Comprehensive History and Physical Examination Template for Syncope
A thorough history and physical examination is the most critical component of syncope evaluation, determining the cause in most cases and guiding appropriate management to reduce morbidity and mortality. 1
Chief Complaint
Patient presents with syncope, defined as an abrupt, transient, complete loss of consciousness with inability to maintain postural tone, followed by rapid and spontaneous recovery.
History of Present Illness
Event Description
- Timing and frequency: When did the episode(s) occur? How many episodes? First-time event or recurrent?
- Position at onset: Standing, sitting, supine, or during position change
- Activity at onset: Rest, exertion, during or immediately after exercise, specific activities (coughing, micturition, defecation, swallowing)
- Environmental factors: Hot environment, crowded space, emotional stress, pain, medical setting
- Prodromal symptoms:
- Visual changes (darkening vision, tunnel vision, loss of color vision)
- Auditory changes (sounds becoming distant, buzzing, ringing)
- Nausea, diaphoresis, pallor (suggestive of reflex syncope)
- Palpitations (suggestive of arrhythmia)
- Shoulder/neck pain in "coat hanger" pattern (suggestive of orthostatic hypotension)
During the Event (from witness account)
- Type of collapse: Gradual (suggestive of syncope) vs. sudden (may indicate cardiac cause)
- Duration of unconsciousness: Brief (<30 seconds) suggests syncope; prolonged (>1 minute) suggests alternative diagnosis
- Presence and nature of movements: Few, asymmetrical movements suggest syncope; many, symmetrical movements suggest seizure
- Color changes: Pallor, cyanosis
- Breathing pattern: Normal, stertorous (snoring)
- Eye position: Open or closed
Post-Event
- Recovery pattern: Rapid and complete (typical for syncope) vs. prolonged confusion (suggests seizure)
- Post-event symptoms: Fatigue, nausea, headache, muscle aches
- Injuries sustained: Tongue biting (lateral suggests seizure; tip suggests syncope), urinary incontinence, trauma
Medical History
- Cardiac conditions: Structural heart disease, coronary artery disease, arrhythmias, congenital heart disease
- Neurological conditions: Seizure disorder, stroke, TIA, autonomic dysfunction
- Metabolic disorders: Diabetes, adrenal insufficiency
- Psychiatric history: Anxiety, depression, panic disorder
Medication Review
- Complete list of medications, including:
- Antihypertensives (especially diuretics, beta-blockers, alpha-blockers)
- Antiarrhythmics
- QT-prolonging medications
- Vasodilators
- CNS medications (antidepressants, antipsychotics)
- Recent medication changes or missed doses
Family History
- Sudden cardiac death, especially in young relatives (<50 years)
- Inherited cardiac conditions (long QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy)
- Family history of syncope
Social History
- Alcohol use
- Recreational drug use
- Sleep patterns
- Recent changes in fluid or food intake
Physical Examination
- Vital signs: Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation
- Orthostatic vital signs: Measure BP and HR supine, immediately upon standing, and after 3 minutes standing
- Orthostatic hypotension defined as ≥20 mmHg drop in systolic BP or ≥10 mmHg drop in diastolic BP 1
- Cardiac examination: Heart rate and rhythm, murmurs, gallops, rubs
- Neurological examination: Mental status, cranial nerves, motor/sensory function, coordination, reflexes
- Carotid examination: Presence of bruits (contraindication for carotid sinus massage)
Risk Stratification Elements
High-risk features (suggesting cardiac syncope):
- Age >60 years
- Male sex
- Known cardiac disease
- Brief or absent prodrome
- Syncope during exertion
- Syncope in supine position
- Low number of episodes (1-2)
- Family history of sudden cardiac death
- Abnormal cardiac examination 1
Low-risk features (suggesting reflex syncope):
- Younger age
- No known cardiac disease
- Syncope only in standing position
- Clear positional trigger
- Typical prodrome (nausea, warmth, diaphoresis)
- Situational triggers (cough, laugh, micturition, defecation)
- Frequent recurrence with similar characteristics 1
Initial Diagnostic Impression
- Suspected etiology based on history and examination findings:
- Reflex syncope (vasovagal, situational, carotid sinus)
- Orthostatic hypotension (neurogenic, volume depletion, medication-induced)
- Cardiac syncope (arrhythmia, structural heart disease)
- Unexplained syncope
Plan
- 12-lead ECG (required for all patients with syncope) 1
- Additional testing based on suspected etiology
- Disposition (outpatient follow-up vs. hospitalization) based on risk stratification
Common Pitfalls to Avoid
- Failing to obtain witness accounts
- Incomplete medication review
- Omitting orthostatic vital signs
- Misinterpreting seizure-like activity (can occur in both cardiac and neurological causes)
- Overlooking subtle cardiac findings
- Neglecting age-specific considerations 2