Syncope case

General Medicine E-log

A 65 year old female presented to the OPD in unconscious state.

Chief Complaints: 

A 65 year old female, resident of Narketpally was brought to the OPD in an unconscious state.

History of presenting illness:

Patient was apparently asymptomatic 6 days ago when she developed chest pain which was sudden in onset, non progressive and non radiating. She was taken to an RMP, where she was given an injection and tablets after which the pain was relieved.

3 days ago she suffered an episode of loss of consciousness after working in the sun and later standing in a line for long. It was associated with cold and clammy palms and soles, profuse sweating. 

It was not associated with blurring of vision, dizziness, dry skin, shortness of breath, increased heart rate, chest pain, headache, vomiting, deviated mouth or slurred speech.

She was brought to the hospital and she regained consciousness after receiving IV fluids.

Past history:

HTN, diagnosed 1 week ago

N/K/C/O DM, TB, asthma, epilepsy, CAD or CVA

Personal history:

Diet: mixed

Appetite: reduced 

Sleep: reduced since 3 days

Bowel and bladder movements: regular 

Addictions: Drinks alcohol occasionally

Smokes 3-4 beedis/ day since the past 45-50 years.

No known allergies.

Family history:

Not significant

General Examination:

Patient is conscious, coherent and cooperative

Pitting type of pedal edema is seen.

No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy.

Vitals:

RR: 12cpm

PR: 70 bpm

BP: 120/80 mmHg

Temperature: afebrile

Systemic Examination:

CNS:

Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact bilaterally 
Reflexes: present 

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
Position of Trachea: central
BAE: present
NVBS heard
No added sounds were heard

Per Abdomen:
Soft, non tender, truncal obesity seen

 No organomegaly present
Hernial orifices are normal
No palpable masses

Bowel sounds were heard

Provisional diagnosis: Syncope and dehydration 

Investigations:

                                       ECG