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Ans:
D) Loss of vision before loss of consciousness

Detailed history taking is of paramount importance to establish a reliable diagnosis in patients with transient loss of consciousess. In this article the clinical symptoms and signs of the successive phases of a syncopal episode are reviewed. A failure of the
systemic circulation to perfuse the brain sufficiently results in a stereotyped progression of neurological symptoms and signs culminating in loss of consciousness; when transient, this is syncope. Prior to loss of consciousness the affected individual tends to exhibit unclear thinking, followed by fixation of the eyes in the midline and a ‘frozen’ appearance. Narrowing of the field of vision with loss of colour vision (‘greying’ out) and finally a complete loss of vision (hence ‘blacking’ out) occurs. Hearing loss
may occur following loss of vision. This process may take as little as 7s in cases of sudden complete circulatory arrest (e.g. abrupt asystole), but in other circumstances it may take longer depending on the rate and depth of cerebral hypoperfusion.
Complete loss of consciousness occurs with the ‘turning up’ of the eyeballs. Profound cerebral hypoperfusion may be accompanied by myoclonic jerks.

thanx for the question

A 52-year-old African American woman who is deaf comes to the office for a health maintenance examination. She works as a paralegal assistant. Medical history is significant for bilateral deafness secondary to bacterial meningitis at age 3 years, essential hypertension, for which she takes nadolol and hydrochlorothiazide, and osteoarthritis in her left knee, for which she takes naproxen as needed. She has been your patient for the past 5 years, and she has always come to the office with her partner of 10 years, who has intact hearing and serves as an interpreter. Today she is alone and tearful. She tries to speak to you but you have difficulty understanding what she is saying and she cannot read your lips. You do not know any sign language. You write her a note asking what she would like to do regarding the communication process. She writes back that writing is difficult because she is too upset. She would prefer a sign language interpreter. She also writes that she is thinking about killing herself. Which of the following is the most appropriate initial management?

A) Arrange for transport to the emergency department for a psychiatric evaluation with an interpreter
B) Assess her suicidality in the office using written communication
C) Excuse yourself from the room and call her partner for emergency assistance
D) Have her return to the office in 1 hour and arrange to have a sign language interpreter at that time
E) Prescribe antidepressant therapy and refer her for psychotherapy

A or B ?? which one??

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"B"

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The correct answer is A

A 95-year-old woman with moderate dementia, Alzheimer type, is brought to the office by her daughter because the patient has had three episodes of urinary incontinence during the past week. The daughter has noted no other symptoms in the patient. Medical history otherwise is unremarkable and the patient takes no medications. Her son, who lives nearby, is her health care proxy. Vital signs are temperature 37.6°C (99.7°F), pulse 84/min, respirations 18/min, and blood pressure 112/64 mm Hg. The patient appears frail and elderly. She is alert and seems suspicious. She pushes your hands away when attempts are made to examine her. Which of the following is the most appropriate next step?

A) Initiate antibiotic therapy
B) Obtain postvoiding residual volume
C) Obtain urinalysis
D) Physically restrain the patient for examination
E) Reschedule the examination when the son is available

C ??