Case history
Case history #1
An 18-year-old man presents to a clinic reporting two episodes of loss of consciousness. The first episode occurred 1 year earlier while playing dodgeball in gym class. He recalls diving to the ground to avoid being hit. On getting up quickly, he noticed feeling lightheaded, sweaty, and nauseated. Apparently, he fell to the ground but does not recall having done so. He later recalls waking up in an accident and emergency (A&E) department. Witnesses reported shaking and clenching of both hands after he had fallen. In the A&E department he was given phenytoin intravenously because of concern that he may have had a seizure. After a negative work-up in hospital he was prescribed carbamazepine, despite no abnormalities on an electroencephalogram. A year later he had a second episode of loss of consciousness while doing bicep curls. He denies palpitations, tongue biting, or incontinence. He experienced a similar prodrome of warmth and lightheadedness. He has no history of seizures outside of these two episodes.
Case history #2
A 60-year-old man presents with syncope while walking outside with his wife. His wife recalls the patient looking at the sky to point out an aeroplane. He then appeared pale and collapsed to the ground, suffering a head laceration in the process. The history suggested the possibility of carotid sinus syndrome (CSS). In the laboratory, carotid sinus massage was undertaken while the patient was in the upright posture on a tilt table. The massage induced 10 seconds of asystole with near loss of consciousness. A dual-chamber pacemaker was implanted on the basis of a presumptive diagnosis of CSS; there was no recurrence of syncope during the next year. This patient has had no further faints but occasionally becomes dizzy when turning his head abruptly.
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