An Approach to a Patient

with Syncope

MPPRC- 2B Group 1
 General Objective

Integrate and apply knowledge

acquired in the subjects of Medicine I,
Pathology, Pharmacology and
Radiology in the management of a
patient with syncope.
 Specific Objectives
1. Identify significant signs and symptoms and
correlate with patients chief complaint.
2. Define and explain the etiology and
pathophysiology of the chief
complaint/symptoms.
3. To identify the necessary ancillary procedures
that can help in the diagnosis of the patient.
4. To formulate an effective pharmacologic and
non-pharmacologic management for the
patient.
 MEDICINE

Diaz, Mary Grace

Dela Cruz, Ma. Katrina Xyza
Diaz, M. G.

General Data
Patients Name: E.R.
Hospital No.07-56-06 Age/gender: 69/F
Bed No.: 209C
Date of Admission:
Civil Status: Married
November 13, Nationality: Filipino
2010, morning
Date of Interview: Occupation: Homemake
November 15, Residence: Sampaloc
2010, 4:30pm
Informant/s: Patient,
Manila
Husband, Birthdate: June 10, 194
daughter
Reliability: 70% Religion: Roman
Catholic
Diaz, M. G.

Chief Complaint:

Dizziness
Diaz, M. G.

History of Present Illness:

Diaz, M. G.

ADMISSION
Diaz, M. G.

Past Medical History

(+) HPN for 3 years; highest BP: 160/80
mmHg
maintained on Captopril 25mg/tab 1 tab BID, non
compliant
(-) DM, thyroid disease, PTB, CA
(+) chicken pox
No previous hospitalizations.
No previous accidents, injuries.
No previous blood transfusions.
No known allergies.
Diaz, M. G.

Obstetric & Gynecologic

History
Menarche: unrecalled
Menopause: at 43
G11P10
TPAL: 11-0-1-11
Firstborn via CS, the rest all normal
delivery
(-) Contraceptive methods, hormone
therapy
Diaz, M. G.

Current Health / Risk Factors

Mixed diet, 3 main meals and 2
merienda a day, w/ occasional midnight
snacks.
Poor water intake; drinks 3 bottles of
1.5 L (~4.5L) of Coca Cola daily
Seldom drinks coffee
Sleeps as early as 7pm and wakes up at
2am; with naps at an average of 5
hours throughout the day
Diaz, M. G.

Current Health / Risk Factors

No regular exercise
Non-smoker
Non-alcoholic beverage drinker
Past travel to Ilocos and Laguna
Denies illicit drug use
Smallpox vaccination
Resides along the street
Diaz, M. G.

Family History
Dad: Died back in WWII
Mom: died at the age 96 due to heart
disease
Sister : (+) CVA
Eldest Son: (+) HPN
(-) Familial CA, DM
(-) PTB
Diaz, M. G.

Personal/Social History
Happily married for 50 years.
Has 11 children, eldest 45 y/o and
youngest 27 y/o
Lives with husband, 7 of her children and
a grandchild; shares bedroom with
husband and one of her daughters
Financially stable
Exposed to one chain smoker in the
household
Diaz, M. G.

Review of Systems
General: No headache, no nausea, No
significant weight loss, No fever, pallor
Endocrine: (-) Cold intolerance
Skin: No rashes, no lumps, no sores, healing
wound both feet
Head: No hair loss.
Eyes: uses reading glasses
Ears: with good hearing, no tinnitus,
Nose: No colds, nor nasal discharge.
Throat and Mouth: no sore throat, no tonsillitis
Diaz, M. G.

Review of Systems
Breast: no self breast exam
Cardiac: No chest pain, no palpitations
Pulmo: No cough, no shortness of breath, no
Difficulty of breathing, no sputum
GIT: no vomiting, no nausea, no diarrhea, no
constipation, no melena, no hematochezia
GUT: (+) nocturia, (+) urgency, no hesitancy,
no hematuria, no discharge
Musculoskeletal: no joint pains
Neurologic: no speech disturbance, no seizure
Dela Cruz, M.K.X.

Physical Examination
Upon admission On interview
Awake, conscious, General: Cooperative,
wheel-chair borne, in hyposthenic, conscious,
cardiorespiratory incoherent , oriented as
distress to place and person
BP: 60/40 mmHg; PR: Not in cardiorespiratory
70 bpm; RR: 18 cpm; distress
T: 36.5 C Vital Signs: BP: 160/80
Ht: 147.5 cm; Wt: 46 mmHg; PR: 71 bpm;
kg; BMI: 21.1 RR: 20 cpm; T: 36.3 C;
Dela Cruz, M.K.X.

Physical Examination
Upon admission On interview
Warm moist skin, (+) dry, scaly plaque on
5x5 cm dry plaques dorsum of both feet (4 x 4
topped with scales on cm on the left and 4 x 2
the dorsal aspect of both cm on the right)
feet, no scalp lesions
Pink palpebral Pink palpebral conjunctiva,
conjunctivae, anicteric anicteric sclera
sclera, pupils 1-2 mm
ERTL
No nasal nor aural
No tragal tenderness, no discharge
nasoaural discharge
Dela Cruz, M.K.X.

Physical Examination
Upon admission On interview
Moist buccal mucosa,
nonhyperemic posterior Thyroid gland not enlarged,
pharyngeal wall no palpable cervical
Supple neck, thyroid not lymphandenopathy
enlarged, midline
trachea, no bilateral
palpable cervical lymph JVP: 2.5 cm at 30 degrees
nodes
Adynamic precordium, AB at
JVP: 4cm at 30 degrees 5th L ICS MCL, no heaves, no
Adynamic precordium, thrills, normal heart sounds
AB 5th LICS, MCL S1>S2
at apex; S2>S1 at base,
(-) murmurs
Dela Cruz, M.K.X.

Physical Examination
Upon admission On interview
No retractions, Symmetrical chest
symmetrical chest expansion, resonant
expansion, resonant on percussion, no
on percussion, (-) adventitious breath
crackles sounds
Peripheral pulses full 1+ edema L foot
and equal, no Pulse 1-2+ on all
cyanosis, no edema extremities
Dela Cruz, M.K.X.

Physical Examination
Upon admission On interview
Globular abdomen, *No abdominal PE
normoactive bowel performed*
sounds, (-) direct or
rebound tenderness,
liver span: 9cm
Traubes space not
obliterated; (+) 11cm
vertical scar at the
infraumbilical area
Dela Cruz, M.K.X.

Neurologic Physical
Examination
Conscious coherent CN VII: can raise
wheel chair borne, eyebrow, puff cheeks,
oriented to 3 spheres smile, frown without
CN I: (+) red-orange asymmetry
reflex on the left eye, CN VIII: no lateralization
pupils responsive to on Webers, AC>BC on
light 1-2mm both eyes Rinnes
CNII :can smell equally CN IX, X: Midline uvula
CN III, IV,V: EOMS intact CN XI: can raise
CN V: can clench jaw shoulders against
resistance
Dela Cruz, M.K.X.

Neurologic Physical
Examination
CN XII: tongue Sensory: no
midline on sensory deficits
protrusion (-) Babinski, no
Motor: MMTs 5/5 on nuchal rigidity
all extremeties
Cerebellum: can do
finger to nose test
with ease\
++ reflexes on all
extremities
Dela Cruz, M.K.X.

Salient Features: Subjective

Pertinent (+)
data
Pertinent (-)
69/F, married homemaker No loss of
Dizziness consciousness
Generalized weakness, loss No vomiting
of postural tone
Cold clammy sweat No nausea
Pallor No fever
Hypokalemia
(+) HPN, BP peaks 180/100
mmHg
(+) nocturia
High Coca Cola intake
Dela Cruz, M.K.X.

Salient Features: Objective

data
Pertinent (+) Pertinent (-)
In cardiorespiratory (-) adventitious breath
distress sounds
BP 60/40 mmHg, PR Adynamic precordium,
70, RR 18 cpm AB 5th LICS MCL,
T 36.5oC S1>S2 at apex; S2>S1
Warm moist skin at base
(-) murmur
Normal Neuro PE
Dela Cruz, J.D.M.

Chief complaint:
DIZZINESS
Dela Cruz, J.D.M.

Doctor, Im dizzy...

Harrisons 17th ed.

Dela Cruz, J.D.M.
Dela Cruz, J.D.M.

Syncope
a transient loss of consciousness and
postural tone due to reduced
cerebral blood flow, is associated
with spontaneous recovery

Harrisons 17th ed.

Dela Cruz, J.D.M.

Pathophysiology of Syncope
Regulation of Systemic blood pressure
Cerebral blood flow can be maintained if
cardiac output (CO) and systemic
arterial vasoconstriction compensate
Failure of these adjustments:
Hypotension with resultant cerebral
underperfusion to less than half of
normal results in syncope

Harrisons 17th ed.

Dela Cruz, J.D.M.

Harrisons 17th ed.

Dela Cruz, J.D.M.

Harrisons 17th ed.

Dela Cruz, J.D.M.

Mechanism of Arterial
pressure

Harrisons 17th ed.

Dela Cruz, J.D.M.

Mechanism of Hypertension
1. Intravascular volume
Primary determinant of arterial pressure over
long term
In general alterations in total ECF volume are
associated w/ proportional change of blood
volume

Vascular volume expand

CO

Harrisons 17th ed.

Dela Cruz, J.D.M.

Mechanism of Hypertension
2. Autonomic nervous system
Maintains CV homeostasis via pressure,
volume and chemoreceptor signals
Adrenergic reflexes modulate BP over short
term
Adrenergic function, with hormonal and
volume-related factors contribute to the long
term regulation of arterial pressure

Harrisons 17th ed.

Dela Cruz, J.D.M.

Mechanism of Hypertension
3. RAAS
Primarily via the vasoconstrictor properties of
Ang-II (potent pressor) and the sodium-
retaining properties of aldosterone

Harrisons 17th ed.

Dela Cruz, J.D.M.

Harrisons 17th ed.

Dela Cruz, J.D.M.

Mechanism of Hypertension
4. Vascular mechanisms
Vascular radius and compliance of resistance
arteries
In hypertensive individuals, structural,
mechanical, or functional changes may
reduce lumen diameter of small arteries and
arterioles.
Vascular remodeling results in decreased
lumen size contributing to increased
peripheral resistance

Harrisons 17th ed.

Dela Cruz, J.D.M.

Harrisons 17th ed.

Dela Cruz, J.D.M.

Guyton 11th edition p230

Dolorical, D.

Electrical Properties of Cardiac

Muscle

Merck Manual, 2009

Malafronte, et al
Dolorical, D.

<3.5 mEq/L

Portable Fluids and Electrolytes. 2008: Lippincott Wiliams & Wilkins. p91-94.
Dolorical, D.

Cardiac hyperexcitability
may occur with severe
hypokalemia. Merck
Manual, 2009

Professional Guide to Diseases, 8th Ed. 2005. Lippincott Williams & Wilkins.
th
 Normalize
Blood glucose
Hyperinsulinemia
Glucose load

Osmotic
diuresis
Inc. Renal K+
wasting
Hypokalemia
Caffeine intoxication
Dela Cruz, J.D.M.
Dolorical, D.
Cardiac

HPN
ACE-I
+
ARB
BP Cerebral SYNCOPE
Blood flow

CO
Arrhythmia
Delayed
Repolarization

Hypokalemia
 Clinical impression

Syncope, secondary to Hypotension

Hypertension, Stage 2
Pathology
Dilla, Ken Lorenz S.

Pathology
Hypertension
Defined as any of the following:
Sustained systolic blood pressure greater
than 139 mmHg.
Sustained diastolic blood pressure greater
than 89 mmHg.

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology
Types of Hypertension:
Essential
Idiopathic hypertension
Secondary
Caused by an underlying pathology
Malignant
Severe hypertension with systolic pressure
of over 200 mmHg, and diastolic pressure of
over 120 mmHg.
Pathologic Basis of Disease, 8th Edition.
Dilla, Ken Lorenz S.

Pathology
Vascular Changes
Hyaline arteriolosclerosis
Presence of pink hyaline thickening which
are associated with narrowing of the
arteriolar lumen.
Due to plasma protein leakage and
increased smooth muscle cell matrix
synthesis.

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology
Hyperplastic Arteriolosclerosis
Presence of concentric, laminated thickening
of the walls and luminal narrowing.
onion-skin lesions
Occurs in malignant hypertension

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology
Cardiac Changes
Cardiac hypertrophy
Increase in size of myocytes due to
increased mechanical work due to an
increase in pressure or volume overload
Increase in number of mitochondria and
nuclei enlargement

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology
Pressure overload Volume overload
hypertrophy hypertrophy

Concentric increase in Ventricular dilatation

wall thickness

New sarcomeres New sarcomeres

assembled parallel to assembled in series to
the long axes of cells existing sarcomeres

Pathologic Basis of Disease, 8th Edition.

Dilla, Ken Lorenz S.

Pathology

Pathologic Basis of Disease, 8th Edition.

RADIOLOGY and ANCILLARY
PROCEDURES
Jan Paolo P. Dipasupil
 Ancillary procedures
Routines:
CBC w/ Plt
Serum Na+ and K+
Urinalysis

Chest X-ray
12 Leads ECG (Holter Monitor)
2D Echo
 CHEST X-RAY
NORMAL ACTUAL
 CHEST X-RAY
NORMAL ACTUAL
Normal ECG
Electrocardiogram (ECG)
LEAD II
V1
V5
 2D Echocardiography

provide excellent images of the heart,

paracardiac structures, and the great vessels.
used to diagnose cardiovascular diseases
Pharmacology

De Mesa, Jasper Angelo

68
De Mesa, Jasper Angelo

TREATMENT
Problem Goals
- Hypotension - To normalize the blood
pressure of the patient

- Low serum potassium - To treat hypokalemia

- Hypertension
- To normalize the blood
pressure and to prevent
further complication

69
De Mesa, Jasper Angelo

Non-pharmacologic
Treatment for Hypotension
De Mesa, Jasper Angelo

Non-pharmacologic
Trendelenberg position
Avoid wearing a shirt with a tight collar
Caution when turning the head (turning to
look while driving in reverse), or
manipulating
the neck (as in shaving).
The patients medications must be noted,
including nonprescription drugs or health
store supplements, with particular attention
to recent changes.
De Mesa, Jasper Angelo

Pharmacologic
Infusion of PLRS
Vasopressor drugs
De Mesa, Jasper Angelo

Pharmacologic treatment for

Hypokalemia

73
De Mesa, Jasper Angelo

Hypokalemia
Replacement by oral route
Tablet or diluted solution
Kalium durule 0.75 gm (10meq) TID PO x 2-3
days.
Oral solution KCLl solution 15-30 cc TID
(1gm KCl = 14meq K+) to be further diluted
in oral feeding or water.
De Mesa, Jasper Angelo

Non-pharmacologic
Treatment for hypertension

75
Hypertension

JNC 7 National Blood Pressure Education Program

Pharmacologic Treatment
For Hypertension
JNC 7 National Blood Pressure Education Program
JNC 7 National Blood Pressure Education Program
JNC 7 National Blood Pressure Education Program
JNC 7 National Blood Pressure Education Program
JNC 7 National Blood Pressure Education Program
JNC 7 National Blood Pressure Education Program
Thank You!

84