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Dr. Sana Hoda

September 21, 2020
* With Thanks to Dr. Serrecchia for use of some slides
 The 5-Minute Presentation

Paragraph 1:
Chief Complaint – Introduction and Prompting Question
“Good afternoon, Mr. Wright, I am Student Doctor _______,
working with Dr. Serrecchia, how may I help you?”

Mr. Wright is a 70-year-old functionally independent male

with poorly controlled systolic hypertension,
hyperlipidemia, and osteoarthritis, who presents after having
fallen while working in his yard 90 minutes previously.
Other Questions?
HPI (Breakdown of Chief Complaint)

· Onset: abrupt onset

· Location:
· Duration: 10 – 15 minutes
· Character:
· Associated symptoms: lightheadedness, numbness in his left hand,
and vague visual disturbance with questionable loss of consciousness.
· Radiation:
· Timing/Treatment: developed while working in yard 90 minutes prior
to presentation
· Severity: patient concerned; “this is the first time anything like this
has ever happened”
Write HPI (OLDCARTS check list) in narrative form for
paragraph 1 and include Paragraph 2: Timeline of disease
and F.I.F.E. (Feelings, Ideas, Function, Expectations)

He states, “This is the first time anything like this has ever
happened.” His fall was preceded by the abrupt onset of
lightheadedness, numbness in his left hand, and vague visual
disturbance with questionable loss of consciousness. After 10–15
minutes all symptoms were resolved and he was able to get up
unaided and has since felt fine. He is concerned about a stroke
and if it would happen again while he was mowing his lawn or
driving.
Objectives:

1. Differentiate collapse from syncope and conduct a history related to

transient loss of consciousness.
2. Describe the related organ system approach to this complex
symptom.
3. List the various etiologies of seizures.
4. List
. the signs and symptoms common to seizures.
5. List the signs and symptoms uncommon to seizures.
Must rule out a simple fall, usually obtained
from a history and observation:
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- “fall together” (Latin), to fall down and become unconscious

- is a VERY nonspecific term with multiple etiologies
- Structure (anatomy), Organ, Science (pathophysiology)
- a popular mnemonic “ AEIOU TIPS ”
AEIOU TIPS

A – Alcohol T – Trauma
E – Epilepsy I – Insulin
I – Infection P – Psychogenic
O – Overdose S - Stroke
U – Uremia
 Syncope
(aka.Vasovagal Syncope, Neurocardiogenic syncope, Fainting)

+ the most common cause of “collapse”

+ a temporary loss of consciousness usually related to insufficient blood flow
to the brain(ie..hypotension, hypoxemia)

+ some stimulus causes a neural reflex due to certain triggers

+ characterized by bradycardia (+vagus nerve) and/or peripheral vasodilation

(-sympathetic)

+ benign, self-limiting
Collapse Differentials:
Differential 1:
Cardiac Syncope (aka Cardiogenic Syncope)
Loss of adequate cerebral perfusion resulting from a sudden reduction in cardiac output
caused most commonly by a cardiac arrythmia (an irregular cardiac rhythm).

Signs and symptoms - collapse, blurred vision, dizziness, pale or dusky

appearance, cardiac arrythmia or murmur(on auscultation)
Etiology – usually from ventricular rates < 35 or > 180 bpm, such as asystole,
A-V block, WPW syndrome, ventricular tachycardia, ventricular fibrillation,
sinus bradycardia, tachyarrythmias, myocardial infarction, aortic stenosis,
Tetralogy of Fallot, pericardial effusion (cardiac tamponade)…
Differential 1: Cardiac Syncope
Cardiac Syncope (continued):

Aortic Stenosis

Pericardial Effusion
(note enlargement due to Tetralogy of Fallot
pericardial sac)

Electrical Alternans
 CHIEF COMPLAINT ORIENTATED HISTORY &
PHYSICAL : CARDIAC SYNCOPE

History/ROS:
- History of HTN, CVD,
Hypercholesterolemia, DM..
- Associated with increased physical
activity, rising from a seated position,
decreased fluid intake, warm
environment..
- Collapse, palpitations, cough, chest
pain, arm or jaw pain, diaphoresis,
nausea/vomiting..
PE:
- Abnormal vital signs, anxious
appearance, respiratory distress,
weakness, JVD, arrythmia, cardiac
murmur, muffled heart sounds,
bilateral crackles, peripheral edema
- OMM/Musculoskeletal;
SympatheticT1 – 5 on left,
Parasympathetic occiput, C1 C2 with
lack of localized peripheral findings
Differential 2: Cerebrovascular Accident (CVA)
the medical term for a stroke; the decreased (ischemic) or increased
(hemorrhagic) blood flow to a specific brain region

Signs and symptoms – headache, altered mentation/confusion, vision

changes, vertigo/dizziness, focal neurologic deficits (sensory or motor loss),
papilledema, retinal hemorrhage, apraxia, agnosia, dysarthria, dysphagia..

Etiology – ischemic (thrombotic, embolic or secondary to

dissection/hypoperfusion) or hemorrhagic (spontaneous, trauma), embolic
from an mural thrombi, abnormal cardiac valves or rhythms,
Differential 2: Cerebrovascular Accident

Transient Ischemic Attacks (TIAs)

- are NOT strokes
- are brief “stroke-like” events that, despite resolving within minutes to hours,
still require immediate medical attention to distinguish from an actual stroke.
- usually associated with decreased blood flow to a specific portion of the
brain
- may be a warning sign for a CVA
TIA, CVA, BELL’S PALSY?
Sickle Cell anemia,
protein C deficiency
& polycythemia from
sludging (increased
viscosity/thickening):
Differential 2: Cerebrovascular Accident
Differential 2: Cerebrovascular Accident
 CHIEF COMPLAINT ORIENTATED HISTORY &
PHYSICAL : CEREBROVASCULAR ACCIDENT
History/ROS: PE:
- collapse, headache, altered - abnormal vital signs, acute
mentation, confusion, vision visual acuity changes, focal
changes, vertigo/dizziness, neurologic deficits(sensory or
apraxia, agnosia.. motor loss), + Rhomberg’s,
papilledema, retinal
hemorrhage, carotid bruits..
- OMM/musculoskeletal;
sensory/motor deficits
 Differential 3: Vasovagal Syncope

NOTE: (aka Vasovagal Syncope, Neurocardiogenic syncope,

Fainting)the transient loss of consciousness associated with loss of tone;
ultimately, the lack of oxygen to the brainstem from decreased cardiac
output
Signs and symptoms – prodromal symptoms may be vague and include
lightheadedness, diaphoresis, dimming vision, nausea, weakness, signs
of resulting trauma;
 Differential 3: Vasovagal Syncope

Etiology – reflex response causing vasodilation, initiated by pain or fear,

cough, sneeze, GU/GI stimulation, volume depletion, drugs,
hemorrhage.. Precipitating factors can include stress (emotional &/or
physical), pregnancy, dehydration, or previous history of similar event.
Differential 3: Vasovagal Syncope
CHIEF COMPLAINT ORIENTATED HISTORY &
PHYSICAL : VASOVAGAL SYNCOPE

History/ROS: PE:
- collapse, prodromal symptoms, - normal vitals, normal physical
lightheadedness, diaphoresis, examination findings..
dimming vision, nausea, weakness
- OMM/Musculoskeletal;
volume depletion, drugs,
normal, except for the possible
hemorrhage, precipitating factors
injury from fall itself..
can include stress(emotional &/or
physical), pregnancy, dehydration,
or previous history of similar event
Differential 4: Seizure
the physical manifestations (clinical &/or subclinical) resulting from
abnormal electrical discharges in the brain

Partial (focal) seizures: Generalized seizures:

- affect single area of brain
- affect brain diffusely
(most common is medial temporal)
- Absence (“petit mal”), blank stare,
- can be preceded by an aura
no post-ictal confusion
- can secondarily generalize
- Myoclonic(quick, repetitive jerks)
- Simple partial(consciousness maintained)
- Tonic-clonic(“grand mal”),
can be motor, sensory, autonomic, psychic
alternating stiffening & movement
- Complex partial
- Atonic(“drop” seizures);
(impaired consciousness)
commonly mistaken for fainting
Differential 4: Seizure

Signs and symptoms – various; altered level of consciousness,

involuntary muscular movements(atonic, tonic posturing or clonic
jerking, may have a preceding aura, focal, generalized or absent,
impaired memory of the event.. Other findings may include nuchal
rigidity, papilledema(increased ICP), tongue lacerations,
incontinence, post ictal confusion or somnolence..
Differential 4: Seizure

Etiology - multiple; infection, hypoxia, stroke(ischemic or

hemorrhagic), toxins, fever(usually children), genetic, metabolic,
trauma, idiopathic..
Epilepsy is characterized by recurrent seizure activity. Febrile
seizures are not epilepsy.
Status epilepticus continuous or recurring seizure(s) that may
result in brain injury; defined as greater by > 5 minutes duration
Most common causes of seizures by age :

Infants – infection, prenatal injury/ischemia, genetic, metabolic

Children – *fever, genetic, infection, trauma, metabolic
Adult – tumor, trauma, stroke, infection
Elderly –stroke, tumor, trauma, metabolic, infection
* Fever in general also increases the neuronal irritability which decreases
the seizure threshold!
 Differential 4: Seizure

Diagnosis: Electroencephalogram(EEG)- an electrophysiological

monitoring method to record the electrical activity of the brain
CHIEF COMPLAINT ORIENTATED HISTORY &
PHYSICAL : SEIZURE
PE:
History/ROS:
- tongue/cheek lacerations from
History of collapse, altered level of
teeth/biting, nuchal rigidity,
consciousness, witnessed or unwitnessed
papilledema(increased ICP),
involuntary muscular movements(atonic,
tongue lacerations,
tonic posturing or clonic jerking, may
incontinence, post ictal
have a preceding aura, focal, generalized
confusion or somnolence..
or absent, impaired memory of the
event.. - OMM/Musculoskeletal; possible
injury from unconscious state..
 Differential 5: Pulmonary Embolism (PE or PTE)
A pulmonary vessel obstruction causing ventilation-perfusion (VQ) mismatch to
hypoxemia and hypocapnia(aka hypocarbia or reduced carbon dioxide in the blood)
leading to respiratory alkalosis.

Signs and symptoms – often variable and nonspecific, but may present
with sudden onset dyspnea, cough, chest pain, tachypnea, collapse..

Large embolis (traveled thrombus) or saddle embolis may cause sudden

death.
 Differential 5: Pulmonary Embolism

Etiology – majority from thrombus in the deep veins of the lower leg
and pelvis, but embolism can be from Fat, Air, Thrombus(blood),
Bacteria, Amniotic, Tumor
Risk factors – obesity, smoking, trauma, infection, heart disease,
immobility, malignancy, surgery, Factor 5 Leiden deficiency,
pregnancy, oral contraceptives(OTCs)
Differential 5: Pulmonary Embolism

Diagnosis: Spiral(Helical) Computor Tomography(CT) and VQ Scan:

CHIEF COMPLAINT ORIENTATED HISTORY &
PHYSICAL : PULMONARY EMBOLISM
History/ROS:
- history of collapse, sudden onset
dyspnea, cough, unilateral/bilateral
chest pain, nausea, tachypnea..
PE:
- normal/abnormal vitals,
conversational dyspnea, fever,
respiratory distress, unilateral
adventitious(abnormal) lung
sounds.
- OMM/Musculoskeletal; T 1-4
unilateral/bilateral, accessory
respiratory muscle use..
8/19/18
 Objectives:

1. Differentiate collapse from syncope and conduct a history related to

transient loss of consciousness.
2. Describe the related organ system approach to this complex
symptom.
3. List the various etiologies of seizures.
4. List
. the signs and symptoms common to seizures.
5. List the signs and symptoms uncommon to seizures.
Questions