Syncope Evaluation Note (Pediatric Cardiology)

Date/Time: [Date and time of encounter]

Patient: [Full name]    DOB: [DOB]

Visit Type: [new consult / return / follow-up from ED]

Referring Clinician: [Name, credentials, organization]

History Sources: [patient / parent-guardian / witness / EMS / outside records] (List all applicable sources. Note if interpreter used: [Yes—language / No].)

Chief Concern

"[Patient's or parent's words describing the concern]"

Syncope Event Narrative

[Attribution: patient reports / parent witnessed / per EMS / per outside records]. [Context and potential triggers (heat, dehydration, prolonged standing, emotional stress, pain/procedure, illness, post-exercise, fasting)]; [Activity level and position at onset]; [Prodrome presence/absence and duration, including lightheadedness, nausea, diaphoresis, tunnel vision, hearing changes]; [Symptoms immediately before loss of consciousness (palpitations, chest pain, sudden drop)]; [Loss of consciousness duration and whether complete syncope or near-syncope]; [Witnessed appearance (pallor, cyanosis, breathing pattern, sweating)]; [Movements or seizure-like activity and timing relative to collapse]; [Incontinence / tongue biting]; [Injuries sustained]; [Recovery characteristics—rapid vs confused/postictal, fatigue duration]; [Interventions provided and response]. (Document in structured paragraph form with clear attribution to sources.)

Prior episodes (if applicable): [First episode timing]; [Total number to date]; [Frequency trend]; [Whether episodes are phenotypically consistent]; [Most concerning episode if different from index event]. (If no prior episodes, state "No prior episodes reported." Omit section entirely if not applicable.)

Contributing physiologic factors: [Typical daily fluid intake]; [Salt intake patterns]; [Skipped meals]; [Caffeine/energy drink use]; [Sleep patterns]; [Recent illness]. (Include only factors that are relevant or reported.)

Menstrual and pregnancy history (post-menarchal adolescents when clinically relevant): [Cycle timing]; [Menorrhagia / anemia symptoms]; [Possibility of pregnancy]. (Omit entirely for prepubertal children.)

Medications and substances: [Current medications and recent changes]; [QT-prolonging agents]; [Stimulants]; [Substance use (age-appropriate): alcohol / cannabis / other]. (If detailed in Medical History, cross-reference rather than duplicate.)

(If critical details are unavailable, explicitly document reason, e.g., "Witness description unavailable—no witness present.")

Cardiac Red Flags

• Syncope during exertion or immediately post-exertion (without clear vasovagal features): [Yes / No / Unknown] — [Brief clarification if Yes or Unknown]
• Syncope while supine: [Yes / No / Unknown] — [Brief clarification]
• No prodrome / sudden collapse: [Yes / No / Unknown] — [Brief clarification]
• Chest pain preceding event: [Yes / No / Unknown] — [Brief clarification]
• Palpitations preceding event: [Yes / No / Unknown] — [Brief clarification]
• Known structural heart disease, cardiomyopathy, or channelopathy: [Yes / No / Unknown] — [Specific diagnosis if Yes]
• Abnormal cardiac exam findings: [Yes / No / Unknown] — [Brief description]

(Use "Unknown" with reason when information is not available rather than defaulting to "No.")

Family History Red Flags

• Sudden unexplained death (especially age <50 or during exercise/sleep/swimming): [Yes / No / Unknown]
• Known cardiomyopathy or channelopathy (e.g., long QT syndrome): [Yes / No / Unknown]
• Pacemaker or ICD placed at young age: [Yes / No / Unknown]
• Recurrent unexplained syncope or "seizures" in relatives: [Yes / No / Unknown]

Details for positive or uncertain items: [Relation, age at event, circumstances, genetic testing performed, autopsy performed]. (When reliably negative, a single summary line suffices. If information is limited, state reason: adopted, limited family contact, incomplete records.)

Medical History

• Prior syncope evaluations: [ED visits / prior cardiology or neurology assessments / prior testing and outcomes]
• Relevant diagnoses: [Anemia / eating disorder / autonomic dysfunction / seizure disorder / migraine / other]
• Surgical history: [Pertinent procedures]
• Allergies: [Drug/food/environmental and reaction type]
• Current medications: [List or "See above"]

Review of Systems

• Cardiovascular: [Exertional intolerance / chest pain / palpitations / edema]
• Neurologic: [Headaches / focal deficits / prolonged confusion]
• General: [Weight changes / dehydration symptoms]

(Omit systems not assessed rather than documenting "all other systems negative.")

Physical Examination

Vital Signs and Orthostatic Assessment

Vitals: BP [value]; HR [value]; RR [value]; Temp [value]; SpO2 [value]; Ht [value]; Wt [value]; BMI [value]

Orthostatics: (If not obtained, remove the table and document reason.)

Position	BP	HR	Symptoms
Supine (after rest)	[BP]	[HR]	[Symptoms]
Standing 1 min	[BP]	[HR]	[Symptoms]
Standing 3 min	[BP]	[HR]	[Symptoms]
Standing 5–10 min (if POTS evaluation)	[BP]	[HR]	[Symptoms]

Interpretation: [normal response / orthostatic hypotension / POTS pattern / indeterminate] — [Brief rationale]. (OH: SBP drop ≥20 or DBP drop ≥10 within 3 min. POTS: HR increase ≥40 bpm in adolescents without hypotension.)

Cardiovascular Exam

• Rate/rhythm and heart sounds: [Regular/irregular], [S1/S2 characteristics]
• Murmur: [Present/absent]; if present: [timing], [grade], [location], [radiation]
• Additional sounds: [Clicks / gallops / rubs / none]
• Peripheral pulses: [Radial], [Femoral], [Symmetry]; [Perfusion]
• Connective tissue features: [Marfanoid features / other findings] (Include if pertinent to history.)

Neurologic Screening

• Mental status: [Alert / oriented / appropriate for age]
• Focal deficits: [Absent / Present—describe]

ECG Review

ECG Date: [Date]    Source: [clinic today / ED / outside record]    Personally reviewed: [Yes / Report only]

• Rhythm and rate: [Sinus / other], [Rate bpm]
• Intervals: PR [ms]; QRS [ms]; QTc [ms] ([Bazett / Fridericia])
• Axis: [Normal / left / right / extreme]
• Hypertrophy: [Present / Absent]
• Pre-excitation: [Present / Absent]
• Brugada pattern: [Present / Absent]
• ST-T abnormalities: [Present—describe / Absent]
• Ectopy/conduction abnormalities: [Findings or none]

ECG interpretation: [Summary statement]

(If ECG not available: [ECG requested / prior ECG on (date) reportedly normal / pending].)

Additional Testing

(Include only tests that were performed or reviewed. If testing was considered but deferred, state rationale.)

• Echocardiogram: [Date]; [Indication]; [Key findings]; [Interpretation]
• Ambulatory rhythm monitoring: [Type and dates]; [Indication]; [Arrhythmia burden]; [Symptom correlation]; [Interpretation]
• Exercise stress testing: [Date]; [Indication]; [Performance]; [ECG changes/arrhythmias]; [Interpretation]
• Laboratory results: [Relevant values: glucose, CBC, ferritin, electrolytes]; [Interpretation]
• Other studies: [Test]; [Indication]; [Findings]; [Interpretation]

Assessment

Working diagnosis: [Synthesis statement integrating history, exam, and testing—e.g., "Syncope most consistent with vasovagal mechanism given classic prodrome, standing trigger, absence of cardiac red flags, and normal ECG."]

Differential considerations: [Diagnosis #1—supporting and refuting features]; [Diagnosis #2—supporting and refuting features]; [Diagnosis #3—supporting and refuting features]. (List in order of likelihood.)

Risk stratification: [High-risk features present: list] or [No high-risk cardiac features identified].

Disposition: [Outpatient management / Urgent referral / Admission] — [Justification]

Plan

Education and Lifestyle Measures

• [Mechanism explanation and reassurance tailored to diagnosis]
• [Hydration target and salt intake recommendation if applicable]
• [Counterpressure maneuvers taught: leg crossing with tensing, handgrip, squatting] — Prodrome duration sufficient: [Yes / No]
• [Trigger avoidance strategies: hydration before prolonged standing, avoid locked knees, heat precautions, rise slowly]

Activity and Sports Guidance

Current status: [cleared / restricted / restricted pending evaluation]

• Restrictions (if any): [Specific activity limitations]
• Precautions if cleared: [Hydration requirements]; [Sit/lie at prodrome]; [Stop activity for chest pain or palpitations]
• Shared decision-making: [Discussion summary and patient/family preferences] (Include when activity decisions are preference-sensitive.)

Diagnostic Testing Plan

• [Test] — Indication: [Specific symptom/red flag]; Clinical question: [What this test aims to clarify]

(Order tests only with stated rationale linked to history or exam findings. If no additional testing indicated, state "No additional testing indicated at this time.")

Follow-up and Return Precautions

Follow-up: [Timeline] with [Provider/clinic]

Return precautions: Syncope during exercise; syncope with chest pain or palpitations; syncope while lying down; prolonged unresponsiveness or confusion; significant injury.