Palpitations

Question 1

SOCRATES

Answer 1

Specify- what do you mean by palpitations
Onset- do they start gradually or suddenly
Character- when they occur, does the heart go fast or slow
Rhythm- regular or irregular
Associated features- see below
Timing- how long do they last/ any particular time eg. Exercise, at night, anxious/ how often do they occur
Exacerbating/ relieving factors- does anything stop them/ does anything you do make them go away (think valsalva)
Severity- have they gotten worse

Question 2

Systems review

Answer 2

FWARJNLBBD

Cardiac- chest pain, SOB, dizzy spells, syncope, oedema
Psychogenic- episodes of anxiety or panic, are you an anxious person
Thyrotoxicosis- do you feel hot all the time/ Lost any weight recently/ diarrhoea/ have your periods been normal
Phaechromocytoma- do you feel sweaty with the palpitations/ nauseous/ abdominal pain/ uncontrolled high blood pressure

Question 3

Important

Answer 3

Must ask about sudden cardiac death in the family- see if they are at risk of this
Palpitations brought on by significant strain/ stress are a sign of significant cardiac pathology
Most arrhythmia don’t produce palpitations

Question 4

AF

Answer 4

Often asymptomatic but there may be signs and Sx or HF
Recent cardiac event or a major surgery
Me be paroxsysmal, persistent or permanent
Causes- IHD, valvular disease, thyrotoxicosis, alcohol, Pneumonia

Question 5

Ectopic beats

Answer 5

Patients feel a skipped beat, followed by an uncomfortable lurch in the chest, some patients can’t catch their breath
Palpitations can be more evident when the patient lies flat, commonly at night time

Question 6

Thyrotoxicosis

Answer 6

Weight loss, heat intolerance, hair loss, altered appetite, loose bowels, tremor, neck swelling, palpitations and menstrual irregularity

Question 7

Anxiety

Answer 7

History of tail s, sweating, dry mouth
Panic or anxiety usually precedes the palpitations
Often regular, slightly fast and tend to come and go gradually

Question 8

Phaeochromocytoma

Answer 8

Catecholeamine secreting tumour of the adrenal glands
Typically present with HTN, sweats, palpitations and tremor
MEN 2

Question 9

Investigations for palpitations (not an extensive list)

Answer 9

12 lead ECG
24-48 hour ambulatory ECG tape (holter monitor)
Bedside OBS eg. BP
FBC UE TFT

Question 10

Patients perspective

Answer 10

How have they affected you
Ideas
Concerns
Expectations

Question 11

PMH

Answer 11

Heart disease, psychiatric, thyroid disease

Question 12

DH

Answer 12

Medications and OTC

Question 13

FH

Answer 13

Heart disease and sudden unexpected death, and thyroid disorders

Question 14

SH

Answer 14

Smoke alcohol recreational drugs
Caffeine
What does your job involve
Home situation

Question 15

Important

Answer 15

Palpitations brought on by minimal exertion can denote severe pathology

Question 16

Ventricular tachycardia

Answer 16

Often short lived and asymptomatic but prolonged episodes can cause haemodynamic compromise

Typically patients have cardiac pathology ie. IHD heart failure cardiomyopathy or long QT syndrome

FH- sudden death in a family member

Question 17

SVT

Answer 17

Paroxysmal palpitations and sometimes associated syncope

WPW syndrome