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National Clinical Guideline Centre for Acute and Chronic Conditions (UK). Transient Loss of Consciousness (‘Blackouts’) Management in Adults and Young People [Internet]. London: Royal College of Physicians (UK); 2010 Aug. (NICE Clinical Guidelines, No. 109.)

Appendix D5Patient profile for interactive diagnostic simulation

In order to understand the context of initial stage assessment and to elicit GDG views in the early stages of guideline development, the GDG took part in an interactive diagnostic simulation exercise.

General practitioner (GP) training has focussed on the importance of what happens within a typical patient consultation. This is usually recorded and analysed to enable new GPs to reflect on the detail within the consultation, in particular, the quality of verbal and non-verbal behaviour, the sequencing of questions and information gathered to enable diagnosis. This is based around simulation and objective structured clinical examination methodology and has effectively enabled GP trainees to experience and develop understanding related to the importance of clinical history prior to physical examination.

In order to test the usefulness of different aspects of patient history including eye witness account, the technical team ran an interactive diagnostic simulation with members of the GDG. A patient profile, based on detailed notes kept by a real patient with recurrent TLoC, was shared by an actor. The patient profile used is given in the appendix to this section.

Four GDG members (a GP, an ED physician, and two cardiologists, one of whom worked in a specialist blackout clinic) then role-played a consultation, with an actor playing the part of the patient, timed at about 10 minutes consultation. All the clinicians observed each others’ consultations, three of whom carried out full consultations and the consultant in the Blackout clinic asked additional questions to which he required answers, to avoid repetition. In the consultation in ED, another GDG member played the part of the patient’s husband, and gave an eye witness account. During each of the role-plays, GDG members were asked to observe the consultation.

The technical team then discussed with the GDG what aspects of patient history had been considered and how these could be used to inform management of the patient, moving towards a possible diagnosis/view of the cause of the TLoC.

The content was analysed and grouped in patient history themes, including eye witness accounts. The number of clinicians addressing each issue is also reported.

1. Pre-TLoCNo. of clinicianscomments
How did the attack start?1
Any precipitating factors, e.g stress3
Pre-TLoC symptoms, e.g. light headed, feeling weak, cold and clammy, breathless and sick4
Of eye witness, did patient look pale?2
Did patient know it was about to happen?
(“like a bird knows it’s going to rain”)
0Additional suggestion by GDG
How did eye witness describe it?
“I thought she was dying”
1Indicates seriousness
How long was pre-TLoC warning?2Including how long was the chest pain before blackout.
Relates to driving, & usefulness of external recorder
Were there auras preceding the event1
Were there palpitations preceding the event?1
2. The TLoC event itselfNo. of clinicianscomments
First determine if it was TLoC1
How long was attack?230 minutes is unlikely to be syncope
How long unconscious? (of eye witness)2
Pain1
What is the tone of the body during blackout?1Stiffer tone with epilepsy; floppy and pale => syncope
Was there incontinence, tongue biting, abnormal movements, injuries on black out?1Syncope can be associated with abnormal movements and incontinence too
Was blackout related to posture or environment?1
Could patient abort an attack?1
Details about chest pain and pressure in chest1
Epilepsy can probably be diagnosed0GDG: Clear epileptic seizure can probably be diagnosed from initial information
3. Eye witness accountNo. of clinicianscomments
Did patient look pale?2
How did eye witness describe it?

“I thought she was dying”
1Indicates seriousness
How long was patient unconscious?1
Record with mobile phone0GDG: recommended that the eye witness should record event with mobile phone video if possible
4. Post-TLoCNo. of clinicianscomments
How quickly came round/how long till felt normal2
Were there prolonged symptoms?1Epilepsy more likely to have post symptoms
How did patient feel?1
What did patient remember on coming round1Lack of memory of the event is more likely to be epilepsy
Any palpitations or fast heart beat1
Was oxygen given in the ambulance?1
Was ECG done in the ambulance?1
Ambulance investigation notes need to stay with the patient1Lot of the assessment is done by ambulance staff
Ambulance staff can give information on home environment e.g. presence of intoxicating substances0GDG suggestion
5. Patient history of TLoCNo. of clinicianscomments
How many previous occasions?3
How frequent?3
How long had it been going on?2Long duration (11y) suggested less likely to be structural heart disease or ischaemia
Has it changed with time?1Same each time is more likely to be cardiac cause
What is difference between attacks (chest pain) with and without TLoC?1
How many times admitted because of blackout?1
How did it all start?1
6. Other aspects of patient historyNo. of clinicianscomments
How patient was when giving information, e.g. calm?1Was there a need for acute care/resuscitation?
Did the patient have any symptoms during consultation?1
Need to take into consideration the patient themself0GDG: could be psychogenic after 11 years
What happens when patient at rest? (re chest pain and any irregular heart flutters)1
What happens when walking up hill, any chest pain?1
Any other comorbidities?2Looking for serious medical conditions, e.g. diabetes, hypertension, rheumatic fever, smoking; also exploring other causes of loss of consciousness
Family history e.g. of early death1
Questions re previous investigations what were they and findings3Were the following done: treadmill, ECG, ambulatory ECG; external recorder
Any allergies?1Routine question
Any head injuriesGDG question
Previous history of myocardial infarction1
Age1Take into consideration
7. DrugsNo. of clinicianscomments
Investigate different prescribed drugs – what are they for?3e.g. amitriptylene is antidepressant

GDG: is the TLoC drug induced?
Prescribed drugs0Looking for history not reported by patient (e.g. psychiatric); confirmation of other indications
Alcohol intake?1
8. Clinical examination the clinicians would carry outNo. of clinicianscomments
Blood pressure1
Bp sitting down and standing up1Cardiac, postural hypotension
Neurology questions (basic)1
Listen to heart1
Unspecified1
9. Routine tests the clinicians would orderNo. of clinicianscomments
12-lead ECG2GDG agreed that should be done for all patients
Finger prick test1diabetes

Both the GP and the ED consultant stated that their approach to the consultation was to determine if there were any areas requiring urgent action, so they focussed immediately on the chest pain symptoms.

The GP used the consultation to determine if the patient should be referred to secondary care for further investigation, and this was based on the perceived seriousness of symptoms, in this case, the chest pain. In some ways it was more difficult for the GP not to refer the patient.

The ED consultant, however, commented it was more difficult to admit the patient for further investigation; e.g. there was no direct route from ED into cardiology.

The GDG was concerned about referral patterns.

The clinicians concluded that the patient should not be considered to be in urgent need for referral because the events had been going on for 11 years, but she should be followed up fairly soon (a few weeks). The GDG noted that there was a need to ensure follow up if the patient was discharged, and there was a need to give lifestyle and safety advice.

The GDG concluded that there was a low chance of structural heart disease or ischaemia because the events had been going on for 11 years, the 12-lead ECG was normal, and problems did not occur on exertion. They suspected an infrequent arrhythmia (tachycardia) which they would investigate either with an external ECG recorder (used when the patient had another attack) or an implantable event recorder.

Appendix: Patient history for interactive diagnostic simulation

Name:Sheila Jones
Date of Birth:08.11.1951
Married:37 years with two chidren, both left home
Employment:PA to CEO of a non-governmental organisation

Medical history

11 year history of chest pain/light headed feeling, with this I can get a feeling of pressure actually in my chest. Sometimes this is associated with pain in my teeth/jaw. Lots of visits to the GP and A and E, nothing ever really established, something that does worry my husband and I. Three previous blackouts, never explained, just told not to worry about them.

Previous cardiology referral about three years ago; I was told I do not have a cardiac problem, and not to worry about the blackouts. Having experienced them for over ten years, I am not going to die from them! It might be gall stones, but nothing showed on an ultrasound.

Quite a few ECGs, never showed anything. BP has been high, on medication. Had a treadmill test which only showed something right at the end, which I understand is normal. I was told I might have too much acid, and was started on Lansoprazole for 3 months, but this was continued. Loads of blood tests, all inconclusive, and I guess over time I have become dissatisfied that no one can tell me what is wrong. I’ve lost count of how many doctors I have seen, it just keeps happening, and I suppose I have learnt to accept that this is just the way it is going to be.

Medication

Solifenacin10mg morning (urinary condition)
Lansoprazole15mg morning (heartburn)
Aspirin75mg morning (high blood pressure)
Lisinopril20mg morning and evening (high blood pressure)
Nicorandil10mg morning and evening (smoking, 25 day for 34 years, gave up 5 years ago)
Simvastin10mg morning (cholesterol)
Amitriptylene1 – 3 before bed (help me sleep)

What happened today

Whilst reading/babysitting, had a very sharp pain in my chest which lasted 15 – 20 minutes. Pain straight across chest, just a flicker in my jaw. Started at 8.35pm and stopped at 9pm. Ambulance arrived at 9.05pm, my BP was 120/90. I felt slightly sick and about to faint. It was similar to last time. I wanted to drink but didn’t feel I had energy to lift the cup, asked for a straw. Bill my husband called for an ambulance because I wasn’t with it for about 10 minutes, he said I was unconscious for about 4 minutes. I had an ECG with the ambulance crew, he thought it might show ‘ischaemia’ and that I should go to hospital.

Copyright © National Clinical Guideline Centre for Acute and Chronic Conditions, 2010.
Cover of Transient Loss of Consciousness (‘Blackouts’) Management in Adults and Young People
Transient Loss of Consciousness (‘Blackouts’) Management in Adults and Young People [Internet].
NICE Clinical Guidelines, No. 109.
National Clinical Guideline Centre for Acute and Chronic Conditions (UK).

NICE (National Institute for Health and Care Excellence)

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