Mock Patient Script – Syncope

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“I just collapsed… but I don’t remember how it happened.”

Syncope refers to a sudden, transient loss of consciousness due to cerebral hypoperfusion, followed by spontaneous recovery. It is a common yet alarming presentation in both outpatient and emergency settings. Distinguishing benign vasovagal syncope from life-threatening causes like cardiac arrhythmias or structural heart disease is crucial.

This article provides a series of realistic mock patient scripts to enhance your skills in history-taking, physical examination, and clinical reasoning related to syncope. These cases are tailored for OSCE, USMLE Step 2 CS, and OET scenarios.

🩺 Case 1 – Standard Case

“Everything went black for a few seconds…”

【1】症例タイトル

“Everything went black for a few seconds…”

【2】Doorway Information

  • Age / Gender: 22-year-old female
  • Chief Complaint: Transient loss of consciousness at school
  • Vital Signs: T 36.8℃, HR 58, BP 102/66, RR 14, SpO₂ 99%

【3】Structured History

🗣️ Opening
“I suddenly collapsed in class—I don’t remember anything until I woke up on the floor.”

📆 Onset & Course
“It happened earlier this morning, just after I stood up to give a presentation. I felt a bit nauseous and sweaty, and then everything went black.”

🌀 Associated Symptoms
“Before fainting, I felt lightheaded, my vision got blurry, and I started to sweat. No chest pain or palpitations. No tongue bite or incontinence.”

😔 Mood / Function / Appetite / Sleep
“I’ve been sleeping fine. I was a little nervous about the presentation, though.”

🏥 Medical History / Medication
“I’m generally healthy. No medications. No history of heart problems.”

👨‍👩‍👧 Family & Social History（PAM HITS FOSS）

  • P: No known medical conditions
  • A: No allergies
  • M: None
  • H/I/T/S: None
  • F: No family history of sudden death or heart disease
  • O: Regular periods, no recent pregnancy
  • S: Not sexually active
  • S: University student, lives alone

❓ Concerns & Questions
“Do I have some serious heart condition? My parents are really worried.”

【4】Physical Examination

  • General: Alert and oriented, appears well
  • HEENT: Normal. No head injury or tongue laceration
  • Neuro: Cranial nerves intact, strength and sensation normal, Romberg negative
  • Cardiac: Normal S1/S2, no murmurs, no irregular rhythm
  • Lung: Clear breath sounds bilaterally
  • Abdomen: Soft, non-tender
  • Extremities: No cyanosis or edema
  • Orthostatic BP: Slight drop on standing (BP 98/62, HR 64) but asymptomatic

【5】Differential Diagnosis

✅ Most likely: Vasovagal syncope
– Supporting: Emotional stress, prodrome (nausea, sweating), young and healthy
– Against: None

2nd: Orthostatic hypotension
– Supporting: Mild drop in orthostatic BP
– Against: No dehydration, no meds, asymptomatic standing

3rd: Cardiac syncope
– Supporting: Occurred while standing/presenting
– Against: No structural disease, normal vitals and auscultation, no palpitations

【6】Clinical Reflection

“Her symptoms, context, and rapid recovery strongly suggest a vasovagal event. Still, I want to be cautious not to miss a hidden cardiac issue. A good history and reassurance are key here.”

【7】Clinical Pearls

  • Vasovagal syncope is common in young adults—look for clear triggers and prodrome.
  • Red flags for cardiac syncope: exertional onset, sudden drop, family history of sudden death.
  • Ask about tongue bite or incontinence to rule out seizure.
  • Orthostatic vitals can support the diagnosis, but mild drops are common.
  • “Sudden collapse without warning” always warrants an ECG.

【8】Challenging Questions

Q: “Could this be something dangerous, like a heart attack?”
A: “It’s very understandable to be worried. Based on your symptoms and exam, it seems more like a common fainting episode. But we’ll run a few tests like an ECG to be sure. If anything looks concerning, we’ll take further steps together.”

Q: “Do I need to stop doing sports or going to school?”
A: “At this point, there’s no strong reason to restrict your activity. However, we’ll wait for the results and see if anything needs to change. If it is vasovagal syncope, lifestyle adjustments may help prevent recurrence.”

【9】SOAP Note

S: 22-year-old female fainted at school during a presentation. Had preceding lightheadedness, nausea, and sweating. No chest pain, palpitations, tongue bite, or incontinence. Fully recovered within a minute.

O:
- T 36.8℃, HR 58, BP 102/66, RR 14, SpO₂ 99%
- Neuro: Normal exam
- Cardio: No murmurs, normal rhythm
- HEENT: No signs of trauma
- Orthostatic BP: mild drop without symptoms

A:
# Transient loss of consciousness with prodrome  
# Emotional stress trigger  
# Unremarkable physical exam  

ddx): Vasovagal syncope, orthostatic hypotension, cardiac syncope  
r/o): Seizure (no postictal signs), arrhythmia (no concerning features)

→ Most consistent with vasovagal syncope. No red flags noted. Will check ECG and provide education on prevention.

P:
- ECG to rule out arrhythmia  
- Education: hydration, avoid triggers, physical counterpressure maneuvers  
- Reassurance; no restriction unless symptoms recur  
- F/U in 1 week or sooner if recurrent episodes

🔍 Case 2 – Challenging Case

“I passed out while walking uphill.”

【1】症例タイトル

“I passed out while walking uphill.”

【2】Doorway Information

  • Age / Gender: 68-year-old male
  • Chief Complaint: Sudden collapse while climbing stairs
  • Vital Signs: T 36.6℃, HR 44, BP 98/60, RR 18, SpO₂ 97%

【3】Structured History

🗣️ Opening
“I suddenly collapsed while climbing the stairs at the station.”

📆 Onset & Course
“It was very sudden—I didn’t feel anything beforehand. No dizziness, no warning. One second I was climbing, and the next I was on the floor. I came to in less than a minute.”

🌀 Associated Symptoms
“I felt a bit tired before it happened, but nothing else. No chest pain, no palpitations. I didn’t hit my head, but people around me said I was unresponsive for about 30 seconds.”

😔 Mood / Function / Appetite / Sleep
“I sleep okay, but I’ve been more fatigued lately. No appetite change.”

🏥 Medical History / Medication
“I’ve had high blood pressure for years. I also had a heart attack 5 years ago. I take metoprolol and aspirin.”

👨‍👩‍👧 Family & Social History（PAM HITS FOSS）

  • P: Hypertension, previous MI
  • A: No known drug allergies
  • M: Metoprolol, aspirin
  • H: Hospitalized for MI 5 years ago
  • I/T/S: No significant injuries or trauma
  • F: Father died of sudden cardiac arrest at 70
  • O: N/A
  • S: Sexually active with wife
  • S: Retired engineer, lives with spouse

❓ Concerns & Questions
“My wife is terrified this might be my heart again. Could it be another attack?”

【4】Physical Examination

  • General: Alert but fatigued appearance
  • Neuro: No focal deficits; alert and oriented
  • Cardiac: Bradycardic at 44 bpm, regular; no murmurs or gallops
  • Lung: Clear to auscultation bilaterally
  • Extremities: No edema, pulses slightly weak peripherally
  • Orthostatic BP: No significant change

【5】Differential Diagnosis

✅ Most likely: Cardiac syncope (bradyarrhythmia, possibly high-grade AV block)
– Supporting: Sudden LOC without warning, exertional onset, bradycardia on exam, history of MI, family history of sudden cardiac death
– Against: No palpitations or chest pain (but not necessary in conduction disorders)

2nd: Vasovagal syncope
– Supporting: Syncopal event, no injury
– Against: No prodrome, no emotional trigger, occurred during exertion

3rd: Seizure
– Supporting: Sudden unresponsiveness
– Against: Rapid recovery, no postictal confusion, no tongue bite or incontinence

【6】Clinical Reflection

“A syncopal episode without any prodrome, especially during exertion and with bradycardia, demands serious concern. A cardiac cause—most likely arrhythmia or conduction abnormality—must be ruled out urgently.”

【7】Clinical Pearls

  • Exertional syncope should always raise concern for cardiac origin—especially in older adults or those with a cardiac history.
  • Bradycardia can be subtle but life-threatening in cases of AV block or sinus node dysfunction.
  • Never dismiss a “no prodrome” syncopal event—this is a key red flag.
  • Always check medications (e.g., beta-blockers) that may contribute to bradyarrhythmia.
  • ECG and cardiac monitoring are essential for anyone with suspected cardiac syncope.

【8】Challenging Questions

Q: “Is this another heart attack?”
A: “I understand your fear. While this doesn’t look like a classic heart attack, the fact that it happened suddenly during exertion is concerning. We need to do an ECG and some tests to see how your heart is functioning. You did the right thing by coming in quickly.”

Q: “Will I need a pacemaker?”
A: “That’s one possibility we’re considering. If your heart is beating too slowly or irregularly, a pacemaker might help. First, we’ll gather more data with monitoring and tests to understand the cause clearly before making decisions.”

【9】SOAP Note

S: 68-year-old male with history of MI collapsed suddenly while climbing stairs. No warning symptoms, recovered within 1 minute. Denies chest pain or palpitations. Wife witnessed the event. No incontinence or tongue biting.

O:
- T 36.6℃, HR 44, BP 98/60, RR 18, SpO₂ 97%
- Cardiac: bradycardic, no murmurs
- Neuro: no deficits
- Lungs clear, no orthostatic change

A:
# Sudden loss of consciousness on exertion  
# Bradycardia on physical exam  
# History of MI and beta-blocker use  

ddx): Cardiac syncope (high-grade AVB, SSS), vasovagal syncope, seizure  
r/o): Vasovagal (no prodrome), seizure (no postictal state)

→ Likely cardiac syncope due to bradyarrhythmia. Requires urgent ECG and cardiology evaluation.

P:
- ECG, consider Holter monitoring  
- Hold beta-blocker temporarily  
- Cardiology referral  
- Admit for cardiac telemetry and syncope workup

✨ Case 3 – Interesting Case

“Every time I stand up, I feel faint.”

【1】症例タイトル

“Every time I stand up, I feel faint.”

【2】Doorway Information

  • Age / Gender: 81-year-old female
  • Chief Complaint: Lightheadedness and near-syncope on standing
  • Vital Signs: T 36.7℃, HR 64, BP 132/74 (supine) → 96/60 (standing), RR 16, SpO₂ 98%

【3】Structured History

🗣️ Opening
“I feel like I’m going to faint every time I get up from bed.”

📆 Onset & Course
“It started about 2 weeks ago. It happens almost every morning. I get dizzy and sometimes my vision goes dark when I stand up, especially from lying down.”

🌀 Associated Symptoms
“I haven’t actually passed out, but I have to sit back down quickly. No chest pain, palpitations, or headache.”

😔 Mood / Function / Appetite / Sleep
“I sleep well. My appetite is okay, but I’ve been avoiding walking too much because I’m scared I’ll fall.”

🏥 Medical History / Medication
“I have high blood pressure and osteoarthritis. I recently started a new water pill—hydrochlorothiazide, I think. Also taking amlodipine, acetaminophen, and calcium supplements.”

👨‍👩‍👧 Family & Social History（PAM HITS FOSS）

  • P: Hypertension, osteoarthritis
  • A: NKDA
  • M: Amlodipine, hydrochlorothiazide, acetaminophen
  • H: Hospitalized 2 years ago for a UTI
  • I/T/S: None
  • F: Non-contributory
  • O: Postmenopausal
  • S: Not sexually active
  • S: Lives alone, uses a cane, daughter visits weekly

❓ Concerns & Questions
“Could this be something serious? I’m afraid I might collapse one day.”

【4】Physical Examination

  • General: Frail-appearing elderly woman, cautious in movement
  • Neuro: Alert and oriented, no focal deficits
  • Cardiac: Normal S1/S2, no murmurs, regular rate
  • Lung: Clear
  • Abdomen: Soft, NT, no masses
  • Extremities: No edema
  • Orthostatic Vitals: BP drop > 20 mmHg systolic, symptoms reproduced on standing

【5】Differential Diagnosis

✅ Most likely: Orthostatic hypotension (medication-induced)
– Supporting: Reproducible symptoms with standing, recent thiazide initiation, elderly, hypertensive
– Against: None significant

2nd: Autonomic dysfunction (e.g., Parkinson’s, diabetes)
– Supporting: Age, possible subclinical neuropathy
– Against: No known autonomic disease or diabetes

3rd: Cardiac arrhythmia
– Supporting: Elderly with presyncope
– Against: No sudden events, no red flag history, symptoms clearly postural

【6】Clinical Reflection

“Elderly patients with multiple antihypertensives are at high risk of orthostatic hypotension, especially after starting diuretics. Her symptoms and vitals fit perfectly. Deprescribing is just as important as prescribing.”

【7】Clinical Pearls

  • Orthostatic hypotension = ≥20 mmHg SBP or ≥10 mmHg DBP drop within 3 minutes of standing.
  • Diuretics, especially in the elderly, are common triggers.
  • Always ask about falls, not just fainting.
  • Encourage slow positional changes and adequate hydration.
  • Polypharmacy is a key fall risk factor in geriatric care.

【8】Challenging Questions

Q: “Do I need to stop all my medications?”
A: “Not all, but we’ll review them carefully. Some may be contributing to your dizziness. It’s important to find a balance between controlling your blood pressure and keeping you safe.”

Q: “Will this keep getting worse as I age?”
A: “It can happen more often with age, but we can manage it. By adjusting your medications and lifestyle, we can reduce your symptoms and help you stay independent.”

【9】SOAP Note

S: 81-year-old female reports 2-week history of lightheadedness and near-syncope upon standing. No LOC, chest pain, or palpitations. Recently started hydrochlorothiazide for hypertension.

O:
- T 36.7℃, HR 64, BP 132/74 → 96/60 (on standing)
- Physical exam: frail but alert, no focal deficits
- Cardiac, lung, abdominal exams unremarkable
- Orthostatic vitals: reproducible drop with symptoms

A:
# Near-syncope with orthostatic trigger  
# Polypharmacy in elderly patient  
# Recent initiation of thiazide diuretic  

ddx): Orthostatic hypotension, autonomic dysfunction, arrhythmia  
r/o): Cardiac (not sudden, no red flags), seizure (no LOC)

→ Likely medication-induced orthostatic hypotension. Plan to adjust medications and monitor.

P:
- Discontinue hydrochlorothiazide  
- Encourage hydration and slow position changes  
- Home BP monitoring  
- Medication review with primary care  
- Consider fall risk evaluation

🧠 Summary

Syncope is a common presentation that ranges from benign vasovagal episodes to potentially life-threatening cardiac arrhythmias. A careful history—including prodromal symptoms, posture, and context—can often guide diagnosis. Vital signs (including orthostatic measurements), medication review, and ECG are essential initial steps. Always be alert for red flags such as exertional onset, no warning signs, or a family history of sudden cardiac death.

🧩 Take Home Messages

  • Not all syncope is benign—identify red flags early.
  • Vasovagal syncope has a prodrome and a clear trigger; cardiac syncope usually does not.
  • Orthostatic hypotension is common in older adults, especially with polypharmacy.
  • ECG is mandatory in all patients with unexplained or exertional syncope.
  • When in doubt, admit for monitoring, especially in elderly or cardiac patients.

🔗 Related Articles

📚 References & Recommended Resources

  • UpToDate: Evaluation of syncope in adults
  • Mayo Clinic: Syncope (Fainting)
  • ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
  • First Aid for the USMLE Step 2 CS
  • ダ・ヴィンチのカルテ〜診断力を鍛える99症例（羊土社）
  • ティアニー先生の診断入門（医学書院）

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