Clinical Case 142: Studying Swooning at Sixteen

Welcome back – this is the first case for a long while and it is also the first case presented on the new podcast segment!

The working Title is: Rob’s Probs and Casey’s Cases  (Ed: may change if we come up with something better)

The new podcast series is all about CLINICAL REASONING.  Exploring how we think through a diagnosis or problem.  IN order to do this I have teamed up with Dr Rob Park, a Queensland GP from the “Sunny Coast”, sounds delightful!  Rob has been on the podcast way back in December 2013 when we chatted about the evils and virtues of Vitamin D.  Since then Rob has been busy working as a GP, writing the RACGP written examination (yep, I know, you would think the bloke writing the exams is a total douchebag… turns out the opposite is true!) and becoming a father – so he clearly has a lot of time on his hands…

The aim of this podcast is to share some clinical cases, not so much to Stump the Chumps (see IM Reasoning for that) but more to show how a prudent senior GP might think their way through a clinical problem.  At least that is what I told Rob… now to try and fool that clever fella!

I have presented this case in stages – broken by horizontal lines – the idea is that you stop at each line and consider what is important, the differentials what you need to think about in the next phase.  Clearly there will be some questions you need to delve into later as more information becomes available.  But to pass the exams it is a good idea to start forcing yourself to pause and think “what next” or “where am I now” as the case unfolds.

Here is the case:

You are working in your suburban GP clinic.  Your next patient is Marli.  Marli is a 16 year old, final year highschooler.  You have not seen her since she was a little kid.  She presents with her mother whom you know quite well.  Marli is currently on study break leading into her final TER exams and her family have high expectations…

She has no ongoing medical problems and is quite fit, doing performance gymnastics up until final year school.  She has no other background issues.


Today she presents with a bruise on her forehead.  She tells you that she collapsed in the bathroom this morning and bumped her head on the vanity… she cannot recall anything for a few minutes.  This happened after she sat on the toilet to urinate then stood up.

Mum was in the next room and heard her fall and saw her on the floor.  Mum observed her laying on the floor and had what seemed like 2 or 3 brief jerky movements of all four limbs. After that she rapidly regained consciousness and sat up.  She was a bit dazed for 20 seconds.  Mum says it was about 30 seconds in total between her initial fall and being alert again.  Mum didn’t notice anything else… no tongue biting or incontinence.  The head bump is small, no laceration over the left eyebrow.

Marli says she has no aura or warning, she just suddenly felt weak in the legs, her vision “tunnelled” and she went limp.

She did not notice any palpitations or nausea.  There was no antecedent painful or particularly emotional events.

Over the last few weeks she has had less sleep as she has been studying late and drinking a lot of coffee to “stay awake”.  She has started doing regular exercise (running) to help with exam stress.  She has had a few episodes where she has felt light-headed on exercising but not actually fainted.


She has had some heavy menstrual periods in the last 18 months and was advised to take iron supplements by the school nurse.  She takes these sporadically.  She has not had any infective sounding symptoms such as fever, cough, coryza, dysuria… she has no abdominal pain or other symptoms.

Marli is happy to talk about her private life with Mum in the room, she says she has not ever been sexually active.  She does agree to undergo a urinary HCG “to be sure”.

Family history: Marli’s paternal uncle died suddenly, aged 30, when swimming on holiday in Greece… unclear as to exact cause.

Meds – intermittent oral iron supps, some vitamins


ON EXAMINATION

Marli is a tall, thin healthy looking young woman.  Her Obs: pulse 80 regular, BP 105/65 sitting (110/70 on standing), SpO2 99%

No clinical anaemia or pallor.  Skin is tanned.

Heart sounds are dual, normal, no bruits /clicks or thrills.  She has strong peripheral pulses.

Chest is clear

Abdomen soft.  No tenderness, or masses

Urinalysis is NAD with a negative bHCG

random BSL is 5.O mmol/L


Marli’s ECG is as follows:

courtesy LITFL ECG Library & Heart Pearls

OK, so let us stop there.  Look at the ECG and describe or diagnose it.

What next? How will you proceed from here?

If you know the diagnosis – then well done.  However if you want to hear this case dissected in audio format – have a listen to the podcast episode below.