Syncope and orthostatic intolerance — structured clinical encounter

Encounter structure

The candidate works through the case in five phases: [5]

1. Recognition (5 minutes): Identify the cardiac red-flag history (exertional syncope, absent prodrome, family history of sudden death) and state that this is cardiac syncope until proven otherwise; distinguish it from a benign vasovagal faint by the absence of the reassuring features. [1]

2. Immediate assessment and sport restriction (5 minutes): Obtain a 12-lead ECG immediately and measure the corrected QT interval, looking for long-QT, Wolff-Parkinson-White, Brugada pattern and hypertrophic-cardiomyopathy voltage; restrict the boy from all competitive sport and physical exertion pending evaluation. [11]

3. Investigation and cardiology referral (5 minutes): Arrange an echocardiogram and cardiology referral; request an exercise stress test and ambulatory ECG monitoring as guided by cardiology; screen first-degree relatives with an ECG given the family history of sudden death. [5]

4. The family conversation (5 minutes): Explain in plain language why exertional collapse with a family history is treated seriously; describe the work-up plan and the temporary sport restriction; set honest expectations about the inherited arrhythmia and cardiomyopathy differential while awaiting results. [11]

5. Contrast and follow-up planning (5 minutes): Contrast this presentation with the adolescent girl whose chronic daily orthostatic symptoms meet POTS criteria (heart-rate rise at least 30 bpm over 10 minutes of standing without a blood-pressure fall), managed non-pharmacologically with hydration, salt and reconditioning; outline the structured follow-up and the clear safety-net for both patients. [7] [9]