Pediatric Primary Care Case Studies (92 page)

Other elements of the history should include questioning about the following:

•   Presence of underlying medical problems (such as diabetes or cardiac history).

•   Menstrual history—did the event occur while menstruating, cramping, or a heavy period with clotting?

•   Access to and use of medications or illicit drugs.

•   Prolonged loss of consciousness or unconscious for more than several seconds with a postictal period. If this occurs, the child should be evaluated for a neurologic disorder, such as a seizure or migraine syndrome.

•   Transient loss of consciousness for less than several seconds in a child with a normal ECG and cardiac examination. This most likely represents noncardiac syncope.

•   Typical characteristics of vasovagal-induced syncope. Vasovagal syncope is a neurocardiogenic incident that is usually diagnosed on clinical features. The absence of a significant prodrome, associated palpitations or chest pain, or a family history of syncope or sudden death may require further cardiac evaluation.

•   Orthostatic hypotension. This is the likely etiology for syncope in patients with postural changes in heart rate and blood pressure and a normal ECG. The underlying cause of these changes such as dehydration/ volume depletion should be identified and treated. Although orthostatic hypotension has also been associated with long QT syndrome, the ECG is abnormal in the vast majority of cases (Atkins, Hanusa, Sefcik, & Kapoor, 1991).

•   A toxic exposure may be suggested by history such as the use of inhalants/huffing or identified by a urine toxicologic screen for medications or illicit drugs including antidepressant drugs or carbon monoxide poisoning.

•   Hyperventilation-induced syncope. This demonstrates an abnormal respiratory pattern prior to the syncopal episode and is commonly seen in adolescents experiencing some type of emotional stress. They may describe additional symptoms such as chest pain, lightheadedness, paresthesias/numbness in hands or feet, and visual disturbances.

•   Breath-holding spells occur in younger children (6 to 24 months). In this case, syncope develops in association with breath holding. A cardiac evaluation is indicated for children with a family history of syncope or sudden death or with episodes that are prolonged, frequent, or precipitated by startle or other nontraumatic stimuli.

•   Somatization disorder/hysteria or a conversion disorder. This commonly occurs in adolescents. Expected physiologic signs of syncope such as sweating, pallor, or changes in heart rate and blood pressure are absent. In addition, patients may disclose details of the event that indicate no loss of consciousness and generally suffer no injury during collapse.

•   Choking games in which an adolescent purposely attempts self-strangulation or allows strangulation by another person with the hands or a ligature. The goal of the game is to reach a euphoric state created by the hypoxia, and then release the pressure just before loss of consciousness. Failure to do so can result in death.

•   Vasovagal (neurocardiogenic) syncope is a diagnosis of exclusion for patients with consistent clinical features.

Using the above information, what other history questions do you need to ask Emma and her mother?

Other questions that are an important consideration as part of your symptom analysis include:

•   Did she have any posturing or shaking of her body or seizure-like activity?

•   Did she experience flashing lights, stars, blind spots, or doubled or blurred vision?

•   Is there a history of headaches, numbness, or tingling?

•   Did anyone notice the color of her skin? Was it pink, blue, or mottled?

•   Has she experienced any recent trauma?

•   Were there palpitations or chest pain associated with the syncope?

•   Did she have shortness of breath?

•   Has she had fever or weight loss or complaints of tiredness or fatigue?

•   What, if any, medication (or medications) is she taking including over-the-counter drugs, herbal or nutritional supplements, and antidepressant drugs?

Emma’s mother, Mrs. Kaplan, has now arrived at the ED and together they provide you with the following information: Mrs. Kaplan reports that Emma has been very healthy. She has never been hospitalized or in the ED before. Her immunizations are up to date, and she has no food or medication allergies and takes no medication or nutritional supplements. She has never passed out before nor does she have a history of recent trauma, headaches, or a heart problem. She has not had a fever, weight loss, or complaints of tiredness or fatigue.

Emma has always been a “B” student and is now attending a new school after Mrs. Kaplan’s recent divorce. Mrs. Kaplan states Emma has adjusted well to the recent divorce and she has made many new friends in a short time in her new school. She feels Emma’s school performance continues to improve. Emma’s last menstrual period was 2 weeks ago and described as a normal 5-day flow. She states she uses pads (not tampons) for her periods.

In the absence of her mother and coach, Emma denies any illicit drug, inhalant/ huffing, and medication use. Emma states that it was a tough field hockey game against the Ridgefield Ravens. This was her first game playing with her new teammates, and she felt she had to prove to the other girls she was a great team player. She focused on making great passes and assists to make each team point. She denies chest pain or shortness of breath, and it seemed she was running more than usual and was very hot and sweaty. Emma recalls the events prior to her passing out and states when the team completed the huddle at the end of the game, she stood up and suddenly felt lightheaded, nauseous, and then things got blurry. The next thing she remembers is waking up, with one of her classmates holding her legs up and the coach asking her to tell him what happened.

You talk to Emma’s coach. He states that there was no trauma during the game, and that at the end of the game, after the huddle, Emma “stood up and passed out.” Emma fell face down and was unresponsive for about 15–30 seconds or so. Emma had no jerking movements, no color changes, and no loss of bowel or bladder control. When she came to, she seemed surprised she was on the ground and has seemed normal ever since.

In considering whether this syncopal episode could have resulted from an underlying life-threatening cardiac issue, you must quickly collect information from Emma and her mother and document their answers about the following key issues:

•   Did the syncope occur during activity/exertion?

•   Is there a family history of early cardiac death?

•   Does Emma have a history of congenital heart disease?

•   Is her past medical history significant for cardiac disease or risk factors (e.g., elevated blood pressure, supraventricular tachycardia, anorexia nervosa)?

From your interviews with Emma, her mother, and her coach, you know that Emma’s syncope took place after the game, and you have also been given assurance that there is no family history of early cardiac death nor does Emma have congenital heart disease or arrhythmias or a history of anorexia or blood pressure problems.

What would be your next plan of action?

Based on Emma’s presenting symptoms, you ask the ED nurse to draw a standard blood panel including complete blood count, chemistry, toxicology, and pregnancy test. You look up at the cardiac monitor and note that she is in normal sinus rhythm. You are now ready to begin your physical examination of Emma.

Physical Examination

The healthcare provider should perform a complete physical exam that includes full vital signs including orthostatic pulse and blood pressure measurements and cardiac and neurologic examinations.

Abnormal blood pressures include a decrease in systolic blood pressure by 20 mm Hg or an increase in heart rate by 20 beats per minute from sitting to standing. More significant than changes in blood pressure is the recurrence of symptoms such as lightheadedness or syncope on standing. However, the presence of orthostatic hypotension does not rule out other causes of syncope, particularly long QT syndrome (Atkins et al., 1991). An age-appropriate neurologic exam should be performed to identify focal deficits or seizures.

Emma’s vital signs reveal blood pressure (BP) 110/60, temperature 97.9°F, pulse 70, respirations 18, and pulse oximetry 98%. Orthostatic BPs are as follows: sitting 110/60 and standing 102/55. Heart rate: sitting 70 and standing 78. Her four-point BPs lying down are: right arm 110/60; left arm 118/64; right leg 100/55; left leg 100/56. General appearance is that of an alert, oriented, well-developed, and well-nourished 14-year-old who is holding her mother’s hand. You perform a thorough cardiac and neurologic examination of Emma. The cardiovascular exam reveals a regular rate and rhythm, normal S1 and S2, and no cardiac gallop, rub, or murmur including with a Valsalva maneuver and squatting. There is no carotid bruit, jugular venous distention, or peripheral edema.
She has strong distal pulses with warm extremities and her capillary refill is less than 2 seconds. Her liver is at the right costal margin without hepatomegaly. The neurologic exam reveals full recall of all incidents before and after her syncopal event. She is alert and oriented to person, place, and time. Her cranial nerves II-XII are intact; she has symmetric bilateral deep tendon reflexes, with good muscle tone and strength, and has a normal gait and stance. The remaining findings of her physical exam are likewise unremarkable.

Children and adolescents, like Emma, with a normal ECG and cardiac examination are unlikely to have a cardiac etiology. However, a change in cardiac exam with evidence of new heart sounds, including gallops, rubs, and murmurs, may suggest the following structural lesions:

•   Aortic stenosis is associated with a systolic ejection murmur and ejection click.

•   Valvar stenosis may be associated with coarctation of the aorta. Four extremity blood pressures should be recorded. A difference in the systolic measurement of 20 mm Hg in the arm greater than in the legs is significant.

•   Hypertrophic cardiomyopathy causes a murmur that is heard best during a Valsalva maneuver or squatting.

•   New onset congestive heart failure may be diagnosed if findings such as rales, a gallop, and hepatomegaly, not noted before, are now evident on examination.

What laboratory tests did you need to order and what were the results?