| | PALPITATIONS
Doorway information about patients
The patient is a 28-year-old man who comes to the clinic sue too palpitations.
Vital signs
.Temperature: 37’C
. Blood pressure : 130/80 mmHg
. Pulses : 80 /min
. Respirations : 12 /min
Approach to the patient
Palpations can be defined simply as an awareness of the heart beat and can be uncomfortable or disconcerting to the patient . Palpations may be fleeing or sustained ,and can be described as rapid , irregular , forceful , or as a strange “flip-flopping” sensation in the chest . The character of the palpations can give clues to the cause(eg,ventricular premature contractions amy present as isolated , forceful beats occurring at rest ), but historical features alone are rarely sufficient for diagnosis.
Although palpations are typically though of as a cardiac phenomenon , patients with anxiety or hyperadrenergic states may experience palpations in the absence of intrinsic cardiac abnormalities. Conversely, recurring palpations can be a source of anxiety and become self-perpetuating . In light of this , it is important to be sensitive to any underlying anxiety a patient may have , but do not allow the presence of anxiety to preempt a thorough evaluation.
Differential diagnosis
Differential diagnosis of palpations
1 Structure heart disease : Valvular heart dies , cardiomyopathy
2 Cardiac conduction disease : Atrial fibrillation , supraventricular arrhythmia /ectopy , ventricular arrhythmia / ectopy
3 Metabolic disorders : Hyperthyroidism , pheochromocytoma , hypoglycemia , anemia.
4 Neuropsychiatric disorders : Anxiety disorder , insomnia.
5 medications : Stimulants , vasodilators , bronchodilators , anticholinergics
6 other substances : caffeine , alcohol(abuse or withdrawal) , cocaine , amphetamines.
Cardiac source of palpitations is more likely in a patient who was a sensation of irregular heartbeat , prolonged symptom(>5 min) or underlying heart disease . Some patient may learn to terminate the symptoms by vagal maneuvers (eg, coughing , valsalva), which suggest a supra ventricular tachycardia. -Syncope or pre syncope _ suggests possible malignant arrhythmias(eg. non sustained ventricular tachycardia ). Occasional “skipped beats “ that occur at rest and disappear with activity in an otherwise healthy , well-conditioned patient are common and usually represent benign ectopy . A cardiac cause iOS more like in patients presenting to the emergency department , whereas a psychiatric cause is more common in a ambulatory clinic setting.
HISTORY AND PHYSICAL EXAMINATIONS
The cardiovascular examination for a patient with palpations should be through and will likely require examination in multiple positions (upright , supine 45 degree). Be sure to allow adequate time for a proper examination.
History of present illness
. Please describe what your palpations feel like.
. Do you have additional symptoms(eg,chest pain , dizziness) with the palpations?
. Have you passed out ?
. When did these episodes begin?
. How often are they happening?
. How long do they last ?
. What are you doing when you have this episode?
. Does anything seem to trigger them?
. Do you drink coffee(caffeine) ? if so , how much?
. Have you had breathing problems or swelling in your legs?
Past medical history
. Have you been diagnosed with any others medical conditions( eg, heart disease , hypertension, asthma)?
Medications/ allergies
. Do you take any medications (prescription or over-the-counter)?
Family history
. Are there any heart conditions in your immediate family?
. Did anyone in your family die unexpectedly at a young age ?
Social history
. Do you smoke ? At what age did you start & How much do you smoke ?
. Do you drink alcohol , include beer ? How much & How often ?
. Have you used recreational drugs?
PHYSICAL EXAMINATION
Neck
. Examine thyroid for enlargement or nodules.
Lungs
. Auscultate for breath sounds & adventitious sounds.
Heart
. Inspect neck viens & precordium.
. Palpate carotid & peripheral pulses .
. Palpation precordium for displaced point of maximal impulse.
. Auscultate for murmurs , gallops&rubs (repeat with Valsalva)
Neurologic
. Evaluate deep tendon reflexes.
. Examine for hand tremor.
Extremities
. Examine for many peripheral edema .
Skin
. Examine skin for warmth , flushing & diaphoresis
Closing the encounter
Following the physical examination , mist patient with palpitations may need only a brief wrap-up discussion . Review the most important findings in the history and physical examination, and discuss your differential diagnosis and any anticipated diagnostic studies . However , patients having significant anxiety regarding the symptoms may require extra time . Encourage them to express their concerns (eg, “what are you concerned may be causing your symptoms ?”) and provide reassurance as appropriated but avoid minimizing their concerns or giving false reassurance .
Diagnostic studies
A resting - 12 -lead -ECG - should be performed on almost all patients with palpitations or other symptoms that are potentially due to cardiac condition disease . In the Step CS exam , an ECG ,ay be provided for you in the patient room , and you should review common ECG abnormalities prior to the exam . More advanced cardiac diagnostics (eg , echocardiogram , exercised stress test ) are usually not ordered as a first step unless there are oath specific indications (eg , prominent heart murmur). Ambulatory monitoring (eg, Holter monitor )can be considered if the patent is having frequent symptoms and the resting ECG is non diagnostic . Laboratory studies are worthwhile in most cases but the initial testes are usually limited to basic markers :
. Complete blood count
. Electrolytes
. Glucose
. TSH
Chest - x -ray ,may helpful to assess the cardiac silhouette , advanced imaging studies (eg , CT scan , MRI ) are usually not needed.
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2018/05/24 09:42pm 
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