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History Taking Format for Neurogenic Syncope

1. Patient Details

  • Name, Age, Sex, Occupation, Address

2. Presenting Complaint

  • Brief description of the episode(s) of loss of consciousness (LOC) or fainting

  • Duration and frequency of episodes

3. History of Presenting Illness

  • Description of the Event:

    • Ask the patient (and any witnesses) to describe exactly what happened before, during, and after the episode.

    • Was there a warning (aura, visual changes, dizziness, palpitations, nausea, sweating, blurred vision, lightheadedness)?

    • What was the patient doing at the time (standing, sitting, lying, during urination/defecation/coughing, emotional stress, pain, after exercise)?

    • Was there any trigger (sudden standing, prolonged standing, heat, pain, fear, emotional stress, sight of blood)?

  • Onset and Duration:

    • Sudden or gradual onset?

    • How long did the episode last (seconds, minutes)?

    • Was the loss of consciousness complete or partial?

  • Position:

    • Was the patient standing, sitting, or lying down?

    • Did the episode occur on standing up quickly (orthostatic hypotension) or in the supine position?

  • Prodrome (Preceding Symptoms):

    • Dizziness, visual changes, tinnitus, nausea, sweating, palpitations, weakness, aura, confusion

  • During the Episode:

    • Was there loss of muscle tone (fall to ground)?

    • Any abnormal movements (twitching, jerking, tonic-clonic activity)?

    • Tongue biting (especially lateral), incontinence (urine or stool), cyanosis

    • Was the patient pale or flushed?

  • Post-event (Recovery):

    • How quickly did the patient recover? (Immediate, within seconds/minutes, or prolonged confusion/drowsiness)

    • Any lingering weakness, confusion, headache, or neurological deficit?

  • Witness Account:

    • If available, ask someone who observed the episode for their description.

4. Past Medical History

  • Previous similar episodes

  • History of neurological disorders (epilepsy, migraine, stroke, TIA, Parkinson’s disease)

  • Cardiovascular history (arrhythmias, heart disease, hypertension)

  • Diabetes, metabolic or endocrine disorders

5. Drug History

  • All current and recent medications (including over-the-counter, herbal, and recreational drugs)

  • Any recent changes in medication or dosage

  • Medications known to cause hypotension or syncope (antihypertensives, diuretics, antidepressants, antipsychotics, antiarrhythmics)

6. Family History

  • Family history of syncope, epilepsy, sudden cardiac death, arrhythmia, or neurological disorders

7. Social and Personal History

  • Alcohol, tobacco, or illicit drug use

  • Occupational exposures

  • Recent travel or infectious contacts

  • Sleep patterns, stress, and psychological factors

8. Systemic Enquiry

  • Fever, weight loss, night sweats (infection, malignancy)

  • Chest pain, palpitations, breathlessness (cardiac causes)

  • Visual, speech, or swallowing disturbances

  • Gait or balance problems

  • Headache, neck pain, or recent trauma

Special Notes:

  • Always clarify if the episode was true syncope (transient, self-limited loss of consciousness with spontaneous recovery and loss of postural tone)67.

  • Differentiate from seizure, psychogenic events, metabolic causes, and cardiac syncope using key historical features235678.

  • Use mnemonics like the “five Ps” (Precipitant, Prodrome, Position, Palpitations, Post-event) and “five Cs” (Colour, Convulsions, Continence, Cardiac problems, Cardiac death in family) to structure your questions28.

Case History

Personal Details:
Mr. Suresh Patel, 78-year-old male, retired accountant

Presenting Complaint:

  • Recurrent episodes of transient loss of consciousness (syncope) for 4 months

History of Presenting Illness:
Mr. Patel reports experiencing multiple episodes of fainting over the last 4 months. The episodes typically occur when he stands up from a sitting or lying position, often after a few minutes of standing. He describes a sensation of dizziness and lightheadedness before losing consciousness. According to his wife, he looks pale and unsteady just before the episodes, and the loss of consciousness lasts only a few seconds, with rapid and complete recovery. There is no tongue biting, incontinence, or confusion after the episodes.

He denies any chest pain, palpitations, shortness of breath, or visual disturbances before or after the events. There is no history of trauma, fever, recent infection, or new medications. The frequency of the episodes has increased recently, now occurring several times per week.

Mr. Patel has a history of Parkinson’s disease, diagnosed 5 years ago, and takes regular levodopa/carbidopa. He has no history of diabetes, coronary artery disease, or arrhythmia. Previous cardiac workup, including ECG and echocardiogram, was unremarkable.

Past Medical History:

  • Parkinson’s disease (5 years)

  • No diabetes, hypertension, or heart disease

Drug History:

  • Levodopa/carbidopa

  • No antihypertensives, diuretics, or other medications

Family History:

  • No family history of syncope, sudden cardiac death, or neurological disorders

Personal and Social History:

  • Non-smoker, does not consume alcohol

  • Lives with spouse, independent in daily activities

Systemic Enquiry:

  • No fever, weight loss, night sweats

  • No chest pain, palpitations, or breathlessness

  • No visual, speech, or swallowing disturbances

Case Summary

A 78-year-old male with Parkinson’s disease presents with recurrent, brief syncopal episodes on standing, preceded by lightheadedness and pallor, with rapid recovery and no post-ictal confusion. Cardiac evaluation is unremarkable.

Differential Diagnosis

  1. Neurogenic Orthostatic Hypotension (nOH) due to Autonomic Dysfunction

    • Most likely, given the history of Parkinson’s disease, orthostatic triggers, and absence of cardiac findings6.

  2. Vasovagal (Neurocardiogenic) Syncope

    • Can present similarly, but typically has clear triggers (pain, emotional distress, prolonged standing) and may occur in younger individuals15.

  3. Cardiac Syncope (Arrhythmia, Structural Heart Disease)

    • Less likely due to normal cardiac workup and lack of cardiac symptoms23.

  4. Seizure

    • Unlikely due to absence of tonic-clonic activity, tongue biting, incontinence, or post-ictal confusion34.

  5. Medication-induced Hypotension

    • Unlikely as the patient is not on antihypertensives or diuretics.

1. What is syncope?
Syncope is a sudden, transient loss of consciousness and postural tone, with spontaneous and complete recovery, usually due to transient global cerebral hypoperfusion.

2. What is neurogenic syncope?
Neurogenic syncope refers to loss of consciousness due to neurological causes, most commonly autonomic dysfunction leading to orthostatic hypotension, but also includes conditions like seizures and certain brainstem lesions.

3. What are the main neurological causes of syncope?

  • Neurogenic orthostatic hypotension (autonomic failure)

  • Vasovagal (neurocardiogenic) syncope

  • Carotid sinus hypersensitivity

  • Seizures (though technically not true syncope, but may mimic it)

  • Brainstem TIA or stroke

4. How does neurogenic orthostatic hypotension present clinically?
It presents as dizziness, lightheadedness, or fainting upon standing, often with rapid recovery, and is commonly seen in disorders like Parkinson’s disease, multiple system atrophy, or diabetic autonomic neuropathy.

5. What is the difference between syncope and seizure?
Syncope is due to transient cerebral hypoperfusion and is usually brief, with rapid and complete recovery, and no post-ictal confusion. Seizures may have tonic-clonic movements, tongue biting, incontinence, and post-ictal confusion or drowsiness.

6. What is the typical prodrome in neurogenic syncope?
Patients may experience dizziness, visual dimming, lightheadedness, nausea, or sweating before losing consciousness.

7. What is orthostatic hypotension?
Orthostatic hypotension is a sustained drop in systolic blood pressure of ≥20 mmHg or diastolic BP of ≥10 mmHg within 3 minutes of standing.

8. What neurological diseases are commonly associated with neurogenic orthostatic hypotension?

  • Parkinson’s disease

  • Multiple system atrophy

  • Pure autonomic failure

  • Diabetic autonomic neuropathy

9. How do you differentiate neurogenic from cardiac syncope?
Neurogenic syncope is typically triggered by standing and has a prodrome; cardiac syncope may occur suddenly without warning and is often associated with exertion or arrhythmias.

10. What investigations are helpful in evaluating syncope?

  • Orthostatic blood pressure measurement

  • ECG and cardiac monitoring

  • Tilt-table test

  • Autonomic function tests

  • Blood glucose

  • EEG if seizure is suspected

11. What is the role of the tilt-table test?
The tilt-table test helps to reproduce symptoms and document blood pressure and heart rate changes with postural changes, aiding in the diagnosis of orthostatic hypotension or vasovagal syncope.

12. What is carotid sinus hypersensitivity?
It is a condition where pressure on the carotid sinus (e.g., turning the neck, wearing a tight collar) triggers excessive vagal response, leading to bradycardia, hypotension, and syncope.

13. What are the management strategies for neurogenic orthostatic hypotension?

  • Non-pharmacological: Increase salt and fluid intake, slow position changes, compression stockings

  • Pharmacological: Fludrocortisone, midodrine, droxidopa

  • Adjusting medications that may worsen hypotension

14. What is the significance of post-ictal confusion?
Post-ictal confusion is typical of seizures, not syncope, and helps in differentiating between the two.

15. What is vasovagal syncope and how does it differ from neurogenic orthostatic hypotension?
Vasovagal syncope is a reflex-mediated syncope triggered by emotional distress, pain, or prolonged standing, while neurogenic orthostatic hypotension is due to autonomic failure and occurs primarily on standing.

16. What is the importance of witness accounts in syncope evaluation?
Witnesses can provide crucial information about the patient’s appearance, movements, duration of unconsciousness, and recovery, which helps differentiate syncope from seizures or other causes.

17. Why is it important to ask about tongue biting and incontinence?
Tongue biting (especially lateral) and incontinence are more suggestive of a seizure than syncope.

18. What are the risks associated with recurrent syncope in the elderly?
Increased risk of falls, fractures, head injury, and reduced quality of life.

19. What is pure autonomic failure?
A neurodegenerative disorder characterized by isolated autonomic dysfunction, leading to neurogenic orthostatic hypotension without other features of Parkinsonism or cerebellar signs.

20. Why is medication review important in syncope?
Certain medications (antihypertensives, diuretics, dopaminergic drugs) can worsen orthostatic hypotension and increase the risk of syncope.