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Self-Assessment Questions

Internal Medicine

Syncope: Review Questions

David McAdams, MD, MS

Dr. McAdams is an assistant professor, Division of General Internal Medicine,
University of Pittsburgh Medical Center, Pittsburgh, PA..



Choose the single best answer for each question.

1. Initial history, physical examination, and electro-
cardiography (ECG) can determine the cause of syncope
in what percentage of patients?
  1. 15%
  2. 25%
  3. 45%
  4. 65%
  5. 85%
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2. Which of the following is the most common cause of syncope?

  1. Cardiac causes (eg, arrhythmias, valve disorders, ischemia)
  2. Orthostasis
  3. Seizure
  4. Stroke
  5. Vasovagal syncope
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3. All of the following statements regarding evaluation and work-up of patients presenting with syncope are correct EXCEPT

  1. Event recording and Holter monitoring have a low yield
  2. An electroencephalogram (EEG) is a good screening tool and should be performed routinely to rule out seizure
  3. Electrophysiologic (EP) studies are abnormal mainly in patients with structural heart disease or an abnormal electrocardiogram (ECG)
  4. The presence of late potentials (ie, very small, computer-enhanced electrical signals) on signal-averaged ECG (SAGE) has a high sensitivity and specificity for inducible ventricular tachycardia during EP testing
  5. Upright tilt-table testing is useful in evaluating vasovagal syncope and is indicated in patients with recurrent unexplained syncope in whom arrhythmias are unlikely or have been ruled out
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  Questions 4 and 5 refer to the following case.

An 18-year-old woman presents to the emergency department with an episode of “passing-out.” She states that she was having “a few beers” with friends and did not have much to eat. She reports experiencing occasional lightheadedness while drinking alcohol, especially when moving from a supine to standing position but has never before lost consciousness. The patient last remembers getting up from a chair, and then waking up on the floor surrounded by her friends. The patient’s roommate witnessed the event, and upon questioning, states that the patient may have had a seizure, as she made “jerking movements” while unconscious. The patient lost consciousness for several seconds, well under 1 minute in duration. She did not lose bladder or bowel function, did not bite her tongue, and was fairly well oriented upon awakening. She hit her head and sustained a scalp laceration. Physical examination reveals dry mucous membranes, but heart, lung, abdominal, and neurologic testing are normal. Supine heart rate is 90 bpm, which increases to 120 bpm with standing.


4. All of the following are reasonable approaches to managing this patient EXCEPT
  1. Measure levels of electrolytes, blood urea nitrogen, and creatinine
  2. Obtain intravenous access and hydrate the patient with normal saline
  3. Perform a computed tomography (CT) scan of the head
  4. Perform a pregnancy test
  5. Perform a urine toxicologic screen
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5. How should this patient be managed?

  1. Admit patient to a monitored unit for observation
  2. Admit patient to a monitored unit and perform an ECG
  3. Admit patient to a monitored unit and perform an ECG and EEG
  4. Discharge patient with a Holter monitor
  5. Discharge patient after alcohol cessation counseling, and instruct her to be careful when moving from a supine to standing position
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