Approach to a patient with Syncope

Definition Of Syncope: Symptom of sudden transient loss of consciousness due to global cerebral hypoperfusion.

Causes Of Syncope: 

• Neurocardiogenic (a.k.a. vasovagal, ~20%; ): ↑ sympathetic tone → vigorous contraction of LV →
mechanoreceptors in LV trigger ↑ vagal tone  → ↓ HR (cardioinhibitory) and/or
↓ BP (vasodepressor) cough, deglutition, defecation, & micturition → ↑ vagal tone and thus can be precipitants related disorder:
carotid sinus hypersensitivity (exagg vagal resp to carotid massage)

• Orthostatic hypotension (10%)
hypovolemia/diuretics, deconditioning; vasodilat. (esp. if combined w/ chronotropes)
autonomic neuropathy [primary = Parkinson’s, Shy-Drager, Lewy body dementia, POTS (dysautonomia in the young); secondary =DM, EtOH, amyloidosis, CKD]

• Cardiovascular
Arrhythmia (15%)
Bradyarrhythmias: Sick sinus syndrome, high-grade AV block, chronotropes, PPM malfunction
Tachyarrhythmias: VT, SVT (syncope rare unless structural heart disease or WPW)
Mechanical (5%)
Endocardial/Valvular: AS, MS, PS, prosthetic valve thrombosis, myxoma
Myocardial: pump dysfxn from MI or outflow obstruction from HCMP (but usually VT)
Pericardial: tamponade
Vascular: PE, PHT, aortic dissection, ruptured AAA, subclavian steal

Impetigo - A Brief Discussion.

Introduction: This is the most superficial of the bacterial skin infections. It is one of the most common skin infections in children. but can also occur in adults.

Etiology: It is caused by Streptococcus pyogenes or Staph. aureus infecting the epidermal layer of the skin.

Clinical features: Because it is so superficial, there is weeping, crusting, and oozing of the skin.
Symptoms start with red or pimple-like sores surrounded by red skin. These sores can be anywhere, but usually occur on the face, arms and legs. The sores fill with pus, then break open after a few days and form a thick crust. They are often itchy, but scratching them can spread the sores.

Impetigo is contagious and can be spread to others through close contact or by sharing towels, sheets, clothing, toys, or other items.

Diagnosis: A specific microbiologic diagnosis is rarely made or necessary. It is mostly diagnosed by the clinical appearance of  “weeping, oozing, honey-colored lesions.”

Introduction to Multivitamin Supplements and Understanding Megavitamin therapy.

A vitamin is one of a group of organic substances, present in minute amounts in natural foodstuffs that are essential for normal body metabolism.

There are 13 vitamins that a human  body needs. They are

• Vitamin A
• B vitamins (thiamine, riboflavin, niacin, pantothenic acid, biotin, vitamin B-6, vitamin B-12 and folate)
• Vitamin C
• Vitamin D
• Vitamin E
• Vitamin K

Each vitamin has specific function in the body and if there is a low levels of certain vitamins, there may be certain health problems and illness. 

Fat soluble and Water soluble Vitamins
Vitamins are either fat-soluble or water-soluble.

Fat-soluble vitamins are stored in the fatty tissues of the body and the liver. Fat-soluble vitamins are easier to store than water-soluble ones and can stay in the body as reserves for days, some of them for months.

Fat-soluble vitamins are absorbed through the intestinal tract with the help of fats (lipids).

Vitamins A, D, E, and K are fat-soluble.

Water-soluble vitamins do not get stored in the body for long - they soon get excreted in urine. Because of this, water-soluble vitamins need to be replaced more often than fat-soluble ones.

Vitamins C and all the B vitamins are water-soluble.

The best way to get enough vitamins is to eat a balanced diet with a variety of foods. In some cases, you may need to take vitamin supplements.

Vitamin Supplements; The best way to get enough vitamins is to eat a balanced diet with a variety of foods. In some cases, however vitamin supplements are indicated in some people in order to prevent or treat deficiencies.

Multivitamin and mineral supplements are easily available in different pharmacies so it is important to understand the need and indications for these supplements and to avoid dangerous overdoses. 

Indications For Vitamin Supplements: In otherwise healthy people, most scientific evidence indicates that multivitamin supplements do not prevent cancer, heart disease, or other ailments, and regular supplementation is not necessary. 

However, there may be specific groups of people who may benefit from multivitamin supplements for example,:

• people with poor nutrition
• couples planning for pregnancy 
• During pregnancy & breast feeding
• elderly individual
• people living in sun deprived areas need vitamin D supplements. 
• vegetarians etc

Approach to a Patient Presenting With Pain

Pain is the most common symptom that brings a patient to a physician’s attention.
Management depends on determining its cause, alleviating triggering and potentiating factors, and providing rapid relief whenever possible.

Pain may be of somatic (skin, joints, muscles), visceral, or neuropathic (injury to nerves, spinal cord pathways, or thalamus) origin. Characteristics of each of the types are summarized below:

Somatic pain

• Nociceptive stimulus usually evident
• Usually well localized
• Similar to other somatic pains in pt’s experience
• Relieved by anti-inflammatory or narcotic analgesics

Visceral pain

• Most commonly activated by inflammation
• Pain poorly localized and usually referred
• Associated with diffuse discomfort, e.g., nausea, bloating
• Relieved by narcotic analgesics

Neuropathic pain

• No obvious nociceptive stimulus
• Associated evidence of nerve damage, e.g., sensory impairment, weakness
• Unusual, dissimilar from somatic pain, often shooting or electrical quality
• Only partially relieved by narcotic analgesics; may respond to antidepressants or anticonvulsants.

Acute Asthma - Assessment

Make an initial assessment of the severity of acute asthma based upon a combination of

• clinical features, 
• peak flow measurement and 
• pulse oximetry 

This is as outlined as below.

Moderate exacerbation of asthma
• Increasing symptoms.
• Peak fl ow 50–75 % best or predicted.
• No features of acute severe asthma (below).

Acute severe asthma
Any one of the following:
• Inability to complete sentences in 1 breath.
• Respiratory rate ≥25/min.
• Heart rate ≥110/min.
• Peak flow 33–50 % best or predicted.