When to Investigate Transient Loss of Consciousness: A Guide for Clinicians

Transient loss of consciousness (LOC) can be a concerning symptom for patients and clinicians alike. However, not all cases require extensive investigation. According to the National Institute for Health and Care Excellence (NICE) guidelines, patients presenting with a transient LOC should undergo a thorough history, examination, and electrocardiogram (ECG). If these are normal and the patient meets certain criteria, further work-up may not be necessary.

For example, uncomplicated vasovagal syncope can be diagnosed if there are no features suggesting an alternative diagnosis and if the patient experiences the 3 Ps of posture-prolonged standing, provoking factors, and prodromal symptoms. Doppler ultrasonography of the carotids would only be indicated if there was suspicion of carotid artery stenosis, while a single syncopal episode is not an indication for a computed tomography (CT) scan of the brain.

Electroencephalogram (EEG) may be considered if the history is suggestive of epilepsy, but it should not be routinely used in the work-up for transient LOC. Features strongly suggestive of epilepsy include a bitten tongue, head turning to one side during transient LOC, no memory of abnormal behavior witnessed by someone else, unusual posturing, prolonged limb jerking, confusion following the event, and prodromal déjà vu or jamais vu. If any of these are present, the patient should be reviewed by a specialist within 2 weeks, who would then make a decision regarding EEG.

In summary, a thorough evaluation is necessary for all patients presenting with a transient LOC. However, if the patient meets certain criteria and there are no features suggesting an alternative diagnosis, further investigation may not be required.

The patient’s symptoms suggest a headache caused by increased pressure within the skull, which is often associated with a space-occupying lesion such as a brain tumor. This type of headache is typically worse in the morning and aggravated by bending forward, coughing, or sneezing. As the tumor grows, other symptoms such as vomiting, seizures, and neurological deficits may develop. Brain tumors can be primary or metastatic, with the most common types being astrocytoma, glioblastoma, oligodendroglioma, ependymoma, meningioma, and primary CNS lymphoma.

The patient’s history does not support a diagnosis of giant cell arteritis, which typically affects individuals over 50 years old and presents with an abrupt-onset headache, scalp tenderness, jaw pain, visual disturbances, and constitutional symptoms such as fever and weight loss. The diagnosis of GCA requires specific criteria, including age at onset, new headache, temporal artery abnormality, elevated erythrocyte sedimentation rate, and abnormal artery biopsy.

The patient’s symptoms are also not consistent with cluster headaches, which typically affect younger males and present with severe, unilateral pain around the eye, accompanied by lacrimation and nasal congestion. Cluster headaches have a circadian pattern and occur in episodes, followed by symptom-free periods.

Migraine is another type of headache that is not likely in this case, as the patient’s symptoms do not fit the typical pattern of unilateral, pulsating pain lasting 4-72 hours, accompanied by nausea/vomiting and photophobia.

Finally, subarachnoid hemorrhage is a medical emergency that presents with a sudden, severe headache, often described as the worst headache of one’s life, along with other symptoms such as vomiting, loss of consciousness, seizures, and neurological deficits. However, the patient’s headache has been progressing over weeks, which is not consistent with SAH.

Antiphospholipid syndrome is the most probable diagnosis due to the paradoxical occurrence of prolonged APTT and low platelets.

Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thromboses, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.

Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.

The sudden painless loss of vision and severe retinal haemorrhages observed on fundoscopy in this patient are indicative of central retinal vein occlusion. Amaurosis fugax, which is caused by atheroembolism from the carotid arteries, results in temporary vision loss that resolves within a few minutes. In contrast, this patient’s vision loss is persistent. While central retinal artery occlusion also causes acute painless vision loss, it is characterized by a loss of relative afferent pupillary defect, a cherry-red macula, and a white/pale retina on fundoscopy. Hypertensive retinopathy may cause flame-shaped haemorrhages and cotton wool spots on the retina, but it does not result in sudden vision loss.

Understanding Central Retinal Vein Occlusion

Central retinal vein occlusion (CRVO) is a possible cause of sudden, painless loss of vision. It is more common in older individuals and those with hypertension, cardiovascular disease, glaucoma, or polycythemia. The condition is characterized by a sudden reduction or loss of visual acuity, usually affecting only one eye. Fundoscopy reveals widespread hyperemia and severe retinal hemorrhages, which are often described as a stormy sunset.

Branch retinal vein occlusion (BRVO) is a similar condition that affects a smaller area of the fundus. It occurs when a vein in the distal retinal venous system is blocked, usually at arteriovenous crossings.

Most patients with CRVO are managed conservatively, but treatment may be necessary in some cases. For instance, intravitreal anti-vascular endothelial growth factor (VEGF) agents may be used to manage macular edema, while laser photocoagulation may be necessary to treat retinal neovascularization.

Overall, understanding the risk factors, features, and management options for CRVO is essential for prompt diagnosis and appropriate treatment. Proper management can help prevent further vision loss and improve the patient’s quality of life.

If a pregnant woman is exposed to chickenpox before 20 weeks and has a negative IgG test, it indicates that she is not immune to the virus or has not been previously exposed to it. In such cases, it is recommended to administer varicella-zoster immunoglobulin (VZIG) as soon as possible, which can be effective up to 10 days after exposure. It is not necessary to inform public health as chickenpox is not a notifiable disease.

If a pregnant woman develops a chickenpox rash, VZIG has no therapeutic benefit and should not be used. However, antiviral agents like aciclovir can be given within 24 hours of the rash onset. It is important to note that antiviral agents are recommended for post-exposure prophylaxis for immunosuppressed individuals.

Women who are not immune to varicella-zoster can receive the vaccine before pregnancy or after delivery, but it should not be administered during pregnancy. Therefore, option D cannot be correct in any situation.

Chickenpox exposure in pregnancy can pose risks to both the mother and fetus, including fetal varicella syndrome. Post-exposure prophylaxis (PEP) with varicella-zoster immunoglobulin (VZIG) or antivirals should be given to non-immune pregnant women, with timing dependent on gestational age. If a pregnant woman develops chickenpox, specialist advice should be sought and oral aciclovir may be given if she is ≥ 20 weeks and presents within 24 hours of onset of the rash.

Differential Diagnosis of a Woman with Acne and Infertility

Polycystic ovarian syndrome (PCOS), endogenous Cushing’s syndrome, Addison’s disease, congenital adrenal hyperplasia (CAH), and primary hypoparathyroidism are all potential differential diagnoses for a woman presenting with acne and infertility. PCOS is the most likely diagnosis, as it presents with menstrual dysfunction, anovulation, and signs of hyperandrogenism, including excess terminal body hair in a male distribution pattern, acne, and male-pattern hair loss. Endogenous Cushing’s syndrome and primary hypoparathyroidism are less likely, as they do not present with acne and infertility. Addison’s disease is characterized by hyperpigmentation, weakness, fatigue, poor appetite, and weight loss, while CAH may present with oligomenorrhoea, hirsutism, and/or infertility.

This question assesses the candidate’s understanding of TIA risk stratification. The individual meets the criteria for crescendo TIAs, having experienced two TIAs within a week. This necessitates prompt evaluation and imaging. Admission is recommended for any patient with a score of more than 4 on the ABCD2 scale or crescendo TIA.

A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).

NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.

Understanding MRSA and Screening for Infection

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that can cause serious infections and is particularly dangerous in hospital settings. To prevent the spread of MRSA, certain patients should be screened for the infection, including those awaiting elective admissions and all emergency admissions starting in 2011. Screening involves taking a nasal swab and checking for skin lesions or wounds. If a patient is found to be a carrier of MRSA, treatment involves using antibiotics such as vancomycin, teicoplanin, or linezolid. However, some strains may develop resistance to these antibiotics, so newer options like linezolid, quinupristin/dalfopristin combinations, and tigecycline should be reserved for resistant cases. It is important to suppress MRSA from carriers to prevent the spread of infection. This can be done through the use of mupirocin and chlorhexidine gluconate. By understanding MRSA and screening for infection, healthcare providers can take steps to prevent the spread of this dangerous bacteria.

Anterior groin pain in active young adults is often caused by femoroacetabular impingement (FAI), which is a common condition that can lead to persistent hip pain. Symptoms include hip/groin pain that worsens with prolonged sitting and is often accompanied by snapping, clicking, or locking of the hip. FAI is typically associated with prior hip pathology, such as Perthes disease in childhood, and is caused by an abnormality in hip anatomy that results in abnormal contact between the femur and acetabulum rim. Over time, this can cause soft tissue damage, including labral tears. Snapping hip syndrome, on the other hand, is characterized by a snapping or clunking sound as tendons move over the hip bones during flexion and extension. This condition is usually painless unless there is an associated labral tear. Stress fractures, in contrast, typically improve with rest rather than worsening. Osteonecrosis of the femoral head is usually associated with other risk factors, such as steroid use, alcohol consumption, or autoimmune conditions. Initially, pain occurs during activity, but it can become constant as the condition progresses.

Causes of Hip Pain in Adults

Hip pain in adults can be caused by a variety of conditions. Osteoarthritis is a common cause, with pain that worsens with exercise and improves with rest. Reduced internal rotation is often the first sign, and risk factors include age, obesity, and previous joint problems. Inflammatory arthritis can also cause hip pain, with pain typically worse in the morning and accompanied by systemic features and raised inflammatory markers. Referred lumbar spine pain may be caused by femoral nerve compression, which can be tested with a positive femoral nerve stretch test. Greater trochanteric pain syndrome, or trochanteric bursitis, is caused by repeated movement of the iliotibial band and is most common in women aged 50-70 years. Meralgia paraesthetica is caused by compression of the lateral cutaneous nerve of the thigh and typically presents as a burning sensation over the antero-lateral aspect of the thigh. Avascular necrosis may have gradual or sudden onset and may follow high dose steroid therapy or previous hip fracture or dislocation. Pubic symphysis dysfunction is common in pregnancy and presents with pain over the pubic symphysis with radiation to the groins and medial aspects of the thighs, often with a waddling gait. Transient idiopathic osteoporosis is an uncommon condition sometimes seen in the third trimester of pregnancy, with groin pain and limited range of movement in the hip, and patients may be unable to weight bear. ESR may be elevated in this condition.

When a patient has normal blood tests except for low thyroid function, which is indicated by low TSH and low free-T4, and presents with symptoms of hypothyroidism, it may be a case of secondary hypothyroidism caused by pituitary failure. This is a rare condition that requires imaging of the pituitary gland to rule out any anatomical or vascular causes, such as a tumor.

Understanding the Causes of Hypothyroidism

Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.

In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.