Aquifer Pediatric: Case 6 - 16 yo M Pre-participation
physical Questions With Completed Answers.
Based on the history you have already gathered (recognizing you have not yet
examined him), what is the most likely cause of these symptoms? (Select the
ONE best answer.)
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Vasovagal syncope
B. Hypoglycemia
C. Dehydration
D. Seizure
E. Heat stroke
A; Vasovagal syncope
Vasovagal syncope, often referred to as fainting, is caused by self-limited systemic
hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or
peripheral vasodilation. Children frequently describe prodromal symptoms that include
dizziness, lightheadedness, sweating, nausea, weakness, and visual changes. Many
times children experience the prodromal symptoms without syncope.
If Mike's cardiac and neurologic physical examination are normal, and the prior
ECG is confirmed to be normal, what additional evaluation do you think is
appropriate? (Select the ONE best answer.)
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Electroencephalogram (EEG)
B. Echocardiogram
C. Exercise Stress test
D. 24-hour Holter monitor
E. No further testing indicated
E. No further testing indicated
No diagnostic testing is necessary in his case (E). Mike's symptoms are consistent with
a neurocardiogenic (vasovagal) mechanism. This episode was not associated with
exercise, chest pain or palpitations, so there is no reason to suspect an underlying
cardiac disorder. Further cardiac evaluation for syncope is not needed in this case. He
also displayed no evidence of seizure activity, thus an EEG (B) is not needed.
The most common cause of sudden cardiac death (and thus a worrisome cardiac cause
for syncope) is hypertrophic cardiomyopathy (HCM). If there is no left ventricular outflow
tract obstruction, the physical examination of someone with HCM may be normal. The
ECG may be abnormal in up to 90% of patients with HCM (demonstrating left ventricular
hypertrophy and/or ST/T wave changes indicative of repolarization abnormalities),
although because about 10% of patients with HCM will have normal ECG's, an ECG is
, not a good screening test for HCM. If there are worrisome elements to the history (i.e.
syncope with activity), an echocardiogram will need to be performed to exclude HCM.
What is the most common cause of chest pain in an adolescent?
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Asthma
B. Gastroesophageal reflux disease (GERD)
C. Musculoskeletal
D. Myocardial ischemia
E. Pericarditis
C. MSK
Types of Chest Pain
Precordial catch syndrome is the most common cause of chest pain in adolescents and
is thought to be a form of musculoskeletal pain of unknown etiology. It is a benign
condition characterized by sudden, sporadic onset of sharp pain, usually along the left
sternal border, which is often exacerbated with deep inspiration. These pains are brief,
lasting seconds to a few minutes, and resolve spontaneously. The pain can often be
"broken" with a forced deep inspiration. It is often not associated with exercise.
Costochondritis is also a benign cause of chest pain but less common. The pain of
costochondritis is due to inflammation and typically will last for hours or days.
Gastrointestinal causes of chest pain include gastroesophageal reflux, gastritis, and
esophagitis. These often cause pain that is described as:
Retrosternal
Burning
Non-radiating
Associated with meals
ASTHMA
DRUGS
Cardiac Chest Pain
Onset
Pain triggered by exertion or stress
Quality
Pressure or crushing sensation
Duration
10-15 minutes
Associated symptoms
Syncope, palpitations
physical Questions With Completed Answers.
Based on the history you have already gathered (recognizing you have not yet
examined him), what is the most likely cause of these symptoms? (Select the
ONE best answer.)
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Vasovagal syncope
B. Hypoglycemia
C. Dehydration
D. Seizure
E. Heat stroke
A; Vasovagal syncope
Vasovagal syncope, often referred to as fainting, is caused by self-limited systemic
hypotension due to altered neurocardiogenic reflexes leading to bradycardia and/or
peripheral vasodilation. Children frequently describe prodromal symptoms that include
dizziness, lightheadedness, sweating, nausea, weakness, and visual changes. Many
times children experience the prodromal symptoms without syncope.
If Mike's cardiac and neurologic physical examination are normal, and the prior
ECG is confirmed to be normal, what additional evaluation do you think is
appropriate? (Select the ONE best answer.)
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Electroencephalogram (EEG)
B. Echocardiogram
C. Exercise Stress test
D. 24-hour Holter monitor
E. No further testing indicated
E. No further testing indicated
No diagnostic testing is necessary in his case (E). Mike's symptoms are consistent with
a neurocardiogenic (vasovagal) mechanism. This episode was not associated with
exercise, chest pain or palpitations, so there is no reason to suspect an underlying
cardiac disorder. Further cardiac evaluation for syncope is not needed in this case. He
also displayed no evidence of seizure activity, thus an EEG (B) is not needed.
The most common cause of sudden cardiac death (and thus a worrisome cardiac cause
for syncope) is hypertrophic cardiomyopathy (HCM). If there is no left ventricular outflow
tract obstruction, the physical examination of someone with HCM may be normal. The
ECG may be abnormal in up to 90% of patients with HCM (demonstrating left ventricular
hypertrophy and/or ST/T wave changes indicative of repolarization abnormalities),
although because about 10% of patients with HCM will have normal ECG's, an ECG is
, not a good screening test for HCM. If there are worrisome elements to the history (i.e.
syncope with activity), an echocardiogram will need to be performed to exclude HCM.
What is the most common cause of chest pain in an adolescent?
The best option is indicated below. Your selections are indicated by the shaded
boxes.
A. Asthma
B. Gastroesophageal reflux disease (GERD)
C. Musculoskeletal
D. Myocardial ischemia
E. Pericarditis
C. MSK
Types of Chest Pain
Precordial catch syndrome is the most common cause of chest pain in adolescents and
is thought to be a form of musculoskeletal pain of unknown etiology. It is a benign
condition characterized by sudden, sporadic onset of sharp pain, usually along the left
sternal border, which is often exacerbated with deep inspiration. These pains are brief,
lasting seconds to a few minutes, and resolve spontaneously. The pain can often be
"broken" with a forced deep inspiration. It is often not associated with exercise.
Costochondritis is also a benign cause of chest pain but less common. The pain of
costochondritis is due to inflammation and typically will last for hours or days.
Gastrointestinal causes of chest pain include gastroesophageal reflux, gastritis, and
esophagitis. These often cause pain that is described as:
Retrosternal
Burning
Non-radiating
Associated with meals
ASTHMA
DRUGS
Cardiac Chest Pain
Onset
Pain triggered by exertion or stress
Quality
Pressure or crushing sensation
Duration
10-15 minutes
Associated symptoms
Syncope, palpitations
