Fainting and Blacking Out (Near-Syncope and Syncope).

Patient reports of fainting or “passing out” are common and warrant a meticulous history to guide
management and possible hospital admission. Causes include seizures, “neurocardiogenic”
conditions such as vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope, and
orthostatic hypotension, and cardiac disease causing arrhythmias, especially ventricular tachycardia
and bradyarrhythmias.

• Begin by finding out whether the patient has actually lost consciousness by asking a
complete description of the event.
o What was the patient doing when the episode occurred?
o Was the patient standing, sitting, or lying down?
o Were there any triggers or warning symptoms such as dizziness?
o How long did the episode last?
o Are there external noise or voices throughout the episode?
o Was the onset and offset slow or fast?
o Were there any palpitations?
If the patient is unconscious, try to interview any witnesses to ask those questions.
Seizures

Seizure is a sudden excessive electrical discharge from cortical neurons. Seizures it may be symptomatic,
with an identifiable cause, or idiopathic. A two or more seizures that are not provoked by other illnesses
or circumstances is called epilepsy. Common causes of acute symptomatic seizures include: head
trauma; alcohol, cocaine, and other drugs; withdrawal from alcohol, benzodiazepines, and barbiturates;
metabolic insults from low or high glucose or low calcium or sodium; acute stroke; and meningitis or
encephalitis. In assessing seizures, it is important to ask question such as:

• How the patient looked before, during, and after the episode.
• Was there any seizure-like movement of the arms or legs?
• Any incontinence of the bladder or bowel?
• Was there any drowsiness or impaired memory after the event that suggestive of a postictal
state?
• The age at onset, frequency, change in frequency or symptom pattern, and use of
medications, alcohol, or illicit drugs. Check for any history of head injury
Tremors or Invountary Movements.

Tremor, “a rhythmic oscillatory movement of a body part resulting from the contraction of opposing
muscle groups,” is the most common movement disorder. It may be an isolated finding or part of a
neurologic disorder.

• Ask about any tremor, shaking, or body movements that the patient seems unable to
control.
• Does the tremor occur at rest?
• Does it get worse with voluntary intentional movement or with sustained postures?
Distinct from these symptoms is restless legs syndrome, described as an unpleasant sensation in the
legs, especially at night, that gets worse with rest and improves with movement of the symptomatic
limb(s).

Important Topics for Health Promotion and Counseling

To prevent stroke and transient ischemic attack. The AHA and the ASA urge patients to seek immediate
care for any of the warning signs below. It is important to teach these to your patients.

Recognizing and treating stroke risk factor such as hypertension, smoking, dyslipidemia, diabetes,
weight diet and nutrition, physical inactivity and alcohol use can also prevent the stroke and TIA.

Carotid artery screening. The Task Force reviewed studies on the benefits and harms of screening for
carotid artery stenosis. They found that screening in the general population has little or no benefit for
preventing stroke. The Task Force also found that carotid artery stenosis screening has potential harms.
Ultrasound screening does not by itself cause physical harm. However, this screening often leads to a
cascade of follow-up testing and surgeries that can cause serious harms, including stroke, heart attack or
death. In addition, screening all adults will lead to many false-positive results because few people have
carotid artery stenosis. This is when a test result says a person has a condition that he or she actually
does not have. False-positive results lead to unneeded tests and surgeries.

Reducing Risk of Diabetic Peripheral Neuropathy. Diabetes causes several types of peripheral
neuropathy. Maintaining optimal glycemic control can prevent or delay the onset of neuropathy,
particularly from type I diabetes.

Diabetic patients should have their feet examined regularly for neuropathy, including testing pinprick
sensation, ankle reflexes, vibration perception (with a 128-Hz tuning fork) and plantar light touch
sensation (with a Semmes-Weinstein monofilament), as well as checking for skin breakdown, poor
circulation, and musculoskeletal abnormalities. The monofilament test involves pressing the
perpendicular monofilament against the skin at the great toe and metatarsals until it bends (Fig. 17-8),
or against the dorsal arch if without calluses; the test is positive if the patient cannot feel the
monofilament.

• Pinprick sensation - With the pinprick, the therapist gently touches the skin with the pin
or back end and asks the patient whether it feels sharp or blunt.

Herpes Zoster Vaccination

The herpes zoster vaccine effectively reduces the short-term risks for zoster and postherpetic neuralgia
in adults ≥50 years. The Advisory Committee on Immunization Practices (ACIP) currently recommends
routinely offering onetime vaccination for adults ≥60 years; the Federal Drug Administration has
approved the vaccine for adults ≥50 years. Because the long-term efficacy of the herpes zoster vaccine is
uncertain, the ACIP is re-evaluating the best age to administer the vaccine and the need for
revaccination
Detecting the “Three Ds”: Delirium, Dementia, and Depression.

Delirium - a multifactorial syndrome, is an acute confusional state marked by sudden onset, fluctuating
course, inattention, and at times changing levels of consciousness. Risk for developing delirium depends
on both predisposing conditions which increase susceptibility and the immediate precipitating factors.

The Confusional Assessment Method (CAM) algorithm is recommended for screening at-risk patients
and can quickly and accurately detect delirium at the bedside.

Dementia - is characterized by declines in memory and cognitive ability that interfere with activities of
daily living. Diagnosing dementia requires exclusion of delirium and depression. To diagnose dementia:

• Instruct the patient to listen carefully to and remember three unrelated words and then
to repeat the words.
• Instruct the patient to draw the face of a clock, either on a blank sheet of paper or on a
sheet with the clock circle already drawn on the page. After the patient puts the
numbers on the clock face, ask him or her to draw the hands of the clock to read a
specific time.
• Ask the patient to repeat the three previously stated words.
• Give 1 point for each recalled word after the clock drawing test (CDT) distractor.
• Patients recalling none of the three words are classified as demented (Score = 0).
• Patients recalling all three words are classified as nondemented (Score = 3).
• Patients with intermediate word recall of one to two words are classified based on the
CDT (Abnormal = demented; Normal = nondemented).
• Note: The CDT is considered normal if all numbers are present in the correct sequence
and position, and the hands readably display the requested time.

Depression - is more common in individuals with significant medical conditions, including several
neurologic disorders—dementia, epilepsy, multiple sclerosis, and Parkinson disease. Two screening
questions, can accurately identify major depressive disorders. Positive responses on this question should
prompt further investigation with scales such as the Geriatric Depression Scale or the 9-item Patient
Health Questionnaire (PHQ9).