PALPITATIONS

PALPITATIONS: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the Following Questions:

1. Are the palpitations constant or intermittent? Constant palpitations may signify tachycardia, and that would suggest hyperthyroidism or overuse of caffeine and other drugs. Intermittent palpitations are more likely related to a cardiac arrhythmia, particularly extrasystoles. Also, constant palpitations may indicate a fever of unknown origin.
2. Are there associated symptoms? Palpitations with weight loss, increased appetite, and polyuria would suggest hyperthyroidism. Palpitations with shortness of breath and pitting edema would suggest congestive heart failure.
3. Are there positive physical findings? If there is cardiomegaly, one must think of the possibility of congestive heart failure or valvular heart disease. If one finds a cardiac murmur, it is more likely that there is valvular heart disease such as acute or chronic rheumatic fever. Cardiomegaly, murmur, and/or fever would suggest a bacterial endocarditis. Cardiomegaly without a murmur would suggest a myocardiopathy, congestive heart failure, and hypothyroidism. Palpitations with no cardiomegaly but with hypertension would suggest pheochromocytoma, particularly if it is systolic hypertension, but it also can be found in hyperthyroidism. Persistent or intermittent palpitations with a totally normal physical examination suggest sensitivity to caffeine or the use of other drugs.

DIAGNOSTIC WORKUP

Before initiating an expensive workup, the patient should eliminate use of all drugs, alcohol, caffeine, and nicotine, if possible, for several days. If this does not eliminate the palpitations, a careful inquiry into the dietary habits should be made, and a CBC should be done to eliminate anemia. In the presence of tachycardia, weight loss, and increased appetite, it is obvious that a thyroid profile should be drawn. If there are palpitations and fever, a workup for an infectious disease, particularly rheumatic fever and bacterial endocarditis, is in order. Blood cultures, ASO titers, sedimentation rate, and echocardiography are useful. If the palpitations are intermittent, a pheochromocytoma should be considered, and 24-hr urine collection for VMA or metanephrines should be ordered. A drug screen may be necessary to ensure patient cooperation in eliminating all drugs. Twenty-four-hr blood pressure monitoring is also useful. In addition, 24-hr or 48-hr Holter monitoring is very useful in the diagnosis of intermittent palpitations. Newer technology involving a continuous-loop event recorder allows monitoring for 2 weeks at a time. Arm-to-tongue circulation times as well as spirometry may diagnose early congestive heart failure.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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