Clinical features

Ask about

• the syncopal episode and situation ^d, particularly: 
  • any nausea or vomiting before collapse ^a  
  • if the syncopal episode occurred on exertion ^b  
  • any tongue biting ^c  
  • post-collapse disorientation ^c  
  • 'blueness' if collapse observed ^c  
    
• when the patient last ate ^a  
• any cardiovascular disease, particularly 
  • known arrhythmias ^a  
  • heart failure ^a  
  • ischaemic heart disease ^a  
  • aortic stenosis ^d
    
• chest pain ^d
• previous episodes of syncope ^a  or seizures ^d
• previous psychiatric problems ^c  
• current medication use ^c 
• family history of unexplained syncope or sudden death ^c  

• cardiovascular causes 
  • an irregular ^b  or slow-rising pulse ^b  
  • apical-carotid delay ^b  
    • No other clinical features usefully diagnose or exclude arrhythmias.
  • heart murmurs particularly aortic stenosis ^b  
    • listen for a reduced or absent second heart sound, or a fourth heart sound
    • listen for a murmur loudest in late systole and radiating to the right carotid
      
• injuries
  
• neurological causes
  • decreased level of consciousness ^d and any focal neurological signs ^d
    
• other causes 
  • carotid sinus hypersensitivity 
    • Perform carotid sinus massage^d - it is safe ^b  
  • orthostatic hypotension ^b