1, diagnostic thinking: first, from the patient's chief complaint, it is repeated palpitation for 7 years, aggravated with dizziness and fatigue 1 day, and syncope twice. This time gives us the impression that the patient is caused by insufficient blood supply to the cardiovascular and cerebrovascular systems. Then after careful analysis, the patient's syncope occurred after defecation. Combined with the patient's medical history, he developed palpitation 7 years ago, which was aggravated after obvious activity, and there was no obvious chest tightness and chest pain. So he went to the hospital to consider the possibility of "coronary heart disease". I was hospitalized in our department 20 days ago because of a marked increase in blood pressure. At that time, ECG showed frequent ventricular premature beats. Cardiogenic can be considered at this time, but TIA cannot be completely ruled out.
2, should improve the examination: patients should improve the electrocardiogram, preferably Hottle, echocardiography, electrolyte exclusion caused by low potassium and magnesium, head CT to exclude cerebrovascular accidents and other corresponding examinations.
3. Possible diagnosis: 1. coronary heart disease
Two: arrhythmia: frequent ventricular premature beats?
Three: Hypertension
Five: Cardiac insufficiency?
Four: TIA?
Novice on the road! Talk about my views and shortcomings, please advise!
1, diagnostic thinking:
1) Identify the causes of syncope: Possible causes of syncope include hypovolemia, arrhythmia, TIA, cerebral ischemia, vasovagal and other carotid artery stenosis.
According to the patient's medical history, firstly, the patient's stool color is dark. Although the patient has a recent history of eating pig blood, Shang Xiao cannot be completely ruled out, so hypovolemic syncope caused by Shang Xiao hemorrhage cannot be ruled out. The second patient had frequent ventricular premature beats more than 20 days ago. At present, the patient still has palpitation discomfort, so arrhythmia leads to syncope (Asperger's syndrome? It cannot be ruled out. If the third patient has TIA and cerebral ischemia, the head CT of the patient has no obvious abnormality, and cerebral ischemia is basically ruled out. TIA may be related to arterial stenosis, so carotid color Doppler and transcranial Doppler are suggested. Vasovagal syncope mostly occurs in young women and is temporarily excluded.
2) The exam should be improved: 1. Routine examination of blood, urine and stool: if there is no abnormality, upper-elimination bleeding is basically ruled out;
2.24-hour dynamic electrocardiogram: the diagnosis of arrhythmia is necessary;
3. Carotid artery color Doppler and transcranial Doppler to exclude arterial stenosis;
Possible diagnosis: 1. According to the patient's medical history, I think the biggest possibility is arrhythmia-frequent ventricular premature beats.
Followed by carotid stenosis and vertebrobasilar insufficiency.
Again: Shang Xiao In addition, in general, patients with hypertension and palpitation should have their myocardial zymogram checked regularly when they are admitted to hospital. After all, his blood pressure has reached 190/ 100mmHg, and has not been systematically controlled by drugs. It is best to rule out myocardial infarction!
Causes of syncope:
1, cardiogenic (arrhythmia): there are risk factors such as old age, male, hypertension, palpitation, etc., and "premature beats" are also found in physical examination.
2, vasovagal syncope: hypertension, palpitation for 7 years, no syncope before. These two syncope occurred recently. When urinating and defecating at night, there may be poor blood pressure control or postural hypotension, or vagus nerve excitement. Further examination: 1, 24-hour dynamic electrocardiogram; 2, heart color ultrasound; 3. Coronary angiography when necessary.
1, patient, male, 63 years old;
2, palpitation for 7 years, aggravated with dizziness and fatigue, 1 day syncope twice (the chief complaint is not standardized)
The patient had no obvious cause of palpitation 7 years ago, and the symptoms were repeated after obvious activity. Suddenly dizzy and weak the day before, I fainted twice in the toilet at night. I fainted when I urinated for the first time, defecated again with the help of my family about an hour later, fainted again after the solution, and woke up about two minutes later. (Syncope is mainly related to defecation) 3. Past history: history of hypertension 10 years,190/110mmhg; I was hospitalized in our department 20 days ago because of a marked increase in blood pressure. At that time, ECG showed frequent ventricular premature beats, and there was no obvious abnormality in head CT. No history of syncope. 4. Physical examination: P: 98 beats/min, blood pressure: 130/90 mmHg, conscious, heart rate: 98 beats/min, audible premature beats; No pathological reflex was caused. Diagnosis:
1, cause of syncope: micturition syncope?
2, hypertension level 3
3. coronary heart disease? The main symptom now is syncope.
The main task is to find out the cause of syncope; Characteristics of syncope in this patient:
1, elderly male
2. Have a history of hypertension and arrhythmia. Before the onset of syncope, the symptoms of palpitation (ventricular premature beats) were obviously aggravated.
3. Syncope attacks are related to defecation, and syncope attacks after defecation. They attack while standing to urinate and help defecate. There was no convulsion and incontinence during the attack. After lying flat for a few minutes, you can relieve yourself.
4. The blood pressure after syncope attack was 130/90mmHg, which was significantly lower than the previous basic blood pressure.
5. Brain CT is negative. No neurological symptoms. Characteristics of voiding syncope:
1, mostly in healthy men, but it is also more common in elderly men with various diseases.
2. It mostly occurs during urination (defecation) or immediately after urination (defecation).
3, incentives: fatigue, eating less, infection and other mechanisms:
When/after urination, the bladder suddenly depressurizes, the bladder mechanoreceptors are implicated, the vagus nerve is excited, the heart rate is slowed down, and the blood pressure is lowered;
During defecation/after defecation, the intestinal wall clipper is excited, and the vagus nerve is also excited.
Even when swallowing and coughing, the mechanism is similar.
Finally, all relevant tests that may excite vagus nerve need to be improved:
1, dynamic electrocardiogram
2. Experimental treatment of vertical inclined pheasant:
1, control blood pressure
2. Add beta blockers.
Agree with Feng Gan.
I suspect it's voiding syncope.
I have seen several such patients, and I can't find any other reasons for syncope.
1, diagnostic thinking:
First find the cause of syncope, 1, reflex syncope; 2. Cardiogenic syncope; 3, brain-derived syncope, etc. The patient syncope when urinating, so it may be micturition syncope, that is, 1. The patient has a history of palpitation for many years, so cardiogenic syncope may be greater. The patient has a history of hypertension, the systolic blood pressure has reached 190, and TIA is possible.
2, the next diagnosis and inspection:
First, carefully collect the medical history at one time, such as whether there is visual rotation when dizzy. If there is, if the eyes can be closed, the brain source may be big. If it is only dizziness, cardiogenic and reflexive are more likely. Measure the blood pressure of both upper limbs. If the artery steals blood, there will be a gap on both sides.
Examination: 1) Blood routine, urine routine and stool routine, excluding anemia syncope and hypoglycemia syncope. 2) Exercise on the treadmill (excluding inert diseases), the patient has palpitation for 7 years, but there is no chest tightness and chest pain after exercise, so basically coronary heart disease is not considered first. 3) Dynamic electrocardiogram (preferably for 48 hours) mainly excludes the fast-slow syndrome. 4) bedside electrocardiogram, the patient's heart rate is 98 times, and analyze what kind of tachycardia it belongs to, whether there is ventricular premature beat or atrial fibrillation. 5) MRI of the head, excluding lacunar cerebral infarction and other minor lesions, 6)TCD, and B-ultrasound of internal carotid artery and vertebral artery, to see the change of flow velocity, whether there is stenosis or insufficient blood supply, and exclude TIA. 7) Biochemical and double renal artery ultrasound can distinguish primary and secondary hypertension.
Possible diagnosis: 1, atrial fibrillation heart rate, microemboli or TIA caused by other reasons.
2, fast and slow syndrome.
3, arrhythmia, frequent premature beats or common micturition syncope.
4. Chronic anemia.
To analyze the possible causes of syncope.
1. Report 1 Case of pheochromocytoma in bladder with hypertension and syncope during urination. Although the patient has hypertension, there is no other manifestation, so hematuria can be screened with 3 methoxyepinephrine. However, the patient's blood pressure remained high for many years, and there was no similar attack in the past, which was not very similar.
2. Vasovagal syncope. Tilt test can be screened.
Situational syncope, micturition (after micturition): especially when micturition occurs twice.
3. Arrhythmia (I have frequent ventricular premature beats, so I need to pay attention to rapid ventricular arrhythmia and do 24-hour dynamic electrocardiogram examination).
4. Acute myocardial infarction/ischemia: electrocardiogram and troponin quantification.
5. Acute arterial dissection: Hypertension was normal when the patient was admitted to hospital for many years. 6. Pulmonary embolism/pulmonary hypertension.
7. Cerebrovascular diseases: Head CT plain scan: Blood pressure increased significantly 20 days ago, ECG showed frequent ventricular premature beats, and head CT showed no obvious abnormality. Reviewable.
8. Metabolic disorders, including hypoglycemia, hypoxia and hyperventilation with hypocapnia (currently not supported)
9. Orthostatic hypotension
1。 1 case of elderly male, repeated palpitation for 7 years, aggravated dizziness and fatigue, 1 day syncope twice. Have a history of hypertension and frequent ventricular premature beats.
2。 The patient's two syncope occurred when abdominal pressure suddenly dropped. Although I am 63 years old, I still consider vasovagal syncope-micturition syncope first. Then TIA.
3。 But do some tests to rule out some diseases: do dynamic electrocardiogram to rule out serious arrhythmia such as Asperger's syndrome. The patient had hypertension 10 years and was highly suspected of arteriosclerosis. TIA caused by vascular stenosis is not ruled out, and carotid color Doppler and transcranial Doppler are suggested. Check blood biochemistry to understand electrolytes. Check the head CT to see if there is any space occupation.
Just check the main ones. In fact, not every pathogen will agree to do all the tests.
Case characteristics:
1。 Elderly men with long-term illness and acute attack/deterioration.
2。 The main clinical manifestations are palpitation+syncope.
3。 Physical examination found that the heart boundary was not large, arrhythmia and high heart rate.
4。 EKG confirmed frequent ventricular premature beats.
Frequent ventricular premature beats are common in organic heart diseases such as coronary heart disease, cardiomyopathy and rheumatic heart disease, and functional ventricular premature beats are not uncommon. However, considering that the patient is an elderly man with a long-term history of hypertension, combined with other medical histories, it is considered that coronary heart disease is the first cause of palpitation, but organic heart disease caused by other factors (such as hypothyroidism) is not excluded.
Syncope can be caused by vagal nerve tension/vascular decompression factors, cardiogenic factors, posture changes, cerebrovascular diseases and other factors. Patients have syncope attacks in standing position (urination) and squatting position (defecation), and vascular decompression factors are more common in young patients. Combined with the cardiovascular history of the above patients, cardiogenic factors (arrhythmia? ) may cause syncope, and TIA (normal head CT can rule out TIA? )。 In addition, the patient's first syncope was only 1 day, and the two syncope occurred at the same time. Electrolyte disorder, hypoglycemia and drug-induced hypotension cannot be ruled out (the patient has a history of taking nitrendipine).
Therefore, the preliminary diagnosis:
Causes of palpitation: coronary heart disease, sick sinus syndrome?
Hypertension grade 3
Remaining problems:
1。 Asking about medical history: According to the description of the current medical history, there is no evidence of "aggravation" of palpitations-dizziness, fatigue and palpitations before syncope? (If there is "aggravated" palpitation, consider that syncope is related to arrhythmia) When is the specific time of syncope attack? (defecation at night is between dinner time? Did you take any other drugs such as nitrendipine before syncope? (antihypertensive drugs may cause syncope! ) Have a history of sugar-free diabetes?
2。 Check carefully: the values of p and r seem to be reversed. The heart is not big (history of grade 3 hypertension 10 years or more, no target organ damage, and the antihypertensive effect should be good, but why did you stay in hospital for hypertension 20 days ago? Leave a question for the time being)
3。 Improve the auxiliary examination: blood routine, stool routine +OB, electrolyte, electrocardiogram/dynamic electrocardiogram, blood sugar, T3+T4+TSH. CAG and intracardiac electrophysiological examination were performed when necessary.
1. Diagnostic thinking: 1. The patient has repeated palpitations for 7 years, which is aggravated after exercise, indicating that palpitations may be related to excessive catecholamine level during exercise or myocardial ischemia during exercise. 2. The main symptoms this time are dizziness and fatigue, and/kloc-0 syncope twice a day. Dizziness and fatigue indicate that patients may have insufficient brain and skeletal muscle perfusion or hypoxia (anemia). The former may be related to the rapid and severe hypotension at admission, especially the use of calcium antagonists. The latter needs to be checked and confirmed. Syncope occurs twice at night, which is related to defecation and does not match the characteristics of palpitation (related to activity), so the correlation between them is small, but it does not rule out the qualitative change of arrhythmia, so HOLTER is essential; It is more likely to be orthostatic hypotension caused by antihypertensive drugs and/or vagal reflex caused by defecation. The pressure reflex of the elderly is not sensitive. If betaloc is used again, it will inhibit the already dull pressure reflex and cause syncope. 3. The patient has no symptoms and signs of nervous system localization, and syncope is not at the time of getting up, so I think TIA is unlikely. 4. The patient's heart rate increased by 98bpm, accompanied by palpitation and hypertension. I remember a post in the garden that ectopic pheochromocytoma of bladder can lead to voiding syncope, and another post that medullary thyroid carcinoma is prone to pheochromocytoma. If the patient is not poor, consider having a check-up. Who made the medical environment so bad? I would rather kill pheochromocytoma of bladder by mistake, but I think if it is ectopic pheochromocytoma of bladder, there is no reason to have an accident at night, so I have the least possibility.
Second, the examination should be improved: first, the immediate and delayed blood pressure monitoring in supine position; 12 lead electrocardiogram; ; 24-hour blood pressure and ECG monitoring; Blood routine, occult blood in stool (now with high specificity, the influence of eating can be ruled out); Carotid artery (including vertebral artery) and cardiac ultrasound; Chest film. Other inspections will wait until these materials come out!
Third, diagnosis: the cause of syncope is unknown, and the possible causes can be found in the diagnostic thinking.
I think: 1. Cardiogenic possibility is very high. Because of repeated palpitations for seven years, dizziness and fatigue worsened, and/kloc-0 fainted twice a day. Have a history of coronary heart disease for 7 years, and the elderly have hypertension 10 years. Electrocardiogram showed frequent ventricular premature beats 20 days ago. This kind of physical examination occasionally leads to premature beats. Therefore, cardiogenic cerebral blood supply deficiency should be considered, and please pay attention to whether the patient has a history of diabetes, because diabetic patients show painless myocardial infarction when they have myocardial infarction.
2, TIA, according to: the elderly, with a history of hypertension 10 years, may have transient internal carotid artery insufficiency and transient syncope, but generally will not leave sequelae.
3, vasovagal syncope, all related to body position, made the action of standing or squatting, so it should be ruled out, but it can't explain the symptoms such as dizziness, fatigue and inability to stand after waking up.
Therefore, I suggest that patients do the following tests: 24-hour dynamic electrocardiogram, color Doppler echocardiography, transcranial Doppler, tilt test and so on. And then check the liver and kidney function to prepare for medication.
This case is simple, but subtle and interesting. In the end, everyone will understand that the comrades upstairs analyzed it comprehensively, but they did not consider it comprehensively. I almost missed the diagnosis, too I hope more comrades will participate. Hehe, cases with few positive signs are more difficult, not to mention the cause of syncope, which is generally cast a wide net. Now I provide some information for emergency investigation after admission. Head CT: multiple lacunar cerebral infarction in bilateral basal ganglia. Hemogram: white blood cell: 13.2x 109/L, HGB: 1 10g/L, electrolyte normal, renal function: bun: 30.1mmol/l.
Syncope in the elderly should be considered:
1. Pharmacological
2. Erectility
3. Carotid sinus allergy
4. If there are diseases and symptoms of cardiovascular system, CAD, AB, SSS and ventricular arrhythmia should also be considered. As far as this patient is concerned, drug-induced syncope and orthostatic syncope cannot be ruled out, but I prefer cardiovascular diseases, such as coronary heart disease and hypertrophic cardiomyopathy.
The reasons for suspecting coronary heart disease are as follows:
1. Old age
2. Male
3. Many years of hypertension history
4. Repeated palpitation for 7 years, aggravated with dizziness and fatigue, and syncope for 2 times 1 day.
In fact, there are also some patients with coronary heart disease in clinic. They have no obvious symptoms of angina pectoris or chest tightness, but they show symptoms of angina pectoris, such as dyspnea, fatigue, abdominal pain, sweating, arrhythmia and syncope. This patient has many risk factors for coronary heart disease. The electrocardiogram showed frequent ventricular premature beats, and now he fainted when defecating. We know that defecation can cause the increase of myocardial oxygen demand, thus causing myocardial ischemia, angina pectoris or acute myocardial infarction, and syncope may occur when the patient's chest pain is not manifested.
Of course, if coronary atherosclerosis is suspected, there may also be insufficient blood supply to the brain caused by cerebral arteriosclerosis. Hypertrophic cardiomyopathy is suspected because the disease will faint when the body position changes, such as standing up from a squatting position and holding your breath. I once managed a female patient, 52 years old, who had high blood pressure for many years and was flustered after exercise. At first, it was suspected to be coronary heart disease. Later, B-ultrasound and cardiac catheterization confirmed that there was no problem with the coronary artery and it was hypertrophic cardiomyopathy. The patient's high heart rate may be caused by taking CCB drugs, but the possibility of insufficient blood volume (even if the blood pressure is normal) or anemia cannot be ruled out. My diagnosis is:
1. The cause of syncope is unknown: it may be a cardiogenic disease.
2. Hypertension level 3, should do extremely high-risk examination:
1. ECG: To know whether the patient has conduction system diseases and myocardial ischemia, but for angina pectoris, the positive rate of ECG is only about 50%.
2. Echocardiography: Understand the size, wall thickness, valve condition and cardiac function of the heart cavity.
3. Cardiac X-ray can understand the overall shape of the heart.
4. Exercise test is needed, and coronary angiography can be done if necessary.
Of course, three conventions are indispensable. At the moment of posting, the landlord has posted the answer.
According to the information added by the landlord, say more!
The patient suffered from hypertension for many years, and his blood pressure increased significantly 20 days ago. I wonder if I had a headache at that time. We know that abnormal fluctuation of blood pressure can easily lead to cerebrovascular accidents, and the occurrence of cerebrovascular accidents can also lead to abnormal increase of blood pressure. It is speculated that lacunar cerebral infarction may have occurred 20 days ago, but no blind spot in CT examination was found in the early stage. From the new information given by the landlord, we know that the patient's target organs: heart, kidney and brain have been damaged to some extent. It is also necessary to check the fundus to understand the damage of the eyes. Patients with inferior myocardial infarction should be added with right heart lead electrocardiogram to know whether there is right ventricular myocardial infarction. Because there is a certain difference between the treatment of right ventricular myocardial infarction and left ventricular myocardial infarction, and right ventricular myocardial infarction is easy to involve the cardiac conduction system, causing AB and ventricular arrhythmia. If so, then the patient's syncope can be well explained. Right ventricular myocardial infarction will lead to poor circulation function of the right heart-less blood pumped into the lungs-less blood returned to the left heart-which is easy to cause syncope.
1. When the patient has difficulty defecating, the intrathoracic pressure increases and the systemic blood volume decreases, which may lead to a decrease in blood pressure and even melena and syncope;
2. When the patient stands up from the squatting position after defecation, the blood stays in the lower limbs, which also leads to the decrease of cardiac blood volume and syncope;
3. The patient has arrhythmia during defecation, such as Ⅱ AB and paroxysmal ventricular tachycardia, which leads to syncope.
1 case of elderly male patients, repeated palpitations for 7 years, aggravated dizziness and fatigue, 1 day syncope twice. He has a history of hypertension of 10 years. First of all, consider the target organ damage caused by hypertension, palpitation symptoms caused by heart disease, cardiogenic cerebral blood supply insufficiency caused by heart disease, electrocardiogram examination, dynamic electrocardiogram examination and echocardiography examination, and make it clear that cerebrovascular diseases caused by hypertension can cause dizziness and fainting. And it is feasible to have a definite head ct examination. Kidney damage can cause anemia, fatigue and other symptoms. Head CT: multiple lacunar cerebral infarction in bilateral basal ganglia. Hemogram: WBC: 13.2x 109/L, HGB:10g/L, electrolyte is normal, renal function: BUN: 30. 1mmol/L, hemogram comes from myocardial infarction, and urea nitrogen is increased. Inferior myocardial infarction is prone to atrioventricular block, which may be accompanied by palpitation, dizziness and fatigue.
The cause of syncope is a very troublesome thing. In view of this situation
1. The patient had frequent ventricular premature beats in the past, so it was highly suspected that syncope was caused by malignant ventricular arrhythmia. There are many reasons for ventricular premature beats. Patients can see deep Q waves in II, III and aF, at least not recent myocardial infarction. However, the elderly patients have a history of hypertension and ECG manifestations of myocardial infarction, suggesting that coronary heart disease cannot be ruled out. Arrhythmia is a prominent manifestation of angina pectoris in some patients, especially ventricular arrhythmia, and even sudden ventricular death may occur.
2. The patient's blood pressure level was once very high, and there were multiple lacunar cerebral infarction in bilateral basal ganglia on CT, so TIA attack could not be completely ruled out.
3. Syncope caused by abnormal heart structure, including valvular disease and hypertrophic obstructive cardiomyopathy. These diseases usually have typical murmurs, but this patient doesn't, so let's not consider them for the time being. Cardiac ultrasound can be simple and clear.
4. Patients should further consider CAG. If the cause of syncope is still unclear through various tests, electrophysiological examination can be considered because the patient has clues about ventricular arrhythmia.