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Great. Hello everyone. Thank you for attending. We can start the teaching session. Now, can e everyone confirm if they can hear me please on the chart? Fantastic. So let's get going. So this is our fourth session of our final series and today we'll be exploring the approach to syncope. Now, this is a very good topic because it's something that you will come across in a OSK style setting. But also when you start working, it's a very common presentation. So it's very good to have an overview on how to really approach this topic and key differentials we have to consider from a cardiology perspective. So to that end the learning objectives today, hopefully by the end of the session, we'll be able to define syncope to describe an initial evaluation of someone presenting with syncope, which includes full history examination and the initial investigations and to provide at least five differentials for syncope. So let's start what is syncope. So, syncope is defined as a transient loss of consciousness due to cerebral hypoperfusion. It is characterized by a rapid onset, a short duration and a spontaneous recovery and often with these syncopal episodes, there's also transient postural failure. So patients often end up falling if they were standing. Now, as seen as this diagram, there is also a term transient loss of consciousness and sometimes T lock, transient loss of consciousness and syncope are confused and used interchangeably. But this wouldn't be the correct thing to do. Syncope is one of the causes of at lock but not all T locks are due to syncope. Other causes of a transient loss of consciousness can include epileptic seizures, non epileptic seizures and other neurological causes which we won't explore too much in detail. We'll focus on true syncope for this session. So we're moving on to history. So in the chart, w would you guys be able to tell me what questions you'd ask for someone presenting with syncope in the history of presenting complaints and to make it easier to structure, we're going to use the common before the syncopal episode during the syncopal episode and after the syncopal episode. So let's focus on before. What kind of things would you want to know about before the syncopal episode? Just put down your ideas in the chat. So, Prodrome, fantastic. So what, what kind of exactly prodromal symptoms? Any common examples that you can think of? Feel free to share any ideas you may have. There's no such thing as an incorrect answer. Sweaty, nauseous, fantastic. Those are two very common prodromal symptoms. Any, any symptoms that are more sinister in nature that we'd also need to ask. That's fine. So what I had in mind was chest pain, palpitations, breathlessness. Exactly. It happened when exercising. So did it happen on exertion? That's absolutely correct. And what, what do you want to know about during the syncopal episode? Exactly. They lost consciousness completely. So fantastic answers. How long it was brilliant. So to, to go through the detailed history. So the history of presenting complaint is really where you get all the answers. And the before during after structure is what you should always use in a osk setting for any syncope or transient loss of consciousness approach. So we've talked about some of the stuff before we want to know if they've had any prodromal symptoms, the nausea, the sweatiness, perhaps they've been dizzy, they've had any sinister stuff like chest pain, shortness of breath palpitations. It might also be useful to know what position they were in before the syncope. Had they been standing for a long time? Had they suddenly changed their position or were they just lying down? You also want to know what they were doing at that time? Were they performing a specific action? Had they just received a new emotional or fear stimulus? Were they exercising as someones correctly said, what were they specifically doing? And then during now with, during syncope, they might not always remember what happened during because they've lost consciousness. So we wouldn't expect them to know, but that's where a collateral becomes very important in your history taking. So in a osk setting, you always want to in your presentation mention collateral histories to make yourself seem more slick and experience. So during, we'd want to know as someone correctly said, have they lost consciousness? Were there any tonic clonic or myoclonic movements that may suggest seizure activity, any incontinence, urinary or fecal? What were, what were their eyes doing during the loss of consciousness? And were they doing any movements, any automatisms like tongue biting or lip smacking? Now, you wouldn't expect these in a syncopal episode. But they're of it's often difficult to tell in the early stages between that and a epileptic seizure, for example. So these questions need to be asked, moving on to after you'd want to know how quick they recover. Were they confused afterwards. Do they have amnesia? So these are all important questions to establish in your before, during after history of presenting complaint for the rest of the history. You want to try and find out more about their background that might may guide you to know what was the cause? Do they have heart disease? Do they have neurological disease? Do they have psychiatric disease? Any medications they're taking, which may, may predispose them? Any antihypertensive antidiabetic agents, diuretics, any painkillers or benzos in terms of family history, sudden cardiac death is of key note. And lastly, you wanna know about the alcohol intake. So we've taken a good history focusing heavily on the history of presenting complaint. We now move on to examinations. Which examinations do you want to perform on this patient? Please put in the chart. Cardiac and neuro. Exactly. You want to do a cardiovascular examination and a full neurological examination, including cranial nerves, upper limb and lower limb. And just very briefly, what are the initial investigations you'd perform in an emergency department setting? Ecg Fantastic. ECG is the single most important uh investigation in someone presenting with syncope. Bloods are always done and the blood cultures you may want to hold off unless they're sho they're showing signs of a fever and a CBG is very important. So the three suggestions are fantastic. So bedside, you want to do a capillary blood glucose, you'd want to do an E CG and then you move on to bloods. Fantastic. So as we've already said, the relevant uh examiner examinations, we'd want the observations as always, the ones of note here would be the BP. You might want to ask for a lying standing BP to explore if there's a difference. And also you'd want to know what their heart rate is doing. So we've talked about ECG, all patients presenting with syncope should get an ECG. It's very important. You're, you're looking for arrhythmia, you're looking for signs of obstructive cardiac disease. It's the key bloods are important. We've already talked about capillary blood glucose is an excellent first investigation to do to rule out hypoglycemia, bloods in general will be done very rarely will they show anything that will help us with the in identifying the cause of syncope? But it should be done regardless after this initial work up, some further investigations you might want to do if you're concerned.