| | [這篇文章最後由JuanFe在 2018/05/11 07:14pm 第 1 次編輯]
SPELL (syncope,seizure)
Doorway information about patient
The patient is a 55-year-old man who comes to the clinic due to passing out.
Vital signs
.Temperature : 37’C
. Blood pressure : 130/80 mmHg
. Pulse 80/min
. Respirations: 12 /min
Approach to the patient
Comparison of syncope & seizure
- Seizures -
Circumstances
invoked by :
. Sleep loss
. Emotions
. Alcohol withdrawal
. Facing light
Clinical clues
. Aura(eg,olfactory hallucinations)
. Can occur with sleeping / sitting position
. head movements
. Tongue biting
. Rapid strong pulses
Sequelae
. Delayed return to baseline
. Usually sleepy & confused afterward (postictal state)
- Syncope (typically vasovagal) -
Circumstances
Invoked by:
. Upright position
. Emotions
. Heat
. Crowded places
Clinical; clues
. Symptoms of presyncope(eg,lightheadedness)
. Unlikely to occur with sleeping/sitting position (except in cardiac arrhythmia)
. Rarely ,several clonic jerks can occur with prolonged cerebral hypoperfusion
. Pallor & diaphoresis
. Weak , slow pulses
Sequelae
. Immediate spontaneous return
The initial step in evaluation a patient with loss of consciousness is to differentiate among the primary types of events:
. Syncope/presyncope : Transit loss of consciousness with spontaneous recovery , usually due to decreased cardiac output or vascular tone.
. Seizure : Disorganized cerebral activity , typically associated with uncontrolled motor activity
. Dizziness/vertigo : Abnormal sensation of motion or disequilibrium without true loss of consciousness
. Anxiety/ panic : sudden fear or apprehension , often with prominent adrenergic symptoms (eg, sweating , palpations )
. other psychological phenomena: Nonepileptic seizure , altered attention , behavioral disturbances.
The patient’s medical history is often helpful unmaking a determination. patients with prior brian injury are more likely to have a seizure . Cardiac arrhythmias are most common inpatient with a history of conduction system or structural heart disease . Patients with nonepileptic seizures often have a history of psychologic illness.
Brief myoclonic activity during syncope can be mistaken for a seizure . Features that suggest true seizure include a prolonged postictal state, tongue biting , head /eye turning to one side , and hypersalivation.
Brief loss of consciousness is often labeled incorrectly as a transient ischemic attack (TIA). Damaged or ischemic tissue for a prior stroke acne serve was a nidus for seizure , but a true TIA rarely present as loss of consciousness.
Differential diagnosis
1 likely etiology
2 clinical clues to diagnosis
1: Vasovagal or neurally medicated syncope
2: Triggers : prolonged standing or emotional distress , painful stimuli
Prodromal symptoms: nausea , warmth, diaphoresis
1: Situational syncope
2: Triggers: cough , micturition, defecation
1: Orthostatic syncope
2: Postural changes in heart rate/blood pressure after standing suddenly
1: Aortic stenosis , HCM , anomalous coronary arteries
2: Syncope with exertion or during exercise
1: Ventricular arrhythmias
2: Prior history of CAD m MI , cardiomyopathy , or decrease EF
1: Sick sinus syndrome , Bradyarrhythmias , atrioventricular block
2: Sinus pauses , ^ PR or ^ QRS duration
1: Torsades de points (acquired long QT syndrome)
2: Hypokalemia , hypomagnesemia, medications causing ^QT interval
CAD = coronary artery disease ; EF = ejection fraction ; HCM = hypertrophic cardiomyopathy ; MI= myocardial infarction
The most common type of syncope i.es neurocardiogenic (vasovagal) syndrome , which is due to an alteration in autonomic drive leading to decreased cardiac output . It is often triggered by prolonged standing , emotional stress , or pay full stimuli and is sometimes preceded by prodrome of nausea, diaphoresis , or generalized warmth . These syndromes amy briefly persist after the episode and can help differentiate neurocardiogenic syndrome form more serious etiologies .
HISTORY AND PHYSICAL EXAMINATION
history
history of present illness
. Describe what happened.
. What were you doing when this happened?
. Has this happened before?
. Did someone see you pass out?
. How long were you out?
. Did you have any jerky movements of your hands or legs ?
. Did you bite your tongue?
. Did you lose control of your bladder or bowels?
. Were you feeling fine before the event?
. Did you have nausea or vomiting?
. Have you had chest pin , palpitations, or breathing problems ?
. Have you had weakness m numbness m or tingling in your face , legs , or arms?
. Have you had change vision?
. Have you had recent trauma?
Past medical history
. Have you been diagnosed with other medical conditions (eg. diabetes , heart disease )?
Medication/allergies
. Do you take nay medications, especially blood pressure , anti epileptic , or diabetes (eg, insulin) medications?
Family history
. Has anyone in your family had heart disease , arrhythmias , or seizures?
. Has anyone died suddenly?
Social history
. Do you smoke? At what age did you start & how much do you smoke ?
. Do you drink alcohol ? How much & how often?
. Have you used illicit drugs ?
PHYSICAL EXAMINATION
Vital signs
. Check for orthostatic hypotension if not included in Doorway information.
Neck
. Auscultate for carotid bruits.
Heart
. Auscultate for murmurs, gallops , rubs
Neurologic
. Determine level of consciousness & mental status.
. Perform a cranial nerve examination.
. Check motor strength &sensation in the face and all the extremities.
. Evaluate balance , gait & cerebellar function.
. Assess deep tendon reflexes
Closing the encounter
Unless an ECG is provided , it s unlikely that you will have a firm diagnosis to the end of the patient encounter, Discuss with the patient the most likely possibilities and any significant abnormalities you noted on examination. If additional testing is indicated, explain what gets you plan to order and what disorders you are ruling out. If you think the patient is at risk of future events , ask about what support is available at home and discuss steps to take if there is another event.
Diagnostic studies
All patient with syncope should have an ECG , which may not be diagnostic but can identify abnormalities (eg, conduction blocks , infarcts , ventricular hypertrophy) that predispose to serious arrhythmias . A young patient with a typical vasovagal event and normal ECG may not need further evaluation. Additional studies to consider based on the clinical presentation and risk factors include:
. Glucose
. Serum electrolytes and magnesium
. Urine toxicology (eg,amphetamine abuse)
. Complete blood count
. Echocardiogram (if murmur or other sign of structural heart disease)
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2018/05/11 07:01pm 
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