An MRI of his internal acoustic meatuses is requested, and this is normal. The patent is referred to an ENT specialist for further investigation of the tinnitus and dizziness. Which investigations were performed in primary care?Ī hearing test is organised due to the recent history of tinnitus. Cardiovascular and ear, nose and throat examination are normal. He is normotensive with no postural drop between lying and standing blood pressures. He describes episodes of buzzing in his ears associated with feeling dizzy, but no loss of consciousness. If initially negative in the supine position, carotid sinus massage should be performed during passive upright tilting as 30% of cases are missed by testing in the supine position alone.Ī 58 year old gentleman consults with his GP with a 2 year history of funny turns.Carotid sinus massage of 10 seconds causing syncope associated with asystole for over 3 seconds and/or a fall in systolic blood pressure of more than 50 mm Hg is diagnostic of CSS.Triggers for CSS include head rotation or pressure on carotid sinus - which may be caused by tumours, shaving, or tight collars.Carotid sinus syndrome (CSS) should be considered in all older patients presenting with syncope with normal examination and normal or near-normal ECG.He is referred for pacemaker insertion and subsequently has no further episodes. ![]() The patient reports dizziness then faints with an associated ventricular pause of 9 Carotid sinus massage is performed with the patient upright and with beat to beat heart rate and blood pressure monitoring. This patient is reviewed by a cardiologist. Syncope clinic would be most appropriate. The next step would be to refer to a specialist for further investigation of this patient's syncope. This patient has unexplained syncope and you should advise him that he must not drive and that he must notify the DVLA. The key investigation in this case is an ECG to identify any underlying cardiac abnormality that may be linked to the patient's symptoms. Which investigations should be performed in primary care? He hasĪ history of anxiety for which he takes sertraline 50 mg once daily. His syncope was briefly preceded by dizziness, and he denies any other warning symptoms. He describes the episodes as occurring when washing and shaving in the morning. ![]() Post-exercise induced neurally-mediated syncopeĪ 68 year old gentleman presents to you with episodes of recurrent syncope.
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