Background

• Any previous similar attacks
• Previous significant head injury (i.e. with skull fracture or loss of consciousness)
• Birth injury, febrile convulsions in childhood, meningitis or encephalitis
• Family history of epilepsy
• Cardiac disease associated with ventricular arrhythmia (previous myocardial infarction, hypertrophic or dilated cardiomyopathy, heart failure)
• Medications
• Alcohol or substance use
• Sleep deprivation

Before the attack

• Prodromal symptoms: were these cardiovascular (e.g. dizziness, palpitations, chest pain) or focal neurological symptoms (aura)?
• Circumstances, for example exercising, standing, sitting or lying, asleep
• Precipitants, for example coughing, micturition, head-turning

The attack

• Were there any focal neurological features at the onset: sustained deviation of the head or eyes or unilateral jerking of the limbs?
• Was there a cry (may occur in tonic phase of fit)?
• Duration of loss of consciousness
• Associated tongue biting, urinary incontinence or injury
• Facial colour changes (pallor common in syncope, uncommon with a fit)
• Abnormal pulse (must be assessed in relation to the reliability of the witness)

After the attack

• Immediately well or delayed recovery with confusion or headache?

Examination

• Conscious level and mental state (confirm the patient is fully oriented)
• Pulse, blood pressure, respiratory rate, arterial oxygen saturation, temperature
• Systolic BP sitting or lying, and after 2 min standing (a fall of >20 mmHg is abnormal; note if symptomatic or not)
• Arterial pulses (check major pulses for asymmetry and bruits)
• Jugular venous pressure (if raised, consider pulmonary embolism, pulmonary hypertension, heart failure or cardiac tamponade)
• Heart murmurs (aortic stenosis and hypertrophic cardiomyopathy may cause exertional syncope; atrial myxoma may simulate mitral stenosis)
• Neck mobility (does neck movement induce presyncope? Is there neck stiffness?)
• Presence of focal neurological signs: as a minimum, check visual fields, limb power, tendon reflexes and plantar responses
• Fundi (check for haemorrhages or papilloedema)