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Recurrent Syncope Robert A. Renjel, Russell W. Steele, Thomas W. Young and Lutifat Kashimawo CLIN PEDIATR 2014 53: 1212 originally published online 19 June 2014 DOI: 10.1177/0009922814540044 The online version of this article can be found at: http://cpj.sagepub.com/content/53/12/1212

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CPJXXX10.1177/0009922814540044Clinical PediatricsRenjel et al

Resident Rounds Clinical Pediatrics 2014, Vol. 53(12) 1212­–1214 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814540044 cpj.sagepub.com

Recurrent Syncope Robert A. Renjel, BA, JD1, Russell W. Steele, MD2, Thomas W. Young, MD2, and Lutifat Kashimawo, MD2 Case Report This 8-year-old Hispanic female presented to the emergency department following 2 syncopal episodes. While waiting to be examined in the emergency department, she had a third episode of syncope during which she fell forward, hitting and cutting her head. A fourth syncopal episode occurred shortly thereafter while the patient was supine on the exam table. A heart monitor recorded that her heart rate dropped to 20 beats per minute. The rhythm strip (Figure 1) also demonstrated a 4.3-second pause with return to normal sinus rhythm shortly thereafter. Her past medical history was significant for an additional 2 episodes of syncope in the past year. The first episode occurred at her dentist’s office, and the second episode occurred at her primary care physician’s office while she was being evaluated for fever and exudative tonsillopharyngitis. The mother reported that the patient typically eats and drinks very little when she is sick, and these illnesses along with poor oral intake appear temporally related to her fainting spells. The child added that she experiences prodromal symptoms of dizziness and “fogginess” for one-half to 5 minutes prior to each episode of syncope. One day prior to presentation, the patient developed a sore throat, fever, and had 2 episodes of vomiting. The patient’s past medical history was negative for neurologic or cardiovascular disease. There was no family history of sudden death or cardiac abnormalities. The father had a history of syncopal episodes during childhood that resolved by age 13 years. While childhood syncope does not typically require hospitalization, she was admitted to monitor her condition given her young age and recurrent episodes of syncope. On admission her temperature was 100.9°F, pulse 118 beats/minute, respiration 23 breaths/minute, blood pressure 101/57 mm Hg, and SpO2 99%. She had exudative tonsillopharyngitis and anterior cervical lymphadenopathy. There was a 1/6 systolic ejection murmur along the left sternal border felt to be functional. She had anerythematous sandpaper-like rash on her chest and abdomen compatible with scarlet fever. Pertinent initial laboratory studies were as follows: white blood cells 17 870/mm3 (normal 4500-14 500), hemoglobin 12.9 g/dL (11.5-15.5), hematocrit 36.5%

(35% to 45%), and glucose 141 g/dL (70-110). A rapid group A strep screen was positive, and an ASO titer was

Recurrent syncope.

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