Solve the Medical Riddle: She Has Been Fainting Often Since She turned 68, Although She Never Passed Out Before That, First Week

By Marie Savard MD

Editor’s note: Welcome to our thirdAGE feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

We’ll start this week by letting you know what the patient told her PCP and how the doctor proceeded with the examination. Next week, the PCP will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis. Then we’ll move on to a new riddle for the following month!

The Patient Reports Her Symptoms

Maureen started fainting once or twice a month soon after her 68^th birthday, although she had never passed out before that.

As always in thirdAGE Medical Riddles, the doctor uses the classic S-O-A-P notes as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendations

This week, we’ll learn what Maureen told the PCP:

 “Two days after my family gave me a big party to celebrate my 68^th birthday, I passed out when I got out of bed in the morning. I had jumped out of bed quickly, but I almost always do that. Luckily I fell back onto the bed and I wasn’t injured. I was scared, though, and so was my husband. My fall woke him up. He said he was very concerned. He wanted me to get checked out right away, but I told him I was probably just overtired from all the excitement of the party, and staying up later than usual that evening. Overall, I’m very healthy. People usually guess me for younger than I am. I’m still teaching visual art — my life’s passion — at the local community center, and I’m having an exhibition of my own watercolors this summer. Also, my husband and I swim at the Y and play with our three grandchildren. I’m pretty active! However, two weeks after the first time I fainted, it happened again. Three weeks later, I was in the kitchen standing cutting vegetables, and I fainted. I would have hit my head on the floor except that my husband was there. He caught me in his arms. That’s when he insisted that I make an appointment to see you, so here I am. I come to within a few seconds after each episode, but my husband says that might not mean I’m OK!”

Subjective:

Maureen said she fainted with almost no warning. She denied any other symptoms. She had no chest pain or palpitations, no heart disease, no chronic illness such as diabetes or Parkinson’s. She wasn’t taking any new medications such as those for high blood pressure or Parkinson’s that can cause orthostatic changes, meaning those related to standing up. Maureen does take multivitamins and extra vitamin D and calcium, but nothing else.

Objective:

Armed with this knowledge, Maureen’s doctor suggested a complete physical exam including check of her blood pressure and pulse while lying down and then again while sitting and standing. This is called an orthostatic blood pressure check. The results were normal.

The doctor also did a carotid sinus massage, which is the act of massaging the neck in area of carotid arteries that carry blood to the head and neck. This did not trigger a worrisome decrease in Maureen’s pulse or blood pressure.

Next the doctor did an electrocardiogram (EKG) in the office. The result was normal. There was no heart murmur.

Because Maureen was over 65 and her fainting episodes were fairly frequent yet she had no evidence of heart disease, the doctor ordered a tilt test during which she would lie on a table with straps to hold her. The table would be rapidly tilted to a 60 degree angle, comparable to standing up. The table has built-in monitors for blood pressure and heart rate. The doctor asked Maureen to come back after the test was completed. In the meantime, he advised her to get up very slowly from a reclining or sleeping position, and to squat or lie down if she experienced any lightheaded warning symptoms. He also told her to drink plenty of fluids.

To be continued . . .

Come back to thirdAGE.com next Thursday to learn the results of Maureen’s tilt test . . .

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.