Presenting complaints

Question 1

List differentials for Palpitations

Answer 1

CVS: Ectopic beats, Atrial Fibrillation, SVT, Ventricular tachycardia, Atrial flutter

GI = Phaeochromocytoma, Anaemia

GU = Pregnancy

Endo = Thyrotoxicosis

Neuro = Anxiety, stress or strong emotion (cause sinus tachycardia)

Drugs = Beta-2 agonists, anticholinergics, cocaine, amphetamines , caffeine, alcohol, digoxin

Question 2

Questions to ask on a palpitations history

Answer 2

Describe the rhythm (clap it out) - regular or irregular?
Previous episodes?
Precipitating / Relieving symptoms?
- Stressful situations (ANXIETY)
Duration of symptoms?
Associated symptoms?
- Chest pain, dyspnoea, dizziness (ARRHYTHMIA)
- Weight changes, temperature intolerance, Bowel changes, menstrual changes (THYROID)
- Vomiting, missed menstrual period (PREGNANCY)
Recent drugs

Question 3

10 Common causes of atrial fibrillation (presents as palpitations)

Answer 3

1. Ischaemic heart disease
2. Valvular heart disease (esp. mitral stenosis)
3. Hypertension
4. Cardiomyopathy
5. Sick Sinus syndrome
6. Alcohol excess
7. Congenital heart disease
8. constrictive pericarditis
9. Hyperthyroidism
10. Idiopathic

Question 4

Management of palpitations

Answer 4

? Cardiac cause = feel pulse and perform ECG (when symptomatic)
? Drug-related = Review all prescribed and recreational drugs
? Thyrotoxicosis = FBC’s, TFT’s
? Pregnancy = Pregnancy test
? Phaeochromocytoma = 24-hour urinary metanephrines
? Anxiety = Further social history
? AF due to structural disease = Echocardiogram (valves, LV hypertrophy, cardiomyopathy)
? AF = calculate CHA2DS2VASc score
Refer to cardiology

Question 5

List differentials for syncope

Answer 5

CVS: Bradyarrhythmia, Tachyarrhythmia, Vasovagal fits, Left ventricular outflow obstruction (e.g. aortic stenosis, hypertrophic obstructive cardiomyopathy)

RS: Acute PE,

Endo: Hypoglycaemia

Neuro: Stroke, Epilepsy,

Other: Aortic Dissection

Drugs: Anti-hypertensive medications can cause orthostatic syncope

Question 6

Questions to ask about a syncope history

Answer 6

Other witnesses
Prodromal symptoms?
- CVS problem: Chest pain, palpitations, dyspnoea
- Neuro problem: aura, headache, dysarthria, and limb weakness

During the episode

• Was there a pulse?
• Limb jerking tongue biting, urinary incontinence (epilepsy)

Recovery

• Prolonged with drowsiness? = Seizure
• Rapid? = Arrhythmia

Question 7

Management of sycope

Answer 7

? Seizure = refer to neurologist and commence anti-epileptics
? Cardiovascular cause = Refer to cardiologist
? Stroke/TIA = confirm diagnosis, CT scan and commence medications
? PE = Wells score, CT PA
? Hypoglycaemia = blood glucose test