Recurrent Syncope in an Adult Woman: Your Impressions?

March 19, 2014

A 35-year-old woman, in the ED for the second time in the same day, is described by ambulance medics as "bizarre." ECG and labs are normal except for elevated urinary and peripheral WBC counts. More, here.

A 35-year-old woman is brought to the ED by ambulance for confusion and syncope. According to medics, the woman’s roommate told them she had been seen earlier that same day in the ED and received a diagnosis of concussion after falling and hitting her head as well as a diagnosis of upper respiratory tract infection. She has a history of bipolar disorder for which she takes valproic acid, has recently had a cold, but is otherwise healthy. The medics describe the patient as “bizarre.” The triage nurse puts her in the area of the ED with the other psychiatric patients. The roommate later arrives and states that he thinks that the first time she fell, she actually fainted, but no one ever asked why she fell. This time he heard a fall while she was in the bathroom and found her on the floor.

On examination, the patient’s behavior is quite odd. She is oriented to name only. When asked if she is in pain she answers “brake light.” When asked the same question again her response is “steak night.” She answers “yes” to all yes or no type questions even when her responses are obviously incorrect, for example, a “yes” reply to the question, “Are you a man?” She is purposeful, but not very cooperative, and keeps pulling the sheets over her head. Vital signs are normal and her exam, though somewhat limited, is unremarkable except for a runny nose and a small occipital contusion. The throat and lungs are clear, and the heart is regular without murmur.

An ECG and lab tests are normal except for a urinary white blood cell (WBC) count of 25 x 103/µL; a peripheral WBC count of 14 x 103/µL; serum glucose level of 215 mg/dL; and a toxicology screen positive for opiates. CT scan of the brain is normal. The patient remains confused and bizarre so a psychiatry consult is called. In addition, a diagnostic procedure is performed with results shown in the Figure.

What is the procedure?

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