Palpitation

Casebank History
1

Nature of palpitation

  • Can you tell me what you mean by palpitation?
  • Do you have an awareness of yout heart racing?
  • Can you tell me what you mean by fluttering feeling?
  • Do you have an experience of thumping in the chest?
  • Are the palpitations fast or slow?
  • Do you have ah experience of pounding in the chest?
  • Do you have an experience like your heart is skipping beats?
  • Did you have a feeling that everything stopped for a moment?
  • Can you tap for me on this table how fast your palpitations are?

FODPARA

  • F - Frequency: How often do you experience palpitations?
  • O - Onset: How did the palpitation start the first time? Suddenly or gradually?
  • D - Duration: When did the palpitations start? How long have you had the palpitations for?
  • P - Progression: Are the palpitations becoming more frequent?
  • A - Aggravating factors: anything which makes it worse or anything which brings it on?
    • Does exercise make it worse?
    • Does stress make it worse?
    • Does drinking alcohol make it worse?
    • Does drinking tea or coffee make it worse?
  • R - Relieving factors: anything which makes it better?
    • Does sitting help with palpitations?
    • Does holding your breath help with your palpitations?
  • A - Association: Differential diagnosis

Note: Ventricular ectopic beats disappear with exercise whereas AF remains the same.

Differential Diagnosis

Hyperthyroidism

  • oligomenorrhea, heat intolerance, palpitations, weight loss, diarrhoea, tremors, palpitations

Questions:
• Do you feel hot when others are comfortable?
• Do you have diarrhoea?
• Have you lost weight? If yes, quantify.
• Do you experience any tremors?
• How is you appetite?

Medications (salbutamol inhaler)

  • Are you taking any inhalers? (Salbutamol)

Hypoglycaemia (history of diabetes)

Questions:
• Do you have any medical problems like diabetes mellitus
• high pressure?

Anxiety/panic attack

  • shortness of breath, chest pain, perioral paraesthea, generalised chest pains, previous episodes of similar symptoms

Questions:

  • When you are having palpitations, do you experience shortness of breath as well?
  • Do you experience any tingling around your lips?
  • Do you get the feeling that you are going to die?

Arrhythmia

  • history of angina or myocardial infarction, hypertension or heart failure

Questions:

  • Do you have any heart problems like angina ?
  • Any heart attacks in the past?

Pheochromocytoma

  • Intermittent abdominal pain, diarrhoea, episodic symptoms of headaches, high blood pressure, panic attacks

Questions:

  • Do you experience headaches or tummy aches at the same time as the palpitations?
  • Have you noticed that your urine is turning dark in colour?

Excess intake of coffee/tea

  • Common in people who drink excess amounts of coffee or tea)
  • Do you drink a lot of tea or coffee?

Anaemia

  • lightheadedness, weakness, tiredness, patient could be on aspirin or NSAIDs for a long period of time
  • Do you suffer from lightheadedness, weakness or tiredness?

Anorexia nervosa

  • amenorrhoea, weight loss, BMI<17.5, over exercising, poor dietary habits

Red flags

  • Refer urgently to a cardiologist
  • Syncope
  • Palpitations during exercise
  • Family history of sudden death
  • Second or third-degree heart block

Other history

  • ICE
  • PMAFTOSA
  • Effects of symptoms
  • Summarise

Examination

  • Observation: HR, BP
  • Cardiovascular
  • Thyroid examination
  • Lower limb
  • Pulse
  • Resting ECG

Atrial Fibrillation

1200×612 129 KB

  • Absent P wave
  • Irregular RR interval (Irregularly irregular rhythm)
  • Narrow QRS complex

Ventricular Extrasystole (ectopics)

Screenshot 2024-09-15 at 10.07.50
Screenshot 2024-09-15 at 10.07.501920×1074 167 KB

  • Broad QRS complex
  • Opposite T wave

Atrial extrasystole

Screenshot 2024-09-15 at 10.06.30
Screenshot 2024-09-15 at 10.06.301920×791 81.6 KB

  • Premature P wave
  • Narrow QRS complex
  • Normal T wave and ST segment

Refer urgently to cardiology if the person has:

  • A history of syncope or near syncope.
  • Palpitations precipitated by exercise.
  • A family history of sudden cardiac death under the age of 40 years.
  • Second degree or third degree atrioventricular block on the 12 lead electrocardiogram (ECG)

Refer routinely to a cardiologist

• Accompanying chest pain or lightheadedness
• History or physical symptoms of structural heart disease or hypertension
• History or recurrent sustained Tachyarrhythmia, atrial fibrillation or flutter

  • Resting ECG abnormally other than second degree or third-degree atrioventricular block
  • A history of symptoms that are consistent with SVT
  • Ventricular extrasystole (ectopic) plus:
    • Suspected heart disease
    • If extrasystoles are frequent or VT suspected

While awaiting referral or if does not need a referral

Investigations

  • ECG
  • Blood test FBC, U&E, Glucose, Calcium, Magnesium, TFT, LFT
  • Ambulatory ECG

  • If palpitation last:
    • More than 1 hour - ask patient to attend the emergency department
    • For few minutes:
      • Everyday: Ambulatory ECG for 24 to 48 hours
      • Once a week: Self activated ECG recording
  • If driving - advice to avoid driving if symptoms are interfering until they have been assessed.

Management

  • Atrial extrasystoles (ectopics) give lifestyle advice.
  • Ventricular extrasystoles (ectopics)
    • If infrequenteassure and offer lifestyle advice
    • Very frequent or if there is underlying cardiovascular disease -refer to the cardiologist

Lifestyle advice

  • Reduce or avoid stress
  • Caffeine - reduce
  • Alcohol - reduce
  • Smoking - stop
2 Likes