Tammy Robbins, a 48-year-old woman, has been experiencing heart racing and chest discomfort for the past three days. Conduct a focused history and physical examination. Her vital signs are as follows: blood pressure 90/70 mm Hg, heart rate 146/min (irregular), respiratory rate 16/min, and temperature 37.5°C.
History of present illness
- Onset: gradual onset? (more common), sudden? (tachycardia due to reentry)
- Course: Is it continuous or intermittent?
- Duration: Is it the first time or have you had it before? If prior episodes - When and how were you diagnosed? What treatment were you given at that time? When was the last episode? How long did it last?
- Quality: Do you feel that your heart is going fast or is it skipping beats?
- Associations: Are the symptoms precipitated by caffeine, chocolate, or food/coke? Is it related to activity? How many blocks are you able to walk?
Review of symptoms
- CVA: Any weakness, numbness, difficulty finding words, or visual problems?
- Cardiac: Shortness of breath? swelling of legs? How many pillows do you use? Chest pain? Dizziness or loss of consciousness?
- GI: Severe vomiting or diarrhea (electrolytes disturbances)
- Endocrine: Weight loss? (hyperthyroidism), Episodic pallor, tremor, headache, diaphoresis? (pheochromocytoma)
- Pulmonary: Wheezes/cough/chest tightness? (Asthma/lung disease)
🔺 RED FLAGS: Associated chest pain, syncope, dyspnea. History of cardiac disease. Duration of episode > 5 mins. Significant family history.
Past medical/surgical history
- Do you take medications on regular basis? Any new medication? (beta-agonists, antiarrhythmics, pseudoephedrine, tricyclics, herbal medication)
- Cardiac risk factors (smoking, DM, HTN, dyslipidemia, family history).
- Past history of Atrial Fibrillation, Wolff-Parkinson-White (WPW) syndrome, arrhythmias, CAD, Congestive heart failure, DM, stroke, TIA, syncope.
- History of thyroid disease, any sweating/diarrhea?
- Recent surgery or immobilization? (Pulmonary embolism)
- Family history of sudden death at a young age? (cardiomyopathy)
- Caffeine, smoking, alcohol?
- Recreational drugs: cocaine, amphetamines, opiates?