History Taking · Foundation · Cardiovascular

Palpitations in a 68-Year-Old Woman

Practise this PLAB 2 history taking station on Atrial Fibrillation. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the Cardiology Clinic. Mrs Helen Patel, a 68-year-old woman, has been referred by her GP because of intermittent palpitations over the past few months. She is concerned about her heart and has never experienced anything like this before. Please take a focused history and discuss your initial assessment and investigations.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Mild CKD stage 3b (eGFR 38), Hypothyroidism

What this station tests

  • Differentiating paroxysmal AF from other causes of palpitations (SVT, ventricular ectopics, anxiety) based on the character, irregularity, duration, and triggers of episodes
  • Recognising the clinical significance of hypothyroidism in a patient with palpitations: both hypo- and hyperthyroidism can cause or worsen arrhythmias, and TFT checking is essential
  • CKD awareness in management planning: eGFR 38 affects anticoagulant choice and dosing, which should be flagged even if not prescribing today
  • Stroke risk communication: explaining the need for anticoagulation in a patient who came in worried about her heart racing, not about stroke
  • Systematic screening for heart failure in a patient with AF and multiple comorbidities

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Palpitation stations test your ability to distinguish benign from pathological arrhythmias through the character of the palpitations. The patient's own description, whether the heart is 'skipping,' 'racing regularly,' or 'all over the place,' often points to the diagnosis before any investigation. Mrs Patel is 68 and has been referred for intermittent palpitations over several months. Open with: 'Your GP has asked us to look into the palpitations. Can you describe what happens during an episode?' Let her use her own words. She describes her heart 'going funny,' 'skipping,' and 'bouncing around,' suggesting an irregularly irregular rhythm consistent with paroxysmal AF.

Core approach

Characterise the episodes systematically. They started five months ago, occur once or twice weekly, last 10 to 30 minutes, and stop on their own. They happen at rest (first episode was putting shopping away), with no exertional trigger. Caffeine worsens them. She feels mildly breathless and dizzy during episodes but has never fainted. No chest pain. Episodes may be increasing in frequency. This pattern, intermittent, irregularly irregular, self-terminating, non-exertional, caffeine-sensitive, fits paroxysmal AF.

The PMH is clinically significant at every point. Hypertension is the commonest cause of AF. CKD stage 3b (eGFR 38) affects anticoagulation choices and dosing. Hypothyroidism is relevant: both under- and over-treated thyroid disease can cause arrhythmias. Check her levothyroxine dose and when TFTs were last checked. Candidates who do not ask about thyroid medication status miss a potentially reversible contributor.

Screen for heart failure: orthopnoea (none, sleeps flat), PND (none), ankle swelling (none), exertional breathlessness beyond the episodes (none). AF with concurrent heart failure changes management significantly, so this screening matters.

ICE: She is frightened because she has never experienced anything like this. She wants to know what is causing it and whether it is dangerous. She may worry about stroke if she has read about AF.

Closing and safety netting

In AF counselling, the two pillars of management, rate/rhythm control and stroke prevention, must both be explained. Start with the diagnosis: 'The most likely cause is atrial fibrillation, where the upper chambers of your heart beat irregularly. It is very common, especially with high blood pressure, and it is treatable.' Outline investigations: ECG today (may or may not capture paroxysmal AF), bloods (TFTs are essential given her hypothyroidism, plus FBC for anaemia, U&E given CKD), echocardiogram, and likely a portable monitor to capture an episode if today's ECG is normal.

Explain anticoagulation. Her CHA2DS2-VASc score is at least 4 (age, hypertension, female sex, vascular disease), so blood-thinning medication to prevent stroke will almost certainly be recommended. Note that her CKD affects which agent and dose. Do not prescribe today, but set the expectation. Practical advice: reduce caffeine. Safety net: episode lasting more than an hour, faintness, chest pain, or sudden weakness or speech difficulty means A&E immediately. The stroke warning is important to include.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for atrial fibrillation. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Detailed palpitation characterisation: irregularity, duration, frequency, self-terminating nature, triggers (caffeine). Thorough PMH including hypothyroidism medication check and TFT status. Heart failure screening. Recognising CKD as relevant to management. Complete medication and adherence history.

Costs marks: Superficial palpitation history ('How long have you had palpitations?'). Not exploring thyroid status. Not screening for heart failure symptoms. Missing the CKD and its relevance to anticoagulation.

Domain 2: Clinical Management Skills (Secondary focus)

Scores well: Clear explanation of AF as working diagnosis. Appropriate investigation plan: ECG, bloods (specifically TFTs and renal function), echo, ambulatory monitoring. Explaining both pillars of AF management: rate/rhythm control and anticoagulation for stroke prevention. Noting CKD impact on anticoagulant choice. Practical caffeine advice.

Costs marks: No mention of stroke risk or anticoagulation. Not planning an echo. Not requesting TFTs. Not arranging ambulatory monitoring for paroxysmal episodes.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Explaining AF in non-technical language ('the top chambers of your heart beat irregularly'). Addressing her fear that something is seriously wrong with her heart. Introducing stroke risk sensitively without causing alarm. Empathic response to her frustration about not being able to predict when episodes occur.

Costs marks: Using 'atrial fibrillation' without explaining what it means. Mentioning stroke risk abruptly without context. Not addressing her anxiety. Dismissing her symptoms as 'just palpitations.'

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not checking thyroid function status. Mrs Patel has hypothyroidism and is presumably on levothyroxine. If her thyroid is undertreated (or overtreated), this could be driving the palpitations. Candidates who do not ask about her thyroid medication and most recent blood results miss a potentially reversible cause.
  2. Failing to screen for heart failure. A 68-year-old with hypertension, CKD, and new-onset AF is at significant risk of concurrent heart failure. Candidates who do not ask about orthopnoea, PND, ankle swelling, and exertional breathlessness miss a critical assessment.
  3. Not mentioning stroke risk. Many candidates focus entirely on rate or rhythm control and forget that the most dangerous consequence of AF is thromboembolism. Mrs Patel needs to understand that anticoagulation is likely the most important part of her treatment, even though her presenting complaint is palpitations.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take an atrial fibrillation history in PLAB 2?

Palpitation stations test your ability to distinguish benign from pathological arrhythmias through the character of the palpitations. The patient's own description, whether the heart is 'skipping,' 'racing regularly,' or 'all over the place,' often points to the diagnosis before any investigation. Mrs Patel is 68 and has been referred for intermittent palpitations over several months.

Where are marks won and lost in this atrial fibrillation station?

Examiners reward: Detailed palpitation characterisation: irregularity, duration, frequency, self-terminating nature, triggers (caffeine). Thorough PMH including hypothyroidism medication check and TFT status. Candidates are penalised for: Superficial palpitation history ('How long have you had palpitations?'). Not exploring thyroid status. Not screening for heart failure symptoms.

Where do candidates most often go wrong in this station?

Not checking thyroid function status. Mrs Patel has hypothyroidism and is presumably on levothyroxine. If her thyroid is undertreated (or overtreated), this could be driving the palpitations.

Can I do well in this station without real-world experience of atrial fibrillation?

This station rewards process over personal experience. The skill being assessed: Recognising the clinical significance of hypothyroidism in a patient with palpitations: both hypo- and hyperthyroidism can cause or worsen arrhythmias, and TFT checking is essential. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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