April Case (Full Version)

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Dr.Wagner -> April Case (April 8, 2008 7:35:51 PM)

A 16 year old female gymnast is preparing for what she considers is her "most important event ever".  You are the PT assigned coverage for the event.

While waiting for her turn on the balance beam, she collapses to the ground.  There are a few random twitches and jerking movements.
15 seconds later she opens her eyes and says "what happened"...


And the case begins...

Note: she recently went to the Doctor for a full physical and blood work, you may use any of that information.



jma -> RE: April Case (April 8, 2008 9:03:17 PM)

Has her weight changed since the last followup? Any changes in her RBC count or hemoglobin? Has she been on any medications recently or was anything new being taken before the collapse? Has this happened before? Any history of seizures?



annpsu25 -> RE: April Case (April 8, 2008 10:13:52 PM)

My first thought: seizure.  You say she recently went to the Dr. for a physical and blood work, what were the results?  What is she eating? Is she eating at all?  Could be an eating disorder?  Is she taking any medications that could cause seizure, drop in BP?



bonez -> RE: April Case (April 8, 2008 10:51:42 PM)

What has been her training plan? Has she been cutting weight for this competition? Had she eaten just before the match? What about a past seizure hx? What was the characteristics of the attack?
Off the top of my head I have seen vasovagal events which have most of the following hx. This is out there but was a pregnancy test part of the physical?



james079 -> RE: April Case (April 9, 2008 2:31:08 AM)

Being a sixteen year old female she has perhaps been having her GARDASIL anti HPV shots and as a result has had a collapse with a seizure and twitching.
Jim McGregor



Shill -> RE: April Case (April 9, 2008 8:19:14 AM)

Eating disorder, dehydration, low BP,  all while prepping for this big event would be first on my suspicion list.  Twitches and things arent all that crazy when we get hypotensive and pass out.  What were the results of her last lab work?  Any history of this before?  Was it hot in the gym? 



Sebastian Asselbergs -> RE: April Case (April 9, 2008 12:14:52 PM)

Or just a strong reaction to the stress? On top of a particularly heavy menses? And maybe after a period of amenorrhea?



Dr.Wagner -> RE: April Case (April 9, 2008 8:04:22 PM)

Results of blood tests

Hgb 14
Hct 40
Wbc 8
plts 140

Na 133
Cl 102
K 4
Co2 28
BUN 10
Cr 1

Past Medical Hx: Asthma
Medications: Albuterol Prn, Centrum
No recent Immunizations
Last Menstruation: 2 weeks ago

Of course this will require an exam...



Dr.Wagner -> RE: April Case (April 9, 2008 8:05:41 PM)

Is the gym hot?  Well, it is typical gym temperature.
No previous history of syncopal events.
Last Period was normal.



Mary.Pavlantos -> RE: April Case (April 9, 2008 9:00:43 PM)

 The blood results look good. Did the pt use her inhaler prior to the incidence? Could this be a side effect of the Albuterol? Seizures are a sign of overdoes, and shaking/nervousness is a common side effect? I still am keeping seizures in my mind, has she had an EEG work up? Was there a change in cognition following the event? Are vitals stable? BP low following the event? Maybe she is anemic . . . don't know enough yet!

Mary



Crevidence -> RE: April Case (April 9, 2008 9:06:28 PM)

I am guessing a potential problem with albuterol at this point.  Maybe she used it excessively to cut weight?  Curious to see the case unravel exam etc..



jma -> RE: April Case (April 10, 2008 9:12:57 AM)

What was there any changes in weight since the last followup visits?



Dr.Wagner -> RE: April Case (April 10, 2008 9:53:32 PM)

After the event, the patient regained full consciousness.  A quick "what happened" and then some tears.  Blood pressure after the event was 110/65 in the supine position.
When asked if she used the albuterol prior to the event she states "no".
When asked if she had eaten prior to the event she stated "my coach has me load the day prior with complex carbs...today I had a bowl of fruit"

She has no history of EEG.
Her weight fluctuates from 90-100 pounds during the year.



jma -> RE: April Case (April 10, 2008 10:10:25 PM)

I'm curious to know what her blood glucose levels were. Did this happen at other events where she loaded up with carbs the previous day?



Dr.Wagner -> RE: April Case (April 15, 2008 12:12:25 AM)

My fault...glucose was 99


Any other testing?

Thoughts?

Should we be concerned now?

With complete resolution of symptoms immediately after the event...is this a seizure?



Tom Reeves DPT ATC -> RE: April Case (April 15, 2008 8:50:20 AM)

did she wet her pants? did she have any sleepiness afterward?  if not, I would vote against seizure



Tom Reeves DPT ATC -> RE: April Case (April 15, 2008 8:51:51 AM)

I have a narcoleptic patient right now.  She hasn't dropped off on me yet but ffor years, they were blaming it on her IDDM.  She finally had an episode while in the hospital for something else and her blood sugar was 110.  to a neurologist she went and narcolepsy was the dia . . . . . . . . .



bonez -> RE: April Case (April 16, 2008 1:55:56 AM)

I too had a patient who voided minutes before his first marathon. Trouble is he missed the race and the lip of the urinal took all his front teeth out on the way down. That dreaded vasovagal thing can be a b@@$h!



Dr.Wagner -> RE: April Case (April 18, 2008 8:01:26 AM)

Sorry for my late response, computer difficulties.


This is a case of SYNCOPE.
Basic and straightforward, this case is very common in teenage females much more than males.  The keys in differential diagnosis vs a seizure is the lack of  "post ictal phase" found in seizures. By definition syncope is the loss of postural tone with complete resolution of consciousness without neuologic sequele.  You can have brief "seizure like" activity moments after the event, but this makes sense as syncope results in momentary cerebral anoxia.  In this patients case it would be reasonable to perform an EKG and perhaps orthostatic blood pressure evaluation.  With a normal neurologic exam, no special testing is needed.
The lab testing done at the previous doctor visit was meant to show that this likely was not going to be pathological "zebra"  and that no other testing would be needed.




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