Cardiology Procedures by Robert C. Hendel & Carey Kimmelstiel

Author:Robert C. Hendel & Carey Kimmelstiel
Language: eng
Format: epub
Publisher: Springer London, London

Case 2

A 28 year old woman is referred for the evaluation of recurrent fainting episodes. These started about 2 years ago, and have consistently recurred. She has no medical history, other than generalized anxiety disorder, and takes no medications or over the counter supplies. The episodes occur without an aura, or clear precipitating event. These last between 5 and 20 min, and the patient just experiences some residual weakness and left lower extremity weakness. She has undergone extensive neurologic evaluation (including MRI and EEG) without a definitive diagnosis. Furthermore, EKG and echocardiography do not show any abnormalities. At the primary care physician’s office her blood pressure was borderline low, but otherwise her vitals were normal. She undergoes TTT, and her vitals remain unchanged but the patient experiences another episode. A psychiatry consultation is placed, and the diagnosis is changed to psychogenic seizures and possibly conversion disorder. With the patient and her family understanding the diagnosis, psychotherapy was started and follow up appointments were provided.

This patient comes with complaints of recurrent syncope without a clear explanation. There is always concern for seizures or syncope of neuro-cardiogenic nature. These seem to have been ruled out. The possibility of vasovagal syncope has to be considered. Her blood pressure was marginally low; however, this is a non-specific finding especially in young healthy individuals. TTTs that reproduce the loss of consciousness without changes in vital signs are suspicious for a psychogenic etiology. The patient and family should be engaged in the therapy, which should remain empathic and consistent throughout. It is crucial to recognize that most of these events are involuntary, legitimate, and disabling to the patient. She should enroll in behavioral and group psychotherapy, and considered for antidepressant or antipsychotic pharmacotherapy.

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