Abstract

Accurately diagnosing patients with TLOC can be achieved in most cases with a detailed clinical history. We set out to assess how patients were assessed in the setting of a district general hospital (DGH) with 570 beds, receiving an unselected intake via general practice and an A&E. Using the ESC guidelines of 2009 we generated a 22-question study proforma for a retrospective review of the medical records. We identified 322 cases for possible inclusion over a 4 month period. 26 of the case notes were not available to analyse, 8 had insufficient details to identify the relevant patient. Therefore in total 288 notes were reviewed. Inclusion required the TLOC to be complete, of rapid onset and short duration with spontaneous complete recovery. A further 123 patients were therefore excluded. This left 165 data sets (58% male). The age distribution was a typical bimodal distribution with 16% between 10 and 29 years of age and 48% over the age of 70 years. 73% were assessed in A&E, 18% were assessed in the Acute Medical Unit (AMU) and 7% were assessed in rapid access ambulatory clinics. Only 4% of the initial assessments were undertaken by consultants, 12% by a Specialist Registrar (SpR), 21% by a year 1 foundation program (FP1) doctor and the majority was assessed by FP 2 or core medical trainees (CMT). Key diagnostic elements of the history are still being neglected. For example, the symptoms at the onset of the TLOC were documented in only 58% of cases; the recovery symptom profile was reported in only 37%. Only 47% (n=78) of records described a witness account. Within the witness accounts that were recorded, key elements remained un-reported for example skin complexion was only reported in 35% of the 78. The duration of the TLOC was recorded in only 44%, Tongue biting in 27% and the presence or absence of abnormal movements was recorded in only 12% of this 78 patients. The presence or absence of a family history of sudden cardiac death was only reported in 2% cases. The family history of a cardiomyopathy was only recorded in 1% and a family history of TLOC was recorded in 1%. A patient past history of cardiac disease was asked about in 40% of cases while a past history of TLOC was only asked about in 35%. In this majority elderly study population, a recent change in drug therapy was only asked about in 2% of cases. This study highlights that in a DGH environment, the initial assessment of patients with TLOC is undertaken by junior medical staff who often do not document key diagnostically differentiating elements of the history and examination indicating an ongoing lack of adequate training regarding the most appropriate and accurate techniques for differentiating the causes of TLOC.