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Adam Fitzpatrick, Sanjiv Petkar, Paul Cooper Version 4 Last Update 16/11/2010
Developed by : Manchester Heart Centre 2010

Form Version 4 Date 16/11/2010 2019:01:22 22:31:21
Demographics Contact Information
First Name
Surname
NHS Number
Hospital Number
DOB:
Age
Sex Male Female
Ethnicity
   
Clinic Seen  
Clinic Type
Date Referred to RABTC
Date Seen in RABTC
Assessment by
Clinic Consultant
   
Include Patient in Study Y N
   
Learning Disability
if Yes - Condition :
if other please state :
If Yes - Diagnosis of epilepsy:
Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode
Tel (Home)
Tel (Work)
Tel (Mobile)
Email Address
GP
GP Name
GP Address
 
 
 
 
Tel
Fax No
Mob No
GP Email

Resource Utilisation
Source of Referral
consultant name
if referred by cardiologist/neurologist which hospital
Previous consultations for blackout  
At GP Surgery Y N No. of times
At NHS Walk-in Centre Y N No. of times
At A&E Y N No. of times
With Physicians Y N No. of times
With Neurologists Y N No. of times
With Cardiologists Y N No. of times
With Others Y N No. of times
Previous Admissions  
Total Number
Date of Last admission (year)
Number of days admitted
Number of days since referral
Where Admitted (list hospitals)
most recent admission first
Select from list or type
(put comma between each item on list)
Preliminary Questions
Presenting Complaint
Is there collapse during the episode ? Y N ?
Is there total loss of consciousness ? Y N ?
When did the blackouts start ? Years months
Last episode ? ago
How often do the blackouts occur ?
Duration of attacks?
Are all the attacks similar ? Y N ?
If N in what way are the attacks different ?
Other Comments
Circumstances Prior to the attack
What is the usual position of the patient prior to the attack ?
Lying Y N ?
Sitting Y N ?
Standing (short time) Y N ?
Standing (immediately) Y N ?
Standing (prolonged) Y N ?
Other
What was the patient doing at the time of the blackout?
Resting Y N ?
Walking Y N ?
Had just changed posture Y N ?
Occurred during exercise Y N ?
Occurred after exercise Y N ?
Associated with defecation Y N ?
Associated with urination Y N ?
Coughing Y N ?
During Swallowing Y N ?
Pre-disposing factors for the blackout
None  
Crowded Place Y N ?
Warm Place Y N ?
Prolonged Standing Y N ?
Postprandial period (after heavy meal) Y N ?
Fear Y N ?
Intense Pain Y N ?
Strong Emotion Y N ?
Headache/Migraine Y N ?
Lying Y N ?
Other

Other Factors  
Adequate fluid intake Y N ?
Do you add salt when you cook food? Y N ?
Do you add salt to your meal? Y N ?
Do you avoid salt ? Y N ?
Blackout ever occurred when lying down? Y N ?
Flashing lights nearby ? Y N ?
Blackout ever occurred asleep ? Y N ?
Do blackouts usually occur after a night out (late + alcohol) ? Y N ?
   

Other Comments

Patient started on any new drugs coincidentally ? Y N ?
  • Name
  • Dose
Onset of Attack
Does the patient get a warning that a blackout is going to occur ?
No Warning Y N ?
Prolonged Warning Y N ?
Brief Warning Y N ?
   
Symptoms just before the blackout
None  
Nausea Y N ?
Vomiting Y N ?
Dizziness Y N ?
Abdominal discomfort Y N ?
Feeling Cold Y N ?
Sweating Y N ?
Aura Y N ?
Blurred Vision/Visual Disturbance Y N ?
Chest Pain Y N ?
Palpitations Y N ?
Other Comments
 
Description of Attack
Description provided by
Tone of the body
loss of tone (the body went floppy) Y N ?
Increased tone (the body went stiff) Y N ?
Skin Colour
pallor (the face went very pale) Y N ?
Cyanosis (face and lips went blue) Y N ?
Flushing Y N ?
Loss of consciousness
the patient was completely out Y N ?
Breathing Pattern
Normal (or nothing noted) Y N ?
Heavy breathing Y N ?
Difficulty breathing Y N ?
Abnormal Movements
Tonic (the patient went stiff in arms and legs) Y N ?
Clonic (there were regular abnormal movements) Y N ?
tonic - clonic (both as above - stiff first) Y N ?
Movements
Are movements symmetrical (as opposed to asymmetrical) Y N ?
Myoclonus ( irregular twitching of arms, legs and face) Y N ?
Automatism (semi-purposeful but inappropriate) Y N ?
   
Onset of abnormal movement in relation to fall
Before the fall Y N ?
After the fall Y N ?
Tongue Biting
lateral Y N ?
tip of tongue Y N ?
Urinary incontinence
sometimes Y N ?
always Y N ?
Faecal Incontinence
sometimes Y N ?
always Y N ?
Description comments :
Video Clips
Video clips shown to patient ? - Y N

if N why?
Subject
Clip Name
View
Patient/Witness Recognises Symptom from DVD/Clip
Convulsive Syncope Convulsive Syncope
Yes No ?
Syncope Syncopal Med Student
Yes No ?
Generalised Seizures Tonic Atonic Alex
Yes No ?
Primary & Secondary gereralisation - tonic clonic seizures Harry
Yes No ?
Sal
Yes No ?
Partial seizures complex Terry
Yes No ?
Margaret
Yes No ?
Neil
Yes No ?
David
Yes No ?
Generalised seizures - absences Jack
Yes No ?
Calum 1 - atypical absences
Yes No ?
Calum 2 - atypical absences
Yes No ?
Partial seizures simple Graham
Yes No ?


Event after an attack
How does the patient feel after a black out ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
   
Recovery of awareness was
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Y N ?
Other Comments
Background
Patient History Blackouts ? Y N ?
  Morning jerks/jolts (myoclonus)? Y N ?
Brain injury or other antecedent cerebral insult (ACI) :
Y N ?
Meningitis
Y N ?
Stroke
Y N ?
Encephalitis
Y N ?
Anoxia
Y N ?
Other Conditions :
Diabetes
Y N ?
Hyper/Hypothyroidism
Y N ?
COPD
Y N ?
Hypercholesterolaemia
Y N ?
Hypertension
Y N ?
Rheumatic Fever
Y N ?
Congenital/Genetic
Y N ?
 
Known Valve Disease Y N ?
Previous MI Y N ?
Alcohol
Amount consumed units per week
Other alcohol comments
Smoking Smoker
  Quantity per day
Caffeine intake eg number of cups coffee per day
Other
Pregnancy exacerbates blackouts
Y N ?
Breathless if lying flat Y N ?
NYHA Class
Exercise tolerance
Regular exercise taken - eg walking
Family History of blackouts Y N ? of structural/congenital heart disease Y N ?
  of premature unexpected sudden cardiac death (age<40 yrs) Y N ? of febrile convulsions Y N ?
  of QT prolongation Y N ? of epilepsy Y N ?
         
Driving Advice has driving advice been given to the patient? Y N ? Driving advice given
(at a glance guide) does the patient need to inform the DVLA? Y N ?

Other Risk/History comments

 
Drugs
Recreational Drug Use Y N ?
Recreational Drug Comment
Is patient on any medication? Y N ?
Antihypertensive Y N ?
Antiarrhythmic Y N ?
Antianginal Y N ?
Diuretics Y N ?
Antidepressants Y N ?
QT prolonging drugs Y N ?
Please List Other Medication Below :
Drug/Total Dose/Freq
Medication Comment
pathway
Click the areas - hightlighted in white on the diagram - left. Your responses will be recorded in the boxes below.

If any of the boxes (below) are empty then the question has not been answered.

T-LOC
12 Lead ECG
History SCD<40
Structural Heart Disease
Exercise T-LOC
Unexpl. SOB
Brain Injury
Epilepsy
New Neurological Deficit
Syncope


Investigations
Abnormal blood results
Respiratory System
Blood Pressure
Readings
Lying
Standing
immediate
1 min
3 min
/
/
/
/
Heart sounds
Signs of heart failure Pulse bpm
  Rhythm
  Jugular Venous Pulse
Investigations : None (if ticked all options below will be set to 'Not Done')
If Abnormal is selected for any of the below options, a comment box will appear for you to complete.
ECG
(Mandatory All Patients)
Echocardiogram
Holter
ETT
Tilt
ILR
Carotid Sinus Massage
Neurology Opinion
EEG
CT Scan
MRI
Miscellaneous
Diagnosis

Click Yes or No, then select an option from each row.
A new row will appear for certain choices.

T-LOC Diagnosis : Yes No

Selected Diagnosis


Management Plan
Investigations Requested Treatment Offered
Loop Recorder Implantation
24hr Tape
Echocardiogram
Tilt Test
EP Study
EEG
CT Scan
Other

 

Followup booked

(goto Followup window to book appointment)

Reassurance only Y N
Drug Therapy (Withdrawal) Y N
  (Addition) Y N
Permanent Pacemaker Y N
Internal Cardioverter Defibrillator Y N
B. Ventricular PPM/Defibrillator Y N
Loop Recorder Y N
Other - please specify
   
Referral other specialist - Yes No
 
Outcome/Conclusion - comments to be included on letter
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