LOC + Loss of Weight

Question 1

What reversible causes of LOC are there

Answer 1

Shock
Hypoxia
Hypoglycemia
Hyperglycemia
Narcotic OD

Question 2

What to ask on hx for LOC

Answer 2

Duration of LOC
Trauma
Pre-existing conditions
Drugs
Toxins
Meds
Sz activity

Question 3

Ix for syncope

Answer 3

EKG
Orthostatic BP
Sustained decrease in sBP ≥20 mmHg or dBP ≥10 mmHg within 3 min of assuming upright posture
Labs (only if indicated)
Consider CBC, BhCG, troponin
Cardiac (if abnormal EKG or suspect cardiac)
Consider echocardiogram if abnormal EKG or suspect structural abnormality
Consider Holter 24-48h only if symptoms reoccur daily
Consider carotid sinus massage if >40yo and no contraindications
Patient supine 5-10 seconds of massage to each carotid sinus (start with right)
Positive if asystolic or ventricular pause > 3s or decrease in sBP of 50 mm Hg
If negative, repeat with patient upright at approximately 60 to 70 degrees
Avoid in recent stroke/TIA <3mo or if carotid bruits
Neurologic (only if suspect epilepsy, focal neuro deficit)
Consider EEG, CT head

Question 4

What tool to use to risk stratify syncope

Answer 4

San Francisco Syncope Rule or OESIL Score

Question 5

What are high risk features in pt presenting with syncope

Answer 5

Clinical history suggestive of arrhythmic syncope (e.g., syncope during exercise, palpitations, or without warning or prodrome)
Comorbidities (e.g., severe anemia, electrolyte abnormalities)
ECG suggestive of arrhythmic syncope (e.g., bifascicular block, sinus bradycardia < 40 beats per minute in absence of sinoatrial block or medication use, QRS preexcitation, abnormal QT interval, ST segment elevation leads V1- V3 [Brugada pattern], negative T wave in right precordial leads and epsilon wave [arrhythmogenic right ventricular dysplasia/cardiomyopathy])
Family history of sudden death
Hypotension (sBP < 90 mm Hg)
Older age
Severe structural heart disease, congestive heart failure, or coronary artery disease

Question 6

What factors are reassuring in syncope hx?

Answer 6

Age less than 50 years
No history of cardiovascular disease
Normal electrocardiographic findings
Symptoms consistent with neurally mediated or orthostatic hypotension syncope
Unremarkable cardiovascular findings

Question 7

Rules for driving after syncope - regular vs commercial:
1) Single episode of typical vasovagal
2) Dx + treated cause
3) Situational syncope w/ avoidable trigger
4) Single episode unexplained syncope
5) Recurrent episode unexplained syncope

Answer 7

Single episode of typical vasovagal - no restriction
Dx + treated cause - wait 1 wk for private, 1 month for commercial
Situational syncope w/ avoidable trigger - wait 1 wk for private + commercial
Single episode unexplained syncope - 1 wk for private, 12 months for commercial
Recurrent episode unexplained syncope - 3mo for private, 12 months commercial

Question 8

Causes of wt loss

Answer 8

Psych: anorexia, depression, schizophrenia, anxiety, neglect
Endocrine: hyperthyroidism, DM, adrenal insufficiency, pheochromocytoma
Drugs: amphetamines, metformin, opioids, laxatives, diuretics
Infection: TB or HIV
Chronic illness: CHF, COPD, cancer, connective tissue dz
GI: PUD, dysphagia, IBD, celiac
Neuro: MND, myopathy
CKD
Pursue underlying cause
Maintain record of pt weights
FU + re-evaluate pts with persistent wt loss of undiagnosed cause

Question 9

Definition of wt loss

Answer 9

Loss of ≥5% weight over 6-12 months

Question 10

What to ask in hx of wt loss

Answer 10

Document weight loss
Pattern of weight loss
Intentional vs. Unintentional (r/o eating disorder)
Dietary history
GI symptoms (N/V/D, dysphagia, abdominal pain, early satiety)
Malignancy (fever, fatigue, chills, night sweats)
Psychiatric (depression, mood)
Medication, Alcohol, Drugs
Social (Income, Activity) and Function (Dementia)

Question 11

Ix for wt loss

Answer 11

height, weight
CBC (Hb, WBC)
Chem (Creat, Calcium)
Glucose, A1C
TSH
LFT (Alk Phos), Albumin
ESR/CRP, LDH
UA
FOBT
CXR
Consider

Question 12

Non lab Ix for eating disorders

Answer 12

BMD, ECG, echo