Scenario 2: Syncope

Chief Complaint 

• Dizziness, weakness, and feeling tired last few days. He reports passing out at school.

History

 • 20 year old male college athlete with no prior medical history. On wrestling and cross country running team. Feeling dizzy, lightheaded, weak, and tired for the past two days. Had three several second witnessed syncopal episodes at school yesterday. Went to university clinic and was referred by nurse. Patient states no palpitations, no tachycardia, and no blurred vision noticed prior to each episode1 . 

• Upon questioning, patient admitted he had to lose 11 lbs. to meet wrestling weight requirement. He accomplished this by ingesting carbohydrates, minimal fluids, heavy exercise, and purging2 .

 • No medication or allergies. Denies alcohol, drugs, supplements, or diuretics use.

Exam

• Looks exhausted. No apparent distress. Afebrile. 

• Orthostatic VS: 

1.  Lying BP 116/78 with HR 56, 
2.  Sitting BP 107/60 with HR 74, 
3.  Standing BP 92/49 with HR 1123

• Mucus membranes pale, skin is dry, with turgor and tenting. Capillary refill is 2-3 seconds. 

• Chest is clear. Heart sounds normal. 

• Labs significant for creatinine (2.13), BUN (43), glucose (60). 

• EKG shows sinus tachycardia4 .

Assessment and Plan 

• Orthostatic intolerance. Dizziness, fatigue, and syncope likely secondary to hypotension, dehydration and hypovolemia. 

• Provided fluid challenge of 2L IV NS in office today with improved condition post infusion including resolution of orthostasis and tachycardia. 

• Ordered nutritional consult for dietary intake requirements, physical activity, and potential bulimia2 .• Recommended patient have a psychological consult for potential bulimia; stated he would think about it. 

• Scheduled a follow-up in 2 weeks to ensure no further symptoms. Return earlier if symptoms persist. No driving until follow up appointment.

Summary of ICD-10-CM Impacts

 Clinical Documentation

1.Since the etiologies for syncope and collapse scenarios are multifactorial, clear documentation is required to support your clinical thinking and judgment. Quantify the number of syncope or pre-syncope episodes. 

2.Note if the purging behavior is recurring or if it is a one-time occurrence (e.g., in this case due to the need for the significant weight loss of 11 pounds). 

3.Orthostatic hypotension should be supported in the record with specific vital signs or measurements, and clinical manifestations whenever possible. This note provided clear documentation to support the orthostatic hypotension and the link with the patient’s initial dehydration and hypovolemia. Given the patient’s presentation, and the resolution of the orthostatic intolerance with IV fluids, addressing the coding for autonomic dysfunction syndrome is not relevant. 4.Ideally, if the note is to stand alone, then more detail needs to be provided to document sinus tachycardia. 

Coding

ICD-9-CM Diagnosis Codes

780.2         Syncope and collapse 

785.0         Tachycardia, unspecified  

458.0         Orthostatic hypotension  

276.51       Dehydration

276.52       Hypovolemia

ICD-10-CM Diagnosis Codes

R55        Syncope and collapse 

R00.0     Tachycardia, unspecified 

I95.1      Orthostatic hypotension 

E86.0     Dehydration 

E86.1     Hypovolemia

Other Impacts 

Documenting the vital signs and lab results supports the medical necessity for administering intravenous normal saline and an EKG.