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Examination in palpitation
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Examination in palpitation
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