provide answers. Whether that’s because the answers don’t exist, or because we’re unable to uncover them, I’m not sure. But I know that it can be frustrating to the patient looking for logic, as I observed here.
If it's a molehill, doesn't an EXTENSIVE workup make it seem like a mountain to the patient? No matter what the physicians say, if they then toss a whole bunch of workup at the patient, there's a duplicity in messages the patient is receiving.
Posted by: Jared | May 20, 2008 4:11:44 AM
To the previous poster;
Your supposition that an extensive medical workup leaves any patient sufficiently anxious about his or her situation is flawed--both logically and relatively. What exactly comprises a "molehill" to you? Any event that a patient cannot easily self-assess, without medical consort, is potentially frightening to the patient. It is the minority that feels anxiety when no concrete answer can be offered--and usually that could signal psychiatric illness in the patient (i.e. hypochodriasis). Many patients feel relief when extensive testing reveals an isolated episode, and there appears to be no imminent nor longterm threat to their health--be it physical or mental. If you see some duplicity in the messages the patient is receiving, then either that is just narcissitic arrogance or you are overthinking the situation as the doctor. Communication is the best remedy for elaying a patient's fears or frustrations when no clear-cut answer(s) can be given for his or her circumstances. Honesty can be very reassurring . . . never discount that, or else you are second guessing the patient. That is arrogant and potentially dangerous. And, we all know that the PATIENT is the best source for information available. Even in the presence of scans, bloodwork, etc.
Posted by: Christopher | May 27, 2008 3:29:07 PM
From your description of the patient's progressing anxiety during the F/U could it be possible you are looking at a pat. that experienced an anxiety Induced syncopic episode? Was the pat. asked about his emotional status during the period leading up to the syncope? Perhaps we're not looking at hypochondriasis or Munchausen's, but simple, transient,anxiety induced hypertension or hyper/hypo ventilation leading to uncomplicated syncope?
Posted by: Tom Malone | May 27, 2008 5:16:37 PM
More semiology, including psychology, would help clear hypothesis for this case and make the patient feel more comfortable as it was mentioned by Chistopher that the patient is the best source.
Posted by: Rafael de Giacomo Araujo | May 28, 2008 11:53:13 AM
maybe it is of a psychogenic cause. Why not send him to the outpatient psychiatry clinic...
Posted by: BT | May 29, 2008 10:04:33 AM
Remember postmodern medical axiom: there are not healthy humans, only insufficiently explored unhealthies
Posted by: R. Herrera | May 31, 2008 3:47:24 PM
You make a very good point about the possibility of a transient anxiety attack with accompanying syncope from hyperventilation. I myself suffer from transient events such as this, with no known precursory trigger and unknown etiology. I know from my own experience that the lack of sufficient explanation has not worsened my condition, nor have I become more frustrated, anxious or conflicted as a result. Just knowing how to control the symptoms--to a degree--and that the condition is neither life threatening nor will it seriously degrade my quality of life is actually a great relief. Even without being able to name the beast.
Posted by: Christopher | Jun 2, 2008 12:21:45 PM
I think the Extensive work-up for this patient is the reason of agitation after he saw no answer to his fainting!
I think we would better to do some of them to rule out life threatening etiologies then observe him for severeal months,in this way we could gather some extra data about the life style and the daily nutrition of patient then we could decide better about etiology of his syncope.
Posted by: Salman V. | Jun 3, 2008 4:14:19 AM
Does the patient have a family history of hypertension? heart disease? cerebrovascular disease? Has the patient been hypertensive? or was he at the time of consult? risk factors for doing the testsss?... then why order the EXTENSIVE work-up when you can do a lot with less tests (example: "A" CT and "AN" MRI instead of the "several CTs" or normal BP & unremarkable cardio-auscultation could have eliminated your need to perform carotid doppler & tilt-table)...
What I'm saying is that the patient reacted the way he did because the EXTENSIVE tests implied "something complex is causing this!" but the results didn't live up to that expectation. I just think that the work-up done was like killing one mosquito with a nuclear bomb.
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Posted by: symptoms of fainting | May 26, 2010 3:12:13 AM
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