Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint: Syncope (fainting) or near syncope (feeling lightheaded or dizzy)
History of Present Illness:
Describe the most recent syncopal episode in detail:
Onset (sudden, gradual)
Duration of loss of consciousness (seconds, minutes)
Preceding symptoms (nausea, lightheadedness, palpitations)
Recovery (spontaneous, assistance needed)
Post-syncopal symptoms (confusion, weakness)
Witnessed or unwitnessed event
Ask about frequency of syncopal episodes and any recent changes.
Inquire about prodromal symptoms (warning signs before fainting).
Past Medical History:
Underlying medical conditions that may contribute to syncope (e.g., heart disease, neurological disorders, autonomic dysfunction)
Previous episodes of syncope or dizziness
Medication use (prescription and over-the-counter)
Allergies
Family History:
History of syncope, sudden cardiac death, or other relevant conditions in family members
Social History:
Smoking history
Alcohol or caffeine intake
Illicit drug use
Dehydration risk factors (e.g., excessive heat exposure, strenuous exercise)
Physical Exam:
Vital signs (heart rate, rhythm, blood pressure, orthostatic changes)
General examination findings (e.g., pallor, diaphoresis)
Neurological examination (orientation, mental status, cranial nerves, motor function)
Cardiovascular examination (heart sounds, murmurs, jugular venous distention)
Additional Tests (as indicated):
Electrocardiogram (ECG) to assess heart rhythm and conduction abnormalities
Electrolytes (potassium, magnesium) to check for imbalances
Complete blood count (CBC) to rule out anemia or infection
Tilt table test to provoke syncope in a controlled setting (if clinically indicated)
Holter monitor (continuous ECG recording for 24-48 hours) to identify arrhythmias
Head imaging (CT scan or MRI) to rule out neurological causes (if indicated)
Assessment:
Type of syncope (if possible):
Neurocardiogenic (vasovagal) syncope
Orthostatic syncope
Situational syncope (e.g., cough syncope, micturition syncope)
Cardiac syncope (caused by heart rhythm abnormalities)
Other causes (e.g., neurological, metabolic)
Severity of syncope: Based on frequency, duration of loss of consciousness, and risk of injury
Risk factors for future syncopal episodes
Plan:
Address underlying medical conditions that may be contributing to syncope.
Initiate or adjust medications as needed to prevent syncope.
Lifestyle modifications:
Increase fluid intake
Avoid dehydration triggers (heat, strenuous exercise)
Gradual rise from sitting or lying position
Compression stockings (if orthostatic hypotension)
Patient education:
Recognizing prodromal symptoms and warning signs
Maneuvers to prevent syncope (e.g., leg crossing)
Importance of staying hydrated
Activities to avoid (if applicable)
Follow-up plan: Schedule outpatient appointments to monitor response to treatment and assess for further testing needs.
Disposition:
Discharge home with instructions and follow-up plan
Admission to inpatient service for further evaluation and treatment (if indicated)
Additional Notes:
Document any additional relevant information not covered in the above sections.