Approach to syncope Quiz: Ace Your Exams

A 22-year-old man is brought to the emergency department due to a syncopal episode at work. The patient works in a warehouse. According to his co-worker, the patient was moving heavy boxes when he suddenly collapsed and fell to the floor, after which he regained consciousness within 20 seconds. The patient was alert and oriented immediately after regaining consciousness. He had no chest pain or palpitations prior to the episode. Over the past year, the patient has had transient episodes of lightheadedness related to exercise. He has a remote history of syncope during a wrestling match in high school that was believed to be caused by orthostatic hypotension. Temperature is 37°C (98.6°F), pulse is 68/min, respirations are 14/min, and blood pressure is 128/74 mmHg while supine and 124/70 mmHg while standing. On examination, the patient has no murmurs and lungs are clear to auscultation. ECG shows normal sinus rhythm with left-axis deviation and inverted T waves in V₂-V₄. Complete blood count, serum electrolytes, and cardiac enzymes are within normal limits. Which of the following is the most appropriate next step in management?