Syncope

This history refers to patients who have experienced a loss of consciousness on more than one occasion. What are some common conditions which might cause this?

Cardiovascular

• Palpitations (AF)
• Vasovagal reflex
• Postural hypotension

Looking at these differentials, the systems we are most interested in exploring during our specific systems review will be the neurological and cardiovascular systems. Remember, common things are common. Someone presenting with syncope is much more likely to have some form of vasovagal reflex, or a side effect of their blood pressure medication than epilepsy – but this is a diagnosis we do not want to miss.

Therefore in the presenting complaint, aside from asking all the OATES questions, it is necessary to ask about how the patient feels before and after. Epilepsy can be preceded by a prodrome and leads to postictal fatigue and symptoms, whereas a vasovagal reflex is usually sudden with fast recovery.

Introduction

• Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)?
• I just wanted to ask you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
• Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
• So, what has brought you in to see the doctor today?

(P) Presenting Complaint

• Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
• (Ask second screening question) – Ok, anything else?
• (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
• (Last screening question) – Are you sure that there is nothing else?
• (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain

• Lost consciousness – Ok, so you mentioned that you lost consciousness, can you tell me a little bit more?

• Dizziness – You also mentioned you felt a bit dizzy, what exactly do you mean by that?

(I) Ideas, Concerns, Expectations

• Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
• Are you particularly concerned about anything?
• What were you hoping to get out of the visit today?

(S) Systems Review

• (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.

Specific Systems Review

• Neurological:
  Have you experienced any headaches?
  Do you get any nausea/vomiting?
  Do you have any problems with your vision? Any double vision? Do you see any flashing lights?
  Have you got any weakness or loss of sensation in your arms or legs?

• Cardiovascular:
  Have you experienced any chest pain?
  Have you been feeling any palpitations?
  Have you got any shortness of breath?

General Systems Review: (Ask general questions to rule out red flags):

(Fever) Have you got a fever?

(Glands) Have you got any swollen glands?

(Weight) Have you noticed any weight loss?

(Appetite) Have you noticed any changes in your appetite?

(Bowels) Have you experienced any changes in your bowel movements?

(Waterworks) Are your waterworks all fine?

(Tired) Have you been feeling more tired than usual?

(Travel) Have you travelled anywhere recently?

(Night sweats) Do you wake up in the night drenched in sweat?

(Rash) Have you got any rashes?

(If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?

(P) Past Medical History

• And now, about your health in general, have you ever seen your doctor about something like this before?
• Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
• Have you ever had any surgeries?
• Have you ever been admitted into hospital before?

(F) Family History

• Is there any incidence of neurological conditions like epilepsy in your family?
• Are there any other conditions which run in your family?

(D) Drug History

• Are you currently taking any prescribed medication?
• Do you take anything else, over the counter?
• Do you have any allergies?

(S) Social History

• (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
• (Home) Do you live with any family or friends? Are you married? Do you have any children?
• (Independence) Would you say that you are fairly independent?

And now these are some questions that we ask everyone:

• Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
• Do you drink? (How much a week? And for how long?)​
• Is there any recreational drug use?