Syncope and orthostatic intolerance — formative SAQs

SAQ 1 — Exertional syncope with a family history (10 marks, 15 minutes)

A 13-year-old boy collapsed while sprinting the 400 metres at school. He had no prodrome. His father died suddenly at 34 years of age, and an uncle drowned in unclear circumstances. On examination the boy is fully recovered, his cardiovascular examination is normal, and his blood pressure is 110/70 with equal four-limb pulses. [5]

a) List the cardiac red-flag features in this vignette and explain why this presentation must be treated as cardiac syncope until proven otherwise. (3 marks) [5] [11]

b) Outline your immediate assessment and investigations, including the role of the ECG and the specific patterns you must exclude. (4 marks) [5]

c) Describe your disposition, including the advice on exercise, and the principles of managing the likely underlying condition. (3 marks) [11]

SAQ 2 — Chronic daily orthostatic symptoms in an adolescent girl (10 marks, 15 minutes)

A 15-year-old girl presents with six months of daily lightheadedness, palpitations, fatigue and brain fog, worse on standing and in the morning and eased by lying down. It began after a viral illness. On a standing test her blood pressure does not fall, but her heart rate rises from 72 supine to 118 beats per minute by 8 minutes of standing, with reproduction of her symptoms. Her ECG and echocardiogram are normal. [7]

a) What is the diagnosis, and state the orthostatic heart-rate and blood-pressure criteria that support it. (3 marks) [7] [8]

b) Outline the first-line management, and explain why the exercise and reconditioning programme is the most evidence-based component. (4 marks) [8] [9]

c) Describe the prognosis and the counselling you would give about recovery, school attendance and the role of medications. (3 marks) [9]