​
https://preview.redd.it/qdkh9ntc0nqc1.png?width=612&format=png&auto=webp&s=f3afb54f10420538cf37371f73e951dbb7416df1
A submental fat, commonly known as a double chin, can be a stubborn aesthetic concern, forming unsightly layers under the chin and impacting jaw line improvement. This condition often arises with weight gain, but can also be influenced by genetics or natural skin laxity due to aging.
If you’re looking to achieve a more sculpted and youthful appearance, various options are available to address a double chin and enhance jaw line definition. Some methods focus on reducing excess fat, while others target skin tightening and contouring.

Exercises that target a double chin

There’s no scientific proof or data yet that says chin exercises are worthwhile in removing the double chin, however, there is enough anecdotal evidence to get you started.
Here are six workout activities that can boost and tone the muscles and skin around the double chin. Each type of exercise can be done every day 10 to 15 times.
Straight jaw jut

1. Incline your head back and look toward the ceiling.
2. Push your lower jaw forward to feel a stretch under the chin.
3. Hold the jaw jut for a 10 count.
4. Relax your jaw and return your head to a neutral position.

Ball exercise

1. Place a 9- to10-inch ball under your chin.
2. Press your chin down against the ball.
3. Repeat 25 times daily.

Pucker up

1. With your head tilted back, look at the ceiling.
2. Pucker your lips as if you’re kissing the ceiling to stretch the area beneath your chin.
3. Stop puckering and bring your head back to its normal position.

Tongue stretch

1. Looking straight ahead, stick your tongue out as far as you can.
2. Lift your tongue upward and toward your nose.
3. Hold for 10 seconds and release.

Neck stretch
Tilt your head back and look at the ceiling.

1. Press your tongue against the roof of your mouth.
2. Hold for 5 to 10 seconds and release.

Bottom jaw jut

1. Tilt your head back and look at the ceiling.
2. Turn your head to the right.
3. Slide your bottom jaw forward.
4. Hold for 5 to 10 seconds and release.
5. Repeat the process with your head turned to the left.

Non-Invasive Procedures to Reduce Double Chin

When the skin is aging, the neck is probably the first place to indicate your age. For most people, fat is more likely to compose underneath the chin. This excess fat and lax skin can affect your overall look. However, a reliable doctor can restore or fix a double chin by employing any of the procedures below:
​
https://preview.redd.it/ckklgwin0nqc1.png?width=1080&format=png&auto=webp&s=f033d2f99aabb38527e055ebf05a7220b48b05f6

1. Define

Define Cheek and Define Chin are advanced hands-free facial technologies specifically designed to enhance the appearance of the lower face and neck. These headsets utilize a patented technology that employs Radio Frequency (RF) energy to treat facial tissue, resulting in improved aesthetic outcomes.

Key Features:

• RF Energy: Harnesses the power of Radio Frequency to target facial tissues.
• Hands-Free Application: Offers a convenient and comfortable treatment experience.
• Focus on Lower Face and Neck: Specifically targets these areas for rejuvenation.

2. Face-Tite

This is an FDA-certified treatment and is slightly invasive. It delivers radiofrequency (RF) energy underneath the skin’s surface to dissolve fat. Since it facilitates collagen production, the skin tightens within the dermis.
The Face-Tite treatment can be used for areas with serious lines and loose skin on the shoulders. But, it is commonly urged to have firmness to the chin, jowls, cheeks, neck, eyes, mouth, brow, forehead, or jawline.
https://preview.redd.it/8gh6a5sq0nqc1.png?width=1080&format=png&auto=webp&s=a2ca9d26da830636de83b6efe336e4151a28563f

3. Suture Suspension Neck Lift

Suture Suspension Neck Lift is a minimally invasive nonsurgical procedure that shapes and rejuvenates the jawline. Using the ICLED® light guided suture system, Dr. Greta McLaren can easily place a suture support system without incisions that immediately elevate ad approximates underly structures. Suture Suspension Neck Lift can be used as a standalone procedure or in conjunction with submental liposuction and energy-based skin tightening technologies like “FaceTite”.

Am I candidate for Suture Suspension Neck Lift?

• Early aging of the Chin and Neck
• Excess fullness or a Double Chin
• Minimal skin laxity
• Sagging glands
• Muscle bands
• Pronounce Jowling
• Turkey Neck (Vertical Banding)
• Subpar Jawline Contouring and Definition

​
https://preview.redd.it/qpvbayos0nqc1.png?width=450&format=png&auto=webp&s=85391aa4d61ff06c2a00ddc2819021808976d6d5

4. Renuvion Cosmetic Technology

Renuvion is a top-of-the-line, mildly intrusive technology that is FDA-approved for cutting, thickening, and melting soft tissue. This is done during unrestricted and laparoscopic surgical methods.
Renuvion is a cutting-edge energy technology that combines the unique features of cold helium plasma with radio frequency energy. Helium plasma concentrates on RF energy for better tissue impact control, allowing for more accuracy and nearly avoiding unwanted tissue harm. Renuvion offers exceptional accuracy and control in minimally invasive operations by combining the unique features of helium plasma with the efficiency of RF energy.
​
https://preview.redd.it/l6d3ffsx0nqc1.png?width=738&format=png&auto=webp&s=a781ccdfd9785dfdcd621c5ad839e1e9b34544bb

5. Kybella Injectables

KYBELLA® is an FDA-approved injectable treatment used to reduce moderate to severe fat below the chin, commonly known as a “double chin.” The active ingredient in Kybella is synthetic deoxycholic acid, a molecule that naturally occurs in the body and helps break down and absorb dietary fat. When injected into the fat beneath the chin, Kybella destroys fat cells, resulting in a noticeable reduction in fullness under the chin. Once these cells are destroyed, they can no longer store or accumulate fat, meaning further treatment is not expected once you reach your desired aesthetic goal.
It’s important to note that Kybella should only be administered by a trained healthcare professional, and the number of treatment sessions varies from patient to patient, depending on the amount of submental fat and the patient’s treatment goals. Treatment sessions are typically spaced at least one month apart, and no more than six treatments are recommended.
​
https://preview.redd.it/lti1tx7z0nqc1.png?width=600&format=png&auto=webp&s=64df3b5f6c5a0661572f1be435e878f97ca3eb74

6. Agnes RF

AGNES Radio Frequency is an energy-based aesthetic and treatment procedure. It is a non-surgical radiofrequency device that treats eye bags without having to go under the knife! It incorporates an enclosed coated microneedle devised for the various deepness of skin with exact pulse and duration control of radiofrequency energy specifically targeting the sebaceous gland (which causes acne), blackheads, syringomas, wrinkles, and fat under the eyes and chin.
Since the needles are developed to a particular depth, they will shield other structures in the skin and also the epidermis while having the treatment. Agnes RF results in minimal disruption and side effects most especially pigmentation.

Cape Coral, FL's Premiere Medical Spa and Anti-Aging Clinic

The face is usually considered as the doorway to the soul. Your anxieties, beliefs, and desires, will be evident on your look in some manner or the other. Whatever consists of your diet and physical activities are being portrayed on the face. One of the worrying features of the face for most people is the double chin.
If you want to have a well-defined face, Skin Secrets does an advanced treatment in Cape Coral, FL to reduce the double chin. We deal with every face in a top-of-the-line technique, utilizing our proficiency in cosmetic remedies to improve your look.
Dr. Greta McLaren is passionate about performing aesthetic practices and agreeably restoring looks for her clients. With well-planned and suitable facial treatments, you will undergo pleasant and naturalistic outcomes.
Our professional and amiable patient care team is willing to meet and discuss with you whatever the skin issues and needs are. We will design a tailored rejuvenative treatment to help you become the best version of yourself.
Contact us today at 239-800-SKIN(7546) to schedule your complimentary consultation.

A submental fat, commonly known as a double chin, can be a stubborn aesthetic concern, forming unsightly layers under the chin and impacting jaw line improvement. This condition often arises with weight gain, but can also be influenced by genetics or natural skin laxity due to aging.
If you’re looking to achieve a more sculpted and youthful appearance, various options are available to address a double chin and enhance jaw line definition. Some methods focus on reducing excess fat, while others target skin tightening and contouring.

Exercises that target a double chin

There’s no scientific proof or data yet that says chin exercises are worthwhile in removing the double chin, however, there is enough anecdotal evidence to get you started.
Here are six workout activities that can boost and tone the muscles and skin around the double chin. Each type of exercise can be done every day 10 to 15 times.

Straight jaw jut

1. Incline your head back and look toward the ceiling.
2. Push your lower jaw forward to feel a stretch under the chin.
3. Hold the jaw jut for a 10 count.
4. Relax your jaw and return your head to a neutral position.

Ball exercise

1. Place a 9- to10-inch ball under your chin.
2. Press your chin down against the ball.
3. Repeat 25 times daily.

Pucker up

1. With your head tilted back, look at the ceiling.
2. Pucker your lips as if you’re kissing the ceiling to stretch the area beneath your chin.
3. Stop puckering and bring your head back to its normal position.

Tongue stretch

1. Looking straight ahead, stick your tongue out as far as you can.
2. Lift your tongue upward and toward your nose.
3. Hold for 10 seconds and release.

Neck stretch

1. Tilt your head back and look at the ceiling.
2. Press your tongue against the roof of your mouth.
3. Hold for 5 to 10 seconds and release.

Bottom jaw jut

1. Tilt your head back and look at the ceiling.
2. Turn your head to the right.
3. Slide your bottom jaw forward.
4. Hold for 5 to 10 seconds and release.
5. Repeat the process with your head turned to the left.

Procedures to Reduce Double Chin

When the skin is aging, the neck is probably the first place to indicate your age. For most people, fat is more possible to compose underneath the chin. This excess fat and lax skin can affect your overall look. However, a reliable doctor can restore or fix a double chin employing any of the procedures below:

1. Face-Tite

This is an FDA-certified treatment and is slightly invasive. It delivers a radiofrequency (RF) energy underneath the skin’s surface to dissolve fat. Since it facilitates collagen production, the skin tightens within the dermis.
The Face-Tite treatment can be used for areas with serious lines and loose skin on the shoulders. But, it is commonly urged to have the firmness to the chin, jowls, cheeks, neck, eyes, mouth, brow, forehead, or jawline.
https://preview.redd.it/jdvyfo9qphec1.png?width=1024&format=png&auto=webp&s=2d85d3f71ded7436505f66eefc4422630ec572eb

2. Suture Suspension Neck Lift

Suture Suspension Neck Lift is a minimally invasive nonsurgical procedure that shapes and rejuvenates the jawline. Using the ICLED® light guided suture system, Dr. Greta McLaren can easily place a suture support system without incisions that immediately elevate ad approximates underly structures. Suture Suspension Neck Lift can be used as a standalone procedure or in conjunction with submental liposuction and energy-based skin tightening technologies like “FaceTite”.

Am I candidate for Suture Suspension Neck Lift?

• Early aging of the Chin and Neck
• Excess fullness or a Double Chin
• Minimal skin laxity
• Sagging glands
• Muscle bands
• Pronounce Jowling
• Turkey Neck (Vertical Banding)
• Subpar Jawline Contouring and Definition

​

3. Renuvion Cosmetic Technology

Renuvion is a top-of-the-line, mildly intrusive technology that is FDA-approved for cutting, thickening, and melting soft tissue. This is done during unrestricted and laparoscopic surgical methods.
Renuvion is a cutting-edge energy technology that combines the unique features of cold helium plasma with radio frequency energy. Helium plasma concentrates on RF energy for better tissue impact control, allowing for more accuracy and nearly avoiding unwanted tissue harm. Renuvion offers exceptional accuracy and control in minimally invasive operations by combining the unique features of helium plasma with the efficiency of RF energy.
https://preview.redd.it/jav92v4vphec1.png?width=600&format=png&auto=webp&s=c3bf86cbb1af6d078c60b286dc7ac699596101d0

4. Agnes RF

Renuvion is a top-of-the-line, mildly intrusive technology that is FDA-approved for cutting, thickening, and melting soft tissue. This is done during unrestricted and laparoscopic surgical methods.
Renuvion is a cutting-edge energy technology that combines the unique features of cold helium plasma with radio frequency energy. Helium plasma concentrates on RF energy for better tissue impact control, allowing for more accuracy and nearly avoiding unwanted tissue harm. Renuvion offers exceptional accuracy and control in minimally invasive operations by combining the unique features of helium plasma with the efficiency of RF energy.
​

Cape Coral, FL's Premiere Medical Spa and Anti-Aging Clinic

The face is usually considered as the doorway to the soul. Your anxieties, beliefs, and desires, will be evident on your look in some manner or the other. Whatever consists of your diet and physical activities are being portrayed on the face. One of the worrying features of the face for most people is the double chin.
If you want to have a well-defined face, Skin Secrets does an advanced treatment in Cape Coral, FL to reduce the double chin. We deal with every face in a top-of-the-line technique, utilizing our proficiency in cosmetic remedies to improve your look.
Dr. Greta McLaren is passionate about performing aesthetic practices and agreeably restoring looks for her clients. With well-planned and suitable facial treatments, you will undergo pleasant and naturalistic outcomes.
Our professional and amiable patient care team is willing to meet and discuss with you whatever the skin issues and needs are. We will design a tailored rejuvenative treatment to help you become the best version of yourself.
Contact us today at 239-800-SKIN(7546) to schedule your complimentary consultation.

Just wanted to share a blog I came across of a Dutch medic (ambulance nurse) visiting Chicago Fire Department EMS on a work trip. In the blog, the Dutch medic describes one of the calls he observed during the trip and then made a detailed description of how the situation would have gone in The Netherlands based on the national ambulance protocols here and an actual case. So basically a broad overview of what he saw in the US to a similar case in The Netherlands via the Dutch approach as a simple comparison. This happened in 2015.

• Source: https://chicagomanp2015.wordpress.com/protocollen-en-benaderingswijze-ambulance-us-vs-nl/
• Translation: https://www.deepl.com/translator
• Grammar: https://app.grammarly.com/
• The video that was used during the trip to show the EMS service the writer came from: https://www.youtube.com/watch?v=I-oLot08_xg

A Chicago Fire Department ambulance

Protocols and ambulance approach: US vs NL

6 April 2015 Steven J. Hofman
The case in Chicago
We are just sitting at the table in the firehouse enjoying the lunch the firefighters made when the horn goes again and the computer voice calls out that there is a deployment for ambulance 11 and Engine 42. Paramedic Jeff jumps up and grabs from the cupboard three take-out boxes to take the contents of our plates packed into the ambulance. paramedic John stands in the garage and presses the computer screen to indicate that the notification has been received. a small printer immediately prints out an A4 sheet with the information as it is on the ambulance screen. This system is intended for when the screen in the ambulance gets stuck or does not respond. The address and the call-out information are then known in any case. In downtown Chicago, there is a lady with palpitations. She is conscious and breathing.
We jump into the ambulance, Jeff is behind the wheel and with his right hand he operates the panel which makes all kinds of siren sounds. Since John is the most experienced paramedic, he handles the communication and registration of the deployment. Chicago's street system is clear and numbered, so there is hardly ever a need to use a navigation system. The response time is only a few minutes. Yet at the scene of the incident, there are already three police cars and a fire engine waiting for us with their lights flashing. John gets out of the ambulance and walks towards the patient who is sitting on a chair surrounded by police and firemen. The lady looks a little anxious around but is alert and has a normal skin tone. The EMT sitting on the fire truck does a short handover to John and briefly explains what he found in the primary survey. The patient gets into the ambulance herself and lies down on the stretcher.
John sits at the headboard and Jeff connects a blood pressure monitor to the patient. John asks what happened. The lady states that she has been under a lot of stress lately. She had gone to buy coffee now and started having palpitations with tingling in her arms. It didn't last long, but a passerby saw it happen and called 911 for her. Jeff connected the 4-lead electrodes and took a heart rhythm strip. The blood pressure was 130/80 and the heart rhythm was a sinus rhythm of 88/minute. Oxygen saturation was 100%. The lady anxiously asked what it could have been that made her feel so strange. John replied that he is not a doctor and he could not comment on that. The lady asked if her heart was fine. Jeff explained that he saw no irregularity in the rhythm strip. When asked if her heart had any problems, Jeff could not reassure her. For that, she would have to go to the hospital. The question that now had to be answered by the patient was whether or not she wanted to go to the hospital. The lady asked if that was necessary. Jeff and John both indicated that she should make the decision herself. Preferably a little quickly, as the ambulance was still in the middle of the street, blocking access. The patient was clearly still not reassured and said she feared she had suffered a stroke. Jeff asked her to squeeze both his hands. He also tested the strength in both feet and asked if she would show teeth. The FAST test was negative. The patient was told that this test showed no abnormalities; no statement was made as to what diagnostic significance this then had.
The lady remained anxious and wanted to go to the hospital anyway. Jeff then connected the 12-lead cable and made a heart movie. The Lifepak 15 provided the ECG with a computer diagnostic that said it was a normal ECG with some interference that could affect the data interpretation. Both Jeff and John had had 3 hours of lecture on ECG interpretation and both felt incompetent to review the ECG. I noticed on the ECG that st-elevation was visible in the last complexes in V3-V5. The rest of the complexes in all leads were perfectly according to normal values. Because the isoelectric ECG line was also not straight in those last complexes I saw that it was interference by the movement of the patient that caused the elevations. I was not allowed to make any statements to the patient about that. Jeff inserted a venflon and John gave the lady two chewable tablets of Ascal. He determined blood sugar to be within normal values. John called the telemetry nurse at the hospital while Jeff drove the ambulance with flashing lights and a siren. I noticed that no one in Chicago looks up when an ambulance drives by. An ambulance with flashing lights and a siren is seen as if a city bus is passing by; the most normal thing in the world.
Arriving at the hospital, Jeff grabs a wheelchair. The lady is wheeled inside and taken to the triage nurse. After registration, she may join the crowded waiting room where the waiting time is at least three hours. John fills in all the data on his Panasonic Toughbook where also the measured vital signs of the Lifepak 15 are recorded via BlueTooth. He leaves a printout with the triage nurse.
Chicago Fire Department paramedic
==========
A case with a condition that was slightly more serious, described via the Dutch approach:
Notification:
Not responsive, collapsed in the living room, breathing is present.
On arrival; Patient Assessment Triangle (PAT):

• Appearance: Lying on back in the living room, anatomically normal position, moaning and with eyes squeezed shut. Moves head from left to right -Work of Breathing: rapid superficial breathing -Circulation to Skin: slightly pale skin color, not clammy. No major bleeding is visible.

Conclusion after PAT: worrisome situation, no scope-and-run scenario
==========
Primary survey according to ABCD method:

• A: Airway is clear, no loose objects in the mouth, no audible breathing
• B: Rapid, shallow breathing; 35/minute. Both thoracic halves rise symmetrically. Vesicular breath sounds audible on auscultation left and right.
• C: Well-filled, regular pulse palpable at the a.radialis, 98/minute. No major bleeding visible, no fractures of long pipe bones visible.
• D: E2M5V2, pupils PEARL, no signs of meningeal excitation.

==========
Specific anamnesis.
Heteroanamnesis via husband, Mrs. does not respond to being addressed.
After an altercation with her husband, she became increasingly oppressive, losing consciousness after several minutes. She complained of a pressing feeling in her chest with palpitations, which were not present before. She expressed the feeling that she was going to die. The oppressive feeling became worse and tingling developed in both arms. She also complained of tingling around her mouth. Breathing was rapid. According to her husband, at the time of loss of consciousness, she had a pale complexion, and her eyes turned upward. The breathing remained present after the loss of consciousness, the skin color did not change. No twitches were seen on arms or legs. She has not been traveling recently. Medical history:
Blank medication:

• none

Allergies:

• none

Diet:

• Does not eat pork. Last few days low appetite and ate little. The last meal was last night
• Physical examination
• General Cared for, a slightly skinny 38-year-old female, appearance older than calendar age.
• Blood pressure: left 117/75 mmHg; right 112/70. Pulse: 98 /min. Sat O2: 100%, temp 37.1 gr. Celsius tymp. Respiratory rate 35 /min. Weight 68 kg, height 1,60 m.

Head/neck:

• Eyes: moist conjunctiva, no redness eyelids.
• Nose: straight, no swellings visible, no pus, mucus, or blood visible. Nostrils are well permeable on both sides.
• Mouth: lips and corners of mouth clear, cheek mucosa clear, moist mucous membranes, cleaned teeth, no tongue abnormalities, no tongue bite visible, pharyngeal arches symmetrical at rest and on movement
• Glands Inspection: no swellings visible. No glands palpable: submental,submandibular, pre- and retro-auricular, occipital, anterior and posterior to m.sternocleidomastoidus.
• Thyroid: no swelling visible, symmetrical shape. Palpation: larynx/thyroid/ring cartilage; symmetrical, no swelling, no palpation pain. No enlargement of the thyroid gland.

Thorax:

• Inspection: shape symmetrical, no scars and retractions, slightly pale skin color.
• Palpation: Thorax well mobile and symmetrically retracting on breathing, no throbbing pain vertebrae.

Lungs:

• Percussion: sonorous percussion across all lung fields, normally mobile lung borders.
• Auscultation: VAG re=li, no side sounds.

Skin:

• Inspection: no hematomas, swelling, redness, erythema.

Abdomen:

• Inspection: slender abdomen, no venous markings. Pants are dry; no leakage of urine
• Auscultation: sparse peristalsis.
• Percussion: variable tympanic, lateral liver border thv 9th rib right
• Palpation: No muscle tension, no défense musculaire. Liver and spleen not palpable. No palpable resistances.

Peripheral vessels:

• Aa. carotis: pulsations re+/li+, souffles re-/li-
• Aa. radialis: pulsations re+/li+
• Aa. femoralis: pulsations re+/li+, souffles re-/li-
• Aa. tibialis posterior: pulsations re+/li+
• Aa. dorsalis pedis: pulsations re+/li+
• No edema or redness on legs
• Neurological examination
• Consciousness: decreased consciousness, Glasgow Coma Scale: E2M5V2 (opens eyes on pain stimulus, On supraorbital pain stimulus moves both hands to the site of pain stimulus, speaks unintelligibly, mumbles)
• No signs of meningeal stimulation: no reflective resistance when bending head in lying position and does not raise legs in the process, no neck stiffness.

Brain Nerves:

• N.I Smell: not tested
• N. II Vision: not tested
• N. III, IV, and VI: Pupils: isocuous, pupil response to light direct and indirect intact. No nystagmus.
• N.V. Facial sensibility: Corneal reflex intact.
• N.VII Facial motor skills: corner of the mouth on left slightly lower than right, cannot be instructed to puff up the cheeks or puff up the lips
• N. VIII Hearing: not tested
• N. IX and X not tested
• N. XI not tested
• N. XII not tested
• Motor skills: locates with both arms on supra-orbital pain stimulus
• Sensibility not tested

Summary:
A 38-year-old female with blank history. Now experiencing a sudden drop in consciousness with dyspnea and chest pain after a severe emotional event. Vital signs are within normal range except for a respiratory rate of 35 per minute. The left corner of the mouth appears to be drooping.
==========
Differential diagnoses.
1 Panic attack
DSM-IV criteria panic attack
A circumscribed period of intense fear or feeling of unease, in which four (or more) of the following symptoms occur suddenly, reaching a maximum within ten minutes:

1. Palpitations, pounding heart, or accelerated heart action
2. Sweating
3. Shaking or trembling
4. The feeling of breathlessness or suffocation
5. Gasping for breath
6. Chest pain or discomfort
7. Nausea or abdominal discomfort
8. The feeling of dizziness, unsteadiness, lightheadedness, or fainting
9. Derealization (feeling of unreality) or depersonalization (feeling detached from oneself)
10. Fear of dying
11. Paresthesias (numbness or tingling sensations)
12. Hot flashes or chills Until a few years ago, when these symptoms were encountered, they were referred to as "hyperventilation syndrome." The assumption was that improper breathing caused an imbalance of carbon dioxide/oxygen in the blood, thus causing the symptoms. With the disappearance of scientific evidence for the underlying pathogenesis of hyperventilation syndrome, the diagnosis of "panic attack" has come more to the forefront. However, hyperventilating is often present during a panic attack as an accompanying symptom. Due to the lowered CO2 level in the blood, sensations such as tingling in fingers, hands, and lips occur. This often includes pain or a feeling of pressure in the chest; in extreme cases, cramps of the fingers in an extended position.

Argues for the diagnosis:

• clear triggering factor
• Symptoms occur within 10 minutes
• Palpitations
• Perspiration
• The feeling of breathlessness or suffocation
• Pain or discomfort in the chest
• Feeling of dizziness
• Fear of death
• Paresthesias

2 Pulmonary embolism
A pulmonary embolism is a blockage of a pulmonary artery. It is usually caused by a blood clot (thrombus). The blood clot usually forms in the blood vessels of the legs or pelvis. Through the bloodstream, the blood clot is carried to the lungs.
Arguments for diagnosis include:

• acute onset of symptoms
• Occurrence of palpitations
• increased heart rate
• accelerated breathing
• feeling of tightness

Argues against the diagnosis:

• no pain associated with breathing
• no coughing or hemoptysis
• no sweating
• no suffering from calf pain, redness, or swelling of the lower leg
• Did not sit still for long periods of time during the past few days
• does not use birth control pills
• Does not smoke

3 CVA/TIA
Both ischemia and hemorrhage lead to acute focal neurological deficits. In addition, as a result of edema formation and mass effect of a hemorrhage, increased intracranial pressure may occur, giving rise to a loss of consciousness. The occurrence of this depends on the size and localization of the lesion.
For the diagnosis advocates:

• decreased consciousness
• at first sight, a drooping corner of the mouth

Argues against the diagnosis:

• moves both arms symmetrically in response to a pain stimulus
• Does not use blood thinners
• no evidence of trauma to the head.
• young age

4 Acute coronary syndrome
Acute coronary syndrome (ACS) includes acute myocardial infarction (AMI) and unstable angina pectoris (IAP) with symptoms at rest. Myocardial infarction is usually caused by a blood clot in a coronary artery that cuts off the supply of blood, which was already low, now completely. This can lead to heart failure, death, or life-threatening arrhythmias. If the myocardium does not receive enough oxygen and nutrition when a coronary artery is narrowed, chest pain can occur: angina pectoris.
For diagnosis advocates:

• oppressive chest pain,
• pale complexion
• dyspnea
• dizziness.

Argues against the diagnosis:

• Had no vegetative symptoms such as sweating, nausea, and vomiting.
• Never had chest pain before.
• No comorbidities such as diabetes present

5 Hypoglycemia
Hypoglycemia is an excessively low blood sugar accompanied by typical symptoms such as a feeling of hunger, trembling, tingling in the hands, feet, or lips, sweating, headache, blurred vision, and palpitations. Signs of severely lowered blood sugar are drowsiness, loss of consciousness, and eventually coma
Pre-diagnosis advocates:

• Eaten poorly in recent days
• Had increased glucose demand due to stress moment
• palpitations
• dizziness
• tingling in hands, feet, or lips

Against:

• not familiar with diabetes
• complaints arose within 10 minutes
• no headache as an omen
• These symptoms occur almost exclusively in diabetic patients who have injected too much insulin

Additional diagnostics
12-lead ECG:

• The purpose of taking an ECG is: observation and early recognition of cardiac arrhythmias, conduction disturbances, and ischemic heart disease that could cause a drop in consciousness in this case.
• A meta-analysis of 11 studies describes the testing properties of the ECG made outside the hospital in patients with chest pain. For the diagnosis of AMI (n = 4481), the sensitivity was 76% (95%-BI 54 to 89) and the specificity 88% (95%-BI 67 to 96). For the diagnosis of ACS (n = 4311), these figures were 68% (95%-BI 59 to 76) and 97% (95%- BI 89 to 92), respectively.
• A sensitivity of 97% to exclude 97% is high but not yet foolproof.
• When assessing the ECG, it is important to work systematically and to include the clinical presentation of the patient in the final working diagnosis.
• At the time the ECG was made, the heart rate had already dropped to 65/minute.

A systematic review of the ECG:
1: Heart rate is a sinus rhythm.
Features of normal sinus rhythm:

• A p top (atrial contraction) precedes the QRS complex
• Each p wave is followed by a QRS complex
• The rhythm is regular but varies slightly with respiration
• The frequency is between 60 and 100/minute.
• The maximum height of the p Summit is 2.5 mm in II and/or III
• The p top is positive in II and aVF, and biphasic in V1

----------
2: Heart rate is 65 beats per minute
----------
3: Conduction times:
PQ time: 0.12 seconds (Normal PQ time is between 0.12 and 0.20 seconds)
QRS time: 0.08 seconds (The ventricles normally depolarize within 0.10 seconds. If they take 0.12 seconds or longer, there is a conduction delay)
QT time: 0.38 seconds (The QT time indicates how long it takes for the ventricles to repolarize. The normal value for the QT time is less than 0.45 sec for men and less than 0.46 sec for women)
----------
4: Cardiac axis: Normal cardiac axis
Positive QRS deflection in lead I: the electrical activity points to the left (for the patient)
Positive QRS deflection in lead aVF: the electrical activity points downward.
A normal cardiac axis lies between -30 and +90 degrees.
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5: p-top morphology:
Height: 1mm, width 8mm, positive in II and aVF, biphasic in V1. The p-top is normal
Characteristics of a normal p top:

• The maximum height of the p top is 2.5 mm in II and/or III
• The width of the p top is normally less than 0.12 second
• The p top is positive in II and aVF, and biphasic in V1.

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6: QRS morphology:
The width of the QRS complex is 0.08 sec, there is no intraventricular conduction disorder. Q waves of 0.01 sec are visible in II, III, and aVF. However, these do not meet the criteria for pathological Q. A pathological Q should be 0.03 sec wide, in this case, there is a physiological q-wave.
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7: ST morphology:
The ST segment is isoelectric in all leads.
The ST segment represents ventricular repolarization: the cardiomyocytes are getting ready for the next cardiac action. It extends from the end of the QRS complex to the beginning of the T wave. This segment is normally isoelectric (at the baseline level).
The T tops are of the same polarity as the QRS complexes. A normal T wave top is congruent with the QRS complex and about 1/8th - 1/3rd as high as the QRS complex. Thus, there are no T wave top abnormalities here
The ECG of Mrs. Abdullah shows no abnormalities indicative of ischemia or ACS

Glucose measurement
Glucose levels are determined by finger prick and point-of-care glucose meter. Ms. Abdullah's blood glucose level is 5.7 mmol/l. Hypoglycemia is said to occur when the glucose level is 3.5 or lower. Glucose higher than 14 mmol/l is said to be hyperglycemia. In this case, the blood sugar is not abnormal and cannot be seen as a cause of the drop in consciousness.

End-tidal CO2 measurement
Using the LifePak 12 monitor as used by the Hollands Midden Regional Ambulance Service, it is possible to perform an end-tidal CO2 (ETCO2) measurement. The connector that is normally placed on the endotracheal tube can be placed between the lips of the patient. In this way, a capnogram is seen measuring the ETCO2 content in the exhaled air.
The first measured ETCO2 in Ms. Abdullah is 22 mmHg.
The normal value is between 35 and 45 mmHg.
The low ETCO2 value in combination with the high respiratory rate confirms the suspicion of hyperventilation without the need for metabolic compensation. If there were a normal or elevated ETCO2 value with this increased respiratory rate, there would be metabolic acidosis. When, for example, due to a severe kidney problem or abnormal blood sugar, the blood is too acidic (low pH), the lungs will try to excrete more CO2. This is because CO2 lowers the pH of the blood. By excreting more of this, the pH of the blood will increase and normalize.

Working diagnosis
Panic attack with hyperventilation. The heteroanamnesis in which the argument preceding the collapse was mentioned and the clinical picture at the time of finding give a high suspicion of a panic attack.
The anamnesis and physical examination found no evidence for a pathological/somatic explanation of the shortness of breath and the collapses. The measurement of the ETCO2 confirmed the low CO2 level which could cause somatic complaints.
The additional examination by ECG indicated no indication of cardiac problems at this time. The normal blood glucose level excludes hypoglycemia at this time. The (limited) neurological examination provides sufficient evidence at this time that no major cerebral ischemia is present. The at first glance drooping corner of the mouth cannot be properly objectified
Age is also an important predictor of the final diagnosis. In the age group 25 to 44 years, the final diagnosis of all patients presenting to the general practitioner with shortness of breath is respiratory in nature in 54%. In 13% of them it is a panic disorder and in almost none of them is there a cardiac cause.
To make the working diagnosis of a panic attack in this acute situation, therapy will have to be started to see if the symptoms disappear quickly. According to the LPA8 (national EMS protocol), the symptoms should resolve within 15 minutes of the arrival of the ambulance, otherwise, underlying pathology should still be considered. In the prehospital situation, no additional diagnostics are available to objectify this acute situation.

Prognosis
The prognosis of treatment for a panic attack is generally favorable. If the patient follows the instructions properly, the symptoms may disappear within 15 minutes.
A panic attack can fit within a panic disorder: recurrent, unexpected panic attacks. In older patients, there is a greater risk of a somatic condition explaining the symptoms, while the likelihood of a first anxiety/panic attack is lower in later life. Stay alert even in older patients with a known panic disorder: a new somatic condition may develop. When having an anxiety/panic attack, it is important that the attack is self-limiting. Research shows rebreathing has no added value compared to a calm approach with careful attention to the patient's symptoms.

Treatment plan
Most important starting point: if the symptoms have not completely disappeared within 15 minutes, then transport and transfer for further examination in the emergency room is necessary.

• A calm approach is essential in the treatment of a panic attack. Provide a low-stimulus environment: refer the family to another room, turn off radio and TV.
• Provide information about the origin of the symptoms: Anxiety enables the body to react by activation of the autonomic nervous system. The body is primed for a 'fight or flight' response, with accelerated heart rate and breathing, increased muscle tension, and sometimes panic.
• breathing exercises: The patient is well advised to breathe calmly, breathing in for three seconds each time and then breathing out for six seconds, counting in their thoughts. The end-tidal CO2 measurement can be used for this purpose. It encourages patients to breathe so calmly that the end-tidal CO2 level rises in the capnogram
• explain the vicious circle according to Clark, in which fear causes physical sensations that reinforce the fear of a somatic abnormality.
• After normalization of respiratory rate and decrease in symptoms (within 15 minutes) perform the complete neurological examination and tract anamnesis to exclude other causes.

After the family was sent out of the room, Ms. Abdullah was approached calmly yet directly. She was summoned to breathe calmly according to the technique described above. She had to be corrected regularly for this because she kept getting tachypneic whereby she let herself fall back into the panic attack, crying and moaning. After a few minutes, she reacted more adequately and dialogue could be started. In the conversation that followed, she indicated that she was suffering from tensions around housing and her financial situation. Within 15 minutes, the symptoms had subsided to the point that a calm conversation was possible. The complaints have now completely disappeared and she agrees with the decision to stay at home and to look at the problems and possible solutions together with the GP.