Collapse/Syncope/Blackout

(1) Please see this 80 year old lady who has had 3 falls. Apart from feeling a little more tired than normal over the last few months she has been unwell. I could find no injuries and her examination was normal except for a pulse of 42 beats per minute.

Please take a history.

(2) (Ma’s exam )

72 y.o man

Presented to casualty with recurrent LOC

Last LOC 1/52 ago, fell down, knocked head, developed haematoma @ R temporal region

This admission, admitted to casualty for another episode of LOC

K/C Psychiatric disorder on olanzapine

Pls take full history

Answer :

Hyponatraemia 2 to Olanzapine

Need TRO Subdural haematoma (treatable)

Syncopal

• How often
• When ( turning head, shavingtight collars)
• Preceeing symptoms (light headed, nausea, sweaty)
• What time of the day ?
• What were you doing at that time ?
• How long ?
• Injure himself
• Social (Driving)

dDx :

• Cardiogenic
• Arrhythmia eg SVT, fast AF (palpitation, SOB, ? regular/irregular)
• HOCM (dizziness, chest pain, SOB, orthopnoea, PND, oedema, strong FHx)
• Aortic stenosis (chest pain, SOB)

• Neurogenic
• Seizure (stiffness, jerky movements, tongue bitting, blue, incontinence, postictal drowsiness, aura, FHx epilepsy)
• Carotid sinus hypersensitivity
• TIA ( weakness, numbness, dysphagia, speech)

• Endocrine
• Hypoglycaemia (tremor, sweating, DM)

• Drugs/Alcohol – sedatives, hypnotics

• Vasovagal/Postural hypotension

• Cough/micturation syncopal

HOPI

What is meant by falls/blackout

Is it seizure – witness account

Onset, duration, how it occurred, frequency

Ass symptoms – chest pain, palpitation, SOB, pedal oedema, orthopnoea, missed beats

- incontinence of urine/feces

- pale during attack with cold, clammy periphery

- aura – visual,sens, auditory, smell, motor

- fever, photophobia, neck stiffness

- focal neurological signs, visual sx, giddiness, speech disturbances, headache, nausea

- happens when coughing

- happens with shaving/turning head too fast

- happens with standing from lying position

- happens with standing for long periods

- happens with getting up to micturate

- symptoms of hypothyroidism

- symptoms of hypoglycaemia

Aggravating fact - getting up to micturate from lying position

- standing long period

- coughing

- turning head too fast

- exertion

- flicking lights, stress, lack of sleep, fever

- missing meals

Relieving factors – lying down, sitting down to rest

- GTN

What have the doctors treated you for ?

Medications ? Side effects ? Useful ?

Progress of disease

Functional status now

Past Med Hx :

HPT, DM, IHD, Valvular heart disease

Medication :

Alpha blocker

Beta blocker

Anti HPT

Sedative/hypnotics

Steroid

OHA/insulin

Anticoagulant

Diuretics – electrolyte imbalance

P. Surg Hx :

Brain surgery before

Family History :

Prolong QT

Sudden myocardial death

Seizures

Social Hx :

Family

House

Work

Finance

Travel Hx

Driving

Diet/exercise

Hobbies

Substance use – alcohol – how much, frequency, withdrawal, dependence, ever tried to stop, get into trouble with law, CAGE

Smoke

Illicit drugs

How the condition affects him/her

Concern

Summarise