Palpitations, a Printout and a Mother Who Answers First
Ms. Reyes is 29 and works as a hospital laboratory technician. She has had three weeks of episodic palpitations lasting 10 to 20 minutes, four or five times a week, sometimes waking her at night, with chest tightness and breathlessness that also occurs at rest. She has attended the emergency department twice; both times the ECG, troponin and D-dimer were normal and she was discharged with a diagnosis of 'anxiety'. She arrives at your primary care clinic with 14 pages of internet printouts, a symptom diary rating every episode, and a normal thyroid function result from last week. Ferritin is pending. You have a 20-minute appointment and you are already eight minutes behind. She speaks quickly, moves between subjects, and at one point says, 'Do you think it's my heart, or do you think I'm mad?' Her mother, who drove her, has come into the room and begins answering for her. Triage recorded no red-flag features, but she has not had a cardiovascular examination.
1. You have roughly twelve usable minutes. Set out how you would structure the interview so that it ends with a defensible assessment and a patient who feels heard.
Read the worked answer
Take control of the agenda before taking the history. 'I've got about twelve minutes, and I want to use them well. There are two things I want to cover - your heart symptoms, and what you're most worried might be behind them. Is there anything that must not be missed?' This buys permission to interrupt later and reveals her actual fear.
Neutralise the mother in one sentence, without humiliating her. 'Mrs. Reyes, I'd like to hear it from Ana first - then I'll ask you what you've noticed, because a witness account is genuinely useful.' Then address the patient only for the next few minutes, maintaining eye contact with her.
Open the narrative and protect it. 'Start from the first time it happened and tell me the story.' Allow 60–90 seconds without interruption; the diagnostic yield of an uninterrupted account is high, and the symptom diary is already a structured record - read it rather than re-asking every detail.
Then funnel to closed questions. Palpitation analysis: onset/offset, rate, regular or irregular, associated syncope or presyncope, exertional trigger, relation to caffeine, alcohol, sleep, menstrual cycle. Red flags: syncope, symptoms at exertion, family history of sudden death under 40 or of cardiomyopathy, known structural disease. Then screen for panic and for anaemia, and review the diary pattern.
Examine her. With normal tests and a presumed anxiety label, the cardiovascular exam is not optional - it is the thing that makes the conclusion defensible and the patient feel taken seriously. Check pulse, BP, heart sounds, thyroid.
Close with a summary and a checked understanding: 'Have I got that right? What have I missed?'
2. How do you answer 'Do you think it's my heart, or do you think I'm mad?' - communicating uncertainty without dismissing her or over-promising?
Read the worked answer
Name both errors and refuse both. 'I'm not going to tell you it's nothing, and I'm not going to tell you it's definitely anxiety. Let me tell you what I actually think.'
Explain the reasoning out loud. 'Two normal ECGs and normal troponins are genuinely reassuring - they make a heart attack or a dangerous rhythm at the time of testing very unlikely. They don't film your heart for 24 hours, so they can't rule out an intermittent rhythm.' This respects her intelligence; she works in a laboratory and will spot a reassurance that does not add up.
Break the false dichotomy. 'Anxiety and a heart rhythm problem are not opposites. Anxiety makes palpitations more noticeable and more frequent, and palpitations make anxiety worse. Both can be true.'
Answer the 'am I mad' part directly, because that is the real question. 'No. You've brought a detailed diary and two ED attendances. That's a person trying to be taken seriously, not someone imagining things.'
Then give a plan with a named review and a safety net. Arrange ambulatory ECG monitoring if available, add ferritin and a full blood count, and state clearly: 'If you get chest pain with sweating, or you faint, or the palpitations last more than a few minutes with breathlessness, go to the ED - don't wait for this appointment.' Ask her to repeat that back, because safety-netting given at the end of a rushed consultation is the part most often misremembered.
Document uncertainty as uncertainty. Write the differential and the plan, not 'reassured'.
3. Three weeks later she returns and says: 'You told me it was stress, and now my GP says I need a Holter.' How do you handle the mismatch, and what does it reveal about the record you wrote?
Read the worked answer
Do not litigate what was said. Arguing about the transcript makes her feel disbelieved and turns a perception gap into a conflict. Open with curiosity: 'That's not what I meant to convey, and I'm sorry it landed that way. Tell me what you took away from that appointment.'
Then account for the gap honestly. Patients under stress reliably retain the reassurance and drop the caveats - 'we'll monitor' is heard as 'nothing is wrong'. That is a predictable feature of how information is processed at the end of a consultation, not a failure of her listening. Say something like: 'I said the tests were reassuring and I also said they couldn't rule out an intermittent rhythm. I clearly didn't make the second half stick, and that's on me.'
Reconstruct the plan together. Explain what the Holter is for, what it can and cannot show, and what happens if it is normal. Give the result a named owner and a date.
Then audit your own note. If it reads 'reassured, likely anxiety' it has recorded a conclusion and not a process - and the next clinician, reading it, inherits a label rather than a differential. A defensible note would say: 'Episodic palpitations, normal ECG/troponin x2, no red flags on history, CV exam normal. Differential includes paroxysmal arrhythmia vs anxiety-related symptoms; neither excluded. Plan: 24-hour Holter, FBC/ferritin, safety-net advice given and teach-back confirmed, review with results.' The note that protects the patient and the clinician is the one that preserves uncertainty and the reasoning behind the plan.