Blackouts

Rapid Access BlackoutsTriage Clinic

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New Patient

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

Form Version 4 Date 16/11/2010 2010:12:09 02:25:43

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

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 ?
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 ?
Primary & Secondary gereralisation - tonic clonic seizures	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 ?
Sweating	Y N ?
Nausea	Y N ?
Vomiting	Y N ?
Feeling cold	Y N ?
Disoriented/Confused	Y N ?

Recovery of awareness was
Quick (< 5 mins)	Y N ?
Prolonged (>5 mins )	Y N ?
Slow (over an hour)	Y N ?
Retrograde Amnesia	Y N ?
Does patient remember starting to fall?	Y N ?
Fatigue / muscle aches	Y N ?
Injury (bruises and cuts)	Y N ?
Fracture	Y N ?
RTA	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

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 premature unexpected sudden cardiac death (age<40 yrs)	Y N ?
	of QT prolongation	Y N ?
	of structural/congenital heart disease	Y N ?
	of febrile convulsions	Y N ?
	of epilepsy	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

Collapse ? Cause

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
Brain Injury
Structural Heart Disease
Exercise T-LOC
Epilepsy
New Neurological Deficit
Syncope

Did the patient have a spontaneous blackout (T-LOC) ?

Consider Falls TIA/CVA
Drug misuse and Usual Care

Yes or uncertain

12 lead ECG with appropriate report

Abnormal

Normal

Is there a family history of SCD<40?

Yes

Is there any history of brain injury?

Yes

Is there significant structural heart disease?

Yes

Does T-LOC occur on exercise?

Yes

Features that strongly suggest epilepsy

Yes

New neurological deficit

Yes

Prompt evaluation
by neurologist

Prompt evaluation
by cardiologist

Features that strongly suggest Reflex Suncope

Appropriate
referral

Yes

Reassurance, await developments

Uncertainty about diagnosis

Recurrent symptoms

Investigations
Abnormal blood results
Respiratory System	Blood Pressure Lying	/
Heart sounds	Blood Pressure Standing	/
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

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

	Title:
	Showing:
	Recognised Symptom	Y N Don't Know
	click OK to close window & record the response on the database. Cancel - close window only

Arrhythmias, Electrophysiology, Ablation & Device Therapy


Rapid Access Blackouts Triage Clinic

Consultant : %Consultant%	Date of Clinic : %DateSeenRABTC%

Demographics

Patient:	%FirstName% %Surname%	GP:	%GPName%	NHS Number:	%NHSNo%
Address:	%Add1%	Address:	%GPAdd1%	Hosp Number:	%HospNo%
	%Add2%		%GPAdd2%	Date of Birth:	%DOB%
	%Add3%		%GPAdd3%	Gender:	%Sex%
	%Add4% %Add5%		%GPAdd4% %GPAdd5%	Referred by:	%RefBy%
Tel:	%TelHome%	Tel:	%GPTel%	Urgency:	Elective
		Fax:	%GPFax%	Consultant/GP:	%RefCon%
		Email:	%GPEmail%	Hospital:	%RefHosp%

History

Symptoms: %BlackoutsStartedMonths%%EpisodeFreq% %attacks% %AdmissionsX% admissions, last admitted in %LastAdmissionMonth% %LastAdmissionYear% %AdmissionHospitals% %PrevHospitals%
History of sudden death in family under 40 years?	%FamilyHisSCD%	Risk Rating:
Blackouts occur during exercise?	%POSDurExercise%	%flag%
History of structural or significant heart disease, or heart failure?	%PathwaySHD%
History very suggestive of epilepsy?	%PathwayEPILEPSY%
History of previous brain injury?	%PathwayBRAIN%
History of new or evolving neurological deficit?	%PathwayDEFICIT%

Investigations

12-Lead ECG:	ECHO	Other +ve Tests
%InvECG1%%InvECG%	%InvEcho1%%InvEcho%	%InvHolter% %InvETT% %InvTilt% %InvILR% %CSM% %Neuro% %EEG% %CT% %MRI% %Misc%

Comments : %comments%
Diagnosis %Diagnosis%	Signed		Follow-up
	Date : 09-12-2010	Date : 09-12-2010	%FU%
	Specialist Nurse	Doctor

Rapid Access Triage Clinic – patient report

Name: %FirstName% %Surname%	Clinic Appointment: %DateSeenRABTC%
	Assessment By : %NURSE%

Patient Details	GP
Hospital No: %HospNo% NHS No: %NHSNo% DOB: %DOB% Age: %AGE%	%GPName% %GPAdd1% %GPAdd2%, %GPAdd3%, %GPAdd4% %GPAdd5%

Presenting Comlaint : %COMPLAINT%

Outcome & Conclusion : %comments%

Diagnosis : %Diagnosis%

Investigations : %INVLIST%

Further Investigation Requested : %FIRLIST%

Examination Findings Today :
Blood pressure : Lying : %BP% Standing : %SBP%	Pulse : %PULSE%
Heart sounds : %CVS%	Rhythm : %RHYTHM%
Repiratory system : %RS%	Jugular Venous Pulse : %JVP%
%HF%
%HF%

%BADBLOOD%

Current Medication and Recommended Changes:

%DRUGSLIST%
%DRUGS%
%RECDRUG%

Recommended Changes: %DCHANGES%

Details of episode:
%COLLAPSE%	%STARTED%
%LOC%	%LASTEP%
	%BOFREQ%
	%DURATION%
Prior to attack
%PATIENTPOS% %PREDISP% %ACTIVITY% %OTHER%
Onset/symptoms/attack description
%WARNING% %SYMPTOMS% %DESC%
History/other factors
History of Blackout : %BLACKOUTHIS%
Exercise Tolerance : %EXTOL%
Breathless if lying Flat : %BLESS%
NYHA Class : %NYHA%

Clinical Details / Risk Factors :
Previous MI/CABG/IHD : %PREVMI%	Family History Sudden Cardiac Death / Arrhythmias : %FAMSCD%
Diabetes : %DIAB%	Hypertension : %HYPTEN%
Hypo/Hyperthyroidism : %HYPTHY%	COPD : %COPD%
Hypercholesterolaemia : %HYPCHOL%	History of Rheumatic Fever : %RFEV%
Congenital/Genetic Conditions : %GENETIC%	Previous TIA / CVA : %STROKE%
Known Valve Disease : %VALVE%
Alcohol Units per Week : %UNITWEEK%	History of Excessive Alcohol Consumption : %ALC%
Smoker : %SMOKER%	Amount smoked per Day : %DAYSMOKE%
Excess Caffeine Intake : %CAFFEINE%
Exercise Tolerance : %EXTOL%	Exercise taken : %EXTAK%
Other : %OTHERRISK%

Specialist Nurse Signature:

Date:

Cause of T LOC :	Syncope Epilepsy Psychogenic Epileptic Seizure Unknown
Syncope Type :	Reflex Syncope Cardiac Syncope Orthostatic Hypotension Undetermined
Reflex Syncope :	Vasovagal Syncope Carotid Sinus Syncope Situational Syncope
Cardiac Syncope :	Cardiac Arrhythmias as a primary cause Structual Cardiac or Cardiopulmonary Disease

Rapid Access BlackoutsTriage Clinic

Other Risk/History comments

Selected Diagnosis