Syncope
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þ Important parts of differential
 - AAA
 - PE
 - Prolonged QT syndrome
 
þ Clinical Decision Rules:
 - San Francisco Syncope Rule: follow-up studies don't seem to confirm that this 
   is a valid rule.  
 

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        Proposing a criterion based upon age for admission of patients
with syncope is meaningful considering the far greater likelihood of
discovering a cardiac etiology with advancing age.  Those under 30
(without obvious cause for syncope) are in a very low risk group, those
over 70 in a very high risk one (1).  Between these extremes is a
twilight zone where (as radiologists are wont to say) 'clinical
correlation is suggested.'  The forty year old alcoholic who presents
without a scratch on his body after reportedly 'fallin' out' on a daily
basis after visiting the liquor store doesn't get admitted. On the other
hand, as a resident, I took care of quite a few teenagers with exertional
syncope in the CCU with V-tach as a result of right ventricular dysplasia.

        I assume that this particular patient was admitted to the floor
because you were mislead into ascribing the cause of her 'syncope' to
seizure in view of her neurological findings and CT scan results.  In the
absence of a true seizure (or neurological findings) a CNS cause of
syncope is extremely rare and does not warrant routine CT scanning (2).

H. Louzon MD

(1) Eagle KA, Black HR, Cook EF, Goldman L
Evaluation of prognostic classifications for patients with syncope.
Am J Med 1985 Oct;79(4):455-60

(2) Kapoor WN, Karpf M, Maher Y, Miller RA, Levey GS
Syncope of unknown origin. The need for a more cost-effective approach to
its diagnosis evaluation.
JAMA 1982 May 21;247(19):2687-91
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