History taking

• Symptoms and signs

Introduction

Detailed history-taking is of paramount importance to establish a diagnosis in patients with transient loss of consciousness (T-LOC); in particular to distinguish syncope from other causes of TLOC, especially epilepsy (Hoefnagels et al., 1991; Sheldon et al., 2002; Colman et al., 2004, Thijs et al., 2008b). In this context, TLOC is the term used to describe a nontraumatic, short-lived, transient loss of consciousness with spontaneous recovery, and syncope is defined as TLOC due to cerebral hypoperfusion (Brignole et al., 2004; Thijs et al., 2004).

History taking is of paramount importance to distinguish the various forms of syncope. Obtaining diagnostic clues often requires assessing as many events as possible to search for patterns of common features. The circumstances immediately prior to the attack often suggest a specific etiology in syncope, much more so than in epilepsy. Obtaining a sequential record of details, beginning with the setting of the event, any provocations or triggers, the clinical symptoms and signs of the prodromal phase, progressing through the period of actual unconsciousness (necessitating eyewitness descriptions), up to and including recovery are all crucial elements of the interview (Weiss 1935; Sharpey-Schafer, 1956; Gastaut, 1974; Stephenson,1990; Thijs et al., 2008b).

Pattern recognition in the patient’s history by the attending physician aids to correctly diagnose situational syncope. Listening and questioning ( – the proces known as “narrative medicine” (Haidet & Paterniti, 2003, BMJ book) is therefore directed towards the detection of typical triggers and predisposing factors that elicit situational syncope. It is difficult to take an intelligent history, conduct a proper physical examination, or explain the occurrence to a worried patient without knowledge of the mechanisms involved Sharpey Schafer