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11/13/24, 8\:11 PM Guide | Palpitations history

Palpitations history

Table of contents

Introduction

Palpitations are a common presenting complaint that can be associated with a wide range of possible underlying diagnoses,
both benign and life-threatening. You may be asked to take a history from a patient presenting with palpitations in an OSCE
setting and this guide has been created to help you prepare for this kind of scenario.
The ability to take a comprehensive history of palpitations will allow you to quickly narrow the di
patients who may require urgent further investigation.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you'd like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you're running through a checklist in your head doesn't mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" T e l l m e a b o u t t h e i s s u e s y o u’ v e b e e n e x p e r i e n c i n g .
"
Provide the patient with enough time to answer and avoid interrupting them.
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Facilitate the patient to expand on their presenting complaint if required\:
" O k , c a n y o u t e l l m e m o r e a b o u t t h a t ?"
" C a n y o u e x p l a i n w h a t t h e p a l p i t a t i o n s f e l t l i k e ?"
De
It is important to
di
can involve the heart feeling like it's pounding,
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

Gather further information to characterise the patient’s palpitations and rule out adverse features.
Onset of palpitations
Clarify how and when the palpitations started\:
" D i d t h e p a l p i t a t i o n s s t a r t s u d d e n l y ?"
" W h e n d i d t h e p a l p i t a t i o n s s t a r t ?"
" W h a t w e r e y o u d o i n g w h e n t h e p a l p i t a t i o n s s t a r t e d ?"
Precipitating and relieving factors
Ask if there are any obvious triggers for the patient's palpitations (e.g. exertion, positional, anxiety, alcohol, ca
deprivation)\:
" A r e t h e r e a n y o b v i o u s t r i g g e r s f o r t h e p a l p i t a t i o n s ?"
If the patient feels alcohol or ca
substances.
Ask if the patient has identi
" D o e s a n y t h i n g s e e m t o m a k e t h e p a l p i t a t i o n s b e t t e r ?"
Rate and rhythm of the palpitations
Try to roughly determine the rate and rhythm of the patient's palpitations\:
" H o w f a s t d o t h e p a l p i t a t i o n s f e e l ?"
" H a v e y o u e v e r r e c o r d e d y o u r p u l s e r a t e d u r i n g a n e p i s o d e o f p a l p i t a t i o n s ?"
" D o e s y o u r h e a r t f e e l l i k e i t' s b e a t i n g i n a r e g u l a r o r i r r e g u l a r r h y t h m d u r i n g p a l p i t a t i o n s ?"
" D o y o u s o m e t i m e s f e e l l i k e y o u' r e m i s s i n g a h e a r t b e a t , o r h a v i n g a n e x t r a h e a r t b e a t ?"
" C o u l d y o u t a p o u t t h e p a t t e r n o f t h e p a l p i t a t i o n s ?"
Duration and frequency of the palpitations
Ask the patient about the duration and frequency of their episodes of palpitations\:
" H o w l o n g h a v e y o u b e e n e x p e r i e n c i n g p a l p i t a t i o n s ?"
" H o w o f t e n d o y o u e x p e r i e n c e p a l p i t a t i o n s ?"
" H o w l o n g d o e s e a c h e p i s o d e o f p a l p i t a t i o n s l a s t o n a v e r a ge ?"
" C a n y o u d e s c r i b e t h e w o r s t e p i s o d e o f p a l p i t a t i o n s y o u h a v e h a d s o f a r ?"
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" A r e y o u a b l e t o s t o p t h e p a l p i t a t i o n s b y s t r a i n i n g o r h o l d i n g y o u r b r e a t h ?"
If the patient reports being able to stop the palpitations by performing vagal manoeuvres such as straining or holding their
breath, this may indicate a diagnosis of paroxysmal supraventricular tachycardia.
Adverse clinical features associated with palpitations
The presence of any of the following clinical features would warrant urgent clinical assessment and investigation\:
Syncope (loss of consciousness)
Pre-syncope (dizziness)
Chest pain
Shortness of breath
Palpitations during exercise/exertion
Sweating
Extreme fatigue (e.g. inability to carry out normal daily activities)

Associated symptoms

The presence of speci
Chest pain (occurring separately from the palpitations)\: consider myocardial infarction.
Low mood\: consider anxiety-related palpitations.
Tremor\: consider anxiety or hyperthyroidism.
Sweating\: consider myocardial infarction, hyperthyroidism and anxiety.
Heat intolerance\: consider hyperthyroidism.
Weight loss\: consider hyperthyroidism or malignancy (e.g. atrial myxoma).
Productive cough\: consider pneumonia.
Fatigue\: consider sleep deprivation and alcohol misuse.
Vomiting or diarrhoea\: consider hypovolaemia and electrolyte disturbances.

Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient's ideas about the current issue\:
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
" I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u g h t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
"
Concerns
Explore the patient's current concerns\:
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t’ s w o r r y i n g y o u ?"
" W h a t’ s y o u r n u m b e r o n e c o n c e r n r e ga r d i n g t h i s p r o b l e m a t t h e m o m e n t ?"
" W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i gh t b e ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?"
" W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?"
" W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?"
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Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient's history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
" O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u' r e h o p i n g w e
What you plan to cover next\:
h i s t o r y .
"
" N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant
to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention
in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include\:
Systemic\: fevers, weight change, fatigue
Respiratory\: dyspnoea, cough, sputum, wheeze, haemoptysis, pleuritic chest pain
Gastrointestinal\: dyspepsia, nausea, vomiting, dysphagia, abdominal pain
Genitourinary\: oliguria, polyuria
Neurological\: visual changes, motor or sensory disturbances, headache
Musculoskeletal\: chest wall pain, trauma
Dermatological\: rashes, ulcers

Past medical history

Ask if the patient has any medical conditions and speci
" D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
" H a v e y o u h a d a n y p r o b l e m s w i t h y o u r h e a r t i n t h e p a s t ?"
Ask if the patient has previously undergone any surgery or procedures (e.g. ablation procedures)\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Examples of relevant pre-existing cardiovascular disease
Cardiovascular disease relevant to palpitations include\:
Arrhythmias (e.g. atrial
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Structural heart disease (e.g. aortic stenosis)
Coronary artery disease
Congestive heart failure
Cardiomyopathy
Congenital heart disease
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Mental health history
Ask if the patient has any current mental health issues\:
Anxiety
Depression
Somatoform disorders

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
Ask about any recent dose changes to their regular medications.
If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form
and route.
Ask the patient if they're currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Medication examples
A wide range of prescribed and over the counter medications have cardiovascular side e
Beta-blockers
Beta-agonists
QT-prolonging medication
Herbal remedies (many contain ca

Family history

Ask the patient if there is any family history of cardiovascular disease\:
" D o a n y o f y o u r p a r e n t s o r s i b l i n g s h a v e a n y h e a r t p r o b l e m s ?"
Sensitively ask if the patient has any history of sudden cardiac death in their family (particularly
" W o u l d y o u m i n d i f I a s k e d i f a n y o n e i n y o u r f a m i l y h a s d i e d s u d d e n l y b e c a u s e o f a h e a r t p r o b l e m ?"
Clarify the age at which cardiovascular disease developed or sudden cardiac death occurred (more relevant if less than 40) and
determine the exact relation of the individual to the patient. Note that sudden cardiac deaths often masquerade as drownings
or accidents and may not have previously been attributed to a cardiac cause.
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Social history

Explore the patient's social history to both understand their social context and identify potential risk factors for palpitations.
General social context
It's important to explore the patient's current social context, as this will be relevant when considering if it would be safe to
discharge the patient home. Areas to cover include\:
the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stair lift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework,
food shopping)
if they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient's smoking history, including the type and amount of tobacco used.
Calculate the number of 'pack-years' the patient has smoked for to determine their cardiovascular risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
See our smoking cessation guide for more details.
Alcohol
intake.
Alcohol is a well-recognised cause of palpitations and arrhythmias, so it is important to accurately quantify the patient's alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Recreational drugs may be the underlying cause of a patient's presentation with palpitations\:
Cocaine, ecstasy and amphetamines activate the sympathetic nervous system and thus have similar cardiovascular e
which can include tachycardia (palpitations), blood pressure abnormalities (dizziness, headache) and coronary artery
vasospasm (chest pain).
Opiates including morphine and heroin activate the parasympathetic nervous system leading to bradyarrhythmias and
hypotension (syncope).
Cannabis activates the sympathetic nervous system at low doses (e.g. tachycardia, hypertension) and the parasympathetic
nervous system at higher doses (e,g, bradycardia, hypotension).
Diet
Ask if the patient what their diet looks like on an average day. Take note of unhealthy foods which are known to contribute to
cardiovascular disease (e.g. high salt intake, high saturated fat intake).
Exercise
Ask if the patient regularly exercises and if so clarify the frequency and activity type of exercise. Ask if exercise triggers
palpitations, as this is a red
Occupation
You should also ask about a patient's occupation in the context of palpitations (particularly those patients who also have other
adverse features such as syncope).
If the patient is experiencing episodes of palpitations with adverse features and works with heavy machinery or at heights, it is
important to advise them to take time o
Driving
If the patient drives and has presented with palpitations associated with adverse features it is important to advise them not to
drive until they have been fully investigated and to inform the relevant driving authority (e.g. DVLA) of their current medical
issues.
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Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. Abbott AV. Diagnostic approach to palpitations. Am Fam Physician. 2005 Feb 15;71(4)\:743-50.
2. Ling LH, Kistler P. The patient with palpitations\: cardiac, systemic or psychosomatic?.
3. Wexler RK, Pleister A, Raman SV. Palpitations\: Evaluation in the Primary Care Setting. American family physician. 2017 Dec
15;96(12).
4. Wilken J. Evidence-based Recommendations for the Evaluation of Palpitations in the Primary Care Setting. Medical Clinics. 2016
Sep 1;100(5)\:981-9.
5. Wol
6. Paul D Reavley. Palpitations. RCEM Learning. Published 6th October 2017. Available from\: [LINK].
Source\: geekymedics.com
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