Emergency Medicine: Syncope History taking Pointer

Table 2

History taking pointers in syncope

Features from history	Suggested diagnosis
The “5Ps”
Precipitants:
Warm or  crowded environments, pain, emotional distress, fear, exercise, dehydration (as a result of drugs or illness), specific activities (coughing, laughing, micturition, eating)	Vasovagal syncope, orthostatic hypotension, situational syncope
Head  movements, tight collars, shaving	Carotid sinus syndrome
During  exercise, or no obvious precipitant	Arrhythmia, structural heart disease
Prodrome:
Light  headedness, dizziness, blurred vision	Vasovagal syncope, orthostatic hypotension
Nausea,  sweating, abdominal pain	Vasovagal syncope
None	Vasovagal syncope in older people, cardiac syncope
Chest pain,  shortness of breath, or no prodrome	Cardiac syncope
Déjà vu,  jamais vu	Seizure
Palpitations	Arrhythmia
Position:
Prolonged  standing	Vasovagal syncope, orthostatic hypotension
Sudden changes  in posture	Orthostatic hypotension
Supine	Arrhythmia, structural heart disease
Post-event phenomena:
Nausea,  vomiting, fatigue	Vasovagal syncope
Immediate  complete recovery	Any cause, common in arrhythmia
Appearance:
Pallor,  sweating	Syncope rather than seizure
“Blue”	Seizure
Abnormal movements:
Minor  twitching but floppy while unconscious (myoclonic jerks)	Syncope (any cause)
Rhythmic  jerking preceded by rigidity or abnormal posturing	Seizure
Eyes:
Open	Seizure or syncope
Closed	Pseudoseizure, psychogenic syncope
Mental state:
Prolonged  confusion, retrograde amnesia	Seizure
Transient  disorientation	Common in neurally mediated syncope
Amnesia  concerning loss of consciousness	Neurally mediated syncope in older people
Other:
Incontinence	Non-specific, but unusual in syncope
Tongue  biting	Seizure
Chronic medical problems
Pre-existing heart disease	Cardiac syncope
Diabetes, Parkinson’s disease, Parkinson plus syndromes, alcohol dependence, renal replacement therapy	Orthostatic hypotension
Hypertension	Drug related neurally mediated syncope, orthostatic hypotension
Family history of sudden cardiac death
	Hereditary long and short QT syndromes, Brugada, arrhythmogenic right ventricular dysplasia, structural heart disease