Question

A 72 year old female presents after "passing out" while walking back to her house from the mailbox. Other than an abrasion on her elbow, she denies any trauma from the fall and recovered quickly following the incident. There was no bowel or bladder incontinence or prodrome before the attack. On review of systems, the patient admits to occasional exertional chest pains that are relieved by taking her husband's nitroglycerin. Physical examination shows vital signs of heart rate 75 and regular, blood pressure 138/78, and respirations 13/min. There is a small abrasion and associated ecchymosis on the patient's left elbow, but no other signs of trauma. On cardiac auscultation, there is a harsh, III/VI systolic crescendo-decrescendo murmur heard best at the base of the heart and bilaterally at the clavicles. Lung fields are clear, and there is no peripheral edema. Neurological examination shows no focal abnormality. EKG shows normal sinus rhythm with left ventricular hypertrophy and normal PR and QT intervals. Which of the following is the most appropriate step in the management of this patient's syncope?

A. UDS
B. Head CT
C. Title table testing
D. Referral to a cardiologist for pacemaker placement
E. Referral to a cardiac surgeon for valve replacement

Answer 1

Referral to a cardiologist is the most appropriate next step for this patient, as she presents with signs indicative of a cardiac cause for her syncope.

Step-by-step explanation:

The most appropriate step in the management of this patient's syncope is referral to a cardiologist. The patient presents with a systolic murmur and a history suggestive of exertional angina relieved by nitroglycerin, which could indicate underlying cardiac conditions such as aortic stenosis or ischemic heart disease. The EKG findings of left ventricular hypertrophy support the likelihood of a cardiac pathology. Referral to a cardiologist is necessary for further evaluation with echocardiography and potentially other tests to define the exact cause of the syncope and direct appropriate management.