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You are an FY1 working on the cardiology ward. Dee Fibb is a 75-year-old woman referred to the outpatient clinic by as she has been experiencing repeated episodes of palpitations. She has no other past medical history of note.

Please take a history from Dee, eliciting her concerns about her symptoms, and perform a relevant examination.

You are Dee Fibb, a 75-year-old woman who is relatively active, enjoying walking every weekend. You live with your husband Alan in the same town you’ve lived in your whole life. You went to see your GP a few weeks ago as you’ve noticed your heart doing some funny things. About three times now you’ve had periods of becoming extremely aware of your heartbeat; it feels like your heart wants to jump out of your chest and you feel like your pulse is racing. You have also noticed yourself feeling dizzy when these episodes happen and need to sit down for a little while- this has led to you becoming more anxious as you haven’t had much wrong with your health in the past.

HPC: You first noticed the palpitations about two months ago. It came on suddenly while you were baking banana bread in the kitchen for your grandchildren. You could hear your heartbeat in your head, and felt like your heart was going very fast. You also became a bit dizzy, and had to sit down for about an hour. The dizziness passed and you were able to finish making your banana bread, and you figured that you must have just been a bit tired or not eaten enough that day. Over the next few days you still noticed your pulse racing in your wrist, but as you felt OK you didn’t think much of it. You think that the pulse was like this for about four days.

The second time occurred two weeks after the first episode. You were out walking with Alan this time, when you started to feel quite breathless, only about two miles into the walk, and felt like you needed to sit down. Alan was worried, as you are usually very fit, and are stubborn and never like to stop during a walk! You started to feel dizzy, just like the first time with the banana bread and you had that same sensation of feeling your heartbeat in your head. You had to turn around and go home, as you felt too dizzy and breathless to go on. You managed to sleep the dizziness off, and again you figured you were just tired or hadn’t eaten enough. The next day you felt fine. You didn’t think to feel for your pulse this time.

The third time occurred three weeks ago. You were in Sainsbury’s when it happened, buying ingredients for the Sunday dinner. You started feeling a strange sensation in your chest, not a pain but more a discomfort, and the heartbeat in your head thing happened again. You did feel your pulse this time and it was very, very fast. You finished your shopping quickly and drove home but it was hard to do so as you felt really dizzy. You got in and made yourself a cup of tea and felt a bit better. However the next day your pulse was still racing and you felt a bit worried, as this was the third time such an event had happened so you called your GP.

You’ve not experienced any bowel trouble, intolerance to heat, or any changes in mood or anxiety.

ICE: You have never had anything like this before in your life, and are normally very fit for your age and very well, so these episodes are very concerning to you. You are worried that it might be diabetes, as your cousin had that and she used to get dizzy. You’re a bit confused as to why you’re at the heart clinic as you haven’t had any heart problems before. You got dizzy, so surely you should be at a head clinic? You really hope it isn’t diabetes, because you don’t fancy those injections she had to take every day!

The most frustrating thing is not being able to carry out your normal activities- every time these events have happened they’ve been a nuisance and you’ve had to stop doing something you enjoy. You don’t like having limitations.

You’re not expecting much from this appointment- in between these episodes you feel 100% normal and you think that they’re just silly things and that the GP was over reacting by sending you here. You’re expecting to just be sent home! You’re really hoping they don’t give you any tablets- you’ve gotten this far without needing any and don’t want to start now!

PMH: Appendicectomy at age 22

DH: None- and you don’t fancy starting now! No allergies

FH: Your mum had heart problems in her later years, but you can’t remember what they were. She died of lung cancer.

SH: You are a retired secretary, and you used to work in a bank up until you retired at age 65. You live with your husband Alan in a 2-storey semi detached house and neither of you have any problems at home. You have two children; your daughter lives in the same town as you, with her husband and two kids who you see every weekend, for Sunday dinner and baking! Your son moved to Australia two years ago and you see him at Christmas. You are a very active person- you go to yoga three times a week, and you go walking twice a week with Alan, and can still walk around 15 miles at a time; a little less than in your younger years but impressive for your age nonetheless! You drink socially- a small glass of wine with a meal about twice a week. You’ve never smoked, as it’s bloody awful for your health.

The student should take a clear history of Dee’s symptoms, and be able to elicit her ideas, concerns and expectations regarding her condition. A cardiovascular examination is appropriate.

Differential Diagnosis:

My differential diagnosis would include atrial fibrillation, and causes of this. Other arrhythmias such as atrial flutter, or ectopic beats could also be possibilities. It is important to consider underlying causes of atrial fibrillation such as hyperthyroidism and valvular disease.

Discussion Questions:

What are some causes of atrial fibrillation? How would you investigate Dee’s symptoms? What is atrial fibrillation? How would you classify Dee’s symptoms? Acute, Paroxysmal, Persistent or Permanent? What would be an appropriate management plan for Dee? What is Dee at a greater risk of now, and how would you assess and manage this risk?