SUPPLEMENTAL MATERIAL Appendix S1: Initial Evaluation of ...

SUPPLEMENTAL MATERIAL

Appendix S1: Initial Evaluation of Syncope Flow Diagram Appendix S2: Initial Evaluation of Syncope Data Form

SCAMPs® Program Syncope CHB SDF 1: Initial Evaluation of Patient with Syncope

Initial Evaluation

© Copyright 2014 Institute for Relevant Clinical Data Analytics, Inc. All Rights Reserved. For permissions contact 617 355-4280.

Page 4 of 11 Last Updated 2014-02-28 16:04:10

Stamp with addressograph, place sticker, or fill out the following

CHB MRN: ____________________

SCAMPs® Program Syncope CHB SDF 1: Initial Evaluation of Patient with Syncope

Pt name:

____________________

Recommended SCAMP Testing: Height, Weight, Sitting HR, Blood pressure, Respiratory Rate, ECG Visit date: _____________

Location __________________

Attending physician name (Please print):

_________________________________

Fellow physician / NP name (Please print): _________________________________  Patient only displays symptoms of dizziness, no history of syncope

SCAMP enrollment status (if applicable):  Patient ineligible for SCAMP (SDF not completed) - If patient is ineligible, please return blank form  Physician enrolling patient in SCAMP, no packet delivered at time of visit Please describe why patient is ______________________________________________________________ ineligible/eligible? General SCAMP Comments:

Patient History Yes No Unk

Yes No Unk 1. Syncope with exercise?







11. Did the patient experience incontinence?







2. Syncope post exercise?







12. Did the patient experience loss of tone?







3. Syncope with rest?







13. Did the patient experience color change (pallor)?







4. Did the patient experience prodrome?







14. History of recurrent joint dislocation?

5. Dizziness or lightheadedness without syncope?

 

 

 

 

 

6. Palpitations?

 

15. Did the patient incur injury during the event?

7. Visual change?







16. Was there any level of disability with the event?

8. Anxiety?







 10. Did the patient have any convulsive like activity? 

 

 

9. Palipitations unrelated to prodrome?

If yes, please describe: _________________________________



17. Were there absences from school?













If yes, how many days?___________________ 18. Was there a situational trigger for the event?? If yes, please describe:___________________

Comments: __________________________________________________________________________________

 Yes

19. Within the last year has the patient been in the ER for potential cardiac complaints? If yes, has the patient been seen for the following: No Unk

Yes

 No

 Unknown

No Unk

a. Syncope?







c. X-ray?





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b. Bloodwork?





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d. ECG?



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

Additional Comments/Questions:__________________________________________________________________ 20. Did the patient see any other specialists prior to this visit?



If yes, please describe: _________________________________

If yes, please describe: ________________________________

Yes



 Yes

 No

 Unknown

If yes, please list_______________________________________________________________________________ 21. Is the patient taking any medications, vitamins, or supplements?

 Yes

 No

 Unknown

If yes, please list_______________________________________________________________________________ _______________________________________________________________________________ © Copyright 2014 Institute for Relevant Clinical Data Analytics, Inc. All Rights Reserved. For permissions contact 617 355-4280.

Page 1 of 11 Last Updated 2014-02-28 16:04:10

SCAMPs® Program Syncope CHB SDF 1: Initial Evaluation of Patient with Syncope Family History (1st and 2nd degree relatives) Yes No Unk

Yes No Unk 22. Sudden Unexplained Death ( 10

3

Never

0

< Weekly

1

Multiple events weekly

2

Daily

3

1 ER visit

2

Injury

3

Normal School Attendance

0

Early pickup and/or > 2 school nurse visits

1

Missed 3-5 days

2

Missed > 5 days

3

Total Score © Copyright 2014 Institute for Relevant Clinical Data Analytics, Inc. All Rights Reserved. For permissions contact 617 355-4280.

____ Page 2 of 11 Last Updated 2014-02-28 16:04:10

SCAMPs® Program Syncope CHB SDF 1: Initial Evaluation of Patient with Syncope Physical Exam  Normal for age. If Abnormal, please evaluate below Questions 34 - 47 Yes No Unk

Yes No Unk

34. Alert and oriented?







41. Non-innocent murmur?



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

35. Cranial nerves intact?







42. Distant Heart Sounds?







36. Gait intact?







43. Gallop?







37. Finger to nose coordination intact? 

  

44. Ĺ Pulmonic Component of S2



47. Increase in heart rate?

   

   

   

39. Joint hypermobility or scoliosis?

 

  

40. Marfaniod Appearance?





38. Positive Romberg Sign?

45. Pericardial Friction Rub 46. Peripheral edema

Comments: _____________________________________________________________ EKG

Date of test: ________________  Normal for age. If Abnormal, please evaluate below Ques 48 - 62 Yes No Unk

Yes No Unk

48. WPW?







56. QTc 450 - 479 ms?







49. Brugada Pattern?





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57. QTc > 480 ms?







50. ST-T segment change > 2 mm?





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58. RAE, LAE







51. QRS axis 130?





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59. RVH







52. PR segment depression?

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60. LVH







53. PR Interval > 220 ms?





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61. Bundle Branch Block







54. Inverted T-waves?







62. Ventricular ectopy







55. Atrial Ectopy













(Other abnormality)

Comments: _____________________________________________________________ Syncope Classification 63. Was education provided to the patient/family regarding syncope?  Yes

 No

64. What type of syncope does the patient have (p.4)?  Typical (p.5)  Exertional (p.6)  Convulsive (p.7)  POTS (p.8)  Atypical/Refractory (p.8) If the patient has typical syncope, please complete the fields below. If other syncope, please skip to page 9. Follow Up What is the severity of the syncope? Typical Syncope Guidelines 0-4 5-8 9-12 Objective Syncope Score Severity  Low  Moderate  *Disabling If low severity, no follow-up required Follow-up chosen (low or moderate typical syncope): None Referred to Other Medical Team 1 Month 2 Months Other ____________

* If disabling, skip to page 9.

Did you follow the SCAMP recommendations for follow-up interval?  Yes  No: ________________________________________

If low or moderate typical syncope with normal ECG and no additional testing, do not continue: FORM COMPLETE. If abnormal ECG/additional testing, continue onto SDF 1a (page 9)

© Copyright 2014 Institute for Relevant Clinical Data Analytics, Inc. All Rights Reserved. For permissions contact 617 355-4280.

Page 3 of 11 Last Updated 2014-02-28 16:04:10