This document discusses a case of a 54-year-old Malay woman who presented with palpitations for the past 6 months. It then provides information on evaluating patients with palpitations, including key questions to ask, differential diagnoses, diagnostic strategies, red flags, evidence-based guidelines and management approaches. Common causes of palpitations discussed include anxiety, ectopic beats, arrhythmias and perimenopausal syndrome. Thorough evaluation is important to rule out serious underlying cardiac conditions.
palpitation is one of the most presentations in outpatients, about 16% of patients presenting to ER complaining from palpitation , for the juniors , my presentation aiming to help them to how to approach with a case complaining of palpitation
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)silla elsa soji
SIADH is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone (ADH). Inappropriate, continued secretion or action of ADH despite normal or increased plasma volume. Results in impaired water excretion, and subsequently hyponatremia and hypo-osmolality.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
palpitation is one of the most presentations in outpatients, about 16% of patients presenting to ER complaining from palpitation , for the juniors , my presentation aiming to help them to how to approach with a case complaining of palpitation
AV nodal reentrant tachycardia (AVNRT), or atrioventricular nodal reentrant tachycardia, is a type of tachycardia (fast rhythm) of the heart. It is a type of supraventricular tachycardia (SVT), meaning that it originates from a location within the heart above the bundle of His. AV nodal reentrant tachycardia is the most common regular supraventricular tachycardia. It is more common in women than men (approximately 75% of cases occur in females). The main symptom is palpitations. Treatment may be with specific physical maneuvers, medication, or, rarely, synchronized cardioversion. Frequent attacks may require radiofrequency ablation, in which the abnormally conducting tissue in the heart is destroyed.
AVNRT occurs when a reentry circuit forms within or just next to the atrioventricular node. The circuit usually involves two anatomical pathways: the fast pathway and the slow pathway, which are both in the right atrium. The slow pathway (which is usually targeted for ablation) is located inferior and slightly posterior to the AV node, often following the anterior margin of the coronary sinus. The fast pathway is usually located just superior and posterior to the AV node. These pathways are formed from tissue that behaves very much like the AV node, and some authors regard them as part of the AV node.
The fast and slow pathways should not be confused with the accessory pathways that give rise to Wolff-Parkinson-White syndrome (WPW syndrome) or atrioventricular reciprocating tachycardia (AVRT). In AVNRT, the fast and slow pathways are located within the right atrium close to or within the AV node and exhibit electrophysiologic properties similar to AV nodal tissue. Accessory pathways that give rise to WPW syndrome and AVRT are located in the atrioventricular valvular rings. They provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular myocardium.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)silla elsa soji
SIADH is a disorder of impaired water excretion caused by the inability to suppress the secretion of antidiuretic hormone (ADH). Inappropriate, continued secretion or action of ADH despite normal or increased plasma volume. Results in impaired water excretion, and subsequently hyponatremia and hypo-osmolality.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Hyperthyroidism is a medical condition in which the thyroid gland produces an excess of thyroid hormones, resulting in a range of symptoms and potential complications. The thyroid gland is a small butterfly-shaped gland located in the neck that produces hormones that regulate metabolism. When the thyroid gland becomes overactive, it produces too much thyroid hormone, causing hyperthyroidism.
The most common cause of hyperthyroidism is Graves' disease, an autoimmune disorder in which the immune system mistakenly attacks the thyroid gland. Other causes of hyperthyroidism include thyroid nodules, thyroiditis, and excess iodine intake.
The symptoms of hyperthyroidism can vary widely but typically include weight loss, increased appetite, rapid heartbeat, sweating, nervousness, tremors, and difficulty sleeping. Hyperthyroidism can also cause eye problems such as bulging eyes and vision changes, especially in patients with Graves' disease.
Diagnosis of hyperthyroidism typically involves blood tests to measure levels of thyroid hormones and thyroid-stimulating hormone (TSH), which regulates the production of thyroid hormones. In some cases, imaging tests such as ultrasound or a radioactive iodine uptake test may be used to evaluate the thyroid gland.
Treatment for hyperthyroidism depends on the underlying cause and severity of symptoms. Options may include medications to reduce thyroid hormone production, radioactive iodine therapy to destroy overactive thyroid cells, or surgery to remove part or all of the thyroid gland.
Complications of hyperthyroidism can include heart problems such as rapid heartbeat, atrial fibrillation, and congestive heart failure. Hyperthyroidism can also lead to osteoporosis, a condition in which bones become weak and brittle, and thyroid storm, a life-threatening condition characterized by extremely high levels of thyroid hormones.
Management of hyperthyroidism typically involves ongoing monitoring of thyroid hormone levels and symptoms, as well as lifestyle modifications such as a healthy diet, stress reduction techniques, and regular exercise. With proper treatment and management, most patients with hyperthyroidism can achieve good outcomes and lead healthy, productive lives.
Case Study, Chapter 34, Management of Patients With Hematologic Neop.docxdrennanmicah
Case Study, Chapter 34, Management of Patients With Hematologic Neoplasms
1. John King, 60 years of age, is a male patient who is admitted with the diagnosis of multiple myeloma. He presents with a spinal fracture of the fifth lumbar vertebrae. The patient is scheduled for a vertebroplasty of the spinal fracture. The patient is to remain on bed rest and should be log rolled. Osteolytic lesions are seen in x-rays of the skull, vertebrae, and ribs. The patient has hypercalcemia. The patient’s uric acid level is elevated. The patient has orders for zoledronic acid (Zometa), thalidomide (Thalomid), allopurinol (Zyloprim), calcitonin, ibuprofen, and Vicodin. (Learning Objective 5)
a. What nursing management should the nurse provide the patient?
Explain the indication and action of the various medications ordered to treat the patient’s symptoms.
2. Susan Clare, age 38, is admitted to the medical oncology unit with acute myeloid leukemia (AML). She has many areas of ecchymosis and petechiae on her skin, as well as generalized pallor. She states she has lost 15 pounds in the last 2 months, and often has a low-grade fever. On physical assessment, you find her liver and spleen to be enlarged on palpation. (Learning Objective 3)
a. What laboratory results would you anticipate due to her ecchymosis and petechia?
Why would it be important to inspect her gums and teeth?
a. Why is her liver enlarged?
Case Study, Chapter 37, Management of Patients With HIV Infection and AIDS
1. The nurse is planning to provide education on HIV infection transmission and prevention strategies at a local senior center. (Learning Objectives 1 and 4)
a. What should the nurse include in the session considering the needs of the older population?
2. Sallie Jefferies, 28-year-old patient, is at the obstetric clinic for a pregnancy visit. The physician informs the patient that her HIV screen test is positive. The patient has no evidence of AIDS. The nurse provides patient education regarding what HIV is and what the clinical management entails. (Learning Objective 5)
a. What clinical management is recommended for the patient during the pregnancy to help decrease the risk of transmitting HIV to the unborn child?
The patient asks the nurse how zidovudine (Retrovir) will help her unborn child from getting HIV. How should the nurse respond?
What explanation about Retrovir should the nurse provide?
The patient asks the nurse if it will be safe to breast-feed her infant after the delivery. The nurse should provide what explanation?
a. The patient asks the nurse what testing schedule for the HIV antibody is needed after her baby is born. How should the nurse respond?
Case Study, Chapter 31, Assessment and Management of Patients With Hypertension
1. Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly because of the cost of .
Carpen ini ditulis khas buat peserta misi kemanusiaan anjuran Kelas Peradaban Nabawi USMKK, Medical Student Relief Team (MERIT) dan juga Medical Student Awareness Team (MESAT). Semoga kita semua terus konsisten dengan usaha dakwah melalui program kesihatan. insyaALLAH suatu hari nanti Islam pasti akan tersebar ke serata dunia kerana “Islam itu Mudah dan Fitrah”
Cerpen ini ditulis khas buat adik-adik peserta SKSPM 2006/2007 dan 2007/2008 serta adik-adikku dan sahabat sekalian. Semoga kita cekal menghadapi hidup. Semoga kita meniti kehidupan ini sambil memandang ke kiri dan kanan kita. Sesungguhnya masih banyak bangsa kita yang berada dalam seribu satu kesusahan. Perjuangan kita bukan lagi perjuangan untuk memenuhkan oerut kita sebaliknya ia adalah perjuangan untuk memajukan bangsa. Inilah masa untuk Revolusi kita bagi mengembalikan kegemilangan ketamadunan kita.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Approach to palpitation family medicine case discussion 2010
1. Palpitation
Department of Family Medicine Case Discussion
Puan Rahimah a 54 years old Malay lady comes with her son to see you in the clinic with the
complaint of palpitation for the past 6 months.
She is married with 4 children and her husband is a pensioner
Questions
1) What question would you ask in assessing patient who presented with palpitation.
2) Based on safe diagnostic strategy, state differential diagnoses.
3) What is your diagnosis for this lady?
4) What investigation would you do for her?
5) How would you treat her?
2. What is Palpitation
An uncomfortable or abnormal awareness of the heart beat, are common in primary care patients.
In one study, recurrent symptoms occurred in 75% of patients and 33% reported lower quality of
life, but the 1-year mortality rate was 1.6% [Robert B. Taylor]
Usually felt over the precordium or in the throat or neck. The patient may describe them as
pounding, jumping, turning, fluttering, or flopping or as missing or skipping beats. Palpitations
may be regular or irregular, fast or slow, paroxysmal or sustained. [Handbook of Signs &
Symptoms 3rd ed]
Palpitation can be caused by cardiac and non cardiac origin. The most common cardiac causes of
palpitation is atrial fibrillation. However, less than half of the total patient presented to GP with
palpitation has significant cardiac problem. Others are benign and most of it are due to
psychological problem especially anxiety.
The initial task is to detect a life-threatening cause of the PPTs. Studies have shown a 7% to 40%
incidence of potentially serious arrhythmias in these patients, although the cause in up to 31% is
psychiatric [Robert B. Taylor]
In woman, palpitation occur at any age especially during the luteal phase of the menstrual cycle,
pregnancy and perimenopausal syndrome. In perimenapausal period, it is usually benign and
related to increased sympathetic activity caused by the menopause.
In order not to miss the causes of palpitation, a mnemonic VITAMIN CDE can be used.
Vascular - (aortic aneurysms, arteriovenous fistulas, anemia, postural hypotension, migraine,
and cardiac disorders such as aortic regurgitation, aortic stenosis, tricuspid insufficiency, CH)
Inflammation/infection - (fever, pericarditis, bacterial endocarditis, rheumatic fever.)
Trauma (due to increase release of catecholamines)
Anxiety / Autoimmune.
Metabolic – electrolyte disorder.
Idiopathic / intoxication - alcohol, tobacco, coffee, soft drinks, and tea
Neoplasm – rarely causes palpitation
Congenital – heart problem
Drugs – digitalis, aminophylline, sympathomimetics, ganglionic blocking agents, nitrates
Endocrine - thyrotoxicosis, pheochromocytoma, menopausal syndrome, and hypoglycemia.
3. Red Flag in palpitation
Like what have been written previously, most of the causes for palpitation are benign and less
than half of it are due to cardiac origin. However, once should pay an attention for Red flag of
palpitation.
1. Syncope
2. Associated cardiac manifestation
Patient with high risk of cardiac etiology could be predicted based on few characteristic which
includes
1. Male gender
2. Irregular heart beat
3. History of heart disease
4. Event duration more than 5
minutes
Since, cardiac arrhythmia is one of the causes for palpitation, one should look for cardinal sign of
unstable patient which includes
1. Altered Mental Status
2. On going chest pain
3. Hypotension
4. Acute Pulmonary Edema
4. Question to be asked in assessing patient who presented with palpitation
1) Characteristic of the palpitation
a) Rapid, irregular (AF, multifocal artrial tachycardia, artrial flutter)
b) Rapid, regular (supraventricular tachycardias, Sinus tachycardia and ventricular
tahycardia)
c) A “stop-start,” “flip-flop,” or “turning over” sensation in the chest (premature
ventricular contractions or premature atrial contractions
d) Palpitation perceived at neck (AV nodal reentrant tachycardia, premature ventricular
contractions)
e) Constant – suggest tachycardia, and that would suggest hyperthyroidism or overuse of
caffeine and other drugs. may also point out fever of unknown origin.
f) Intermittent palpitations -cardiac arrhythmia, particularly extrasystoles.
2) What patient did during the attack occur?
a) Anxiety or somatization disorders
b) Catecholamine release (exercise, emotional stress)
c) At rest - benign condition
d) In changes of posture - SVT or PVCs
3) Onset and termination
a) abrupt onset and termination of PPTs suggests PSVT
b) Anxiety can lead to sinus tachycardia following an arrhythmia, precluding the patient
from sensing an abrupt cessation.
4) Associated symptoms
a) Ruled out sustained or nonsustained VT if syncope, presyncope, or dizziness occurs
b) weight loss, increased appetite, and polyuria – hyperthyroidism
c) shortness of breath and pitting edema - congestive heart failure
5) Others relevant history
a) Occurs after taking some drugs or changing into another type of drugs
b) Association with food
c) Any known medical illness like Diabetes mellitus, thyroid problem,congenital heart
problem etc
d) Menstrual history in woman.
5. Safe Diagnostic Strategy
A Safe Diagnostic strategy was designed by John Murtagh and the method was publish in
Australian Family Physician Journal, volume 19 in the year of 1990. It outlines a diagnostic
model applicable to all common problems encountered in general practice. It has an inbuilt
safety strategy to help the busy practitioner consider life threatening conditions and other serious
illnesses during the diagnostic process.
A health care personnel must bear in their mind that there are 5 questions need to be answered
when dealing with a patient who presented to them. The strategy is to demonstrate that you have
a logical and safe approach to making diagnoses.
What is the most likely
diagnosis?
Case Study What serious disorders must
not be missed?
54 years old Malay lady with
complaint of palpitation for What conditions are often
the past 6 months missed?
Could the patient have a
masquerading illness? List at
least 7
Is the patient trying to say
something?
Differential diagnosis
1) Most likely diagnosis – Perimenopausal syndrome
2) Serious disorder not to miss – Unstable Atrial fibrillation
3) Condition often miss – Diabetes mellitus, hyperthyroidism, pheochromocytoma
4) Masquerading illness – alcohol intoxication, caffeine abuse, stess and anxiety
5) Is the patient try to say something – most likely related with psychological aspect.
6. What is your diagnosis for this lady?
The most probable diagnosis for this patient based on limited data given (age, sex, onset and
duration) is mainly benign and non cardiac related. I’m confidently say that based on data
provided by Hoefman E, et al
Therefore my most probable differential diagnosis would be
1. Perimenopausal syndrome
Palpitations associated with menopause and the perimenopausal period are usually related to
sinus tachycardia or to simple arrhythmias because of increased sympathetic drive. The
menopausal state is characterized by a marked decrease in ovarian estradiol production and an
associated increase in adrenergic activity. In menopausal women, cardiovascular control shifts
toward a sympathetic predominance. Estrogen replacement therapy improves this altered control
and can improve the cardiovascular symptoms such as hot flushes and papitations. Of note, some
progestins given in conjunction with estrogen replacement may trigger cardiac arrhythmias in
patients; however, this effect is usually remedied by decreasing the progestin dose or by using a
natural progestational agent. [Elizabeth R. Keeler et al]
2. Anxiety disorder.
Management for this patient
1) 12 lead ECG for cardiac problem screening
2) Re assurance for the patient.
3) Psychological councelling to relieve anxiety.
4) Severe anxiety may require further referral to psychiatrist for anti anxiety management.
7. Evidence Based Medicine
1) Relationship between pulse palpation and atrial fibrillation
Georga Cooke et al has analysed three studies by Morgan & Mant, Somerville et al and Sudlow
et all that compared pulse palpation with ECG. The estimated sensitivity of pulse palpation
ranged from 91% to 100%, while specificity ranged from 70% to 77%. Pooled sensitivity was
94% (95% confidence interval [CI], 84%–97%) and pooled specificity was 72% (95% CI, 69%–
75%). The pooled positive likelihood ratio was 3.39, while the pooled negative likelihood ratio
was 0.10. Therefore the author conluded that pulse palpation has a high sensitivity but relatively
low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may
also be a useful screen to apply opportunistically for previously undetected atrial fibrillation.
Assuming a prevalence of 3% for undetected atrial fibrillation in patients older than 65 years,
and given the test’s sensitivity and specificity, opportunistic pulse palpation in this age group
would detect an irregular pulse in 30% of screened patients, requiring further testing with ECG.
Among screened patients, 0.2% would have atrial fibrillation undetected with pulse palpation.
2) Goal standard in accessing cardiac arrhythmia
Obtaining a 12-lead echocardiogram (ECG) at the onset of symptoms is the gold standard in
diagnosing cardiac arrhythmias. The resting 12-lead ECG offers valuable information regarding
the presence of pre-existing conditions such as pre-excitation and ischaemic heart disease. Event
recorders used over a 2-week period offer an effective way to capture cardiac arrhythmias.
Holter monitors are also used in patients who have frequent symptoms. With the advent of new
transcatheter cardiac ablation techniques and depending on the rhythm disturbance, management
has become more successful (Ramzi YK & Mark D)
3) Differential diagnosis for palpitation
The majority of patients presenting with palpitations are suffering from either anxiety or ectopic
beats. In anxious patients, a recording of their ECG showing sinus rhythm while they have
symptoms is reassuring for patient and doctor alike. The majority of ectopics are also benign, but
in the case of ventricular ectopics it is important to ensure that there are not more serious
ventricular arrhythmias occurring at other times. Again a recording of the rhythm while the
patient is symptomatic is very helpful.Palpitations can be a reflection of dangerous cardiac
arrhythmias. In one study of 190 patients with palpitations, 1.6% died and 1.1% had a stroke
within 1 year of presentation (Ramzi YK & Mark D)
8. 4) Accurate prediction by GPs of the presence of a (relevant) arrhythmia in patients
presenting with palpitations and/or lightheadedness
This study by Emmy Hoefman et al confirmed that an accurate prediction by GPs of the presence
of a (relevant) arrhythmia in patients presenting with palpitations and/or lightheadedness and an
inconclusive standard ECG is not possible at this moment. GPs do not have an accurate
instrument at hand to predict which patients might profit from further diagnostic evaluation. As
our sample was small, further research is needed to develop accurate triage rules.
In cases where a standard ECG does not lead to a diagnosis, evidence suggests that a continuous
event recording (CER) might be very helpful in the decision to treat or refer a patient. Reassuring
a patient without using this diagnostic test might be premature.Therefore, a low threshold for
further diagnostic testing seems adequate.
5) Non-cardiac chest pain and benign palpitations in the cardiac clinic in 94 consecutive
referrals by general practitioners to a cardiac clinic with the presenting disorder of
chest pain or palpitations.
Fifty one patients were given no major physical diagnosis. Although all were new referrals to the
clinic, many had already received considerable medical care for their symptoms.
Conclusion: A substantial proportion of the consecutive referrals continued to describe
symptoms and disability throughout the three years after clinic attendance. Outcome was poor
for those who had negative investigations and were reassured that they had no cardiac disorder or
other serious physical finding. These results have implications for defining the role of
psychological assessment and for the formulation of cost effective clinical measures to (a)
minimise disability associated with cardiac disorder; and (b) prevent and treat handicaps in those
without major physical diagnoses [Richard Mayou et al]
6) Characteristics of patients presenting to a cardiac clinic with palpitation
Most patients presenting to secondary care with palpitation do not have serious underlying
cardiovascular conditions. Concurrent psychological problems are common and persistent.
Aetiology may be seen as an interaction of pathology, awareness of normal physiology, and
psychological variables. Few patients require specialist cardiological treatment, but simple
reassurance is of limited effectiveness. A stepped care approach may improve outcomes and
needs rigorous evaluation.[R. Mayou et al]
9. 7) Laboratory Evaluation of palpitation based on article by Elizabeth R. Keeler et al
A few basic hematological and chemistry studies should be performed to assess for anemia,
hyperthyroidism, electrolyte disturbances (especially in patients taking digitalis), and
hypoglycemia. If there is evidence suggesting a pheochromocytoma, a 24-hour urine assessment
for vanillylmandelic acid is helpful
All patients complaining of palpitations should have an electrocardiogram to distinguish
supraventricular from ventricular tachycardias and to help to identify the type of SVT during the
arrhythmia
If the history, physical examination, and a 12-lead electrocardiogram fail to point to an etiology
of the palpitations, further investigation should be performed.
If palpitations occur on a daily basis, 24-hour continuous ambulatory electrocardiographic
monitoring may be helpful (Holter monitors)
When palpitations are associated with exertion, an exercise stress testing should be done because
ventricular tachycardia may be uncovered
An echocardiogram should be done when the history, physical exam, or EKG raise suspicion of
valvular disease or cardiomyopathy
Electrophysiological studies (EPS), either via the transesophageal or intracavitary route, are able
to identify some arrhythmias. Because this technique is invasive, EPS should be limited to
individuals who have asymptomatic nonsustained VT and either evidence of underlying heart
disease or a reduced ejection fraction (< 40%)
8) Prevalence of palpitations, cardiac arrhythmias and their associated risk factors in
ambulant elderly, by Lok NS, Lau CP, Int J Cardiol. 1996 Jun;54(3):231-6.
To determine the prevalence of palpitations, cardiac arrhythmias and associated cardiovascular
risk factors in an ambulatory elderly population, 1454 ambulatory elderly people (219 men and
1235 women, age range 60-94 years) were assessed in a territory-wide health survey including
anthropometric measurements, biochemical blood tests, questionnaire interview and resting
surface ECG examination. Prevalence of palpitations and ECG abnormalities were determined
and correlated with coronary risk factors and biochemical blood tests. Palpitations were present
in 121 subjects (8.3%) and cardiac arrhythmias were found in 183 subjects (12.6%). Conduction
abnormalities and sinus bradycardia were the commonest findings (9.8%). Premature beats
(atrial 2.3%; ventricular 1%) were the next most frequent arrhythmia. Atrial fibrillation was the
commonest sustained arrhythmia that was present in 19 subjects (1.3%). Compared with those