Palpitations

Question 1

Key history in palpitations

Answer 1

Gradual vs. acute onset/offset
Context (exertional, caffeine, anxiety)
Other symptoms (lightheadedness, LOC, chest pain, dyspnea, fever, sweating, flushing, diarrhea)
Hyperthyroid symptoms
Hx of bleeding or anemia
Hx of heart disease, HTN or DM

Question 2

Key physical exam in palpitations

Answer 2

Vital signs
Endocrine/thyroid exam, including exophthalmos, lid retraction, lid lag, gland size, bruit and tremor
CV exam

Question 3

70 yo diabetic M with episodes of palpitations and diaphoresis
+ uses insulin

Answer 3

Hypoglycemia
Cardiac arrhythmia
Angina
Pheochromocytoma
Carcinoid syndrome

Glucose, CBC, electrolytes, TSH, ECG, Holter monitor, 24-hour urinary catecholamines, 5-HIAA

Question 4

35 yo M with several episodes of palpitations, sweating and rapid breathing
+ occur unexpectedly without triggers
+ 4-5 episodes per month
+ separation anxiety as a child

Answer 4

Panic attack
Generalized anxiety disorder
Hyperthyroidism
Substance abuse/dependence
Pheochromocytoma

CBC, electrolytes, TSH, FT4, ECG, echocardiography, urine toxicology, 24-hour catecholamines

Question 5

19 yo F with episodic palpitations, especially during presentations in front of class
+ heart pounding, facial blushing, hand tremor
+ excessive sweating and rapid breathing
+ intense worry and trouble sleeping for weeks before
+ avoids all social events due to fear of being humiliated

Answer 5

Social phobia
Avoidant personality disorder
Agoraphobia/specific phobia
Hyperthyroidism

CBC, electrolytes, ECG, echocardiography, TSH, FT4, MMSE

Question 6

34 yo F with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain

Answer 6

Mitral valve prolapse
Cardiac arrhythmia
Panic attack
Pheochromocytoma

ECG, echocardiography, Holter monitor, 24-hour catecholamines