A previously healthy 25-year-old man presents to urgent care with a forehead laceration. He reports that he woke up on the floor of his apartment bathroom about 2 hours ago, with his face bleeding; he has no recollection of how he came to be on the floor. He notes that there was some urine both in the toilet and on the bathroom floor. He has no current symptoms other than a mild headache in the area of injury. He specifically denies chest pain, palpitations, light-headedness, vomiting, or blood in the stool. He also denies recent use of alcohol or any other substances, and says he takes no medications. He admits to a previous “passing out spell” which occurred “a couple of years ago” when he stood up quickly while experiencing nausea.
The physical examination reveals an alert, oriented, pleasant young adult man with normal vital signs, an unremarkable cardiopulmonary examination, and normal pupillary and neurologic examinations. There is a “V”-shaped laceration about 3 cm in length in the right supraorbital region with mild oozing. There is no dental or nasal trauma, his cervical spine is nontender, and the neck demonstrates full active range of motion. No extremity deformities or tenderness are noted.
Orthostatic vital signs are obtained and show that the patient’s systolic blood pressure increases by about 10 points on standing. His heart rate increases by 8 beats/min upon standing. His blood glucose level is 88 mg/dL and the ECG shows a normal sinus rhythm with a ventricular rate of 71. The tracing is interpreted as normal. What is the most appropriate course of management for this patient?
A. Repair the laceration, then send him to ED for head CT and monitoring.
B. Activate EMS for immediate transport to the ED.
C. Repair the laceration and discharge him with appropriate instructions for closed head injury and syncope, as well as recommendation to follow up with his primary care provider.
D. Order stool guaiac testing along with a CBC, a basic metabolic panel, and troponin and D-dimer levels. Repair the laceration and discharge the patient to await results of testing.
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Answer: C. This is low-risk case of syncope, and all clinical features point to micturition syncope — a benign, neurally mediated syncope. The patient does not meet any criteria for advanced neuroimaging, prolonged cardiac monitoring, exhaustive laboratory workup, or admission. Counseling with appropriate follow-up and discharge instructions is a safe and cost-effective course of management for this patient.
Last Updated on January 26, 2023