Palpitations History Taking – OSCE Guide

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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 differential diagnosis and identify 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.

Confirm the patient’s name and date of birth.

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 offering them a seat).
  • 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:

  • “What’s brought you in to see me today?”
  • “Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.

Facilitate the patient to expand on their presenting complaint if required:

  • “Ok, can you tell me more about that?”
  • “Can you explain what the palpitations felt like?”
Defining palpitations

It is important to first tease out that the patient is, in fact, experiencing palpitations. The term palpitations can hold different meanings amongst different people. Palpitations are heartbeats that suddenly become more noticeable. This can involve the heart feeling like it’s pounding, fluttering or beating irregularly, often for just a few seconds or minutes.

Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of 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 differential diagnosis.


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:

  • “Did the palpitations start suddenly?”
  • “When did the palpitations start?”
  • “What were you doing when the palpitations started?”

Precipitating and relieving factors

Ask if there are any obvious triggers for the patient’s palpitations (e.g. exertion, positional, anxiety, alcohol, caffeine, sleep deprivation):

  • “Are there any obvious triggers for the palpitations?”

If the patient feels alcohol or caffeine are triggers for their palpitations, it’s important to quantify their intake of these substances.

Ask if the patient has identified anything that improves or stops the palpitations:

  • “Does anything seem to make the palpitations better?”

Rate and rhythm of the palpitations

Try to roughly determine the rate and rhythm of the patient’s palpitations:

  • “How fast do the palpitations feel?”
  • “Have you ever recorded your pulse rate during an episode of palpitations?”
  • “Does your heart feel like it’s beating in a regular or irregular rhythm during palpitations?”
  • “Do you sometimes feel like you’re missing a heartbeat, or having an extra heartbeat?”
  • “Could you tap out the pattern of the palpitations?”

Duration and frequency of the palpitations

Ask the patient about the duration and frequency of their episodes of palpitations:

  • “How long have you been experiencing palpitations?”
  • “How often do you experience palpitations?”
  • “How long does each episode of palpitations last on average?”
  • “Can you describe the worst episode of palpitations you have had so far?”
  • “Are you able to stop the palpitations by straining or holding your breath?”

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
  • Sweating
  • Extreme fatigue (e.g. inability to carry out normal daily activities)

Associated symptoms

The presence of specific clinical features may provide clues as to the underlying cause of the palpitations:

  • 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 fluid throughout the consultation in response to patient cues. 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:

  • “What do you think the problem is?”
  • “What are your thoughts about what is happening?”
  • “It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns

Explore the patient’s current concerns:

  • “Is there anything, in particular, that’s worrying you?”
  • “What’s your number one concern regarding this problem at the moment?”
  • “What’s the worst thing you were thinking it might be?”

Expectations

Ask what the patient hopes to gain from the consultation:

  • “What were you hoping I’d be able to do for you today?”
  • “What would ideally need to happen for you to feel today’s consultation was a success?”
  • “What do you think might be the best plan of action?”

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 different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.

Signposting examples

Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”

What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”


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 specifically ask about any pre-existing cardiovascular disease: 

  • “Do you have any medical conditions?”
  • “Are you currently seeing a doctor or specialist regularly?”
  • “Have you had any problems with your heart in the past?”

Ask if the patient has previously undergone any surgery or procedures (e.g. ablation procedures):

  • “Have you ever previously undergone any operations or procedures?”
  • “When was the operation/procedure and why was it performed?”

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 fibrillation, atrial flutter, heart block)
  • Structural heart disease (e.g. aortic stenosis)
  • Coronary artery disease
  • Congestive heart failure
  • Cardiomyopathy
  • Congenital heart disease

Allergies

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 anaphylaxis).

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:

  • “Are you currently taking any prescribed medications or over-the-counter treatments?”

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 effects from their medication:

  • “Have you noticed any side effects from the medication you currently take?”
Medication examples

A wide range of prescribed and over the counter medications have cardiovascular side effects including:

  • Beta-blockers
  • Beta-agonists
  • QT-prolonging medication
  • Herbal remedies (many contain caffeine)

Family history

Ask the patient if there is any family history of cardiovascular disease:

  • “Do any of your parents or siblings have any heart problems?” 

Sensitively ask if the patient has any history of sudden cardiac death in their family (particularly first-degree relatives):

  • “Would you mind if I asked if anyone in your family has died suddenly because of a heart problem?”

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.


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 profile:

  • 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

Alcohol is a well-recognised cause of palpitations and arrhythmias, so it is important to accurately quantify the patient’s alcohol intake.

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 effects 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.

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 off work until they have been fully investigated.

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.


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. Wolff A, Cowan C. 10 steps before you refer for palpitations. British Journal of Cardiology. 2009;16(4):182.
  6. Paul D Reavley. Palpitations. RCEM Learning. Published 6th October 2017. Available from: [LINK].

 

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