Case
#32 ‘Just a Syncope Case’
While you are preparing for a trauma code (pedestrian struck by a car), your resident joins you in the resuscitation suite and notes he just saw a 72 y/o syncope patient, no chest pain, no shortness of breath. He explains the patient hadn’t been eating or drinking for a few days, and passed out when he stood up to go to the refrigerator. He notes the vital signs were fine, and he assures you he started the syncope workup.
After the trauma code is stabilized, you return to the syncope patient. (about 25 minutes have passed). He has a working IV, is getting a 500 cc normal saline bolus, and labs have been sent. An EKG is available which shows normal sinus rhythm, without injury or ischemia changes.
Vital signs HR 95, RR=24, BP=152/87, Temp= 97F, Sat=96%
Patient has a history of newly diagnosed colon cancer. He is planning on leaving for the Mayo Clinic tomorrow for a second opinion. His internist recently ordered a CT scan of the abdomen because of the weight loss (20 lbs in 6 months) and chronic back pain. This revealed metastatic cancer, presumed to be colon. He has not had much appetite, and has to force himself to drink or eat. He has not had any new pains, but has had chronic back pain for the past 6 months that he has had treated by a chiropractor. Prior to the fall, he did not have any chest pain, or dyspnea. No history of vomiting, diarrhea or bleeding.
When he got up from the chair to go to the refrigerator, he became dizzy, and passed out. His wife came to his side (she heard the thump), and called 911.
PMH: Recently diagnosed colon cancer, hypertension. He had a myocardial infarction years ago, and has a stent.
Social History: Neg
Meds: Lopressor, aspirin
FH: Noncontributory
PE: Thin male, in no acute distress
HEENT: Normal pupils, he denies any neck pain, and no neck tenderness, normal oropharynx
HEART: RRR, no murmurs, rubs or gallops
Lungs: Equal breath sounds, no abnormalities
Abd: Soft, schaphoid, no AAA
Ext: No edema
Neuro, Alert and oriented, normal cranial nerves, motor grip strength: patient able to slightly wiggle fingers, unable to grasp (2/5). Cannot move shoulders, elbows, or wrist (0/5). Legs: able to lift heels barely off cot, but then, they quickly fall back to the cot. (3/5). Sensation decreased below C-6. Rectal tone present but weak, and sacral sensation is preserved. Patient is areflexic.
Rectal: Guiac negative.
1. What is the name for this neurologic entity and how is it related to syncope?
2. How do you grade muscle strength?
3. What are the 5 criteria for NEXUS and how is the Canadian C-spine rule different? Which is better?
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