Immediate Steps in the ED

Given the patient's history of diabetes and insulin use, a few immediate actions are critical for safety.

• Hemodynamic Stability: Confirm the patient's stability with the examiner, as is standard practice in an ED setting.
• Check Blood Glucose: Inform the examiner that you would immediately check the patient's blood glucose level if it hasn't already been done. This is a crucial safety step that can significantly change the diagnosis and management plan. You can state, "I'll be taking my history simultaneously while checking the blood sugar level."

Detailed History Analysis

The history taking follows the same "Five Ws" structure as other syncope cases, but with a specific focus on diabetes-related triggers.

• What, When, Where, Witness: Ask the standard questions about the event, its timing, location (shopping mall), and any witness accounts.
• Why (Diabetes-Specific Triggers): Since the patient is on insulin, your questions about triggers should be more focused.

Red Flags and Post-Event Symptoms

• Screening Questions: Rule out other causes by asking the standard cardiac, neurological, metabolic, and infectious red flag questions.
• Post-Syncopal State: Ask about confusion, headache, nausea, or fatigue after the event to assess for post-ictal states or signs of Diabetic Ketoacidosis (DKA).
• Injuries: Always ask if the patient was injured during the fall.

Past Medical and Social History

• Previous Episodes: "Has this happened before?"
• Comorbidities: Ask about heart problems, high blood pressure, high cholesterol, seizures, or strokes. Since hypertension and diabetes often coexist, it's also important to ask about kidney problems (diabetic nephropathy).
• Diabetes Management (Modified Social History): Focus on the patient's routine.
  • Diet: "Do you eat your meals at regular times?" "How do you manage your carbohydrate intake?"
  • Insulin: "Do you store your insulin correctly?"
  • Support Systems: "How have you been managing your diabetes overall?"

Physical Examination

If not provided with an ECG, you would perform a full physical exam, including:

• Orthostatic Vitals: Measure blood pressure and heart rate while the patient is lying down, immediately upon standing, and after three minutes of standing to check for orthostatic hypotension.
• Cardiovascular Exam: Listen for murmurs and extra heart sounds like S3 or S4, which can be present in patients with hypertension.
• Signs of Heart Failure: Check for JVP distension and peripheral edema.
• Neurological Exam: Assess for any focal deficits.
• Point-of-Care Glucose: Confirm the blood sugar level.

ECG Findings

In this case, an ECG was provided and showed signs of a myocardial infarction (MI).

• MI Location: The ECG reportedly showed ST elevation in leads II, III, and aVF (inferior wall) and possibly in V5-V6 (lateral wall), indicating an inferolateral MI.
• Reciprocal Changes: Reciprocal ST depression might be seen in opposing leads (like aVL), which helps confirm the diagnosis.

Provisional Diagnosis

Given the missed meals, insulin use, and ECG findings, there are two likely coexisting diagnoses:

1. Insulin-Induced Hypoglycemia: This is a highly plausible explanation for the near-fall, given the patient missed meals and was more active than usual.
2. Silent Myocardial Infarction (Inferolateral STEMI): This is a critical "not-to-miss" diagnosis supported by the ECG findings.

Differential Diagnoses

Other potential causes to consider include:

• Vasovagal Syncope
• Orthostatic Hypotension
• Cardiac Arrhythmias
• Seizures or TIA
• Dehydration or electrolyte imbalance

Urticaria, commonly known as hives, presents as transient, intensely itchy, raised red weals (plaques) caused by dermal edema. It can be associated with Angioedema, which involves deeper dermal and subcutaneous swelling (commonly lips, eyelids, and genitalia).

Pathophysiology

• Mechanism: Widespread activation of mast cells and basophils releasing histamine and vasoactive mediators.
• Effect: Vasodilation and increased vascular permeability lead to fluid leakage (edema/weal formation) and itching.
• Classification:
  • Acute: Lasts less than 6 weeks. Causes include infections (viral/bacterial), medications (NSAIDs, antibiotics), foods, or insect bites.
  • Chronic Spontaneous Urticaria: Lasts >6 weeks without a clear trigger (formerly idiopathic).
  • Inducible: Triggered by physical stimuli (cold, heat, pressure, sun, exercise).

The diagnosis is often clinical based on the "fleeting" nature of the rash. The history should focus on ruling out anaphylaxis and identifying triggers.

1. Characterizing the Rash

• Transient Nature: Ask "How long does each spot last?" In simple urticaria, individual lesions usually disappear or migrate within 24 hours.
• Appearance: Are they red, raised weals? Do they blanch with pressure? (Urticaria blanches; vasculitis/petechiae do not).
• Symptoms: Is it itchy? (Classic). Is it painful or burning? (Suggests vasculitis).

2. Red Flags: Anaphylaxis & Angioedema

You must assess Airway, Breathing, and Circulation (ABC) stability immediately.

• Airway/Mucosal: Any swelling of the lips, tongue, or throat? Difficulty swallowing?
• Breathing: Shortness of breath, wheeze, or chest tightness?
• Circulation: Feeling faint, dizzy, or lightheaded?
• Gut: Nausea, vomiting, or diarrhea?

3. Triggers & Risk Factors

• Infections: Recent cold, flu, or viral symptoms?
• Medications: Started anything new? (Antibiotics, NSAIDs like Ibuprofen/Naproxen).
• Exposures: New foods, insect bites, or physical triggers (heat, cold, stress).

While the diagnosis is often clear, knowing when it is not simple urticaria is vital.

1. Pharmacotherapy

• Antihistamines (First Line): Non-sedating H1-antihistamines (e.g., Cetirizine, Loratadine, Fexofenadine).
  • Clinical Practice Point: In chronic or resistant cases, the dose can be increased up to four times the standard dose.
• Corticosteroids: For severe or extensive cases (with angioedema), a short course of oral Prednisolone (e.g., 25-50mg) can be used for 1 week and tapered over the next 2 weeks.
• Adrenaline (Epinephrine): Indicated ONLY if there are signs of Anaphylaxis (airway/breathing/circulation compromise). It provides bronchodilation and circulatory support.

2. Symptomatic Relief & Avoidance

• Avoid Triggers: If a specific trigger (drug/food) is identified, strict avoidance is key.
• General Measures: Cool compresses, calamine lotion, and keeping nails short to prevent secondary infection from scratching.