Palpitation

Palpitation

• Physical Exam:
  • – VS: state or WNL (WNL except ___)
  • – General: No Acute Distress
  • – Endocrine/Thyroid Exam, including exophtalmos, lid retraction, lid lag, gland size, bruit, and tremor
  • – HEENT: => NC/AT, PERRLA, EOMI without nystagmus, no papilledema, mouth and oropharynx normal
  • – Neck Exam: Carotid auscultation => Supple, No carotid bruits, 2+ carotid pulses with good upstroke bilaterally, thyroid normal
  • – Chest: Auscultation => Clear breath sounds bilaterally/Clear breath sounds bilaterally
  • – Heart: Auscultations, Palpation => Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
•  DDX:
  • – Hypoglycemia
    
  • – Cardiac Arrhythmias
    
  • – Hyperthyroidism
    
  • – Panic Attacks
    
  • – Pheochromocytoma
    
  • – Carcinoid Syndrome
    
  • – Angina
    
  • – Hyperventilation Episodes
    
  • – Generalized Anxiety Disorder
    
  • – Agoraphobia/Social Phobia
    
  • – Substance Abuse/Dependence
• Work-up:
  • – Glucose
    
  • – CBC with diff
    
  • – Electrolytes
    
  • – TSH
    
  • – BUN/Cr
    
  • – ECG

Carcinoid Syndrome

• Presentation:
  • – Serotonin overproduction
  • – Tumor of serotonin producing cells in GIT → APUD (Amine Precursor Uptake Decarboxylase) Cells
  • – Slow-growing but often malignant type of neuroendocrine tumor, originating in cells of neuroendocrine system
  • – Most commonly found in the foregut (35.6% cases) with lung, bronchus and trachea constituting 27.9% cases from where they rarely metastasize (except in case of pancreas).
  • – Sx = Cutaneous flushing accompanied by sweating, GI hypermotility → causing diarrhea, Bronchospasm
  • – Increased 5-HIAA excretion of in urine

Hypoglycemia

• Presentation:
  • episodes of palpitations and diaphoresis. on insulin.
• DDX:
  • – Hypoglycemia
    
  • – Cardiac arrhythmias
    
  • – Angina
    
  • – Hyperthyroidism
    
  • – Hyperventilation episodes
    
  • – Panic attacks
    
  • – Pheochromocytoma
    
  • – Carcinoid Syndrome
• Work-up:
  • – Glucose, CBC with diff, Electrolytes, TSH, BUN/Cr
    
  • – ECG
    
  • – Holter monitor

Hyperthyroidism

• Presentation:
  • – Hyperthyroidism is a condition caused by an overactive thyroid gland.
  • – The gland makes too much T4 and T3 hormones.
  • – Hormones are substances that affect and control many important functions in the body.
  • – Heat Intolerance → Excessive sweating and heat intolerance
  • – Weight Loss → despite ↑ Appetite
  • – Diarrhea → Frequent bowel movements
  • – Nervousness
  • – Emotional Labiality
  • – Poor Concentration
  • – Palpitations
  • – Swelling of Eyes
  • – Double of Vision
  • – Weakness and Fatigability
• • Signs
  • – Dressed Inappropriately for Ambient Temperature
  • – Weight Loss
  • – Hyperactive
  • – Fidgety, Restless
  • – Tremors of hand
  • – Tachycardia/Afib
  • – Periorbital Edema
  • – Opthalmoplegia → Diplopia
  • – Exopthalmos/Proptosis
  • – Lid Retraction, Lid Lag
  • – With Graves’ disease, eye signs such as stare, lid lag, and exophthalmos
  • – Proximal Muscle Weakness

Panic Attack

• Presentation:
  • several episodes of palpitations, sweating, and rapid breathing. Episodes occur unexpectedly and does not recall any triggers. has had 4 – 5 episodes per month for several months. Each episode lasts 2 – 3 minutes. does not have any history of psychiatric illness except for separation anxiety as a child.
• Types:
  • • PANIC DISORDER with or without agoraphobia
    • – Recurrent unexpected panic attacks
    • – ≥ 1 of the attacks has been followed by ≥ 1 month of ≥ 1 of the following: (*Anticipatory anxiety)
      1. Persistent concern about additional attacks*
      2. Worries about implications of attack or its consequences*
      3. Significant change in behavior related to the attacks (avoidance)
  • – Panic Disorder without Agoraphobia
    • – Recurrent, unexpected panic attacks
    • – Persistent worry/concern about additional attacks or their consequences
  • – Panic Disorder with Agoraphobia
    • – Meets criteria for panic disorder Fear/avoidance of situations where panic attacks might occur
• DDX:
  • – Panic Attack
  • – Generalized Anxiety Disorder
  • – Acute Stress Disorder
  • – Specific Phobia
  • – Hyperthyroidism
  • – Agoraphobia
  • – Substance Abuse/Dependence
  • – Mitral Valve Prolapse
  • – Pheochromocytoma
• Work-up:
  • – CBC with diff, Electrolytes, TSH, FT4
  • – ECG
  • – Echocardiography
  • – Urine toxicology

Pheochromocytoma

• Presentation:
  • – Rare catecholamine-secreting tumor derived from chromaffin cells.
  • – Tumors arise outside the adrenal gland are termed extra-adrenal pheochromocytomas or paragangliomas b/c of excessive catecholamine secretion
  • – May precipitate life-threatening hypertension or cardiac arrhythmias.
  • – Check Urine catecholamines

Social Phobia 

• Presentation:
  • – Marked fear/avoidance of social situations due to the possibility of embarrassment or humiliation

Specific Phobia

• Presentation:
  • episodic palpitations especially during presentations in front of her class. Episodes include heart pounding, facial blushing, and hand shaking. also states she experiences excessive sweating and rapid breathing. complains of intense worry and trouble sleeping for days or weeks before upcoming social situation. Now avoids all social events because she is always afraid of humiliating herself.
• DDX:
  • – Specific Phobia*
    
  • – Avoidant Personality Disorder
    
  • – Agoraphobia/Specific Phobia
    
  • – Panic Attack
    
  • – Generalized Anxiety Disorder
    
  • – Substance Abuse/Dependence
    
  • — Hyperthyroidism
• Work-up:
  • – CBC with diff, Electrolytes, TSH, FT4
    – ECG
    – Echocardiography
    – Mental Status Exam