Collapse / Syncope OSCE - Vasovagal Syncope | Free OSCE Practice

Case Overview

Age/Sex: 18/F
Occupation: University student
Setting: Emergency department after brief collapse in exam hall
Chief complaint: "I collapsed — I think I blacked out"

Patient Script

Who I Am

I'm 18, a first-year university student, and I was in an exam when this happened.

What Brings Me In

I suddenly felt dizzy and fainted for a short time during my exam — people helped me up and brought me here because I don't remember much.

My Story

I had been awake all night revising and felt really anxious about the exam. About 20 minutes before the end of the exam I stood up to hand my paper in and within a few seconds I felt very hot, sweaty, and light-headed. My vision went like I was looking through a tunnel and I felt nauseous. Then I remember popping up lights and the next thing I know people were around me — I had been out for a very short time (maybe less than a minute). When I came round I felt a little shaky and weak but recovered quickly and could talk straight away. A friend said my arms twitched a little while I was down, but there was no long shaking or anything. I bit my lip a bit when I came round.

I had skipped breakfast because I was panicking about the exam and only had two strong coffees this morning and an energy drink an hour before the exam. I haven't drunk alcohol in the last 48 hours. I have been really stressed and sleeping very little for the last 3 nights.

My Medical Background

Past medical history: None significant; no epilepsy or heart disease that I know of
Medications: Combined oral contraceptive pill for contraception (started 6 months ago)
Allergies: None known
Social: Lives in student accommodation, drinks coffee/energy drinks a lot during exams, rarely smokes (one cigarette every few months), doesn't use illicit drugs regularly
Family history: Uncle had a heart attack in his 50s (not sure of details)

What I Think & Worry About

I think I fainted because I was stressed and didn’t eat or drink properly.
I'm scared I might have something wrong with my heart or that I could have a seizure.
I worry this could happen again during an exam or while I'm alone.

If You Ask Me About Other Symptoms...

Headache: No ongoing severe headache, just felt a bit lightheaded afterward
Confusion: I was disoriented for a minute but got my memory back quickly — no prolonged confusion
Tongue biting/incontinence: I bit my lip a little, but I did not bite my tongue and I didn't wet myself
Chest pain/palpitations: I felt a bit of a fast pounding feeling before I stood up earlier in the day, but no chest pain now
Breathlessness: No shortness of breath
Recent illness/fever: No
Pregnancy: I am aware a pregnancy test might be needed — I don't think I'm pregnant

Clinical Summary

Examination

General: Alert, well appearing, sitting comfortably in ED
Vital signs (supine): BP 115/72 mmHg, HR 68 bpm, RR 14/min, T 36.6°C, SpO2 99% on air
Vital signs (immediate standing): BP 90/56 mmHg, HR 54 bpm, patient reports reproduced lightheadedness
Neurology: GCS 15, pupils equal and reactive, no focal neurological deficit, normal gait when observed
Cardiovascular: Heart sounds normal, no murmurs, peripheral pulses present and symmetric
Other: No evidence of tongue laceration other than small superficial lip bite; no incontinence noted

Investigations

ECG: Sinus rhythm, rate 62 bpm, PR 140 ms, QRS 90 ms, QTc 410 ms (no ischaemic changes, no conduction block)
Capillary glucose: 5.6 mmol/L (normal)
Serum electrolytes: Na 139 mmol/L, K 3.9 mmol/L, Mg 0.9 mmol/L (within reference ranges)
Troponin I: <0.01 ng/mL (not elevated)
Pregnancy test (urine): Negative
Consider if needed: 12-lead ECG monitoring/Holter if recurrent or suspect arrhythmia

Diagnosis

Primary diagnosis:

Vasovagal (neurocardiogenic) syncope — supported by a clear prodrome of dizziness, sweating, nausea, tunnel vision, a recognized trigger (emotional stress/prolonged standing after tiring night), short duration of LOC (<1 minute), rapid recovery without prolonged confusion, reproducible orthostatic drop in BP with relative bradycardia, and normal ECG and basic blood tests.

Differential diagnoses with reasoning:

Seizure: less likely because of short duration of unconsciousness, rapid recovery without prolonged post-ictal confusion, only brief limb twitching reported rather than generalized tonic-clonic activity, no tongue biting or incontinence.
Cardiac arrhythmia (e.g., intermittent tachy/bradyarrhythmia): less likely given normal ECG and troponin, and presence of classic vasovagal prodrome; consider if recurrent or if event occurred without prodrome.
Orthostatic hypotension from dehydration: possible contributing factor (skipped breakfast, poor sleep, caffeine), but the significant prodrome and emotional trigger point more to vasovagal mechanism.
Panic attack with syncope: panic can cause hyperventilation and lightheadedness, but true transient loss of consciousness with the described prodrome and orthostatic changes is more consistent with vasovagal syncope.

Management

Immediate: Reassure patient and advise laying flat with legs elevated when feeling prodrome; ensure adequate IV access if needed but not mandatory if stable.
Treat contributing factors: encourage good hydration, eat regular meals, avoid excess caffeine and energy drinks, counsel on sleep hygiene during exams.
Self-help and prevention: teach physical counter-pressure maneuvers (leg crossing, handgrip, tensing leg muscles) to abort the faint when prodrome begins; avoid prolonged standing; rise slowly from sitting.
Safety advice: avoid driving or riding a bike alone until syncope-free for an appropriate interval per local guidelines; do not climb ladders or swim alone until assessed.
Follow-up: arrange outpatient review with primary care or cardiology if recurrent episodes; consider ambulatory ECG monitoring (Holter) if suspicion of occult arrhythmia or if events occur without prodrome.
Red flags prompting urgent cardiology workup or admission: syncope during exertion, abnormal ECG, family history of sudden cardiac death with concerning features, recurrent unexplained syncope.

Key Learning Points

Vasovagal syncope typically has an identifiable trigger and a characteristic prodrome (nausea, sweating, pallor, tunnel vision) with rapid recovery — these distinguish it from seizure or primary cardiac causes.
Always measure orthostatic vitals and obtain a 12-lead ECG in syncope assessment; basic blood tests and pregnancy testing are appropriate for young women.
Management focuses on education, avoidance of triggers, hydration, and teaching counter-pressure maneuvers; investigate further if episodes are atypical, recurrent, or if ECG/clinical features suggest cardiac disease.