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In addition to the mechanism described above, a number of other medical conditions may cause syncope. Making the correct diagnosis for loss of consciousness is difficult. The core of the diagnosis of vasovagal syncope rests upon a clear description of a typical pattern of triggers, symptoms, and time course.
It is pertinent to differentiate lightheadedness, seizures, vertigo, and low blood sugar as other causes.
In people with recurrent vasovagal syncope, diagnostic accuracy can often be improved with one of the following diagnostic tests:
- A tilt table test (results should be interpreted in the context of patients' clinical presentations and with an understanding of the sensitivity and specificity of the test)
- Implantation of an insertable loop recorder
- A Holter monitor or event monitor
- An echocardiogram
- An electrophysiology study
Treatment for reflex syncope focuses on avoidance of triggers, restoring blood flow to the brain during an impending episode, and measures that interrupt or prevent the pathophysiologic mechanism described above.
Treatment for lightheadedness depends on the cause or underlying problem. Treatment may include drinking plenty of water or other fluids (unless the lightheadedness is the result of water intoxication in which case drinking water is quite dangerous). If a sufferer is unable to keep fluids down from nausea or vomiting, they may need intravenous fluid. Sufferers should try eating something sugary and lying down or sitting and reducing the elevation of the head relative to the body (for example, by positioning the head between the knees).
Other simple remedies include avoiding sudden changes in posture when sitting or lying and avoiding bright lights.
Several essential electrolytes are excreted when the body perspires. When people are out in unusual or extreme heat for a long time, sweating excessively can cause a lack of some electrolytes, which in turn can cause lightheadedness.
Lightheadedness is a common and typically unpleasant sensation of dizziness and/or a feeling that one may faint. The sensation of lightheadedness can be short-lived, prolonged, or, rarely, recurring. In addition to dizziness, the individual may feel as though his or her head is weightless. The individual may also feel as though the room is what causes the "spinning" or moving (vertigo) associated with lightheadedness. Most causes of lightheadedness are not serious and either cure themselves quickly, or are easily treated.
Keeping a sense of balance requires the brain to process a variety of information received from the eyes, the nervous system, and the inner ears. If the brain is unable to process these signals, such as when the messages are contradictory, or if the sensory systems are improperly functioning, an individual may experience lightheadedness or dizziness.
If the person is hemodynamically unstable or other treatments have not been effective, synchronized electrical cardioversion may be used. In children this is often done with a dose of 0.5 to 1 J/Kg.
Because the adrenergic storm overlaps with so many other similar conditions, such as hypertensive crises, stimulant intoxication or overdose, or even panic attack, and because the treatments for these overlapping conditions are largely alike, it is not necessary to obtain a differential and definitive diagnosis before initiating treatment. However, analysis of the patient's medical history, checked against the possible causes of the adrenergic storm such as those above, should be done, because some adrenergic storms can be caused by serious underlying conditions. If a patient has an adrenergic storm and all or most of the other factors are ruled out, the adrenergic storm could lead to the discovery of a pheochromocytoma, which can become malignant. However, not all cases of adrenergic storm have an identifiable cause. Like a seizure, sometimes a patient has a single one, or perhaps a few, and then does not for the rest of their life. The mechanisms of idiopathic adrenergic storm are very poorly understood.
Serotonin syndrome, in which an excess of serotonin in the synapses causes a similar crisis of hypertension and mental confusion, could be confused with an adrenergic storm. The difference is that serotonin, being a tryptamine (non-catecholamine) involved in higher brain functions, can cause dangerous hypertension and tachycardia from its effects on the sympathetic nervous system, but as there are no serotonin receptors in the heart or blood vessels there are no direct effects on the heart. Thus, the presence of arrythmia, abnormal echocardiograms, or chest pain indicates an adrenergic crisis and rules out serotonin syndrome.
A number of physical maneuvers increase the resistance of the AV node to transmit impulses (AV nodal block), principally through activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve. These manipulations are collectively referred to as vagal maneuvers.
The valsalva maneuver should be the first vagal maneuver tried and works by increasing intra-thoracic pressure and affecting baroreceptors (pressure sensors) within the arch of the aorta. It is carried out by asking the patient to hold his/her breath while trying to exhale forcibly as if straining during a bowel movement. Holding the nose and exhaling against the obstruction has a similar effect.
There are other vagal maneuvers including: holding one's breath for a few seconds, coughing, plunging the face into cold water, (via the diving reflex), drinking a glass of ice cold water, and standing on one's head. Carotid sinus massage, carried out by firmly pressing the bulb at the top of "one" of the carotid arteries in the neck, is effective but is often not recommended in the elderly due to the potential risk of stroke in those with atherosclerotic plaque in the carotid arteries.
Pressing down gently on the top of closed eyes may also bring heartbeat back to normal rhythm for some people with atrial or supraventricular tachycardia (SVT).
If there is evidence of overdose or it is suspected, the patient should be given gastric lavage, activated charcoal, or both; this could make the difference between life and death in a close situation. It can however aggravate the patient which should be taken into account.
The first line treatments are diazepam and a non-selective beta blocker; other antihypertensive drugs may also be used. It is important to note that not all benzodiazepines and beta blockers are safe to use in an adrenergic storm; for instance, alprazolam and propranolol; alprazolam weakly agonizes dopamine receptors and causes catecholamine release while propranolol mildly promotes some catecholamine release - each worsening the condition.
Adrenergic storms are often idiopathic in nature; however if there is an underlying condition, then that must be addressed after bringing the heart rate and blood pressure down.
A number of labs may be helpful in determining the cause of shortness of breath. D-dimer while useful to rule out a pulmonary embolism in those who are at low risk is not of much value if it is positive as it may be positive in a number of conditions that lead to shortness of breath. A low level of brain natriuretic peptide is useful in ruling out congestive heart failure; however, a high level while supportive of the diagnosis could also be due to advanced age, renal failure, acute coronary syndrome, or a large pulmonary embolism.
A chest x-ray is useful to confirm or rule out a pneumothorax, pulmonary edema, or pneumonia. Spiral computed tomography with intravenous radiocontrast is the imaging study of choice to evaluate for pulmonary embolism.
DSM-5 diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within minutes:
- Palpitations, and/or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or being smothered
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, lightheaded, or faint
- Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- Fear of losing control or going insane
- Sense of impending death
- Paresthesias (numbness or tingling sensations)
- Chills or hot flashes
In DSM-5, culture-specific symptoms (e.g., tinnitus, neck soreness, headache, and uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
Some or all of these symptoms can be found in the presence of a pheochromocytoma.
Screening tools such as the Panic Disorder Severity Scale can be used to detect possible cases of disorder and suggest the need for a formal diagnostic assessment.
Tests of vestibular system (balance) function include electronystagmography (ENG), Videonystagmograph (VNG), rotation tests, Computerized Dynamic Posturography (CDP), and Caloric reflex test.
Tests of auditory system (hearing) function include pure-tone audiometry, speech audiometry, acoustic-reflex, electrocochleography (ECoG), otoacoustic emissions (OAE), and auditory brainstem response test (ABR; also known as BER, BSER, or BAER).
Other diagnostic tests include magnetic resonance imaging (MRI) and computerized axial tomography (CAT, or CT).
Many people being treated for panic attacks begin to experience limited symptom attacks. These panic attacks are less comprehensive, with fewer than four bodily symptoms being experienced.
It is not unusual to experience only one or two symptoms at a time, such as vibrations in their legs, shortness of breath, or an intense wave of heat traveling up their bodies, which is not similar to hot flashes due to estrogen shortage. Some symptoms, such as vibrations in the legs, are sufficiently different from any normal sensation that they clearly indicate panic disorder. Other symptoms on the list can occur in people who may or may not have panic disorder. Panic disorder does not require four or more symptoms to all be present at the same time. Causeless panic and racing heartbeat are sufficient to indicate a panic attack.
The difficulty of making the right vestibular diagnosis is reflected in the fact that in some populations, more than one third of the patients with a vestibular disease consult more than one physician – in some cases up to more than fifteen.
Diagnosis of a balance disorder is complicated because there are many kinds of balance disorders and because other medical conditions—including ear infections, blood pressure changes, and some vision problems—and some medications may contribute to a balance disorder. A person experiencing dizziness should see a physiotherapist or physician for an evaluation. A physician can assess for a medical disorder, such as a stroke or infection, if indicated. A physiotherapist can assess balance or a dizziness disorder and provide specific treatment.
The primary physician may request the opinion of an otolaryngologist to help evaluate a balance problem. An otolaryngologist is a physician/surgeon who specializes in diseases and disorders of the ear, nose, throat, head, and neck, sometimes with expertise in balance disorders. He or she will usually obtain a detailed medical history and perform a physical examination to start to sort out possible causes of the balance disorder. The physician may require tests and make additional referrals to assess the cause and extent of the disruption of balance. The kinds of tests needed will vary based on the patient's symptoms and health status. Because there are so many variables, not all patients will require every test.
Heliophobia can be treated using talk therapy, exposure therapy, self-help techniques, support groups, cognitive-behavioral therapy, and relaxation techniques. For people who are severely heliophobic, anti-anxiety meditation is a recommended mode of treatment.
Although patients will often mistake the pain of Tietze's syndrome for a myocardial infarction (heart attack), the syndrome does not progress to cause harm to any organs.
It is important to rule out a heart attack, as the symptoms may be similar. After assessment, providers often reassure patients that their symptoms are not associated with a heart attack, although they may need to treat the pain, which in some cases can be severe enough to cause significant but temporary disability to the patient.
Published epidemiological data for akathisia are mostly limited to treatment periods preceding the arrival of second-generation antipsychotics. Sachdev (1995) reported an incidence rate of acute akathisia of 31% for 100 patients treated for 2 weeks with antipsychotic medications. Sachdev (1995) reported a prevalence range from 0.1% to 41%. In all likelihood, rates of prevalence are lower for current treatment as second-generation antipsychotics carry a lower risk of akathisia.
A patient suffering from dysesthesia can find it to be unbearable at times. Dysesthetic burning has been called "Dante-esque" pain. The terminology used to describe it is usually interchangeable with descriptions of Hell in classic literature. It is the "bluntest" pain of which the human body is capable, and is characterized by the absence of accurate discriminative information.
Temperature change and heat both affect the sensation and raise the level of the steady pain. This pain upgrades with tonic light touch, phasic rubbing, or rough textures to become evoked pain.
The patient often cannot endure the touch of clothing. His or her entire life becomes an exercise in avoiding evoked pain. It causes difficulty in obtaining rest because bed-clothing contacts the skin. It drives the patient to a hysterical search for relief of the pain, which ends in some degree of resignation and frequent depression. Patients indicate that it has robbed them of their identity, since their values and mental priorities are so consumed by its avoidance.
Chronic anxiety is often associated with dysesthesia. Patients suffering from this anxiety may experience numbness or tingling in the face. In one study, those patients that were examined psychologically had symptoms of anxiety, depression, obsessive-compulsive personality disorder, or somatoform disorder.
Typical atrial flutter is recognized on an electrocardiogram by presence of characteristic "flutter waves" at a regular rate of 200 to 300 beats per minute. Flutter waves may not be evident on an ECG in atypical forms of atrial flutter. Individual flutter waves may be symmetrical, resembling p-waves, or may be asymmetrical with a "sawtooth" shape, rising gradually and falling abruptly or vice versa. If atrial flutter is suspected clinically but is not clearly evident on ECG, acquiring a Lewis lead ECG may be helpful in revealing flutter waves.
Daily oral muscle physical therapy, or the administration of antidepressants have been reported as effective therapy for occlusal dysesthesia patients. Tooth grinding, and the replacement or removal of all dental work should be avoided in patients with occlusal dysesthesia, despite the frequent requests for further surgery often made by these patients.
Antidepressants are also often prescribed for scalp dysesthesia.
Prakash et al. found that many patients suffering from burning mouth syndrome (BMS), one variant of occlusal dysesthesia, also report painful sensations in other parts of the body. Many of the patients suffering from BMS met the classification of restless leg syndrome (RLS). About half of these patients also had a family history of RLS. These results suggest that some BMS symptoms may be caused by the same pathway as RLS in some patients, indicating that dopaminergic drugs regularly used to treat RLS may be effective in treating BMS as well.
The presence and severity of akathisia can be measured using the Barnes Akathisia Scale, which assesses both objective and subjective criteria. Precise assessment of akathisia is problematic, as it is difficult to differentiate from a multitude of disorders with similar symptoms. In a study of movement disorders induced by neuroleptics, akathisia was found in only 26% of patients originally diagnosed with akathisia. The primary distinguishing features of akathisia in comparison with other syndromes are primarily subjective characteristics, such as the feeling of inner restlessness. Akathisia can commonly be mistaken for agitation secondary to psychotic symptoms or mood disorder, antipsychotic dysphoria, restless legs syndrome (RLS), anxiety, insomnia, drug withdrawal states, tardive dyskinesia, or other neurological and medical conditions.
Additionally, the controversial diagnosis of "pseudoakathisia" is given, as noted by Mark J. Garcia. In his article discussing akathisia among adults with severe and profound intellectual disability, he describes pseudoakathisia as "comprising all the symptoms of abnormal movements seen with akathisia, but without a sense of restlessness".
The symptoms of heliophobia depends on the person. Mild sufferers may feel uncomfortable, shaky, nauseated, or numb. Severe sufferers may feel anxious or suffer panic attacks. Other symptoms include heightened senses, lack of focus, feeling trapped, irregular heartbeat, air hunger, rapid breathing, parched mouth, sweating, muscle cramps, and physical discomfort that is not actually caused by bodily injury, but is a physical manifestation of the panic and fear that the heliophobic person experiences when exposed to light. This physical pain may be expressed, for example, as a phantom sensation of their skin burning under direct sunlight, even when it is visually apparent that their skin is not actually burning any more than healthy skin would as a result of sun exposure, but nonetheless still feels like real pain for the sufferer. However, other differential diagnoses like the rare genetic defect erythropoietic protoporphyria characterized by a severe burning sensation of all exposed skin areas without leading to immediate visible signs have to be excluded.
Holiday heart syndrome is an irregular heartbeat pattern presented in individuals who are otherwise healthy. Coined in 1978 the term is defined as "abnormal heart rhythms sometimes following excessive alcohol consumption; usually temporary".
Holiday heart syndrome can be the result of stress, dehydration, and drinking alcohol. It is sometimes associated with "binge drinking" common during the holiday season. The condition can also occur when individuals consume only moderate amounts of alcohol.
Irregular heartbeats can be serious. If palpitations continue for longer than a few hours patients should seek medical attention. Some arrhythmias associated with HHS after binge drinking can lead to sudden death, which may explain some of the sudden death cases commonly reported in alcoholics. Atrial fibrillation is the most common arrhythmia in holiday heart syndrome. Symptoms usually resolve themselves within 24 hours.
Holiday heart can also cause abnormal burning sensation whilst urinating and/or the feeling of passing blood similar to a kidney stone. This generally subsides in days or weeks.
Episodes of sleep paralysis can occur in the context of several medical conditions (e.g., narcolepsy, hypokalemia). When episodes occur independent of these conditions or substance use, it is termed "isolated sleep paralysis" (ISP). When ISP episodes are more frequent and cause clinically-significant distress and/or interference, it is classified as "recurrent isolated sleep paralysis"(RISP). Episodes of sleep paralysis, regardless of classification, are generally short (1–6 minutes), but longer episodes have been documented. With RISP the individual can also suffer back-to-back episodes of sleep paralysis in the same night, which is unlikely in individuals who suffer from ISP.
It can be difficult to differentiate between cataplexy brought on by narcolepsy and true sleep paralysis, because the two phenomena are physically indistinguishable. The best way to differentiate between the two is to note when the attacks occur most often. Narcolepsy attacks are more common when the individual is falling asleep; ISP and RISP attacks are more common upon awakening.
Several circumstances have been identified that are associated with an increased risk of sleep paralysis. These include insomnia, sleep deprivation, an erratic sleep schedule, stress, and physical fatigue. It is also believed that there may be a genetic component in the development of RISP, because there is a high concurrent incidence of sleep paralysis in monozygotic twins. Sleeping in the supine position has been found an especially prominent instigator of sleep paralysis.
Sleeping in the supine position is believed to make the sleeper more vulnerable to episodes of sleep paralysis because in this sleeping position it is possible for the soft palate to collapse and obstruct the airway. This is a possibility regardless of whether the individual has been diagnosed with sleep apnea or not. There may also be a greater rate of microarousals while sleeping in the supine position because there is a greater amount of pressure being exerted on the lungs by gravity.
While many factors can increase risk for ISP or RISP, they can be avoided with minor lifestyle changes. By maintaining a regular sleep schedule and observing good sleep hygiene, one can reduce chances of sleep paralysis. It helps subjects to reduce the intake of stimulants and stress in daily life by taking up a hobby or seeing a trained psychologist who can suggest coping mechanisms for stress. However, some cases of ISP and RISP involve a genetic factor—which means some people may find sleep paralysis unavoidable. Practicing meditation regularly might also be helpful in preventing fragmented sleep, and thus the occurrence of sleep paralysis. Research has shown that long-term meditation practitioners spend more time in slow wave sleep, and as such regular meditation practice could reduce nocturnal arousal and thus possibly sleep paralysis.