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Name
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Rosalina Frederic
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DOB
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25/06/1984 (31 years)
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Occupation
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Taxi driver
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History
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I feel my heart race and thump in my
chest every once in a while. It lasts about half a minute. I feel dizzy and
get some chest pain and shortness of breath. Once I actually fainted when it
happened! This was very embarrassing as it occurred whilst I was in a
supermarket. They occur in random locations and there isn\'t a specific
trigger. The symptoms go when my heart stops racing. I avoid exercising in
case that sets it off. Do you think I should avoid exercising? I deny any
other symptoms.
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Past Medical History
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Nil
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Drug History
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Nil
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Family History
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Nil
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Social History
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Non-smoker. Occasional alcohol. 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 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 (Paroxysmal supraventricular tachycardia, Arrhythmia, Anxiety)
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0
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1
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