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Assessment:
Patient presents with an episode of syncope characterized by a brief loss of consciousness and spontaneous recovery. A detailed history and examination suggest a possible vasovagal origin, but differential diagnoses include orthostatic hypotension, cardiac arrhythmias, seizure disorders, and neurologic causes.
Plan:
Order common diagnostic tests, including an electrocardiogram (ECG) to assess for arrhythmias, orthostatic vital signs to evaluate blood pressure changes, and laboratory tests including a complete blood count (CBC) and comprehensive metabolic panel (CMP) to check for anemia, electrolyte imbalances, and other metabolic issues. Consider a Holter monitor for 24-hour cardiac monitoring if arrhythmias are suspected. If initial testing is negative, consider an EEG and potential neurology referral to evaluate for seizure disorders. Recommend lifestyle modifications such as increased fluid and salt intake, and advise the patient to avoid known triggers. Educate the patient about the importance of safety measures to prevent injury during future episodes. Schedule a follow-up appointment to discuss test results and further management based on findings. Document the patient’s response and any new symptoms at the next visit.
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