Getting Lucky

I have taken care of many many syncope cases. The routine is.

Observation
Telemetry
Echo
Orthostatics

Everything is normal and on they go. The most common diagnosis is that there is no diagnosis

Usually the basket diagnosis of vaso vagal syncope.

An old person trying to crap
A young person distraught over their break up.

Rarely is it seizure
Rarely is it stroke (I'd say just about never)
Rarely is it structural cardiac disease in the abscence of known cardiac disease
Rarely is it life threatening

If anything, my main concern is always cardiac arrhythmia. More so in a structurally abnormal heart or an abnormal EKG.

The history, more than anything drives the workup and diagnostic testing.

And it should.

In a recent case of mine, I think we got lucky.

A young patient was out on the town at a local sports bar. Not drunk. Living his life normal. The next thing he knows, he's on the ground with a bunch of people looking down at him.

He passed out. Medically, syncope.

His history was negative.

Very negative.

No pre aura. No post ictal. No cardiac. No pulmonary complaints. No head ache. No bowel or bladder dysfunction. No leg pain, cramping or swelling., No Chest pain. No cough. No shortness of breath. He does have a history of melanoma and is actively followed. A negative brain MRI 6 weeks ago. Nothing strikingly abnormal on basic panels. He does have a family history of aortic aneurysm, but he complains of no pain at all.

A transient event. A self limited event.

An unexplained event, like so often it is. Go home and live your life.

Labs OK
CXR OK
EKG OK
Echo OK, except for right ventricular pressure (RVP) of about 40.

It certainly peeked my curiosity on why a young nonsmoking man would have elevated pulmonary artery pressures.

My partner, who admitted the patient on the night shift was concerned about aneurysm of the aorta and ordered a CTA of the chest, catching both aneurysm eval and PE eval at the same time.

I had just finished giving my routine talk to syncope patients to him.

"If all these tests are negative, you go home."

I reviewed with the oncologist. No cardiac toxic chemo. My suspicion in this case was simply that it was a garden variety vaso vagal.

Until that Echo came back.

Elevated pulmonary pressures.

Normal O2 sats. No shortness of breath.

Could he infact have a pulmonary embolism? An asymptomatic (minus his syncope) PE?

While the suspicion for aortic aneurysm is low, the CTA had been ordered and in fact the patient was on his way to get it just after I saw him.

A little while later I get the call.

Pulmonary Embolism.

He certainly has the one risk factor that puts him at risk. Cancer. But that's it.

And that was his only presenting "complaint", which in actuality, is not even a complaint.

It is a part of his history.

In the end, I think a little bit of luck saved the day.

I must admit, a CT angiogram of the chest to evaluate for pulmonary embolism is not part of my routine evaluation for syncope, especially in a negative ROS.

The history drives the diagnosis.

Nothing on his history or physical, subjective or objective data pointed to pulmonary embolism.

Except that elevated pulmonary pressure.

Had my partner not ordered the chest CT, I think I may have.

If not for the only reason to settle my internal curiosity as to why a young man had elevated pulmonary pressures.


Had the patient been morbidly obese, the echo tech may not have been able to document RVP and I would have NO suspicion for PE.

I present this case history to any doctors out there reading this.

The often forgotten diagnosis of pulmonary embolism, a sometimes fatal condition, is usually only diagnosed when you think of it.

As a member of our hospital wide committee for the prevention of venous thromboembolism and a member of the Society of Hospital Medicine collaborative effort for the prevention of VTE, I find myself thinking of it often.

Regardless

I still think a little bit of luck played out here.