What is the history of present illness (HPI) for a patient presenting with syncope?

From the Guidelines

The history of present illness (HPI) for syncope should include a detailed account of the syncopal episode, focusing on onset, duration, and associated symptoms, as outlined in the 2009 European Heart Journal guidelines 1. When evaluating a patient with syncope, it is essential to begin by documenting when the episode occurred, whether there were any prodromal symptoms such as lightheadedness, nausea, diaphoresis, visual changes, or palpitations. Note the patient's position before syncope (standing, sitting, or lying down) and any positional changes that preceded the event. Include any potential triggers like prolonged standing, emotional stress, pain, micturition, defecation, coughing, or swallowing. Document the duration of unconsciousness, whether the patient experienced any seizure-like activity, tongue biting, or urinary incontinence, and their condition upon regaining consciousness including any confusion, weakness, or focal neurological deficits. Some key points to consider in the HPI include:

• Position and activity before the episode
• Presence of prodromal symptoms
• Duration of unconsciousness
• Presence of seizure-like activity or other associated symptoms
• Condition upon regaining consciousness
• Similar previous episodes and their frequency
• Relevant medical history, including cardiac conditions, arrhythmias, structural heart disease, neurological disorders, and medication use
• Recent changes in medications, alcohol consumption, or inadequate food or fluid intake As noted in the 2006 Circulation journal article 2, a meticulous history is crucial in evaluating the patient with syncope, and the process of evaluating the history, physical examination, and ECG should also include assessment of the medication list for agents associated with proarrhythmia. Additionally, the 2006 Journal of the American College of Cardiology article 3 highlights the importance of various aspects of the history in establishing the diagnosis, including the observations of onlookers and the occurrence of tonic-clonic, seizurelike activity. By taking a comprehensive history, healthcare providers can distinguish between cardiac, neurological, or vasovagal causes of syncope, guiding appropriate diagnostic workup and management.

From the FDA Drug Label

Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated. The History of Present Illness (HPI) for syncope related to midodrine use should include:

• Onset and duration of syncope
• Associated symptoms, such as dizziness, cardiac awareness, or pulse slowing
• Timing of syncope in relation to midodrine administration
• Presence of other medications that may contribute to bradycardia or hypertension, such as cardiac glycosides, beta blockers, or vasoconstrictors 4 Key points to consider:
• Bradycardia may occur with midodrine use, increasing the risk of syncope
• Concomitant medications may enhance or precipitate bradycardia or hypertension
• Patient education is crucial to recognize and report symptoms of supine hypertension and bradycardia 4

From the Research

History of Presenting Illness (HPI) for Syncope

The HPI for syncope is crucial in determining the underlying cause of the condition. According to 5, the classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic, and reflex (neurally mediated) mechanisms.

• The patient's history should include information about the onset of symptoms, duration, and any triggers or precipitating factors.
• A thorough history and physical examination, including orthostatic assessment, are crucial for making the diagnosis, as stated in 6.
• The patient's medical history, including any previous episodes of syncope, should be obtained to identify any potential underlying conditions that may be contributing to the syncope.

Key Components of HPI for Syncope

The HPI for syncope should include the following key components:

• Description of the syncopal episode, including the duration and any associated symptoms such as dizziness, lightheadedness, or palpitations.
• Any triggers or precipitating factors, such as changes in position, emotional stress, or certain activities.
• Any underlying medical conditions, such as heart disease, hypertension, or diabetes.
• Any medications the patient is currently taking, as some medications can contribute to syncope, as mentioned in 5.

Importance of HPI in Syncope Diagnosis

The HPI is essential in diagnosing the underlying cause of syncope. According to 7, a careful, well-conducted medical history focused on the suspected syncopal event is crucial for the diagnosis. The HPI can help identify potential causes of syncope, such as cardiac arrhythmias, orthostatic hypotension, or reflex syncope.

• The HPI can also help determine the risk of major cardiovascular events or sudden cardiac death, as stated in 7.
• A thorough HPI can help guide further evaluation and management of the patient, including the need for additional testing or referral to a specialist, as mentioned in 5 and 6.