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PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
1
Palpitation:Anunexpectedawarenessofheartbeat.
DIFFERENTTYPESOFPALPITATIONTypes EctopicBeat Supraventricular
tachycardia(SVT)Ventricular
Tachycardia(VT)Atrial
fibrillationAnxiety
Characteristic Heartmissesandthumps
Regular,Fast
Regular,Fast
Fast,Irregular
Forceful/pounding,Regular,Notfast
Otherfeatures
Worseatrest Instantaneousonset,Relievedbyvagalmaneuvers
Associatedwithseveredizziness/syncope,Pre-existingheartfailure
CAUSESFORPALPITATIONCardiac Endocrine Metabolic Others
AtrialfibrillationEctopicbeatSVTVTHOCM
PheochromocytomaHyperthyroidismHypoglycemiaMenopause
HypokalemiaHyperkalemia
AnaemiaAnxietyDiet(Caffeine,Alcohol)Medication(Salbutamol)Recreationaldrugs(Cocaine)
Cardiaccauses
- AtrialFibrillation(A-fib)o Definition
§ Achaotic,irregularatrialrhythmat300–600beatsperminute
o TypesofA-fib§ Paroxysmal(<7days)§ Long-standing(>7days)§ Persistentlong-standing(>12months)§ Permanent(decisiontonottreata-fib)
o ClinicalFeatures
§ Irregularlyirregularpulse,a-fib-likepalpitations,fatigue,pre-syncope/syncope,generalizedweakness
§ Riskfactors:• Elderly(>75yearsold)
o Causes
§ Cardiac:ischemicheartdisease,hypertension,congestiveheartfailure,mitralvalvedisease
§ Respiratory:Pneumonia,PE,COPD§ Endocrine:Thyrotoxicosis§ Other:Caffeine,alcohol,post-op
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
2
o Investigation§ 12leadECG–lookforirregularlyirregularQRScomplexes,absenceofpwaves§ Echocardiography–lookforleftatrialenlargement,mitralvalvedisease,poorLV
function§ Bloodtest–TFTs,cardiacenzymes,U&E
o Management
§ Acute(<48hours)• Emergency:O2,cardioversion(ifunavailable,giveIVamiodarone5mg/kg
over1hour,then900mgover24hoursviacentralline)• Treatunderlyingcausee.g.MI,pneumonia• Ratecontrol:Bisoprolol2.5-5.0mg/dPO(Verapamil40-120mg/8hPOfor
situationswherebisoprololiscontraindicatedsuchasasthmatics)• Anti-coagulation:(unsureaboutembolirisk)Heparin,(highembolirisk)
warfarin–targetINR2.5§ Chronic
• Ratecontrol:beta-blocker,Ca2+blocker• Rhythmcontrol:Sotaloloramiodarone(foryoungerandfitpatients)• Anti-coagulation:Warfarin–targetINR2-3orAspirin300mg/dPO(2nd
line)
- HypertrophicObstructiveCardiomyopathy(HOCM)o Definition
§ Presenceofleftventricularoutflowtractobstructionfromasymmetricseptalhypertrophy
§ Leadingcauseofsuddencardiacdeathintheyoung
o Clinicalfeatures§ Dyspnoea,palpitation,syncope§ Jerkypulse,double-apexbeat,systolicthrillatlowerleftsternaledge§ PMHofangina,congestiveheartfailure§ Riskfactors:
• Wolff-Parkinson-Whitesyndrome,Mutationinbeta-myosin,alpha-tropomyosinandtroponinTgenes
o Investigation
§ ECG–ProgressiveTwaveinversion(indicatesLVH),deepQwaves@inferior+lateralleads
§ ECHO–Asymmetricalseptalhypertrophy,smallLVcavity§ Exercisetest+Holtermonitor
o Management
§ Symptomaticrelief:BisoprololorVerapamil§ Preventiveforemboli:Anti-coagulate§ Implantabledefibrillator§ Septalmyomectomy
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
3
- Supraventriculartachycardia(SVT)
o Definition§ Tachyarrhythmiaabovetheventricularmuscle(e.g.SAnode,AVnode)
o Classification(Basedonsiteoforigin)
§ Sinoatrialnode:Sinoatrialnodere-entranttachycardia(SNRT)§ Atrialnode:Atrialfibrillation,Atrialflutter§ Atrioventricularnode:AVnodere-entranttachycardia(AVNRT),Wolff-Parkinson
Whitesyndrome
o Clinicalfeatures§ Heartrate>100bpm§ Riskfactor:Underlyinghyperthyroidism,electrolyteabnormalities
o Investigations
§ ECG–NarrowQRScomplexes(<120ms)
o Management§ Acute:Vagalmanoeuvre,IVadenosineorverapamil(ifnotonbeta-blocker)§ Emergency:Cardioversion§ Maintenance:Beta-blockerorverapamil
Endocrinecauses
- Phaeochromocytomao Definition
§ Adrenalglandtumourwhichproducesexcesscatecholamine.§ Ruleof10%:10%malignant,10%extra-adrenal,10%bilateral,10%familial
(Thyroid,MEN-2a,MEN-2b,neurofibromatosis,vonHippel-Lindausyndrome)
o Clinicalfeatures§ Classictriadof:Episodicheadache,SweatingandTachycardia§ Hypertension
o Investigation
§ Fullbloodcount–raisedWCC§ Urinesample–3x24hoursurinesampletotestforfreemetadrenalineand
normetadrenaline§ Clonidinesuppressiontest–onlyifborderline§ AbdominalCT/MRIscan–lookforextra-adrenaltumour
o Management
§ Alpha-antagonist:Phenoxybenzamine§ Beta-blockeriftachycardicorheartdisease§ Surgery
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
4
- Hypoglycaemiao Definition
§ Whenplasmaglucoseis<3mmol/L
o Causes(EXPLAIN)§ Exogenousdrugs(alcohol,aspirinoverdose,insulinoverdose)§ Pituitaryinsufficiency§ Liverfailure§ Addison’sdisease§ Isletcelltumours(insulinoma),Immunehypoglycaemia(anti-insulinreceptor
antibodiesinHodgkin’sdisease)§ Non-pancreaticneoplasms(Fibrosarcoma,Hemangiopericytoma)
o Clinicalfeatures
§ Autonomic:Sweating,Anxiety,Hunger,Tremor,Palpitation,Dizziness§ Neuroglycopenic:Confusion,Drowsiness,Visualtroubles,Seizures,Coma
o Investigation
§ Bloodtest–HbA1C,plasmaketones,c-peptide,insulin
o Resultsinterpretation§ Highinsulin(=Hypoglycemichyperinsulinaemia)–Insulinoma,Exogenousdrugs§ Lowinsulin,low/noketones–Non-pancreaticneoplasm,immunehypoglycaemia§ Lowinsulin,highketones–Alcohol,pituitaryinsufficiency,Addison’sdisease
o Management
§ Giveglucose(seeLOCofpatient):Oralsugarandlongactingstarchor25-50ml50%glucoseIVwith0.9%salineviacentrallineorglucagon1mgIM
§ Rationalizeinsulintherapy(fordiabetics)
- Hyperthyroidismo Definition
§ Excessthyroidhormone,usuallyfromglandhyperfunction
o Causes§ Graves’disease:CirculatingIgGautoantibodiesbindingtoandactivatingG-protein-
coupledthyrotropinreceptors§ Toxicmultinodulargoitre:elderlyandiodine-deficientareas§ Toxicadenoma:SolitarynoduleproducingT3andT4§ Ectopicthyroidtissue:Metatasticfollicularthyroidcancer,strumaovarii§ Exogenous:Excessiodine,excesslevothyroxine,amiodarone§ SubacutedeQuervain’sthyroiditis:Self-limitingpost-viralwithpainlessgoitre
o Clinicalfeatures
§ Diarrhoea,lossweight,increaseappetite,sweating,heatintolerance,palpitation,tremor,irritability,labileemotions,oligomenorrhea,infertility
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
5
§ Irregularandfastpulse,palmarerythema,thinhair,lidretraction,lidlag§ Graves’disease:Goitre,exophthalmos,Pretibialmyxoedema,thyroidacropachy
(clubbing,painfulfingerandtoeswelling,periostealreactioninlimbbones)
o Investigations§ Fullbloodcount–lowTSH,highT4andT3,TPOantibodies(onlyforGraves)§ Serumbioprofile–ESR,LFT,Ca2+
o Management
§ Drugs:• Symptomaticrelief:Propanolol40mg/6h• Anti-thyroid:Carbimazole20-40mg/dPO(titratedown4weekstoevery1-
2months)§ Radioiodine(131I)§ Thyroidectomy
Metaboliccauses
- Hypokalemiao Definition
§ Whenthepotassiumlevelinthebloodislessthan3.5mmol/L§ [K+]<2.5mmol/L=life-threatening
o Clinicalfeatures
§ Muscleweakness,hypotonia,hyporeflexia,cramps,tetany,palpitations,light-headedness
o Investigation
§ Bloodtest§ ECG–SmallorinvertedTwaves,prominentUwaves,longPRinterval,depressedST
segment
o Management§ Mild(>2.5mmol/L):OralK+supplements(>80mmol/24hours)§ Severe(<2.5mmol/L):IVpotassium(max20mmol/h,40mmol/L)§ Ifonthiazide,changemedicationtoK+sparingdiuretics
- Hyperkalemia
o Definition§ Whenbodypotassiumlevelismorethan5mmol/L.§ When[K+]>6.5mmol/L
o Causes
§ Acuterenalfailure,Addison’sdisease,Rhabdomyolysis,Metabolicacidosis,K+sparingdiuretics,ACE-I,Suxamethonium,Burns
PALPITATIONHISTORYTAKINGLearningDocument
Lastupdated:Mar2018
ByEsteeSoh(DEM3,Classof2020)
6
o Clinicalfeatures§ Fastirregularpulse,chestpain,weakness,palpitations,light-headedness
o Investigation
§ ECG–tallTwaves,smallbroadPwaves/absentPwaves,wideQRScomplex
o Management§ 10ml10%calciumgluconate–stabilizecardiacmembrane§ 10unitsofactrapid(insulin)in50ml20%glucose–driveK+intocells§ 0.5mgslowIVsalbutamolor10mgnebulizedsalbutamol–stimulatesNa+-K+ATP
pump§ 50gpolysytrenesulfonateresinin100-200ml30%sorbitolor10%glucose§ Treatunderlyingcause
Others
- Anxietyo Definition
§ Theabruptonsetofintensefearordiscomfort
o Clinicalfeatures§ Palpitation,sweating,tremor,chills,dyspnoea,chestpain,nausea,dizziness,
parasthesia,fearofdying,depersonalization
o Investigations§ Asthisisadiagnosisofexclusion,beawareofhowthepatientmayrespondtothis
diagnosis.
