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Name
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Kristeen Alexandre
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DOB
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27/04/1989 (26 years)
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Occupation
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Porter
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History
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I feel my heart race and thump in my
chest on a regular basis. If asked directly, it feels regular and occurs
around 3-4 times per week lasting less than half a minute. It usually happens
around 11am whilst I have been at work for an hour or two. If asked directly,
usually shortly after my second or third cup of coffee. I am otherwise well
with no chest pain, dizziness, shortness of breath or other symptoms.
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Past Medical History
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Diabetes which is well controlled
with medication
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Drug History
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Metformin
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Family History
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If asked directly, mother had severe
social anxiety. Otherwise nil
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Social History
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5 cigarettes per day. 5 units alcohol
per day. No recreational drug use.
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Introduces self
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes duration of episodes
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0
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1
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Establishes frequency of episodes
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0
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1
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Establishes whether regular or
irregular rhythm (may be helpful to ask patient to tap out)
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0
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1
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Asks for triggers (caffeine, alcohol,
activity)
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0
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1
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Asks how episodes end (sitting down,
spontaneous, specific habit/compulsion)
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0
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1
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Screens for associated symptoms:
chest pain, shortness of breath, polyuria (arrhythmia)
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0
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1
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Screens for hyperthyroid symptoms
(weight loss, sweating, agitation, diarrhoea, feeling hot)
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0
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1
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Screens for hypoglycaemic symptoms
(hunger, sweating)
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0
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1
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Screens for anxiety and associated
symptoms (tingling, nausea)
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0
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1
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Elicits past medical history
(specifically cardiovascular disease, diabetes mellitus, hypertension,
hyperlipidaemia, thyroid disease, anxiety)
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0
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1
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Elicits family history (specifically
asking for early cardiovascular disease, sudden death, arrhythmias, thyroid
disease)
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0
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1
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Elicits drug history (including use
of salbutamol if asthmatic)
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0
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1
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Checks for allergies
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0
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1
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Checks if patient smokes or drinks
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0
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1
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Asks if any history of illicit drug
use
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0
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1
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Asks about stress and the impact of
symptoms on life and occupation
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (Caffeine, Stress, Anxiety, Diabetes mellitus)
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0
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1
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