Topic: Diagnostic Investigations
Subject: Medicine
A 50-year-old male is brought to the emergency department because of a syncopal episode. Prior to the episode, he felt bad for 30 minutes, then developed nausea followed by vomiting. During a second bout of vomiting he blacked out and fell to the floor. His wife did not observe any seizure activity, and he was unconscious only for a few seconds. His history is otherwise negative, his past medical history is unremarkable, and he currently takes no medications. A physical examination is normal.
Which one of the following would be the most helpful next step?

Correct Answer : D.

The workup of patients with syncope begins with a history and a physical examination to identify those at risk for a poor outcome. Patients who have a prodrome of 5 seconds or less may have a cardiac arrhythmia. Patients with longer prodromes, nausea, or vomiting are likely to have vasovagal syncope, which is a benign process. Patients who pass out after standing for 2 minutes are likely to have orthostatic hypotension. In most cases, the recommended test is an EKG. If the EKG is normal, dysrhythmias are not a likely cause of the syncopal episode. Laboratory testing and advanced studies such as CT or echocardiography are not necessary unless there are specific findings in either the history or the physical examination.