Identifying Data:
Full Name: XX
Address: XX
Date of Birth: XX
Date & Time: 02/09/24 at 4PM
Location: Queens Hospital Center, NY
Religion: Muslim
Source of Information: Self and Mother
Reliability: Reliable
Source of Referral: Mother
Mode of Transportation: EMS

Chief Complaint: “I fainted this afternoon”

History of Present Illness:
A 12 y/o female with no PMHx BIBEMS presents to the ER s/p witnessed LOC at school as she was spinning around in a circle while playing musical chairs. Patient arrived on a stretcher with her eyes closed and crying. She refused to open her eyes as it exacerbated the dizziness. After several minutes, the patient was able to open her eyes and explain that she was feeling dizzy while running around, then lost consciousness but was caught by her friend. She admits to feeling the room spinning before fainting, denies blurry vision. She reports that she was out for one minute and was given water and regained consciousness. Patient admits to feeling stress from mother due to school grades, long hours, and not eating properly while in school from 8-5pm. Reports having only a peanut butter jelly sandwich since this morning. Admits to headache and dizziness. Denies previous episodes of syncope. Denies currently menstruating. Denies fever, chills, vomiting, head trauma, chest pain, palpitations, ataxia.

Past Medical History:
Present Illnesses – N/A
Immunizations: Fully up to date

Past Hospitalizations:
None

Past Surgical History:
None

Medications:
Vitamin D supplementation, unsure of dose

Allergies:
No known drug, food, or environmental allergies

Family History:
Mother – alive and well
Father – alive and well
Maternal Grandmother – alive with HTN, DM2
Maternal Grandfather – alive with DM2
Paternal Grandmother – alive with HTN, DM2
Paternal Grandfather – deceased

Social History:
Ms. RI lives with her mother, father, and younger brother in Jamaica, Queens.
No smokers in the home, no pets.
Safety: admits to using seatbelt; home equipped with smoke and carbon monoxide detectors
Travel: Denies recent travel
Diet: admits to a poorly balanced diet, not eating 3 meals per day on school days, diet consisting mainly of carbohydrates (rice, bread) and some protein (beans, lentils, chicken, fish).

Review of Systems:
General – Denies fever, weight loss, malaise, weight change, or night sweats.
Skin, hair, nails – Denies discoloration, pruritus, excessive sweating, skin changes, and hair changes.
Head – Endorses headache, dizziness, fainting. Denies trauma and Hx of vertigo.
Eyes – Denies discharge, diplopia, eye pain, visual changes, and photophobia. Last eye exam: 3 months ago.
Ears – Denies deafness, pain, discharge, tinnitus.
Nose/Sinuses – Denies sinus pressure, epistaxis, nasal congestion, discharge, swelling.
Mouth/Throat – Denies dysphagia, sore throat, hoarseness, cough. Last dental exam: 3 months ago.
Neck – Denies pain with movement, stiffness, swollen glands and trouble swallowing.
Breasts – Denies skin changes, lumps, nipple discharge.
Pulmonary System – Denies cough, SOB, DOE, wheezing, hemoptysis or cyanosis.
Cardiovascular System – Denies chest pain, palpitations, edema. Last EKG: never.
Gastrointestinal System – Denies abdominal pain, loss of appetite, changes in stool, hemorrhoids, constipation, rectal bleeding or diarrhea.
Genitourinary System – Denies flank pain, frequency, oliguria, urgency, nocturia, incontinence.
Sexual History – Denies being sexually active. Denies history of STIs.
Nervous – Denies paresthesias, changes in cognition/mental status.
Musculoskeletal system – Denies stiffness, swelling, joint pain, muscle soreness, reduced mobility. Denies tenderness to palpation and erythema.
Peripheral vascular system – Denies pins and needles, edema, calf pain, varicosities, cyanosis.
Hematological System – Denies Hx of DVT/PE, lymph node enlargement, blood transfusions, anemia, clotting.
Endocrine system – Denies diabetes, heat or cold intolerance, excessive hunger/thirst.
Psychiatric – Admits to changes in mood, anxiety. Denies suicidal ideations, changes in eating habits.

Physical
General: Well groomed female, appearing as her stated age of 12 years. She appears to be awake and oriented, but in acute distress as she was sobbing on the stretcher with her eyes closed, feeling dizzy.
Vital Signs:
BP: Seated – (R) 117/65
R: 20 breaths/min, unlabored
P: 128 beats/min, regular rate and rhythm
T: 97.3 F (tympanic)
O2 Sat: 100%, room air
Height: 5’0 inches Weight: 116 lbs BMI: 22.7

Skin, Hair, Nails, Head:
Skin: Warm and moist. No discoloration. Good turgor. No ulcerations on upper/lower extremities. No visible scarring.
Hair: Regular quantity, even distribution. Color is dark brown, and the texture is normal. No visible dandruff or lice.
Nails: No clubbing, pitting, signs of infection. Capillary refill < 2 seconds in upper extremities.
Head: Normocephalic, atraumatic, non-tender to palpation.

Eyes:
Eyes appear symmetrical. Eye lashes are well distributed. PERRLA. No strabismus, lid lag, or ptosis noted. Sclera white with no jaundice, cornea clear with no signs of abrasion or nodules. Conjunctiva is clear with no foreign bodies.

Ears:
External ears with no masses or discharge. TMs pearly gray, no effusions or pus noted.

Thorax/Lungs
Clear to auscultation. Chest was symmetrical with no signs of labored breathing. No tenderness to palpation.

Heart
Tachycardia with normal rhythm. Distinct S1/S2 with no murmurs, splitting, friction rubs, or S3/S4 appreciated.

Mouth/Neck/Pharynx
Lips: Pink, slightly cracked, no cyanosis or edema.
Buccal Mucosa: Pink, poorly hydrated.
Palate: Pink, poorly hydrated.
Teeth: normal dentition, no caries present.
Gingivae: Moist, with no bleeding, ulcerations, hyperplasia, or discoloration.
Tongue: Pink, well papillated. Symmetrical with normal texture.
Oropharynx: Poorly hydrated, no exudates, masses, or foreign bodies. Uvula pink, midline elevation, no ulcerations.
Neck: Trachea midline. No masses, scars or pulsations noted. Non-tender to palpation.

Musculoskeletal:
Normal range of motion in extremities. Grip strength symmetrically decreased. Flexion and extension of elbows and shoulder 5/5.

Neuro Exam
Mental Status: AOx3.
No focal deficits. No cranial nerve deficits. No pronator drift. Patient denied standing up to assess gait/Romberg.

Differential Diagnosis
Vasovagal syncope
Electrolyte abnormality: hypocalcemia
Hypertrophic cardiomyopathy
Severe anemia
Second degree heart block

Labs/Imaging
CBC with differential
BMP
POC Glucose
POC Urine pregnancy
EKG

Assessment
12 year old female BIBEMS s/p loss of consciousness at school while playing musical chairs. On physical exam, the patient is PERRLA with no nystagmus, lungs CTA, heart RRR, AAOx3. Grip strength is symmetrically decreased although flexion and extension of elbows and shoulders are 5/5. CBC with differential reveals iron deficiency anemia. EKG reveals sinus tachycardia without signs of brugada, WPW. Rest of the exam is unremarkable.

Diagnosis: Vasovagal syncope

Plan
0.9% sodium chloride infusion – 1000mL
Re-evaluate and discharge

Patient Education:
Vasovagal syncope is caused by a sudden drop in heart rate and blood pressure leading to fainting, often in reaction to a stressful trigger. This is due to reduced blood flow to the brain.
The patient was advised to ensure she increases her fluid and salt intake and avoid triggers such as running around in circles. She was also advised to change positions slowly, rather than making abrupt movements that may trigger orthostatic hypotension.
The parent was advised to follow up with her primary care provider to manage iron deficiency anemia.
The parent was advised to follow up with a cardiologist should symptoms persist or other cardiac symptoms arise, such as dyspnea on exertion, chest pain, or palpitations.
The parent was advised to follow up with psychiatry to manage the patient’s life stressors and anxiety symptoms.
Patient was advised to return to the ER should symptoms worsen or repeat.