A Thorough Examination of Medical History - Case Study Example

SYNCOPE Course Instructor Institution City State Date Paramedic Introduction Lily, 57 years old woman called me to her office when she was experiencing an episode of syncope. She has a history of complaining feeling increasing unwell for the previous 24 hours with pain in her chest. She has been getting bruised easily over the last 3 months and is currently being investigated by her GP. The GP found: PMHx: Angina diagnosed 2 years ago, angioplasty (successful), HT, Asthma, GORD, Med’n: Atenolol, GTN spray, transiderm-nitro patch, atorvastatin, salbutamol inhaler, symbicort inhaler, omeprazole, aspirin, paracetamol PRN, Allergies: Morphine, Comm. Diseases – Nil Known, up to date with vaccinations, Social Hx: Lives with partner, Family Hx: Father died of heart disease, mother died of breast cancer, Alcohol: Social, Smoking: stopped 10 years ago (30/day), Assessment: When I arrived I found the patient looking distressed, Vital signs: BP 90/60, PR 105, RR 28, SpO2 96%, T35.1°C, Appearance: Pale, cool, clammy, distressed. Generally, syncope turns to be perceived as a short-term, but abrupt, postural tone and consciousness loss (Grubb & Olshansky, 2007, p. 74). Its cause turns to be a reversible intrusion of the cerebral function; characteristically as a result of glucose delivery and cerebral oxygen deficit. In fact, the oxygen delivery deficit might be brought about by; decreased peripheral vasodilatation, cardiac output or cerebral blood flow obstruction (Strickberger, 2006). The other causes include cardiopulmonary disease or structural cardiac, cerebrovascular, cardiac arrhythmias being the primary cause, neutrally-mediated (reflex) and orthostatic hypotension. The issues that will be debated in this paramedic paper are the causes of syncope, diagnosis, treatment and management. They have been chosen because they would provide a remedy to the people experiencing episodes of syncope. Differential Diagnosis The two differential diagnoses to be used in Lily’s syncope episode are performing an electrocardiogram (ECG) and a thorough examination of medical history. As a matter of fact, an electrocardiogram (ECD) turns be the medical test which discovers cardiac (heart) anomalies through measuring the electrical bustle caused by the heart when it contracts (Farwell & Sulke, 2015). The ECG is capable of diagnosing various conditions comprising of heart enlargement, heart arrhythmias, coronary heart ailment and heart inflammation (myocarditis or pericarditis). An ECG is recommended if the patient is undergoing symptoms like dizziness, breath shortness, irregular or fast heartbeats (palpitations), or fainting. There are three main kinds of ECGs that can be performed. First is the resting ECG, where a patient lies on a table or bed. Places on the patient’s chest, legs and arms where minute metal discs or electrodes would be put turn to be cleaned and might be shaved for the purposes of offering a smooth, clean surface for appending the electrode disc (Brignole, 2007). An extraordinary ECG paste or minute pads that turn to be soaked within alcohol are put between the electrodes and the patient’s skin for the purposes of improving electrical impulses conduction, but within several scenarios disposable electrodes turn to be utilised which requires no alcohol or paste. Then, multiple electrodes are appended to the skin on every leg, arm and on the patient’s chest. The electrodes are then hooked to the machine which maps out the patients’ activities of the heart on the paper. The moment an aged machine is utilised, the electrodes might be at various times the time of testing for the purposes of measuring the patient’s electrical activities of the heart from various positions on the heart of the patient. This is the type of ECG that is applied to Lily in order to diagnose the actual kind of syncope she is having. This is because Lily is an old woman and would be advisable to perform an ECG while she is resting. The other kind is the Ambulatory ECG. The Holter or ambulatory turns to be carried out utilising a transportable recording machine which is worn for a minimum of twenty four hours (Farwell & Sulke, 2015). In this ECG, the patient possesses the freedom of moving around commonly when the monitor turns to be appended. That kind of ECG turns to be utilised for patients whose signs turn to be irregular and might surface the moment of a relaxing ECG. In point of fact, people who are recuperating from heart attack turn to be observed in that way for the purposes of ensuring functioning of the heart (Shah & Ludwig, 2013, p. 225). The patient normally records signs within a diary, recording the time in order for their personal experience to be contrasted with that of ECG. The other kind of ECG is the cardiac stress test. This test turns to be utilised in recording an ECG of a patient while the sick person is riding on an exercise bicycle or walking on the treadmill. Normally, that kind of ECG’s duration turns to be 15-30 minutes to accomplish. After ECG procedure, there is the wiping off of the electrode paste. As a matter of fact, an ECG turns to be completely non-invasive or painless since the skin turn not to be penetrated. The doctor is capable of interpreting the patient’s ECG results straight away grounded on his/her medical history, clinical examination and symptoms. Paramedic Interventions After conducting an ECG, there was potential diagnosis of arrhythmias. As a matter of fact, noticeable symptoms of arrhythmia comprise of chest pain, dizziness, fainting (syncope) or close to fainting, light-headedness, a fast heartbeat (tachycardia), breath shortness, a slow heartbeat (bradycardia), and a trembling in one’s chest (Grace, 2008). Some of those signs can also be confirmed in Lily’s medical history like, chest pain, and tachycardia among others which gives a further proof of arrhythmia presence. In point of fact, the arrhythmia treatments are dependent on the types, symptoms and arrhythmia’s risk of the prognosis of the patient. Those treatments comprise of medications, lifestyle changes, ablation, catheter-grounded process defibrillator or pacemaker implantation, and surgical treatment. Interestingly, a number of arrhythmias do not need treatment. It is also possible to cure arrhythmias utilising medicines. The moment another problem turns to be bringing about arrhythmia, treatment turn to be intended to caring of that particular problem. The first way of treating arrhythmia turns to be medicines. In this case, medicines slow down a heart which is beating very fast (Brignole, 2012). In addition, medicines are also capable of altering an abnormal rhythm of the heart to normal constant rhythm. In fact, medicines which do that are referred as antiarrhythmics. A number of medicines utilised in slowing down a rapid rate of the heart turn to be beta blockers (like, atenolol and metoprol), channel blockers of calcium (like, verapamil and diltiazem), and digitalis (digoxin). Those medicines are normally utilised in treating atrial fibrillation (AF). A number of those medicines utilised in restoring a normal rhythm of the heart are quinidine, flecainide, amiodarone, propafenone, sotalol, ibutilide, disopyramide, and procainamide. More often than not, those medicines possess side effects. In point of fact, it has been proven that a number of side effects are capable of worsening an arrhythmia or even generate a different type of arrhythmia (Luscher, et al., 2009). Presently, no medicine is reliably capable of speeding up a heart rate that is slow. As a matter of fact, abnormally heart rates that are slow turn to be treated using pacemakers. A pacemaker turns to be a device which sends minute electrical impulses to muscles of the heart for the purposes of maintaining an appropriate heart rate. Primarily, pacemakers thwart the heart from pounding very slowly (Humes, 2011, p. 334). In this case, the pacemaker possesses a pulse generator (that houses the tiny computer and the battery) and directs (wires) which transmit impulses from a pulse generator to the muscle of the heart. In fact, newer pacemakers possess several sophisticated elements which are engineered to assist in coping arrhythmias as well as optimizing heart pace-associated function to the best extent. People who possess AF together with other arrhythmias might be treated using blood-thinning drugs. Those medicines lessen the forming of the blood clots risk. The examples of blood-thinning drugs are aspirin, dabigatran, warfarin and heparin. The moment medicines fail to work, a process referred as catheter ablation turn to be utilised in treating a number of arrhythmias (Camm, 2012). During that process, a thin, elastic tube turns to be inserted in a blood vessel within a patient’s groin, or arm, or neck. After that, the tube turns to be guided to the patient’s heart. An exceptional machine conveys energy via the tube to the patient’s heart. The energy discovers and damages small parts of tissues of the heart where anomalous rhythms of the heart might begin. Catheter ablation normally turns to be done within a hospital being portion of a study of electrophysiology. The doctor might propose transesophageal echocardiography a head of catheter ablation for the purposes of ensuring no presence of blood clot within the atria (the upper chambers of the heart). Since Lily’s case diagnoses possesses potential of cardiac arrhythmia as the primary cause of the syncope, therefore permanent pacemaker implantation or internal cardioverter defibrillator would be carried out on her (Benditt, 2006, p. 98). As a matter of fact, permanent pacemakers are inserted for the purposes of offering dependable heartbeats the moment the own rhythms of the hearts are very slow (Strickberger, 2006). On the other hand, interior defibrillator/cardioverters placed in patients turn to be in danger of serious ventricular arrhythmias. In point of fact, the process of inserting either defibrillators or pacemakers turn to be very alike. The procedure normally takes roughly 3 - 4 hours from beginning to finish. In the case of Lily, a small incision turns to be made within the chest beneath the clavicle and to admittance one of the bigger veins within the body’s upper part. Afterwards, one or more wires turn to be moved on in the heart (Grace, 2008). The moment the wires get placed within suitable places within the heart, they turn to be attached to the generator and the pocket turn to be created underneath the skin and, lastly the generator turn to put there. In this procedure of defibrillator implantation, Lily would remain within the hospital overnight and would go back home the following day. Lily would go back to entire unlimited activity in a month, and would resume total activity in a few days. The other way of treating arrhythmias is through surgery. One kind of surgery for atria fibrillation turns to be known as maze surgery. During that surgery, the surgeon makes minute burns or cuts within the atria. Those burns or cuts avert the distribution of unsystematic electrical signs. The moment coronary heart ailment turns to be a patient’s arrhythmia cause; the doctor might commend coronary artery bypass implanting. That surgery advances flow of blood to the muscle of the heart. As a matter of fact, arrhythmia can also be treated using changes in lifestyles that are arrhythmia risk features (Strickberger, 2006). First, individuals who smoke need to cease smoking. The other lifestyle change is limiting one’s drinking of alcohol. The other change in lifestyle is ceasing or stopping consuming caffeine. In this scenario, a number of people turn to be perceptive to caffeine and might notice additional signs the moment of utilising products that are caffeinated (like, colas, coffee, tea and a number of over-the-counter prescriptions). The other lifestyle change is avoidance of stimulants’ ingestion. In this case, individuals should familiarise themselves with stimulants utilised in cold and cough prescriptions and nutritional or herbal supplements (Benditt, 2007, p. 145-46). A number of such prescriptions comprise of ingredients which prop up abnormal rhythms of the heart. The other treatment of arrhythmia is the electrical cardioversion. In fact, patients having relentless arrhythmias (like atrial fibrillation); a usual rhythm might not be attained with the therapy of drug alone. Therefore, electrical cardioversion turn to be performed (Dains, Baumann & Scheibel, 2007, p. 234). In this scenario, subsequent to short-acting anaesthesia administration, an electrical shock turns to be delivered to the patient’s chest wall which harmonizes the heart and permits the restarting of the ordinary rhythm. Implantable Cardioverter Defibrillators Management After operation of implantable cardioverter defibrillators has been accomplished, a patient is safe to have a shower or bath after the first three to four days (Hall & Todd, 2006). Secondly, the patient should keep his/her arm upon similar side like defibrillator beneath the level of the shoulder, till the initial check-up of the ICD (little chance exists that the leads are capable of moving). The other thing that the patient ought to ensure is doing shoulder and arm exercises for the purposes of keeping the arm moving. The other thing a patient should do after recovery (four to six weeks); the patient ought to increase the activity levels if doable. Importantly, a patient might have some admonition that his ICD turn to be about to transmit a shock (feeling dizzy or palpitations). Then, the patient ought to recuperate very fast. In addition, after the initial shock, it is imperative to get in touch with the plant centre for the purposes of having the device examined. In fact, it does not turn to be essential to have the ICD examined subsequent to each shock unless one feels sick (Hall & Todd, 2006). In case, the device offers multiple shocks, it is important to call 999 for an ambulance for the purposes of having the ICD checked in order to know the reason of the shocks. On the other hand, it is imperative to maintain one’s card with someone always (settings, model and make of the device). During sexual activities, the device would not bring about whichever harm, even if the shock turns to be delivered to a patient when having sex. In fact, a patient can utilise electrical equipment (like drills) safely. In addition to this, electromagnetic intrusion (microwaves, computers, cookers, fridges and radios) causes no effect to one’s ICD. On the other side, during travelling, the ICD might start out the security alarm of airport. However, a patient’s ICD turn to be never harmed provided a patient walk quickly through the arch (Hall & Todd, 2006). Several ICDs go with a list of insurance companies that are ICD-friendly. Importantly, patients should avoid arc welding. In addition, patients should keep their handsets 6 inches far from the ICD (it is advisable for the phone to be held above than the ear upon the device’s opposite side) (Khan, 2015, p. 111-120). Importantly, grave undesirable events as a result of ICDs turn to be infrequently reported. However, there are a number of recorded complications as described in this paper. The first complication is unsuitable discharge of ICD. The second complication is infection. The other complication is bleeding and haematomas. The other complication is leads that might migrate or dislodge. The other complications are cardiac perforation, pneumothorax and effusion and malfunction/dysfunction Conclusion We have discussed about syncope; its causes, differential diagnosis, paramedic interventions and implantable cardioverter defibrillators management with detailed explanation of each of them. We have identified potential diagnoses such as arrhythmias. As a matter of fact, noticeable symptoms of arrhythmia comprise of chest pain, dizziness, fainting (syncope) or close to fainting, light-headedness, a fast heartbeat (tachycardia), breath shortness, a slow heartbeat (bradycardia), and a trembling in one’s chest. In point of fact, the arrhythmia treatments are dependent on the types, symptoms and arrhythmia’s risk of the prognosis of the patient. Those treatments comprise of medications, lifestyle changes, ablation, catheter-grounded process defibrillator or pacemaker implantation, and surgical treatment. It is also possible to cure arrhythmias utilising medicines. Since Lily’s case diagnoses possesses potential of cardiac arrhythmia as the primary cause of the syncope, therefore permanent pacemaker implantation or internal cardioverter defibrillator was to be carried out on her. Management of implantable cardioverter defibrillators turn to be simple rules that a patient ought to follow. References Benditt, D. (2006). Evaluation and treatment of syncope. Oxford, Blackwell Pub. BRIGNOLE, M., & BENDITT, D. G. (2011). Syncope: an evidence-based approach. London, Springer. Benditt, D. G. (2007). Syncope and transient loss of consciousness multidisciplinary management. Malden, Mass, Blackwell Futura. Brignole, M. (2007). Diagnosis and Treatment of Syncope. Heart. 93(1).130-136. Camm, J, A. (2012). Accuracy of the ICD-10 Discharge Diagnosis for Syncope. Oxford Journals. 15(4). 595-600. Dains, J. E., Baumann, L. C., & Scheibel, P. (2007). Advanced health assessment and clinical diagnosis in primary care. St. Louis, Mo, Elsevier Mosby. Farwell, D & Sulke, N. (2015). How do we Diagnose Syncope? Journal of Cardiovascular Electrophysiology. 13(1). DOI: 10.1111/j.1540-8167.2002.tb01946.x Grace, A. (2008). Management of Cardiac Arrhythmia. Journal Article, Review. 8(2). 175-176. Grubb, B. P., & Olshansky, B. (2007). Syncope mechanisms and management. Hoboken, NJ, John Wiley & Sons. Hall, M, C, S, & Todd, D, M. (2006). Modern Management of Arrhythmias. Postgraduate Medical Journal. 82(964). 117-125. Humes, H. D. (2011). Kelley's essentials of internal medicine. Philadelphia, Lippincott Williams & Wilkins. Khan, M. I. G. (2015). Heart disease diagnosis and therapy a practical approach. Totowa, N.J., Humana Press. Luscher, F, T et al. (2009). Guidelines for the Diagnosis and Management of Syncope. European Heart Journal. 30(21). 2631-2671. Shah, S., & Ludwig, S. (2013). Difficult diagnoses for common complaints: a pediatric casebook. Philadelphia, Pa, Lippincott Williams & Wilkins. Strickberger, S, A., et al. (2006). AHA/ACCF Scientific Statement on the Evaluation of Syncope. Journal of the American College of Cardiology. 47(2). doi:10.1016/j.jacc.2005.12.019 Read More