This document discusses the evaluation of a patient presenting with palpitations. It begins by defining palpitations and describing the general and systemic examination findings that should be assessed. These include vital signs, heart auscultation findings, and an ECG. It then lists key clinical findings associated with different arrhythmias and cardiovascular conditions that could cause palpitations. The document concludes by discussing the differential diagnosis of palpitations, which can be due to arrhythmias, psychiatric conditions, medications, nonarrhythmic cardiac causes, or extracardiac etiologies. A thorough history, physical exam, and testing are needed to determine the underlying cause.

1. GENERAL EXAMINATION AND
SYSTEMIC EXAMINATION IN A
CASE OF PALPITATION

2. PALPITATION
 Definition:
„an awareness of ones heartbeat that is thought
inappropriate to the circumstances

3. GENERAL EXAMINATION
 PATIENT PANIC / NOT PANIC
 BUILT AND NOURISHMENT
 PALLOR
 ICTERUS
 CYANOSIS
 CLUBBING
 LYMPHADENOPATHY
 EDEMA

4. GENERAL EXAMINATION
 VITALS
PULSE-
RATE- tachycardia/bradycardia
Heart rate >120 beats/min or < 45 beats/min
while at rest
RHYTHM-
Regular-
occasional-SVT/VT
continuous-sinus tachycardia
high output states
Irregular- Atrial Fibrillation / Ectopics
sustained and irregularly irregular /chaotic -AF

5. GENERAL EXAMINATION
Intermittent and irregular/ felt as
missed beats- Ectopics
Volume-high/low
character-normal/abnormal
Condition of vessel wall-thickened/not
thickend
Radiofemoral delay-present/absent
peripheral pulsations-felt normal/not

6. GENERAL EXAMINATION
 BP
Hypotension / Hypertension

7. SYSTEMIC EXAMINATION
 INSPECTION
 shape of precodium
 Position of apex beat
 Visible pulsations-jvp elevated/not
 Visible scars

8. SYSTEMIC EXAMINATION
 Palpation
 Palpation of the apcal impulse
 Left parasternal heave
 Sub xiphoid pulsations
 Palpation of the pulmonary arterial pulsation
 Thrills – palpable murmurs

9. SYSTEMIC EXAMINATION
 Percussion
 Identfy whether heart is enlarged or not

10. SYSTEMIC EXAMINATION
 Auscultation
 S1
 S2
 Ejection sounds
 murmurs

11. Resting ECG
• Features to check
Sinus rhythm / arrhythmia
PR interval
QRS duration
QT Intervals
ST segment shape (LVH/Brugada)
T waves (? Cardiomyopathy)

12. KEY CLINICAL FINDINGS WITH PALPITATIONS AND
SUGGESTED DIAGNOSES
 Finding  Suggested diagnosis
 Single “skipped” beats  Benign ectopy
 Feeling of being unable to  Ventricular premature
catch one‟s breath contractions
 Single pounding sensations  Ventricular premature
 Rapid, regular pounding in contractions
neck  Supraventricular
 Palpitations that are worse arrhythmias
at night  Benign ectopy or atrial
 Palpitations associated with fibrillation
emotional distress  Psychiatric etiology or
 Palpitations associated with catecholamine-sensitive
activity arrhythmia
 General anxiety  Coronary heart disease
 Panic attacks

13. KEY CLINICAL FINDINGS WITH PALPITATIONS AND
SUGGESTED DIAGNOSES
 Finding  Suggested diagnosis
 Medication or recreational drug use  Drug-induced palpitations
 Rapid palpitations with exercise  Supraventricular arrhythmia, atrial
fibrillation
 Positional palpitations  Atrioventricular nodal tachycardia,
pericarditis
 Heat intolerance, tremor, thyromegaly
 Hyperthyroidism
 Palpitations since childhood
 Rapid, irregular rhythm
 Supraventricular tachycardia
 Atrial fibrillation, tachycardia with
 Palpitations terminated by vagal variable block
maneuvers
 Supraventricular tachycardia
 Heart murmur
 Midsystolic click
 Heart valve disease
 Friction rub
 Mitral valve prolapse
 Pericarditis

14. EVALUATING A PATIENT WITH PALPITATIONS

15. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 ARRHYTHMIAS
 Atrial fibrillation/flutter
 Bradycardia caused by advanced arteriovenous block or
sinus node dysfunction
 Bradycardia-tachycardia syndrome(sick sinus
syndrome)
 Multifocal atrial tachycardia
 Premature supraventricular or ventricular contractions
 Sinus tachycardia or arrhythmia
 Supraventricular tachycardia
 Ventricular tachycardia
 Wolff-Parkinson-White syndrome

16. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Psychiatric causes
 Anxiety disorder
 Panic attacks
 Drugs and medications
 Alcohol
 Caffeine
 Certain prescription and over-the-counter agents
(e.g., digitalis, phenothiazine, theophylline, beta
agonists)
 Street drugs (e.g., cocaine)
 Tobacco

17. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Nonarrhythmic cardiac causes
 Atrial or ventricular septal defect
 Cardiomyopathy
 Congenital heart disease
 Congestive heart failure
 Mitral valve prolapsed
 Pacemaker-mediated tachycardia
 Pericarditis
 Valvular disease (e.g., aortic insufficiency, stenosis)

18. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Extracardiac causes
 Anemia
 Electrolyte imbalance
 Fever
 Hyperthyroidism
 Hypoglycemia
 Hypovolemia
 Pheochromocytoma
 Pulmonary disease
 Vasovagal syndrome