MORNING REPORT

08/06/14
WEI SONG
TRIPLE BOARD YEAR 3
HISTORY
12 year old girl with history of severe depression, PTSD, and 3 prior suicide attempts presents
with 3 week history of feeling lightheaded and passing out.
Over last week had daily episodes of pre-syncope or syncope, especially when standing up
quickly. Improve with continued activity, though she is not an active girl.
Pro-drome of tremulousness, tunnel vision, and dizziness.
Has been tired all month, sleepy, fatigue
Yesterday had syncope at home: fell from toilet in bathroom, hit head on edge of tub
Today went to urgent care when she had symptoms again at grandmothers house.
At urgent care had BP of 80/40, received 500cc NS then transferred to PCH
Initial EKG showed 1
st
degree AV block, no QTc prolongation

MORE HISTORY
PMH:
Severe depression with 3 suicide attempts, 2 inpt hospitalizations, auditory and visual
hallucinations. Denies current SI or intent.
PTSD related to father committing suicide, intense nightmares helped by prazosin
Self-harm (cutting) behaviors when stressed
Transient prolonged QT with trazodone overdose five months ago
Genetic COX-1 disorder that leads to easy bruising
No PCP. Seen by an outpatient psychiatrist.
Surg Hx:
Tonsillectomy and Adenoidectomy
MORE HISTORY
Home Medications:
Prazosin 2mg QHS (Started 5 months ago)
Cymbalta 60mg PO qAM (Started 1 month ago)
Abilify 5mg PO QHS (Started 5 months ago)
Used to take Prozac prior to Cymbalta
Mom locks up all her meds and administers them to her.
Immunizations up to date
Allergies: Amoxicillin (Rash)
Diet: Normal for age. Likes burgers and fries. Eats all meals. Drinks many large cups of water
each day though notes urine is sometimes dark.
MORE HISTORY
FH:
h/o of Asthma
Father committed suicide with a gun (h/o depression)
No h/o arrhythmia, heart failure, SIDS, hearing defects or sudden death
SH:
Lives with mom. Legal guardianship held by mom.
Just started period five days ago, about to end today. Periods regular.

PHYSICAL FINDINGS
VS:
T 36.2, HR 57, RR 18, BP 104/56, SaO2 98% on Room Air
Weight 61.7 kg (91%ile), Height 168.0 cm (95%ile)
Orthostatics:
Supine BP 103/58, HR 68
Sitting BP 98/55, HR 84
Standing BP 100/71, HR 122
PHYSICAL FINDINGS
Gen Lying in bed asleep, appropriately arousable, NAD
HEENT NCAT; PERRL, EOMI, No conjunctival injection; TM normal; No nasal discharge or obstruction; mildly
dry mucus membranes, tonsils symmetric without exudate; no pharyngeal erythema or lesions; No LAD
CV RRR, S1 S2 normal with normal splitting of S2, no murmur rubs or gallops; cap refill < 3 secs; distal pulses
palpable in upper and lower extremities
Lungs: CTAB, good air flow, no wheezing or rales, no retractions
Abd: Soft, NT, ND, NO HSM. No bruits
Extremities: No clubbing cyanosis or edema, warm extremities
Neurological: Sleeping but appropriate arousal to light touch, CN II XII grossly intact, grossly normal strength
and tone. Patellar reflexes normal bilaterally. After fluids was able to get up from sleeping position, to a sitting
position, then stand up walk steadily to the bathroom.

DIFFERENTIAL
Long QT syndrome
Brugada syndrome
Catecolaminergic polymorphic ventricular tachycardia
Preexcitation syndrome (e.g. WPW)
Congenital short QT syndrome
Hypertrophic Cardiomyopathy
Coronary Artery anomalies
Valvar aortic stenosis
Pulmonary hypertension
Dilated cardiomyopathy
Acute myocarditis
Heat illness
Anaphylaxis
Vasovagal syncope
Breath holding spells
Orhtostatic hypotension
Toxic exposure / Medication
Hypoglycemia
SVT
Bradycardia
Seizures
Migraines
Conversion
Hyperventilation
Intentional strangulation
Narcolepsy
Intentional ingestion of meds

VASOVAGAL SYNCOPE
SYNCOPE
Approximately 15% of children experience a syncopal episode prior to end of adolescence
Some evaluating questions:
Exercise During exertion is concerning for cardiac etiology; after is more like vasovagal
Acute arousal or startle Some pt with long QT syndrome can be triggered this way
Postural changes upright prolonged or had just changed positions vasovagal
Pain, or emotional stress vasovagal or certain inherited arrhythmias
Palpitations or chest pain may be concerning for cardiac etiology or vasovagal
Motor activity If it starts at beginning of event, followed by prolonged recovery, think
seizures
SYNCOPE
Past histories:
Congential Heart Disease
Acquired Heart Disease (Kawasaki, rheumatic heart disease, myocarditis)
Arrhythmias
Previous syncopal events
DM or other conditions associated with hypoglycemia
Access to medications or illicit drugs and/or previous history of SA via overdose
Family histories of early cardiac death (<50 years of age), unexplained sudden deaths,
known arrhythmias, familial cardiomyopathies, or vasovagal syncope


VASOVAGAL SYNCOPE
Also known as neurocardiogenic, reflex, or situational syncope.
Most common cause of fainting among children, >50% of cases presenting to ED
Thoughts of causes:
Cardioinhibitory response enhanced parasympathetic tone, drop in heart rate and
contractility, leading to decreasein cardiac output
Vasodepressor response decreased sympathetic tone, drop in blood pressure without
much change in heart rate, most likely due to vasodilation
Clinical features:
Standing or physical or emotional stress, swallowing, hair grooming, micturition
Prodrome of lightheadedness, blurry vision, tunnel vision, double vision, nausea, pallor,
diaphoresis
VASOVAGAL SYNCOPE
Increase oral intake of water to approximately 30-50ml/kg per day
Add salty snacks (e.g. pretzels, pickles, or crackers); may need to add NaCl supplementation if
refractory
Avoid caffeinated beverages
Perform techniques to prevent venous pooling, including keeping knees slightly bent when
standing for a long time; contracting extremity muscles, toe raises, folding of the arms, and
crossing of the legs
A large percentage of patients may improve with non-pharmacologic treatment with oral
fluids and salt intake alone.