Case: 68-year-old Man Presenting with Fainting Episodes

00:01 In this lecture, we'll talk about the approach to presyncope or syncope.

00:05 Let's start with a case.

00:07 A 68-year-old man with a history of hypertension, hyperlipidemia, diabetes, and prior stroke presents for recurrent episodes of dizziness.

00:17 The patient says that for the past two months, when he stands he becomes severely lightheaded and dizzy.

00:23 He says that it feels as if he's having tunnel vision, and one time, he actually passed out.

00:29 In fact, he was told that he slumped over to the ground and began to convulse throughout his body.

00:35 Afterwards, he stood right up and asked what had happened.

00:38 At times, this will develop immediately after he stands, and at other times, it can be about five minutes or so when he's walking around that he'll become dizzy.

00:48 He's on three anti-hypertensives including amlodipine, lisinopril, hydrochlorothiazide, and metoprolol.

00:54 so four medicines, which were started about two months ago.

00:58 Examination is unrevealing with normal cerebellar signs and no nystagmus.

01:04 Blood pressure, when he's lying down is 125/75 with a heart rate of 70 beats/minute.

01:11 And three minutes after standing, his blood pressure drops to 90/50, with a heart rate of 75.

01:17 So what's the diagnosis? Well, there are many features of this case that we should be attuned to.

01:24 When when we approach dizziness, one of the things we focus on is the timeline of onset.

01:29 This began about two months ago, it's subacute and onset.

01:33 It's not acute beginning within the last one day.

01:36 It's not chronic going on for months or years, but it started within the last several months a subacute onset condition.

01:44 The second factor is the provoking factors or provoking signs.

01:49 And this is also important when evaluating anyone with dizziness.

01:53 These episodes begin when he stands.

01:56 And this could point us in the direction of orthostatic hypotension, or when the patient stands their blood pressure drops, which is one type of syncope or presyncope.

02:07 We also focus on the patient's description, which again is important when evaluating any patient with dizziness.

02:14 This patient describes lightheadedness, a fainting feeling.

02:18 He passed out with one of the episodes and after passing out, convulsed.

02:23 This gives a description of syncope or presyncope with one event that may have been a convulsive syncopal event.

02:31 And so the patient's description is critical in evaluating this vignette.

02:37 So what is the most likely diagnosis? Is this a cerebellar stroke? A seizure? BPPV or Benign Paroxysmal Positional Vertigo? Syncope? Or is it labyrinthitis or vestibular neuritis? Well, it doesn't sound like labyrinthitis or vestibular neuritis.

02:55 Those are two causes of vertigo.

02:57 And this patient's description is consistent with syncope.

03:00 He's not describing vertigo.

03:04 What about a cerebellar stroke? This doesn't sound like cerebellar disequilibrium.

03:09 The patient's description is more of a syncopal episode as opposed to a cerebellar disequilibrium.

03:15 It's also not acute and onset.

03:17 This patient's presentation is subacute over several months.

03:20 And we would expect a cerebellar stroke to present acutely.

03:26 This doesn't sound like BPPV.

03:29 The exam findings aren't consistent with BPPV.

03:32 We tend to see nystagmus or a rotary nystagmus.

03:35 It is episodic.

03:37 And BPPV is an episodic condition, but patients frequently described vertigo and room spinning that is initiated or provoked by head turning.

03:46 This patient describes episodes that are initiated by standing.

03:50 So BPPV is not our favored diagnosis.

03:55 What about a seizure? This patient describes seizure.

03:57 His episode of convulsion was convulsive syncope.

04:01 The description where he fainted first, and then convulsed is more consistent with convulsive syncope.

04:07 Seizures begin with shaking or convulsing first, followed by passing out.

04:12 There was also no post-event confusion as we would expect from a seizure.

04:17 So the right answer here is syncope.

04:19 The patient describes tunnel vision and lightheadedness, were which are common descriptions of syncope.

04:25 The episodes are provoked by standing up, which is common from orthostasis, and the presentation overall is suggestive of an orthostatic neurally mediated syncope.