問診と身体診察を極めよう、OSCEに向けて：動悸 / Unleash your Mastery - The art of hystory taking and physical examination: Palpitations

Hello everyone!

こんにちは～

Today marks the inaugural edition of our series on studying medical history taking and physical examination!

And what better way to kick things off than by delving into the topic of "Palpitations"!

今日は

問診と身体診察を勉強していくシリーズの記念すべき第一弾！！

テーマは「動機/palpitations」についてです

For those who haven't read the introductory explanation about this series yet, be sure to check it out before diving into today's topic.

このシリーズについての説明は

総論で行っているので、まだ読んでいない方はぜひ読んでからがおすすめです！

poohmedical.hatenablog.com

Today,

I've delved into a common phenomenon encountered in clinical practice – palpitations!

さて

今日は、臨床の現場でよく遭遇する動機について勉強しました！

I'm here to share a summary of what we've learned,

but I'm also eager to hear your thoughts, questions, and anything else you'd like to share.

まとめをみなさんに共有するので

気になることとか、質問とかあったらどしどしよろしくお願いします～

While I've provided the basic summary in English,

If you're interested in seeing a Japanese version too,

Just drop us a line, and I'll be happy to share it with you!!

基本まとめは英語で行っていますが、

もし日本語版もみたい！

という声があれば、公開するのでぜひ教えてください～

--------------------------------------------------------------------------------------------------

[Palpitations]

Definition: "Awareness of one’s own heartbeats"

Introduction to Palpitations:

Palpitations are a common symptom that many patients experience, often described as a sensation of the heart pounding, fluttering, or beating irregularly. While palpitations are often benign, they can sometimes indicate serious cardiac conditions, making proper evaluation essential.

Approach to Palpitations

Chief Complaints (℅):

• “I have palpitations.”
• “My heart is pounding/fluttering/flip-flopping.”
• “My heart is skipping beats.” (*Note: "My heart skips a beat" often refers to excitement, amazement, or shock.)

Specifics: Quality (rhythms) and Timing (provoking factors/situations)

Quality: “Could you tap out your heartbeats on the desk?”

                → Irregular heartbeat: atrial fibrillation (AF)

                     Regular heartbeat: others

 Timing: vItMIn cd

             I: infection

           M: metabolics (hypoglycemia, hyperthyroidism, anemia) 

             I: iatrogenic (medication: anti-arrhythmias, stimulants: caffeine, drugs)

• psychiatric: panic, stress, somatization disorder
• postural: postural tachycardia (autonomic dysfunction: DM, MAS)hycardia (autonomic dysfunction: diabetes mellitus, MAS)

⇒Remember that palpitations can be caused by non-cardiac factors, including stress, anxiety, and certain medications or substances.

<History Taking>

1. Red Flag Symptoms:

• Severe shortness of breath (SOB) / fatigue
• Syncope / pre-syncope

• Chest pain

• Sweating

1. Exact Nature of Palpitations:

• Rate, rhythm, missed beat, extra beat, duration, onset/offset, precipitants, frequency

1. Factors Increasing Likelihood of Cardiac Cause:

• Onset during sleep or at work
• Prior cardiac disease

1. Additional History Questions:

• Onset: "When did you first notice the palpitations?"
• Duration: "How long do the palpitations last?"
• Frequency: "How often do you experience them?"
• Triggers: "Do any specific activities or situations trigger your palpitations?"
• Relieving factors: "Does anything make them better or worse?"

<Physical Examination>

• Vital signs (heart rate, blood pressure, respiratory rate)
• Inspection (skin, mucous membranes for pallor or cyanosis)
• Palpation (pulse, precordial area for heaves or thrills)
• Auscultation (heart sounds, murmurs, extra heart sounds)

<Diagnostic Workup>

• Electrocardiogram (ECG)
• Holter monitoring or event recorder
• Blood tests (complete blood count, thyroid function tests, electrolyte levels)
• Echocardiography
• Stress testing

<Management Strategies>

1. Lifestyle modifications (reducing caffeine, alcohol, and stress)

• Pharmacological treatments (beta-blockers, anti-arrhythmic medications)
• Referral to a specialist (cardiologist, electrophysiologist)

1. Patient Education:

• Encourage patients to keep a diary of their symptoms, noting the frequency, duration, and possible triggers.
• Advise patients on when to seek immediate medical attention (e.g., if they experience chest pain, severe shortness of breath, or syncope).

Differential Diagnosis (DDx) of Palpitations

Arrhythmias:

1. Tachycardia/Tachyarrhythmia:

• Supraventricular tachycardia (SVT):
• Sinus tachycardia: Most common
• Consider: Psychiatric disorders (panic disorder, somatization disorder)
• Intoxication (medications, stimulants)
• Metabolic disorders (hypoglycemia, hyperthyroidism)
• Atrial fibrillation (AF): Irregularly irregular atrial rhythm
• Atrial flutter (AFL): Regularly irregular atrial rhythm
• Paroxysmal supraventricular tachycardia (PSVT)
• Atrioventricular reentrant tachycardia (AVRT): WPW syndrome
• Atrioventricular nodal reentrant tachycardia (AVNRT)
• Jugular vein pulse (JVP): Frog sign (due to simultaneous contraction of atria and ventricles)
• Ventricular tachycardia (VT): Adams-Stokes syndrome
• Monomorphic ventricular tachycardia (MVT)
• Polymorphic ventricular tachycardia (PVT): Torsades de pointes
• Ventricular fibrillation (VF)

1. Bradycardia/Bradyarrhythmia:

• Sick sinus syndrome (SSS)
• Atrioventricular (AV) block: Adams-Stokes syndrome
• First-degree
• Second-degree: Mobitz type 1 (Wenckebach) and Mobitz type 2
• Third-degree

1. Premature Contractions:

• Premature atrial contraction (PAC)
• Premature ventricular contraction (PVC)

Tips and Clinical Pearls:

1. Thorough History Taking:
• Ask the patient to describe the palpitations in detail: onset, duration, frequency, and associated symptoms.
• Inquire about the patient’s medical history, including any known heart conditions, recent illnesses, and medication use.
• Explore lifestyle factors such as caffeine, alcohol, and drug use.
2. Identifying Red Flags:
• Be alert for symptoms that may indicate a serious underlying condition, such as syncope, severe chest pain, or shortness of breath.
• Assess for risk factors of cardiac disease, including family history, hypertension, diabetes, and smoking.
3. Characterizing the Palpitations:
• Ask the patient to tap out the rhythm of their palpitations. This can help differentiate between regular and irregular rhythms.
• Determine if the palpitations are episodic or persistent and if there are any identifiable triggers.
4. Physical Examination:
• Perform a thorough cardiovascular examination, including checking vital signs, palpating pulses, and auscultating the heart for murmurs or abnormal rhythms.
• Look for signs of hyperthyroidism (e.g., tremors, goiter) or anemia (e.g., pallor).
5. Electrocardiogram (ECG):
• Obtain an ECG to identify arrhythmias or other cardiac abnormalities.
• Consider a Holter monitor or event recorder if the palpitations are intermittent and not captured during the initial ECG.
6. Laboratory Tests:
• Order blood tests to check for conditions that can cause palpitations, such as anemia (CBC), electrolyte imbalances, and thyroid dysfunction (TSH, T4).
7. Patient Education:
• Explain to the patient the potential benign and serious causes of palpitations.
• Advise on lifestyle modifications, such as reducing caffeine and alcohol intake and managing stress.
8. Referral to Specialist:
• Refer to a cardiologist if there is evidence of a significant arrhythmia or if the diagnosis remains unclear despite initial workup.
• Consider referral to an endocrinologist if hyperthyroidism is suspected or confirmed.
9. Reassurance and Follow-Up:
• Reassure the patient if initial evaluation suggests a benign cause.
• Schedule follow-up appointments to monitor symptoms and response to any interventions.

Harrison's Principles of Internal Medicine:

The American College of Cardiology (ACC) and the American Heart Association (AHA) Guidelines:

European Society of Cardiology (ESC) Guidelines:

UpToDate:

Mayo Clinic:

Journal Articles and Reviews: