VASOVAGAL SYNCOPE

IMPRESSION:
1. Syncope
    -He has syncope preceded by a prodrome of nausea and flushing sensation,
    with classic triggers include
  -Overall, this is a consistent with vasovagal syncope
    -Treatment usually aims at removal of triggers:

    -Physiologic isometric counterpressure manuevers (leg crossing etc) can
    be helpful

    -Empiric trial with medications would be one options with either:
  (a) Midodrine 5 mg po TID (can go up to 10 mg po TID)
  (b) Fluorinef
  (c) Bentyl 20 mg po TID - QID
  -Off label indication
 
    -If syncope refractory to medications (midodrine, fluorinef etc) --> can
    consider implanting ILR
  -If > 3.0 seconds on ILR (or other monitoring), can consider
    pacing
  -From uptodate:  "Evidence from clinical trials suggests a
    limited role for pacemaker therapy in patients with vasovagal
    syncope. Pacemaker therapy is not helpful as a general
    treatment for all patients with vasovagal syncope, but some
    evidence suggests that pacemakers may be helpful in selected
    patients with recurrent syncope who have asystole =3 seconds
    with syncope or asystole =6 seconds without syncope"

    -I have advised him that in accordance to Texas State Law, he is to not
    drive.  He replies that due to his history of seizures, he is not
    driving anyways to begin with