Syncope history

Question 1

What are the differentials for syncope?

Answer 1

1. Cardiogenic
2. Seizure
3. Situational syncope
4. Postural hypotension
5. Vasovagal syncope

Question 2

What is a cariogenic syncope?

Answer 2

This refers to collapse secondary to a period of compromised cardiac output which stems from heart disorders such as valvular disease, arrhythmias, or acute coronary syndromes.

Question 3

What are the key features of cariogenic syncope?

Answer 3

The key symptoms to enquire about in the “before” section of the history are chest pain, breathlessness, and palpitations. If any of these were experienced, serial ECGs or 24/72h monitoring, with high sensitivity troponins is essential

If there is any specific family history of sudden cardiac death, an echocardiogram is also essential to evaluate for structural heart diseases such as hypertrophic obstructive cardiomyopathy (HOCM) and arrhythmogenic right ventricular dysplasia (ARVD)

Question 4

What is a seizure?

Answer 4

A seizure is a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness

Question 5

What are the key features of seizure syncope?

Answer 5

Typically, patients experience either no warning symptoms, very mild visual or olfactory aura, or phenomena such as deja vu

Following this, they typically lose consciousness, experience rigid tonicity, following by violent myoclonic jerks. An ictal cry may also occur. During a seizure, patients often bite their tongue (laterally) and can experience urinary or faecal incontinence. These may only be noticed by a patient in the period following a seizure

Seizures may self-terminate, but often also need pharmacological termination

Finally, a post-ictal state where patients feel drowsy, confused and myalgic is common

Question 6

What are common causes of a seizure?

Answer 6

• Structural - brain tumour, abscess
• Vascular - ischemic stroke, intracranial haemorrhage
• CNS infection
• Metabolic - hypoxia, hypoglycemia, hyponatraemia, hypernatraemia, hypercalcaemia, uraemia, hepatic encephalopathy, eclampsia
• Drug intoxication - anti-depressants, anti-psychotics, cocaine
• Drug withdrawal - alcohol, barbiturates and benzodiazepines
• Primary epilepsy disorders

Question 7

What causes situational syncope?

Answer 7

Micturition, defecation, and prolonged coughing can all stimulate vagal responses which result in syncope

Carotid sinus hypersensitivity can also manifest as syncope during activities like shaving, where the carotid sinuses are manually massaged, an act which too can instigate a strong vagal response

Question 8

What are key features about postural syncope?

Answer 8

Identified in the history by noting a collapse occurring following a stand from a sitting or lying position, and a period of lightheadedness

Commonly occurs in those on anti-hypertensives or anti-cholinergic medications, or those with autonomic dysfunction such as parkinsonian disorders.

Question 9

What causes vasovagal syncope

Answer 9

This is characterised by the ‘3 Ps’ which are posture (or prolonged standing) provoking factors such as pain or fear, and prodromal symptoms which most commonly include light-headedness, nausea and feeling hot or sweaty.

Question 10

What are key features about vasovagal syncope?

Answer 10

In vasovagal syncope, loss of consciousness is transient and typically lasts for less than a minute. Mild myoclonic jerks can be observed, but behaviours like the ictal cry, body rigidity and limb clonus are not. Individuals also tend to recover and feel normal again within a few minutes.

Typically, there will be no positive examination or investigative findings.

Question 11

How would you structure a syncope presenting complaint?

Answer 11

1. Before
2. During
3. After

Question 12

What questions would you ask to understand what happened before syncope?

Answer 12

1. Asks what they were doing prior to the collapse
2. Asks about any symptoms immediately preceding the collapse
3. Asks if anyone witnessed the collapse

Question 13

What questions would you ask to understand what happened during syncope?

Answer 13

1. Asks about loss of consciousness
2. Asks if they bit their tongue and if so, where
3. Asks if there was unintentional urinary or faecal incontinence
4. Asks if they incurred any injuries to the head or any other body part

Question 14

What questions would you ask to understand what happened after syncope?

Answer 14

1. Asks how they felt when they regained consciousness
2. Asks how long it took before they felt normal again
3. Asks if they were under the influence of any substances at the time
4. Asks if this is the first such episode of collapse and if not, how did this compare to previous episodes

Question 15

What questions would you ask about the systems review as part of a syncope history? (muscles, cardiac, malignancy, headaches, bleeding)

Answer 15

1. Asks about muscle weakness
2. Asks about altered sensation, e.g. numbness, paraesthesiae
3. Asks about visual symptoms
4. Asks about chest pain
5. Asks about palpitations
6. Asks about breathlessness
7. Asks about fevers
8. Asks about recent unintentional weight loss
9. Asks about recent night sweats
10. Asks about morning headaches
11. Asks about headaches which worsen on coughing, sneezing, or leaning forward
12. Asks about any recent bleeding, e.g. urine, heavy periods, rectal bleeding, etc

Question 16

What is important about the PMH during a syncope history?

Answer 16

1. Asks about existing medical conditions
2. Asks specifically about epilepsy
3. Asks specifically about heart conditions, e.g. irregular heart rhythms
4. Asks about previous surgeries

Question 17

What is important about the past drug history during a syncope history?

Answer 17

1. Asks if they take any regular or over the counter medications
2. Asks if they have any allergies

Question 18

What is important about the family history during a syncope history?

Answer 18

1. Asks if any medical conditions run in the family

2. Asks specifically about sudden deaths due to heart conditions within the family

Question 19

What is important about the social history during a syncope history?

Answer 19

1. Asks about current living situation
2. Asks about current employment
3. Asks about smoking history
4. Asks about alcohol consumption
5. Asks about recreational drug use
6. Asks about any recent travel