CARDIOPULMO - Palpitation

Question 1

Palpitation Differentials

Answer 1

Differential diagnosis (TIHA)
-thyroid (weather preference and bowels habit)
-infections (fever)
-hypoglycemia (skipping meal)
-anaemia (bleeding)
General (imp to know risk)
-medications
-PMH (heart failure or attack, hypertension, DM)
-smoking, alcohol, coffee
-family history and stress at work or home

1. PSVT
2. Hyperkalemia
3. Atrial flutter
4. Hyperthyroidism
5. Coffee/Stress

Risk factors or cause
1-thyroids
2-infection
3-anaemia
4-medications
5-hypertension, heart disease
6-electrolyte imbalance
7-alcohol, coffee, stress
8-family history

Question 2

Palpitations Differentials JM

Answer 2

Probability diagnosis  
Anxiety 
Premature beats (ectopics)—atrial and ventricular 
Sinus tachycardia, e.g. fever, exercise 
Supraventricular tachycardia 
Drugs (e.g. stimulants) 

Serious disorders not to be missed  
Myocardial infarction/angina 
Arrhythmias: 
• atrial fibrillation or flutter 
• ventricular tachycardia 
• bradycardia/heart block 
• sick sinus syndrome 
• torsade de pointes 
Long QT syndrome 
Wolff–Parkinson–White (WPW) syndrome 
Electrolyte disturbances: 
• hypokalaemia 
• hypomagnesaemia 
• hypoglycaemia (type 1 diabetes) 

 Pitfalls (often missed)  Fever/infection 
Pregnancy 
Menopause 
Drugs (e.g. caffeine, cocaine) 
Mitral valve disease 
Aortic incompetence 
Hypoxia/hypercapnia 
Rarities: 
• tick bites (T1–5) 
• phaeochromocytoma 

Masquerades checklist  Depression 
Diabetes (indirect) 
Drugs (see list) 
Anaemia 
Thyroid disorder, hyperthyroidism 
Spinal dysfunction 

Is the patient trying to tell me something?
Quite likely. Consider cardiac neurosis, anxiety.

Question 3

Palpitation - Key History

Answer 3

Key history

Ask the patient to describe the onset and offset of the palpitations, the duration of each episode and any associated features. Then ask the patient to tap out on the desk the rhythm and rate of the heartbeat experienced during the ‘attack’. If the patient is unable to do this, tap out the cadence of the various arrhythmias to find a matching beat.

An irregular tapping ‘all over the place’ suggests atrial fibrillation, while an isolated thump or jump followed by a definite pause on a background of a regular pattern indicates premature beats (ectopics), usually ventricular.

Take a past history and family history including caffeine intake, smoking, alcohol, social drugs such as marijuana or cocaine, and prescribed drugs (β blockers, antipsychotics, antidepressants, thyroxine, digoxin, nifedipine, sympathomimetic).

Question 4

Palpitation - Key PE

Answer 4

Key examination

• The ideal time to examine the patient is during the palpitations. If not, the examination is usually normal
• The cardiovascular examination should assess the pulse rate, rhythm, volume and character
• The general examination should investigate features suggestive of anaemia, anxiety, tremors, dyspnoea and thyroid disease
• Look for evidence of mitral valve prolapse

Question 5

Palpitation - Key Investigation

Answer 5

Key investigations 
A checklist includes:
•FBE
•TFTs
•serum glucose
•urea, electrolytes and magnesium
•ECG
•cardiac enzymes
•echocardiography
•Holter monitoring.

Question 6

Palpitation - Diagnostic Tips

Answer 6

Diagnostic tips
•A relatively non-specific symptom.
•Consider hyperthyroidism as a cause of atrial fibrillation or sinus tachycardia even if the clinical manifestations are not apparent.
•Arrhythmia of sudden onset suggests paroxysmal supraventricular tachycardia (PSVT), atrial flutter/fibrillation or ventricular tachycardia.
•Common triggers for premature beats and PVST are smoking, anxiety and excessive caffeine.