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Internal Medicine


Answer 4
  1. Perform a CT scan of the head. The patient seems to have vasovagal syncope based on history and physical examination. Given her use of alcohol, it is probably prudent to perform a toxicologic screen to see if any other drug use may be complicating her presentation. She clearly appears to be dehydrated on examination and therefore checking standard chemistries and obtaining intravenous access for rehydration are reasonable. Since pregnancy can also present with presyncope and syncope, it is also useful to perform a pregnancy test. Despite the presence of a scalp laceration, the utility in performing a head CT scan in this patient remains low. CT scans of the head are diagnostic in only approximately 4% of patients, almost all of whom have focal neurologic findings or a history of a seizure disorder. This patient’s presentation is not consistent with a stroke, and her neurologic examination is normal. In addition, she was unconscious for only a short time, had no loss of bowel or bladder function, and had no tongue biting. Patients with syncope can have myoclonic jerking, but this is distinctly different from tonic-clonic seizure activity.

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