Workup For Syncope in Primary Care
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Show notes:
Your patient passed out for no obvious reason, so their family insisted that they see their PCP. Now they’re waiting in your exam room, and you need a roadmap to determine what happened, what is going on, and how we got here.
If even thinking about a patient with syncope makes you feel a little lightheaded yourself, you are in the right place.
Workup for Syncope in Primary Care for New NPs
Let’s talk about how to approach the visit for the patient with syncope in primary care, why you will want to work backward to assess this patient, the four main categories of syncope, and more.
✅ Things that can look like syncope – but aren’t
✅ Specific, targeted questions to ask the patient with syncope
✅ Medications that can play a role in a syncopal episode
✅ Why family history is important in syncope, and which questions to ask
✅ Red flags in a patient with syncope
Syncope can feel like a huge problem to solve as a new grad. With some guidance and plenty of practice, it gets easier to narrow down. Having a framework to approach the visit will boost your confidence and make these visits more manageable.
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Well, hey there, it's Liz Roar from Real World NP and you are watching the Real World NP YouTube
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channel. We make weekly episodes to help save you time, frustration, and help you take the best
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care of your patients. Hello! This episode we are going to be talking about syncope.
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So the way I want to approach this video is thinking about being a nurse practitioner
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in primary care. Somebody comes in and their chief complaint is syncope, right? So I want to focus on,
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I've talked about this in a couple of videos, but the longer you are in practice as a nurse practitioner
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and the larger the knowledge base you develop, when you go into a visit you start with the
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differentials in the front of your mind and you work your way backwards. So I want to work
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this episode in that way, acknowledging that if you are a new grad or student listening to this,
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this is not going to be the way that it is for you in primary care. The hack of getting around
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that is like I've mentioned in other symptom-based videos and episodes, which is using the
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acronyms of old cart, onset, location, duration, etc. in your history taking and then
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doing a full ROS and physical exam to kind of work your way backwards into the differentials,
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right? But anyway, we'll start with the differentials, the general categories of
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differentials for syncope, and then we'll get into the history questions, the physical exam,
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and red flags to watch out for, as well as some of the testing we want to watch out for.
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And I really want to tie them back to those general categories of differentials.
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So let's first talk, what is the definition of syncope? And this is important, not for semantics,
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but actually in practice because patients who come in saying that they had a syncope episode
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or they fainted, it could be true syncope or it could be kind of like pseudo-syncope. It
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could be something else, right? So it's a transient loss of consciousness that is caused
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by a period of inadequate cerebral blood flow and nutrients. It's quick onset, it's brief,
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and it's self-limited. That's like the definition of a transient loss of consciousness, aka syncope.
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Okay, so next I want to talk about those four main categories of causes.
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So I'm not going to talk about every single differential that exists because that is very
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long. So this is one of those doorway episodes. If you haven't listened to
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many of my episodes before, a lot of the hacks that I use to keep things straight in my mind
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when there's so much knowledge to know is knowing what is the first place to start?
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What is that first level of knowledge that I must have for this chief complaint or this
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topic that will lead me to my next doorway of where to go to pursue that information
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further? Especially in those really huge broad differential chief complaints,
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and this is potentially one of them. What are those four main places to start in terms of
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categories? And then once you get there, what's the doorway that you're going to open that's
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leading you towards one direction? And then you can consult your further resources to build
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out your knowledge and your investigation further, right? So this is the doorway episode.
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Okay, four main categories of syncope. The first one is called reflex mediated.
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So if you're a student or a newer grad, you might be like, well, what are we talking about here?
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So it's fascinating. And actually, again, this is a doorway. So definitely something to
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investigate if you're not feeling comfortable with all the differentials inside of reflex,
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mediated syncope. But those are traditionally things that are triggered by something else
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that causes a syncopal event. So commonly this is vasovagal responses, right? Some people
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have that vasovagal response, they have a syncopal episode. Micturition, voiding,
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and defecation, those can also trigger a syncopal event. Interesting, as can swallowing,
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and coughing and sneezing. Fun fact. Definitely read about reflex mediated. Those are not the
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only options, but there is like something that it triggers the event, right? And so definitely
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deepen your knowledge base in that if you're not familiar with those differentials, right?
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The next one is orthostatic hypotension. And that's the general parent category. And like the
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children are like the little differentials, right? So what are the general categories inside
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medication related or orthostatic hypotension? So medication related, primarily predominantly,
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most common ones are caused by diuretics, vasodilators, specifically calcium channel
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blockers, nitrates, alpha blockers. Those are really common, not the only options,
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but very common ones. Volume depletion states, hemorrhage, GI illness, et cetera,
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and various autonomic reasons. This is a little bit of a zebra-ish place to go,
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but just keeping in mind, again, this is like the doorway to pursue down, right? So Parkinson's
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secondary to other illnesses, amyloidosis, diabetes, stuff like that, right? Go down
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that doorway if you want to go down that door. But the moral of the story is second major
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cause is orthostatic hypotension from whatever underlying cause there is, right? So just think
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about reflex mediated, orthostatic hypotension. And then the next one is cardiopulmonary disease,
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right? This is a broad category as well. So we're thinking things like arrhythmias,
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cardiac arrhythmias, structural heart disease, cardiomyopathy, severe aortic stenosis,
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pulmonary embolism, pulmonary hypertension, right? Again, this is a doorway. So go into
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that pathway for thinking more on that line. But as long as you're keeping those first
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things in your mind, first three categories that will help you guide your visit to ask the
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appropriate history questions, physical exam, or the tests, right? Et cetera. Okay. So next,
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I want to talk about pseudo-syncope. So the things we really want to be careful of is
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getting our adequate history with these patients because we have to rule out,
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we have to figure out what direction to go, right? So the other things you want to be
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mindful of that are not actually syncope are things like seizures, sleep disturbances
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of a variety of kinds, right? That's like the parent category, accidental falls,
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metabolic and electrolyte disturbances can contribute to cognitive changes, but not
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necessarily true syncope. Some psychiatric conditions, whether it's a pseudo-seizure or
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something else that's going on. So just being really mindful of like, is this actually true
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syncope in those three first categories, or is it something else? Okay. Next,
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let's talk about the history questions. So as I mentioned at the beginning, there's old cart,
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onset location, duration, et cetera. But there are specific questions to ask for syncope. So
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I want to go over some of those. You want to talk about how many episodes this person has
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had. How long do they last? How often it's happening? How many, is this the first time?
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Multiple times. Were there any symptoms prior to the episode, right? Because we're tying it back
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to reflex mediated causes, voiding, defecating. Were they diaphoretic? Were they nauseous? Do
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they have palpitations? Were they hot, cold? Do they have chest pain, shortness of breath,
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right? Tying it back to those categories. Position of their body before or after the
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episode, right? Were they, again, tying back to orthostasis? Were they going from sitting to
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standing and then they fainted? Lost consciousness, et cetera? And if it's happened a number of times,
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is there something that's consistently seeming to trigger it, right? Is it all kind of tied
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together? And then a really important question is were they by themselves or were they with
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somebody else? Because if there was a witness, we really want to ask that person too,
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what did you see? Did they have any body physical movements, right? Are we trying to
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event? Was there any change in their breathing? What did they look like? Were they,
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were they like cyanotic appearing, right? Using the appropriate language with a person
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who's with them. Any other pre-existing conditions that we know about already,
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medications that they're taking. And then family history is always a good one to throw
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in. I feel like I missed that aspect of the evaluation when I was a newer grad.
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I would have it family history as part of my assessment, but I didn't realize like,
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I just didn't make that connection of like how important that answering that question is,
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right? And you can give them options, right? Because again, we're looking for
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cardiopulmonary disease here. Did they have any arrhythmias, structural heart disease,
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heart attack, stroke, et cetera? One note here, important note I want to make is that
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actually reduced blood flow to the brain from cerebral artery atherosclerosis is actually
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quite uncommon. So just, it is a possibility, but it's actually not the most common thing
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to think about. Okay, let's talk about some red flags to watch out for. So you've probably put
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this together already and you have those categories in your mind, but let's just put
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it in a little list here, right? Exertional onset. Why do we care about that? Right?
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Because we're worried about something cardiac going on, cardiopulmonary, chest pain, dyspnea,
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palpitations, focal neurologic deficits. Of course, we want to see what's going on with
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things like diplopia, ataxia, dysarthria, speech, visual changes, right? Weakness.
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Severe headache would be really concerning too, right? Because we could potentially be
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tying into some sort of vascular thing going on that contributed to the loss of syncope,
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loss of consciousness, right? So those are the main red flags to watch out for.
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In terms of the evaluation, you want to do your full physical exam,
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specifically focusing in on H-E-E-N-T, cardiovascular, their general appearance,
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of course, pulmonary, right? Because we're trying to get into those categories.
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And then this more additional kind of like exam testing things we want to think about.
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We want to do blood pressures in both arms. Even if you're not really sure what the
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structural cardiac abnormality might be, that's one piece of evidence to help support yes or
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no. Is there something going on there cardiovascular wise, right? So testing it in both arms,
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seeing if there's a discrepancy between blood pressures. Absolutely orthostatic vital signs.
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I know they're not the most fun thing to do, but hopefully you can get your support staff
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to help you with them if you cannot yourself. That is absolutely must vital. One of the
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categories, right? EKG is wise to do because we want to look for arrhythmia. You can
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find some signs of structural abnormalities on your EKG. Definitely seeking out support
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need help with interpretation and consider labs based on their history, right? So
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CMP, complete metabolic panel, we want to think about are there electrolyte disturbances? Does
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that make sense based on their history of CBC? Do they have underlying anemia or something
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else like that? A1C, perhaps if we're thinking maybe they have some underlying diabetes,
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which could be contributing in a secondary way to like that reflex mediated one. It's a
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you just really kind of take it from there. It really depends on what the potential
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in terms of the management really depends on the history, your exam and where you're kind
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of going with each of those doorways, right? Just to recap that reflex mediated and digging
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into that, if you're not feeling super comfortable with that orthostatic hypotension
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from whatever cause, right? And cardiopulmonary disease. So depending on your assessment and
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labs, you get to make that decision of like, who do I need support from next? Is this more likely?
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I don't actually, excuse me, hold on. I don't even think I mentioned neurologic exam and
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my physical exam. I think I was just like intuiting that, but that is absolutely part
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of your physical exam. So I don't want to leave that out, but yeah, you want to
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decide is there, do you need cardiology to help you? Do you need neurology to help you?
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Do you need your supervising collaborating provider to help you? Things like that.
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So that's it. So hopefully that's a helpful summation of the approach to diagnosing syncope
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in primary care. If you haven't grabbed the ultimate resource guide for the new NP head over
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to realworldnp.com slash guide. You'll get all of these episodes sent straight to your inbox
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every week with notes from me, patient stories, and bonuses I truly don't share anywhere else.
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Thank you so very much for watching. Hang in there and I'll see you soon.
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