Traction Alopecia

Traction Alopecia means hair loss (alopecia) due to pulling on the hair (traction).  It’s caused by a variety of hair styles which require traction.  It’s much more common in women than men, and in adults than children, simply because it’s adult women who tend to style their hair as such.

The first sign, usually before actual hair loss, may be red, inflamed hair follicles, the tiny pores from which hair grows.  This is sometimes referred to as “scalp pimples,” which they really aren’t.  It could be confused with the skin infection Folliculitis, which wouldn’t have a pattern to the locations.  Other skin diseases involve all the scalp in an area, not just the individual hair follicles.

Pony tails, buns, braids, weaves, and dreadlocks are some common causes.  Hair extenders, which attach to braids, can also be responsible (see bottom picture below).  Another common sign may be thin hairs growing at the margins of hair loss patches.

Treatment is obvious, namely leaving the hair to hang loose, avoiding any hair styles which require yanking.  This may feel harsh by those attached to their hair styles, but it’s the only solution.  It’s also important to avoid chemicals and heat devices (e.g. curling irons) which can make hairs more vulnerable.  Hopefully the scalp won’t be permanently damaged.  Certain injected or applied medications might help, but won’t really be able to overcome the effect of traction.

Prevention is important.  Any hair styling which causes pain, redness, or hair loss should be stopped immediately.  For those who require traction hair styles, they should be used only for short periods, then taken down as soon as possible.

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Alopecia Areata

Alopecia Areata is an autoimmune disease.  It usually occurs alone, by itself, but may be a manifestation of Lupus (SLE).  It presents as one or more patches of complete baldness surrounded by normal hair (pictures below).  If we look carefully we might see some “exclamation point hairs,” for which the shaft near the skin is narrower than the growing tip.  These can pluck out easily, confirming the diagnosis. Sometimes there are also fingernail and toenail changes.

To rule out SLE, we inquire about other possible SLE symptoms, and order blood tests for Antinuclear Antibodies (ANA).  We also order a Rapid Plasma Reagin (RPR) blood test, for Syphilis, which can also cause similar type of hair loss. The problem, however, is that a positive RPR might mean patchy hair loss due to 2° Syphilis, but might be a false-positive, which commonly occurs with SLE. 

A “confirmatory test” is done routinely with the RPR to distinguish between Syphilis and a false-positive.  However, if a person ever had syphilis treated in the past, the “confirmatory” will remain positive forever from that one episode.  False-positives RPR values (titers) are usually low (≤1:8); with 2° Syphilis they’re usually lots higher, but it could be hard to distinguish (see link for stages of Syphilis). Other causes of a false-positive RPR include HIV, pregnancy, and other autoimmune diseases.

We treat Alopecia Areata by injecting the area with steroids.  If it’s due to SLE (suspect if a very high ANA), we’d want a Rheumatologist to manage full treatment.  Focal hair loss can rarely advance to Alopecia Totalis (complete baldness), or more rarely even Alopecia Universalis (loss of all body hair).

Alopecia Areata

aafp.org   …                                                                                                 …dermatology.org

Telogen Effluvium

This is the most common cause of hair loss.  It may involve from 5% to 15% of hairs.  Upon close examination, the patient’s overall hair appears to be thinning.  Casual observers are rarely aware, because about half of ones hairs need to be lost to be noticeable.  But patients themselves see large quantities of hair falling when they comb or brush, & are scared to death.

The normal activity of each hair follicle progresses through 2 main phases:

  • Anagen: Hair strand grows continuously for 3-6 years (~90% of hairs)
  • Telogen: Resting phase lasting 1-6 months (~10% of hairs)

The hair is shed at the end of Telogen, and Anagen resumes with a new strand.  At birth, follicles gradually begin their activity, cycles are not synchronized, so Telogen hairs don’t all fall out together.  However, various physical or psychological stressors can cause many follicles to suddenly enter Telogen all at once.

Such triggers can include significant illness, surgery, injury, after childbirth, sudden weight loss, starting or stopping certain medications (in particular birth control or acne pills), and major psychological trauma.  I’ve had two friends experienced this upon leaving home.  New medications may be another possibility; there’s no good data, but those implicated have included beta-blockers, anticoagulants, retinoids, propylthiouracil, carbamazepine, and immunizations.

Telogen Effluvium occurs 3 to 6 months after its trigger.  It usually resolves within 6-12 months.  A chronic form of the condition can persist longer, with ongoing diffuse hair thinning, but not total baldness.  This is much less common.

Our diagnosis is made clinically (without tests): Diffuse, non-focal hair loss without any evidence of scalp disease.  It’s nice if we can identify a trigger event.  Dermatologists have a variety of diagnostic tricks involving pulling out hairs, but I don’t refer patients.  I might order blood tests such as a thyroid test (TSH), a complete blood count (CBC), ferritin level (for iron-deficiency), and a Vitamin D level.  I’d rule out other possibilities by history.

Even if I can’t pinpoint the trigger, I reassure patients that:

  1. Most people aren’t able to notice;
  2. Nobody becomes totally bald; and
  3. Hair will begin to grow back normally within 6 months.  If not, I send to Dermatology [have never had to].
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Syphilis — Pictures

The following are pictures of some common manifestations of the first two stages of Syphilis:

  • Primary:  begins 2-10 weeks after becoming infected, lasts 4-8 weeks
  • Secondary: begins 2-4 months after becoming infected, lasts 1-2 years

See also Syphilis, and Syphilis Blood Tests

Primary Syphilis

The Chancre: a painless ulcer with heaped-up edge at point of infection (depending on how someone has sex)

Chancre on Penis

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sdc.urologicpyside.pw……………………….smile.stomatology.biz……………………………………………………………………davidson.edu

Secondary Syphilis

Hair Loss: Patchy, without complete baldness in each patch

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Mucus Patches: Shallow non-tender erosions

Condylomata Lata: Moist gray / whitish plaques

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Body Rash: Reddish spots, usually also on palms / soles

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Leg Cramps

Sudden cramps in a calf at night are very common, and may occur in almost half of all adults.  They’re more common with older age, and also occur in children.  They last seconds to minutes.  The best treatment is to stretch the knee straight, and stretch the foot upwards and back (“dorsiflex”).  This may require getting out of bed, and leaning against a wall.

In most cases, nobody knows what causes cramps.  They may occur more Parkinson’s and other neurologic diseases, joint abnormalities such as flat feet or knees which bend backwards, pregnancy, and perhaps certain medications.  If a new medicine was begun recently before the cramps began, it may be worth discontinuing it, if possible, to see what happens, and then trying it again (when any symptom abates with stopping a medication, and recurs with restarting, such rechallenge provides decent evidence as to the cause).

Even though nighttime leg cramps may occur during the progression of other more serious conditions, in such cases, there are always other symptoms which predominate.  There’s no need to order any special tests when cramps are the only symptom.  In pregnancy it may be worth checking the blood level of magnesium, and testing for sodium and potassium in patients taking diuretics (“water pills” for blood pressure).  We might test iron levels for “restless leg syndrome,” but that involves an inability to lie with legs still, but does not include muscle pains.

Unfortunately, there’s no proven treatment to prevent muscle cramps.  Many suggestions include exercise, staying well-hydrated, stretching before bedtime, avoiding alcohol and caffeine, taking a variety of vitamins / supplements, and more.  None have been proved to work.  Medical providers might try a couple of possibilities, none of which have strong evidence in their favor. 

There was indeed one over-the-counter drug, quinine, which had proven benefit; sufferers swore by it.  The problem was that up to one in 25 people experienced certain heart arrhythmias or other possibly life-threatening side effects.  So the FDA has banned over-the-counter quinine, and no provider would risk getting sued for a death from their prescription.

“Just a Virus”

Clinicians often tell patients that the cause of their symptoms is “just a virus.” For example, there are all sorts of viruses that can make a patient suddenly feel fatigued, or simply not well. Maybe there’s a low-grade fever; more commonly, the person feels like they have a fever, but the temperature is normal (that’s always disappointing to me, personally, because then I can’t take off work). Maybe they have cold symptoms, maybe upset stomach and/or diarrhea, but maybe not. Such viruses get better on their own, sometimes in 1-2 days, always within a week.

We never identify which exact virus is responsible, because there are so many possibilities, and clinically, it doesn’t matter. They’ll get better; antibiotics don’t work at all. Of course, there are many specific viruses, some of which can do bad things, such as Herpes, HIV, Covid-19, Rabies, different Hepatitides (plural of Hepatitis), Ebola, and more. This is never what we mean when we say “just a Virus.”

See also Differences Among Germs; also Common Cold, Gastroenteritis (for diarrhea), and our diagnostic approach to a person with Fatigue.

Bulimia

Bulimia is a condition in which a person uncontrollably binge eats an enormous amount of food.  They feel guilty and ashamed, often make themselves vomit, and may try to exercise hard & diet to extremes until it all happens again (at least weekly, usually more often).  Patients express an abnormal concern about weight and body image.  Half the time, Bulimia begins by age 18; it’s six times more common in women than men.

It’s unknown exactly why it occurs.  There’s possibly a genetic component, but patients often have a history of childhood trauma, such as abuse or separation.  Most patients have other mental health conditions such as Depression, Anxiety, or Post-Traumatic Stress Disorder (a form of anxiety).  Alcohol problems, smoking, and drug use are common.  Some may intentionally cut or pick at themselves, or attempt suicide.

As opposed to Anorexia Nervosa, patients with Bulimia are normal weight or overweight.  Diagnosis is made by questionnaires, asking things like:

  • Do you ever make yourself so full as to feel sick?
  • Have you lost control over your eating?
  • Does food dominate your life?
  • Are you unhappy with the way you eat?
  • Do you ever eat in secret?

Patients may conceal their feelings and behaviors, especially when it comes to making themselves vomit.  Sometimes we may notice calluses or skin changes on the knuckles (from stomach acid).  Friends and family may report that the patient often “goes to the bathroom” immediately after eating. Some patients exercise compulsively, even if they’ve injured themselves.

Treatment primarily involves psychotherapy, dealing with the root causes of their emotional stress.  Many patients eventually recover, although up to 25% my relapse again.

Lymphoma

Lymphoma is essentially a cancer of Lymphocytes, a type of White Blood Cell (WBC)Leukemia is also a cancer of WBCs, sometimes involving lymphocytes, which begins while the cells are still immature, newly made in the bone marrow.  Lymphomas usually begin once cells have matured and left the marrow.

Since lots of lymphocytes reside in our lymph nodes, that’s where Lymphomas commonly arise.  There are many types and sub-types of Lymphoma, depending on the type of lymphocyte, and determined by a variety of features on biopsy.  The broadest classification of  Lymphomas are:

  • Hodgkin’s Lymphoma (HL)  (previously called Hodgkin’s Disease)
  • Non-Hodgkin’s Lymphoma (NHL)

Both can involve a single main lymph node, or many (more common with NHL).  Both can involve other organs (brain, stomach, skin, etc.), again more common with NHL.  And both can be either aggressive; spreading and killing rapidly (especially NHL), or indolent (cause symptoms for quite a while before becoming aggressive).

Cancer in a lymph node can also be a metastasis from a cancer which originated in another part of the body.  For example, throat cancer can first be noted by enlargement of lymph nodes in the neck; breast cancer can spread to nodes in the armpit; abdominal and genital cancers can spread through the main lymph duct to the node above the left collarbone.  These are not lymphomas.

We suspect Lymphoma in two settings.  One is when a lymph node has recently begun to enlarge (the medical term is lymphadenopathy).  Infections cause lymph nodes to enlarge, but painfully.  Nodes from cancer are almost always painless.  They’re quite firm, maybe even hard; there may be others nearby.  The key criterion for us is that it’s changing.  Sometimes the node or nodes are internal, and we find them by chest x-ray, CT scans or other imaging.  If advanced, we may note a large liver or spleen on physical exam.

We also suspect lymphoma when a patient simply hasn’t been feeling well, in fact, feeling a bit worse week by week, month by month.  Fatigue is common.  The key symptoms we ask about are called “B” Symptoms in medical jargon:

  • fevers
  • drenching sweats
  • weight loss

When these have been going on at least 2-3 weeks, and we don’t find abnormalities on physical exam or various blood tests, we’d order the imaging tests mentioned above.  Obviously, many other diseases can cause these symptoms, including infections which also cause lymphadenopathy.  Diagnosis is made by biopsy.

There are four types of biopsy: excisional (surgically removing an entire lymph node); incisional (removing part of it); core needle (aspirating a specimen through a large needle); or fine needle (a thin one).  The latter is quickest and easiest, but may not retrieve an adequate specimen.  For deep internal nodes, an “interventional radiologist” can manipulate a needle while doing a CT scan to get the sample.  It’s important that an experienced pathologist perform the microscopic examination (often doing extra tests on the biopsy material as well).  It’s also important for the patient not to have taken steroids if possible, since they obscure results.

The treatment and prognosis of Lymphoma depends entirely on the subtype, determined by biopsy.  Some lymphomas can be cured, or controlled for a long time.  Others resist therapy and advance rapidly.  One complication of lymphoma treatment is that the chemotherapy and/or radiation used to cure the disease can itself cause a second cancer years later.  It’s hard to know how to watch for this, except by investigating new symptoms, performing annual skin exams for skin cancers, and frequent mammograms.

Auras

An aura is a funny feeling that something is about to happen.  With Migraines, it occurs just before or right at the start of the headache; it can last 5-10 minutes (there ae odd case reports of really long ones).  With Epileptic Seizures, the aura occurs just before the seizure, and is much shorter.

Migraine auras tend to be strange lights or visual sensations, maybe numbness or tingling, less commonly word-jumbling, or involuntary movements.  If a person with migraines has medications to stop the headache abruptly, it’s ideal to take them at the time of aura.

Seizure auras can be much more variable; below is a (long) list of possibilities:

……….Movements
Lip smacking / Chewing
Teeth clenching / grinding
Tongue biting
Uttering sounds / Slurred Speech
Twitching / Shaking
Drooling / Swallowing
Breathing difficulty
Eyelid fluttering
Foot stomping / Hand waving
Inability to move / Staring / Stiffening
Tremors
Walking, Running Undressing
Screaming

……….Bodily Functions
Incontinence
Skin color changes
Sweating
Urge to urinate or defecate
Racing heart / Palpitations
……….Sensations
Electric shocks
Sound distortion
Visual distortion / loss / blurring
Spacial perception distortions
Dizzy / Lightheaded / Spinning
Tingling
Tightness

……………Mental
Altered perception of body size / weight
Confusion
Deja-vu / Jamais vu
Psychic experience
Racing thoughts
Memory loss
One side of body different than other
Out-of-body experience
Spacing out
Time perception distortion
x

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Passing Out / Amnesia — Full Text

What do we when a patient comes to us saying they “passed out,” usually sometime recently? Or the “lost time,” a period which they can’t recall anything? Today they look perfectly well, act completely normally.  We perform a good physical exam, focusing on the heart and the neurologic system (for the brain), but if they’re fine today, everything is invariably normal.

Our diagnosis will be made entirely by history.  We’ll order tests based on the history, but they may also be normal.  Below, we use the abbreviation LOC (Loss of Consciousness).

The work-up for a patient actively confused, seizing, or in a coma, is extensive.  I learned the mnemonic “Vowel TIPS”, which is how E.R. providers orient their thought diagnostic process.  But for the person who had a “spell” or “episode” that’s over & done with, and now feels fine, possibilities are much more limited.  This is our current topic.

Causes of Loss of Consciousness (LOC)

…………..Patient Fell to Floor  
Faint (a.k.a. Syncope)
Seizure (generalized)
Transient Ischemic Attack (TIA)
Concussion  (from Head Trauma)
Conversion Reaction
Hyperventilation
Intoxication
……….Episode of Amnesia (without Fall)  
Complex-Partial Seizure
Dissociative State
Transient Global Amnesia
Intoxication

x
x

Diagnosis in a Nutshell

1.  Our diagnosis will be made entirely by taking a good history.

  • After deducing the likely condition, we order tests to better understand it
  • Tests are often normal

2.  If a person fell to the ground unconscious, it was most probably a Faint or a Seizure

3.  If a Faint, we distinguish between a Non-Dangerous Faint, or one due to Heart Disease

WITNESSES PRESENT

Witnesses are obviously especially helpful.  If they didn’t accompany the patient to our office, we call them.  If the patient doesn’t know how to reach them, we have them try to find out & let us know tomorrow.  We query witnesses systematically to rule-out or rule-in the above conditions.  We use the abbreviation LOC (Loss of Consciousness).

Patient Fell to the Ground

Faint (medical term is “Syncope”) – see link for different types (some can be very dangerous)

  • Sudden momentary drop of blood circulation to the brain
  • Lasts less than 30 seconds (very rarely longer)
  • Patient regains consciousness immediately; may feel sleepy or fatigued a few minutes, but is alert & thinking normally
  • There may be a trigger, like the sight of blood (see link)
  • Suspect due to heart disease if occurs during exertion, there are risk factors for heart disease, or family history of sudden death
  • A Faint may include very brief shaking resembling a Seizure
  • Head trauma caused by the faint (fell & hit head) may confuse things greatly (rare)

Seizure —  Generalized (a.k.a. “Grand Mal”, “tonic-clonic”)

  • Nerve transmission in brain goes haywire; massive short circuits
  • Lasts 20-90 seconds usually, but can go on and on
  • Symmetrical shaking movements, both arms & legs
  • Face may turn blue
  • May foam at mouth, eyes may move abnormally
  • May bite tongue, may be incontinent of urine / stool
  • Patient recovers alertness gradually, usually takes 15-30 minutes
  • Patient has no memory of what occurred during the event
  • May sense an aura: weird feeling / movement just before the seizure

Concussion  (from Head Trauma)

  • Witnesses say the LOC occurred immediately with the trauma (as opposed to fainting first, & hitting head with fall)

Transient Ischemic Attack (TIA)  —  from Basilar Artery territory (back of brain)

  • Start of a stroke, that resolves quickly on its own
  • Patient may recall severe vertigo (room-spinning)
  • Maybe previous episodes of basilar artery disease: vertigo, double-vision, slurred speech, problem swallowing saliva, imbalance, partial blindness, half of face / body goes numb
  • Risk Factors for Stroke (same ones for Heart Disease which causes Fainting)

Hyperventilation  —  very fast breathing from Anxiety

  • Witnesses describe reason for anxiety, maybe note there was rapid breathing immediately beforehand
  • Patient recalls feeling dizzy (not vertigo), tingling of lips / hands
  • LOC lasts briefly (unless Conversion Reaction follows, see below)
  • In clinic we may listen to lungs while patient breathes hard & fast, which may provoke the dizziness / tingling

Conversion Reaction  —  Psychological “escape” from an intolerable situation (see link)

  • Can last any period of time
  • Any “jerking” movements are random, not symmetrical or consistent
  • Patient squeezes eyes shut, or cries (cannot occur with a seizure)
  • Bites tip of tongue, or lip (with seizure, it’s side of tongue)
  • Level of consciousness may fluctuate, come & go
  • Patient had some awareness of environment during the episode, can describe what people did or said (with Seizure there’s complete amnesia)
  • The LOC comes & goes

Intoxication  —  With witnesses, the diagnosis is easy.  If from poisoning, may be hard

Patient Did Not Fall  (see Explanations below)

Seizure  —  Complex-Partial, without generalization (no “Grand-Mal”)

  • Seizure in only one part of the brain (usually temporal lobe)
  • Begins with staring; smacks lips / grimaces
  • May include a variety of behaviors / utterings (see link)
  • Doesn’t respond (loss of awareness), with complete amnesia for the event
  • May last up to 4 minutes; may come out of it quickly or even 1-2 hours

Dissociative State  —  Psychological reaction to intolerable traumatic memories

  • The form relevant here is by definition temporary; some forms can be long-lasting
  • Almost always occurs without witnesses, when patient is alone
  • Loss of awareness, doesn’t respond appropriately to stimuli
  • Period of amnesia may last hours
  • If witnesses present, they may describe outbursts or strange moods

Transient Global Amnesia

  • Identified in 1956, cause unknown
  • Age >50 years-old, usually older
  • Lasts 1-10 hours
  • Patient is confused: knows own name, but asks repeated questions
  • May have memories of past events, usually not the recent past
  • No LOC: is aware of things happening around them
  • Able to perform complex tasks like drive, cook, play piano, etc.

Some Explanations:

Complex-Partial Seizure —  a true neurologic event in the brain, with abnormalities on electroencephalogram (EEG).  Synonyms in the past included “Psychomotor” and “Temporal Lobe” seizures / epilepsy.  If it happens to “generalize,” there’s a fall to the ground with shaking, etc. (a.k.a. “Grand Mal seizure”), but often that doesn’t happen.  Rather, the patient does weird things like make strange facial movements, keep repeating words, even walking around or undressing.  It lasts several minutes; the patient may come out of it quickly or slowly (up to 2 hours)  There’s complete amnesia for what happened.

Franklin was a blind AIDS patient with complex-partial seizures, which he described as episodes of complete amnesia.  At one visit, he commented he’d just had one, on the way to the clinic with his health worker.  So I asked the health worker, “What happened?  What did you talk about?”  He replied, “Nothing.  Billy was in his own mood, just mumbled, didn’t feel like talking.”   The health worker had actually accompanied a patient in the midst of a seizure, & didn’t realize it!

Dissociative State —  a person loses awareness due to psychiatric mechanisms that preoccupy them with inescapable thoughts, which are usually trauma-related (PTSD).  They “trance-out,” become unresponsive, and have amnesia for the episode.  When temporary (some forms can be long-lasting), it usually occurs when the person is alone, thus not distracted.  See the movie Primal Fear with Richard Gere, Edward Norton, Laura Linney [not my top pick of cinema but quite entertaining; R-rated, may offend some devoutly religious].

Transient Global Amnesia (TGA)  —  A newly-recognized (1956) syndrome in which a person over 50 years-old (usually older) suddenly becomes unable to form new memories, so they can’t understand what’s going on from moment to moment.  They know who they are, and can recall some distant memories, but not recent ones, so they are profoundly disoriented as to what is occurring to them, and ask questions repeatedly. 

TGA lasts less than a day, and usually doesn’t recur.  Medical scientists have been unable to define its cause (may be neurologic, cardiovascular, or psychological).  TGA is usually so blatant and concerning to anyone in contact with the person, that they’re taken to an emergency room.

Conversion Reaction —  The mind’s way to escape an intolerable situation, by subconsciously doing something that winds up forcing the person out.  If it involves falling with “LOC,” it’s now called “Psychogenic Non-Epileptic Seizure,” instead of previous less-friendly names like “pseudo-seizure” or “hysterical seizure.”  It isn’t “faking it,” because there’s no conscious control. 

In a generalized seizure, there is complete loss of awareness during the event, & also during the 15-30 minutes it takes to recover.  For amnesia & LOC to alternate on-and-off with normal thought is not possible with true neurologic brain disease [so we would think Conversion Reaction].  Of course, a person can seize, begin to recover, then seize again.  This qualifies as Status Epilepticus, but is life-threatening, pretty rare, & highly unlikely to have resolved on its own.

See the link for some interesting examples of Conversion Reactions.

UNWITNESSED EVENT

Often there are no witnesses.  A patient describes an episode of amnesia several days ago.  Maybe they awoke on the floor, maybe not; they just don’t remember what happened.  This is harder.

If they awoke on the floor, the causes may be:

The last five are unlikely.  Concussion from head trauma without memory of the blow is possible but highly doubtful; at least, the head would feel sore.  We’d only consider a basilar artery TIA if it recurred, or if a patient recalled severe vertigo initially.  Transient Global Amnesia usually lasts long enough for the person to interact with others, who’d be very concerned and take them to an ER.  Collapse from a Conversion Reaction only occurs if others are around (who provoked the stress).  Diagnosing Intoxication requires patient insight and honesty.

So we’re usually left with Seizure vs. Fainting, & nobody to describe how long it lasted.  The diagnostic approaches are very different.  We obtain clues from the little history we have.  Most important, we try to get a sense of how much time elapsed, asking about the last thing they remembered before, & the first thing afterward.  If the event occurred in a busy public area, it’s unlikely to have lasted more than a few minutes before someone would call for help (thus a Faint, not seizure).

For example, one of my patients fell in the bathroom.  A family member heard the thud, ran in, & the patient was already awake.  Time here was clearly short.  No tongue bite or incontinence.  Diagnosis: Faint (probably caused by reflex slowing of the heart from the Vagus Nerve, which also controls urination; so some people faint when they pee).

People who faint retain memories up to the point they lose consciousness.  But they don’t remember the fall.  Someone who trips, hits their head, and is knocked out, may recall going down.  But if not, it’s much harder to know, unless hand injury shows they had tried to protect themselves with their hands.

Another patient awoke on the floor by her bed.  Could have fainted from sudden standing (orthostatic syncope), but then she’d have remembered losing consciousness right after arising.  Her inability to describe a rapid coming-to suggested a longer time course (post-ictal phase after a seizure).  Diagnosis: Seizure (which may occur disproportionately at night).

Epileptic seizures often have auras which might be recalled.  They include a wide variety of phenomena, depending on the part of the brain where it all began.  Click for a list of possible auras.

If there was No Fall, just a period of unwitnessed amnesia for less than an hour, the possibilities are:

Transient Global Amnesia (see above) lasts over an hour, maybe up to 10 hours.  A Dissociative episode can be ongoing, but eventually the person would interact with others and come out of it.

I once worked-up a friend who’d been working abroad during a civil war, and was having episodes of amnesia.  She visited San Francisco, I ordered an EEG and MRI to rule out Seizure (both were normal).  A consulting Neurologist said there was no way to distinguish between the 2 conditions, leaned toward the latter since tests were normal & war is tough.  But I knew her situation abroad, which wasn’t particularly traumatic or dangerous.  It was only weeks later, before flying to Chicago, that she confided she was about to confront a brother who’d molested her in childhood.  Diagnosis: Dissociative Episodes.

Diagnostic Tests for Loss of Consciousness

We order tests and refer to specialists depending on the reason we think a person had lost consciousness.  This depends entirely on the medical history we’ve obtained.  Again, this is in the context of the event having occurred some time ago, and the person feels perfectly fine today.

The main tests available which we might consider include:

We never order all of these, which are described below.  Rather, we order those most appropriate based on our History, which identifies the most likely Cause:

Faint (Syncope)

Whether or not we do any tests depends on the reason we think they fainted (see link for more discussion):

Vasovagal Syncope – the most common cause of fainting.  We’d be convinced if there’s a clear history (e.g. fainted at sight of blood; in a hot crowded room; right after urinating, etc.).  The patient often feels woozy or nausea right before.

  • Further testing is not necessary, as long as we’re sure it’s not due to heart diseases (see below).
  • We just explain, and reassure the patient there’s nothing serious.

Orthostatic Syncope  —  Occurs immediately after standing up (usually from lying down, maybe from sitting).  We suspect this if the person was dehydrated, or just began a new medicine with fainting as a possible side effect.  Long-standing Diabetes, Parkinson’s, and other diseases can cause this.

  • If patient still feels any symptoms upon standing, we check their Postural Vital Signs (heart rate and blood pressure while lying down, & then after standing abruptly; see link for explanation).
  • Treatment is mainly warning patient to get up slowly

Heart Arrhythmia  —  There are various kinds of abnormal heart rhythms that can cause fainting.  Some can be serious, even life-threatening (see link).  We suspect an Arrhythmia if the patient faints without any warning symptoms like dizziness or nausea.  We order the following tests (see Arrhythmias for more explanation):

  • EKG.  Usually normal if no symptoms at the time, but rarely there are clues to uncommon causes.
  • Ambulatory EKG, i.e. portable.  Worn on a belt if done for 24-48 hours; a patch on the chest if for 2-4 weeks (showering is OK).
  • Implantable recorder, if recurrent faints and the above tests are normal

Other Heart Disease  —  We especially suspect this if fainting occurs during exertion.  There may also be symptoms like chest pain, shortness of breath, nausea, or burst of cold sweat which occur just beforehand.  Two types of heart disease may cause fainting with exertion:

  • Coronary Artery Disease (causes Heart Attacks)
  • Cardiac Outflow Obstructions that interfere with blood as it’s pumped out of the heart (tumors, heart valve disease, abnormal muscle growth)
  • See also The Heart – Anatomy (with diagrams)

To diagnose Coronary Artery Disease, we obtain an EKG, order Stress Tests, maybe refer for cardiac catheterization (see link).

To diagnose Cardiac Outflow Obstructions, we obtain an Echocardiogram.

Abnormal Neck Anatomy  —  This is very rare, but if someone faints only when they turn their head a certain way, we’d order an Angiogram by MRI or CT, and/or perhaps refer to a Vascular specialist.

Tilt Table Testing as noted above: what’s this?  The patient is strapped to a table, abruptly raised from supine to upright, and held there (maybe for over 30 minutes).  If a faint occurs, it diagnoses Vasovagal Syncope.  The problem is that false-positives and false-negatives are common, and accuracy is low.  I’ve never had it performed on a patient, much less ever ordered it.

It might be useful for the older patient with risks for heart disease but a completely negative cardiac work-up, if we want some reassurance that frequent faints were in fact vasovagal.  Other indications include frequent unexplained falls, to prove any shaking movements are in fact from faints (vs. seizure), & maybe for fainting in a person with a high-risk occupation (pilot, acrobat, etc.).

Seizure

Generalized Seizure (a.k.a. “Grand Mal”) causes the classic fall to floor, body shakes, foams at mouth.  Complex-Partial Seizure begins with weird facial movements, then a trance during which a patient may still walk and mumble.  The patient has complete amnesia for the event.  We order the same tests no matter what kind of seizure we suspect may have occurred.

  • MRI of Brain  —  This won’t show if there’s a seizure, but will find a tumor if one exists.  A CT scan is able to find masses large enough to cause headaches, but for a tiny tumor capable of causing a seizure, we need the MRI.  Both MRI and CT can find a Subdural Hematoma (blood clot in the brain from a prior fall), which can cause seizures later on.
  • Electroencephalogram (EEG)  —  Scalp electrodes used to detect abnormal brain waves, to diagnose a seizure predisposition.  It’s best if the patient is sleep-deprived before the test.
  • CBC and CMP, common simple blood tests which may reveal an underlying illness

An EEG is always abnormal during an actual seizure, but may be normal at other times.  This is especially so with a Complex-Partial Seizures, because the abnormal electrical discharges may come from deep in the brain.  If seizures are frequent enough, Neurologists may admit a person to the hospital for 3 days to perform a continuous EEG while video-recording the patient.  In rare cases an EEG may be done surgically, placing electrodes deep in the temporal lobe.

Transient Ischemic Attack (TIA)

This is the start of a Stroke, but the patient recovers fully.  It’s not a common cause of having passed out, but one to think of if a person has risks for Atherosclerosis.  This type of TIA would come from the brain’s basilar artery, which might also cause vertigo, double vision, slurred speech, or trouble swallowing saliva.  If we suspect a TIA, we’d order:

  • MRI of Brain  —  To make sure the patient didn’t have a full stroke
  • Angiogram by MRI or by CT, of both the Head and also the Neck, to look for abnormal arteries which can cause a stroke
  • Echocardiogram to look for clots in the heart which can be swept to the brain
  • EKG, Ambulatory EKG, to look for Atrial Fibrillation which can cause clots in the heart

Other Causes of Passing Out

Other entities in the table are suspected and diagnosed by history alone; there are no useful supportive tests.  Transient Global Amnesia, as noted, is so startling that patients are invariably transported to an E.R.  If all tests there are normal (see the mnemonic Vowel-TIPS for diseases causing abnormal mental status at the moment), the patient is observed until they recover.

Dissociative episodes, psychological escape mechanisms for avoiding intolerable traumatic thoughts, can be impossible to distinguish clinically from Complex-Partial Seizures (due to physical abnormalities in the brain).  We commonly order an EEG and MRI, with subsequent referral to a Neurologist, to reassure both patient and ourselves.  There are recent 72-hour ambulatory (portable) EEGs which may be available.  Up to 40% of patients hospitalized for 3-day EEG plus video-recording are diagnosed to have a psychiatric cause of their episodes.

That’s all for “Passing Out”  —  we hope you’ve retained consciousness while reading all this.

See also Passing Out for the clinician’s condensed thought-process when face-to-face with a patient.

𝗗𝗜𝗔𝗚𝗡𝗢𝗦𝗜𝗦 𝟭𝟮𝟯