A 52 years old woman with known Down’s syndrome presents to the Majors department in the ED following a collapse at home.

She live with her partner in sheltered accommodation. This morning while she was brushing her teeth she had a witnessed collapse with LOC for around 20 seconds before coming around to her normal self.

She was not confused or disorientated afterwards but felt mildly groggy headed. She was not incontinent during this collapse and there was no tongue biting. There was some shaking movement of her arms just after she collapsed for a few seconds. She denies any palpitations or SOB prior to the incidence.

She has a past medical history of Down’s syndrome, cardiac surgery as a child, hypertension, GORDx and epilepsy. She has been taking all her medication regularly.

Her partner states that this is the 3rd episode of collapse like this she has had in 1 month.

Q1. What further points in the history would you like to ask to help differentiate the cause of this collapse?

Her partner states that she has been seizure free for almost 2 years and that her seizures are usually quite different to what he witnessed here. He also noticed that the patient had become quite sweaty and pale just before the episode.

Q2. What initial investigations and examinations would you perform for this patient?

Her Obs include a BP of 100/70 mmHg and a heart rate of 46 bpm with an ECG that shows sinus bradycardia. Electrolytes are normal with and an Hct 32%. Examination reveals a mild ejection systolic murmur with no evidence of cardiac failure. Respiratory and neurological exam were normal.

Q3. What points in the history would point you towards a diagnosis of neurocardiogenic or orthostatic cause of syncope?

Q4. What points in the history point towards a diagnosis of cardiac or neurological cause of syncope?

Q5. How would you score this patient on the EGSYS , San Francisco and OESIL scores and what are their significance?

Q6. What is the appropriate disposition for this patient and why?

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case.