Morning Report. Nikhil Jariwala Dr. Ward July 12, 2010. MKSAP.
July 12, 2010
hypotension, clear lung fields, and elevated estimated central venous pressure represent the classic triad of RV myocardial infarction.
Past Medical History:
Mother died age 63 from unknown cause
Father died age 82 from lung cancer
No cardiac disease or sudden cardiac death
Smoked 1 ppd x 12 years, but quit 24 years ago
Can be precipitated by pain, exercise, micturition, defecation, or stressful events
Often associated with prodromal symptoms (sweating and nausea)
Not to be confused with:
“Drop attacks” = falls without LOC
Dizziness and vertigo typically do not result in LOC or loss of postural tone
Seizures have disorientation after the event, slowness in returning to consciousness, and unconsciousness lasting more than five minutes
Both syncope and seizures can have associated rhythmic movements
Definition of Syncope
Source: From five population-based studies between 1984-1990. Ann Intern Med. 1997 Jun 15; 126(12): 991.
VITALS: T 36.3, P74, R 21, BP 123/83, O2 99% RA
Sitting BP 117/71, P 71; Standing BP 128/82, P 88
GEN: Well appearing, NAD, A&Ox3
HEENT: EOMI, PERRLA, no lymphadenopathy
CV: RRR. Normal S1 and S2. No M/R/G. No JVD. No edema.
PULM: CTAB. No wheezes, rhonchi, or rales.
GI: S/NT/ND. Normal bowel sounds. No hepatosplenomegaly. Small umbilical hernia.
MSK: Normal bulk and tone. 5/5 strength all extremities
SKIN: No rashes or lesions
NEURO: CN II-XII intact. Sensation intact to light touch. Normal finger-to-nose, heel-to-shin. Normal gait
PSYCH: Normal mood and affect
Clinical prediction tool to determine short-term (7day) outcome of patients presenting to ER with syncope
Serious outcomes included: death, MI, PE, arrhythmia, stroke, subarachnoid hemorrhage
Source: Ann Emerg Med. 2004 Feb; 43(2): 224-32.
Congestive heart failure
Shortness of breath
Any patient with one positive item is at high risk for serious outcome
In the Emergency Room, the patient complains of abdominal pain and becomes diaphoretic and pre-syncopal.
Vitals are obtained: HR 43, BP 63/41
You obtain an EKG…
Source: “Management of Symptomatic Bradycardia and Tachycardia.” Circulation. 2005 Nov; 112; IV-68.
He receives 0.8mg IV atropine which improves his HR to 87 and his BP135/87.
Mental status improves and diaphoresis resolves.
The patient is admitted to Cardiology
Acute hepatitis panel: Non-reactive
CT Angio Chest/Abdomen: No aortic dissection or aneurysm. Focal pancreatitis of tail without complication. Cholelithiasis without inflammation.
TTE: LV EF 61%, no wall motion abnormalities. LV and RV normal size and performance. No significant valvular disease
Exercise SPECT: SSS 8. Duke treadmill prognostic index 7 (low-risk). Mildly abnormal perfusion scintigraphy with evidence for mild exercise-induced completely reversible myocardial ischemia in multivessel distribution.
Kapoor, WN. “Syncope Review Article.” NEJM. 2000 Dec 21. 343(25):
Linzer, M; Yang, EH; et al. “Diagnosing Syncope. Part 1: Value
of History, Physical Examination, and Electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians.” Ann Intern Med. 1997 Jun 15; 126(12): 989-96.
Linzer, M; Yang, EH; et al. “Diagnosing syncope. Part 2: Unexplained
Syncope.” Ann Intern Med. 1997 Jun 15; 127(12): 76-86.
“Management of Symptomatic Bradycardia and Tachycardia.” Circulation.
2005 Nov; 112; IV-67-77.
Quinn, JV; Stiell, IG; et al. “Derivation of the San Francisco Syncope Rule to
predict patients with short-term serious outcomes.” Ann Emerg Med. 2004 Feb; 43(2): 224-32.