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					Presenting Problem:
   Palpitations

“I feel my heartbeats”
             DDx

• Cardiac causes
• Non-cardiac causes
            Cardiac Causes:

• Premature beats
• Angina/ AMI
• Arrhythmias (e.g. Ventricular tachycardia,
  Bradycardia, atrial fibrillation, etc.)
• Mitral valve disease
• Aortic incompetence
Non-cardiac cause:
• Physiological(common):   •   Thyrotoxicosis
     – Anxiety             •   hypoglycaeima
     – Exercise
                           •   Phaeochromocytoma
                           •   Pregnancy
     – Pain
                           •   Electrolyte disturbance
     – Fever                   (e.g. hypoK, hypoMg)
•   Sepsis                 •   Menopause
•   Hypovolemia            •   Drugs
•   Pulmonary embolism
•   Anaemia
Drugs commonly causing
     palpitations:
     •alcohol
     •amphetamines
     •antidepressants
     •caffeine
     •Ca channel blockers
     •cocaine
     •digitalis
     •diuretics
     •decongestants
     •glyceryl trinitrate
     •nicotine
     •salbutamol
                        History
• Characteristics:
    – Onset/ offset; duration; rhythm; rate
• Describe:
    – “Irregular, all over the place” (AF)
    – “Isolated blowing in the chest” (ectopics)
    – “very fast fluttering” (supraventricular or ventricular)
•   Any related stress/ worry? (anxiety)
•   Other related symptoms?
•   Any chest pain during attack? (AMI/ AS)
•   Any SOB during attack? (anxiety, MS)
• Any dizziness/ fainting during attack
  (arrhythmias/ hypoglycaemia)
• Any medication taken currently (drugs)
• How much tea, coffee, Coke do you drink?
• Any recent weight loss/ tremor
  (thyrotoxicosis)
     Physical examination
        General exam:
• High temperature and other signs of
  fever and infection
• Signs of anaemia e.g. pallor
     Cardiovascular exam:

• Pulse rate:
  – <150 beats/min  VT, AF
  – >150 beats/min sinus tachycardia (exercise, fever,
    drugs or thyrotoxicosis)
• Rhythm:
  – Regularly regular  sinus tachycardia
  – Regularly irregular  ectopic beats
  – Irregularly irregular  AF
• Pulse character:
  – weak, small volume  shock, MS
  – Large, volume, bounding  Hypertension
  – Collapsing  Aortic incompetence, high output states
    e.g. anaemia, fever
  – Plateau  AS
  – Pulsus alternans  Severe myocardial dysfunction
  – Pulsus bigeminus  premature ectopic beats
  – Pulsus bigeminus followed by sinus beat  digoxin
    toxicity
• Raised JVP
• Displaced apex beat
• Murmur e.g. Mitral valve prolapse
• Lung bases
• Ankle edema
Others:
• Features of anxiety state and depression illness
    e.g. shaking, hyperventilation
•   Signs of thyrotoxicosis: goitre, sweaty hands,
    fine tremor
•   Signs of Grave’s disease: exophthalmos, lid lag,
    lid retraction, pretibial myxoedema
•   Signs of alcohol abuse: stigmata of chronic liver
    disease, parotid swelling, testicular atrophy
•   N.B. Pregnancy test
        When to investigate &
          Which tests to do
• This depends on the problem and test
  availability
• The number and complexity of
  investigations should be selected
  according to individual case
                   Ix:
• Chest X-ray
 (for cardiomegaly)
• ECG (12 lead)
 (for pathological arrthymias
  e.g. ectopic beats, heart block,
       atrial fibrillation…)

 Key Dx:
 ECG tracing during an episode of
 arrhythmia
                   Ix:
• Ambulatory 24 hour ECG monitoring
 (when a timed ECG cannot be organised)
• Echocardiography
 (for valvular heart disease and assess
   left ventricular function)
                          Ix:

• Blood Tests (for underlying disease)

• Haemoglobin and film
• Thyroid function tests
• Serum potassium and magnesium
  –   Serum digoxin (for suspected digitalis toxicity)
  –   Virus antibodies (for myocarditis)

				
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posted:2/11/2012
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