AL-KHALILI · Atrial Fibrillation

Patient Details

Name: Amira / Amar Al-Khalili
Age: 50–70 years
Opening statement: "I had an issue at work the other day where my heart was pounding"

Facilitator Notes

New presentation of AF — recognise from history and examination
Discuss potential underlying causes of AF (differential list)
Next steps in investigation and interim management
Opportunity for risk assessment (CHA₂DS₂-VASc / ORBIT) and NNT discussion

Resources: thennt.com (warfarin for AF stroke prevention); NICE CKS – Atrial fibrillation.

Clinical Details

Open questions — give freely:

Two weeks ago, about to give a presentation on further redundancies. While waiting to speak: pounding in chest (not painful, racing), anxious. Continued for some minutes. On standing to present: dizzy, difficulty concentrating, clammy, needed to sit down. Left the room embarrassed; improved shortly after. Took rest of day off. Booked GP (2-week wait) as episode was disconcerting.

Only if asked directly:

More tired past few weeks; shorter walks to reach 10,000 steps; slight breathlessness on walking (unusual)
Ankles a bit swollen by end of day
No chest pain
Work stressful (recent store closure / redundancies) — not new
Possible weight loss (started wearing a belt); does not weigh self

Systems review (if explored): No night sweats but generally sweatier (hot weather). Bowels more often / looser (not diarrhoea). Poor sleep, wakes often. Generally anxious about business future.

Patient Perspective (ICE)

Ideas: Thought racing heart during presentation was “nerves” — has done this many times before. Could it be stress-related?

Concerns: Cannot take the stress any more; is it time to retire/sell? Also concerned about dizziness — wants heart check-up. Worried BP will be up / heart attack.

Expectations: GP check-up — examination including BP and weight.

Feelings: Low self-esteem that successful business is not working out; feels bad about making long-standing employees redundant. Hoping GP will legitimise plan to step back.

Past Medical History

Hypertension
Hypercholesterolaemia
Osteoarthritis of knees

Medication

Ramipril 5 mg once daily
Amlodipine 5 mg once daily
Atorvastatin 20 mg once daily

Family History

Father — died in 60s from heart attack
Mother — died in 70s from breast cancer

Social History

Married; heterosexual; 3 children
Business person (chain of hardware stores, Midlands); partner is architect
Ex-smoker — gave up 10 years ago (was 20/day)
Alcohol: nil
Left Saddam Hussein’s Iraq in the 1980s; now successful; harder times with online retail competition
Attends surgery once a year for medication review

Demeanour

Anxious
Fine tremor if reaching out; no resting tremor

Physical Examination (only if requested)

Generally well but appears anxious; fine symmetrical tremor; hands clammy
Pulse 93 bpm irregularly irregular
BP — digital failed first two attempts; manual 135/115
Heart sounds normal, no murmurs; chest clear
Mild pitting oedema of ankles

Information for the Student

Name: Amira / Amar Al-Khalili · Age 50–70 · Ethnicity Arab British
Setting: GP clinic · New presentation
PMH: 2010 Hypertension · 2011 Hypercholesterolaemia · 2015 OA knee
Medication: Ramipril 5 mg OD · Amlodipine 5 mg OD · Atorvastatin 20 mg OD
Recent: 6 months: BP check HCA 135/82, BMI 27, encouraged exercise. 9 months: flu jab. 13 months: bronchitis (deferred antibiotics), BP 147/87

Primary Care Block · University of Buckingham