DOORWAY-PALPITATIONS

Question 1

PALPITATIONS-DIFFERENTIALS

Answer 1

Cardiac Arrhythmia, Caffeine, Fever, Anxiety/Panic Disorder, HypoGlycemia, Anemia, HyperThyroidism

Question 2

RULE OUT CARDIAC ARRHYTHMIA

Answer 2

a. Have you noticed any chest pain? SOB? Racing of heart? Skipped beats? Sweating?

Question 3

CARDIAC ARRHYTHMIA WORKUP

Answer 3

ECG

TEE

Event monitor

Holter monitor

24~hour urinary

catecholamine&

Question 4

RULE OUT CAFFEINE

Answer 4

a. Do you consume caffeinated beverages? If yes, then ask how much?

Question 5

RULE OUT ANXIETY/PANIC DISORDER

Answer 5

a. Is there any event associated with the racing of heart?
b. Does your breathing rate increase or feel shortness of breath during the episode?
c. Do you feel dizzy during the episode?

Question 6

ANXIETY WORKUP

Answer 6

CBC

Electrolytes

TSH,FT4

Question 7

RULE OUT HYPOGLYCEMIA

Answer 7

a. Do you have a Hx of High blood sugar level?
b. Have you skipped meals? Or changed any dose or medications recently?

Question 8

HYPOGLYCEMIA WORKUP

Answer 8

Glucose

CBC

Electrolytes

TSH

ECG

24,hour urinary

catecholamines

5,HIAA

Question 9

RULE OUT ANEMIA

Answer 9

a. Have you noticed any change of skin color?
b. Have you noticed SOB on exertion?
c. Have you noticed bleeding (excessive-for menses) from any site of the body?
d. Have you noticed any change in your stool color?
e. What does your diet consist of?
f. Do you have any craving for ice?

Question 10

ANEMIA WORKUP

Answer 10

CBC

Question 11

RULE OUT HYPERTHYROIDISM

Answer 11

a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors/shaking of hands?

Question 12

HYPERTHYROIDISM WORKUP

Answer 12

TSH,FT4

Thyroid ultrasonography: Can diagnose the etiology of hyperthyroidism (e.g., diffuse enlargement, solitary/multiple nodules, increased vascularity of the gland)

Question 13

RULE OUT PHEOCHROMOCYTOMA

Answer 13

Do you have headache? Any sweating?

OTHER

Clinical presentation is related to fluctuating levels of excess epinephrine, norepinephrine, and dopamine.

Episodic hypertension (or persistent hypertension in some cases)

Paroxysmal

Throbbing headache

Diaphoresis

Heart palpitations and tachycardia

Pallor

Abdominal pain and nausea

Anxiety

Hypertensive crises can be triggered by palpation of the tumor on abdominal exam!

Question 14

PHEOCHROMOCYTOMA

Answer 14

24,hour urinary catecholamines

Question 15

PALPITATIONS WORKUP

Answer 15

CBC

Electrolytes

TSH,FT4

ECG

Echocardiography

Urine toxicology

24~hour urinary

catecholamines

Glucose

CBC

Electrolytes

TSH

ECG

24,hour urinary

catecholamines

5,HIAA

Question 16

RULE OUT CARCINOID SYNDROME

Answer 16

Do you have diarrhea?

How is your diet?

How is your weight? Has it changed?

OTHER

Asymptomatic

Abdominal pain

Carcinoid syndrome

Diarrhea and abdominal cramps

Cutaneous flushing

Possible triggers: alcohol consumption, food intake, stress

In severe cases, may be accompanied by tachycardia and fluctuating blood pressure

Dyspnea, wheezing (asthma-like attacks)

Possible weight loss despite normal appetite

Carcinoid heart disease

Tricuspid insufficiency and/or pulmonary stenosis

Symptoms of right-sided heart failure

Possible pellagra (niacin deficiency)

Presents as a triad of dermatitis, diarrhea, and dementia.

Question 17

CARCINOID SYNDROME WORKUP

Answer 17

Biochemistry tests should be performed first if a carcinoid tumor is suspected. Imaging tests are then used to localize and stage the tumor.

Biochemistry tests

↑ 5-hydroxyindoleacetic acid (5-HIAA) in 24-hour urine

↑ Serotonin serum levels

Imaging

CT scans of the abdomen and pelvis

Somatostatin-receptor scintigraphy (e.g., OctreoScan®)

MRI

Transabdominal ultrasound: although not part of the workup, sometimes detects a mass if routinely conducted

Biopsy