Palpitations are a common presenting complaint that can relate to 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
- Introduce yourself (including your name and role)
- Confirm the patient’s details (name and date of birth)
- Explain the need to take a history
- Gain consent
- Ensure the patient is currently comfortable
It’s important to use open questioning to elicit the patient’s presenting complaint:
- “So what’s brought you in today?” or “Tell me about your symptoms”
- Allow the patient time to answer, trying not to interrupt or direct the conversation
Facilitate the patient to expand on their presenting complaint if required:
- “Ok, so tell me more about that”
- “Can you explain what the palpitations felt like?”
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.
History of Presenting Complaint
Gather further information to characterise the patient’s palpitations and rule out adverse features.
- Do the palpitations start suddenly?
- What were you doing when the palpitations started?
Precipitating and Relieving Factors
- Is there any obvious trigger for the palpitations? (e.g. exertion, positional, anxiety, alcohol, caffeine, sleep)
- Is there anything that helps to improve or relieve the palpitations?
- If the patient feels alcohol or caffeine are triggers for their palpitations, it’s important to quantify their intake of these substances.
Rate and rhythm of the Palpitations
- How fast do the palpitations feel?
- Does your heart feel like it’s beating regularly, or irregularly?
- Do you sometimes feel like you’re missing a heartbeat, or having an extra heartbeat?
- Could you tap out the pattern of the palpitations? (this will provide clues as to the rate and whether the palpitations are regular or irregular)
Duration and Frequency of the Palpitations
- How long have you been experiencing palpitations?
- How often do you experience palpitations?
- How long does each episode of the palpitations last on average?
- Can you describe the worst episode of palpitations you have had?
- When the palpitations go away, do they suddenly stop? (e.g. paroxysmal supraventricular tachycardia)
- Are you able to stop the palpitations by straining, holding your breath or coughing? (e.g. paroxysmal supraventricular tachycardia)
Adverse Clinical Features Associated with Palpitations
The presence of any of the following concerning features would warrant urgent clinical assessment and investigation:
- Syncope (loss of consciousness)
- Pre-syncope (dizziness)
- Chest pain
- Shortness of breath
- Extreme fatigue (e.g. inability to carry out normal tasks of daily living)
The presence of specific symptoms may provide clues as to an underlying cause for the palpitations:
- Chest pain (occurring separately from palpitations) – myocardial infarction
- Depression (anxiety related symptoms)
- Tremor (anxiety or hyperthyroidism)
- Sweating (myocardial infarction, hyperthyroidism, anxiety)
- Heat intolerance (hyperthyroidism)
- Weight change (thyroid disease)
- Productive cough (pneumonia)
- Fatigue (sleep deprivation, alcohol misuse)
- Vomiting or diarrhoea (hypovolaemia/electrolyte disturbances)
Ideas, Concerns and Expectations (ICE)
- Clarify what the patient’s thoughts are regarding their symptoms
- What do you think is going on?
- Explore any worries the patient may have regarding their symptoms
- Is there anything that you’re concerned about at the moment?
- Is there anything that is troubling you at the moment?
- Gain an understanding of what the patient is hoping to achieve from the consultation
- What were you hoping you’d get out of our consultation today?
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has told you so far.
It also provides an opportunity for the patient to correct any inaccurate information and expand further on relevant aspects of the history.
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 involves explaining to the patient:
- What you have covered so far: “Ok, so we’ve talked about your symptoms.”
- What you plan to cover next: “Now I’d like to discuss your past medical history.”
Past Medical History
Pre-existing Cardiac Disease
Ask the patient if they’ve had problems with their heart in the past:
- Structural heart disease (e.g. aortic stenosis)
- Coronary artery disease
- Congestive heart failure
- Congenital heart disease
- Arrhythmias (e.g. atrial fibrillation, atrial flutter, heart block)
- Cardiac surgery
Other Medical History
Ask the patient if they have any medical conditions such as:
Mental Health History
Ask if the patient has any current mental health issues:
- Somatoform disorders
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 this 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.
Taking a comprehensive medication history is essential, as many prescription and over the counter medications have cardiac side effects:
- Prescribed medications (e.g. beta blockers, beta agonists, QT-prolonging medication)
- Over the counter medications
- Herbal remedies (these can often contain significant amounts of caffeine)
You should also clarify any recent dose changes to their regular medications.
Check if the patient has any allergies, as this is important to document in any history.
It’s important to gain some insight into the patient’s current social context, as this may be relevant when considering if it would be safe to discharge the patient home:
- Who do you live with?
- Where do you live? (e.g. house with stairs, bungalow, care home)
- Are you able to do all of your daily activities without any help? (if not, consider if they have adequate support)
Alcohol is a well-recognised cause of palpitations and arrhythmias, so it is important to accurately quantify the patient’s alcohol intake:
- Do you drink alcohol?
- How many times a week do you drink alcohol?
- How much alcohol do you drink on an average week?
Smoking is a significant risk factor for cardiovascular disease and therefore it’s important to accurately assess the patient’s smoking history:
- Do you smoke?
- How much do you smoke each day? (e.g. 20 a day)
- How long have you smoked for?
Recreational drugs can often have both psychological and cardiac side effects, so it’s important to gain an accurate history as to what the patient has been taking:
- Do you use any recreational drugs at the moment?
- What drugs, in particular, are you using at the moment?
- When did you last take these drugs?
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).
It may be that they need to take time off work, for their own safety, whilst the cause for their palpitations is investigated (e.g. someone working at heights).
Closing the consultation
- Summarise the history and ask the patient if there’s anything else they’d like to add
- Thank the patient
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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. [LINK]