text: REASON FOR REFERRAL:,  Chest pain, possible syncopal spells.,She is a very pleasant 31-year-old mother of two children with ADD.,She was doing okay until January of 2009 when she had a partial hysterectomy.  Since then she just says "things have changed".  She just does not want to go out anymore and just does not feel the same.  Also, at the same time, she is having a lot of household stressors with both of her children having ADD and ODD and she feels she does not get enough support from her husband.  Her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,In this setting, she has been having multiple cardiovascular complaints including chest pains, which feel "like cramps" and sometimes like a dull ache, which will last all day long.  She is also tender in the left breast area and gets numbness in her left hand.  She has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  Twice it happened, when getting up quickly at night and another time in the grocery store.  She suffered no trauma.  She has no remote history of syncope.  Her weight has not changed in the past year.,MEDICATIONS: , Naprosyn, which she takes up to six a day.,ALLERGIES:,  Sulfa.,SOCIAL HISTORY: , She does not smoke or drink.  She is married with two children.,REVIEW OF SYSTEMS:,  Otherwise unremarkable.,PEX:,  BP:  130/70 without orthostatic changes.  PR:  72.  WT:  206 pounds.  She is a healthy young woman.  No JVD.  No carotid bruit.  No thyromegaly.  Cardiac:  Regular rate and rhythm.  There is no significant murmur, gallop, or rub.  Chest:  Mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  Lungs:  Clear.  Abdomen:  Soft.  Moderately overweight.  Extremities:  No edema and good distal pulses.,EKG: , Normal sinus rhythm, normal EKG.,ECHOCARDIOGRAM (FOR SYNCOPE): , Essentially normal study.,IMPRESSION:,1.  Syncopal spells - These do sound, in fact, to be syncopal.  I suspect it is simple orthostasis/vasovagal, as her EKG and echocardiogram looks good.  I have asked her to drink plenty of fluids and to not to get up suddenly at night.  I think this should take care of the problem.  I would not recommend further workup unless these spells continue, at which time I would recommend a tilt-table study.,2.  Chest pains - Atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  The Naprosyn is not helping that much, I gave her a prescription for Flexeril and instructed her in its use (not to drive after taking it).,RECOMMENDATIONS:,1.  Reassurance that her cardiac checkup looks excellent, which it does.,2.  Drink plenty of fluids and arise slowly from bed.,3.  Flexeril 10 mg q 6 p.r.n.,4.  I have asked her to return should the syncopal spells continue.cardiovascular / pulmonary, chest pain, syncopal, echocardiogram, ekg, cardiac etiology, syncopal spells, rhythm, flexeril, cardiac, chest, 