Palpitations

Summary of Common Conditions Seen in OSCEs

Condition Key points in history Key points in management
Atrial fibrillation Elderly patientPast medical history of ischaemic heart disease, hypertension, congestive heart failure, mitral valve diseaseRecent onset coinciding with symptoms suggestive of lower respiratory tract infection See Chapter 65 on ECGs
Supraventricular tachycardia Past medical history of COPD (predisposes to multifocal atrial tachycardia)Associated with symptoms of compromise, e.g. chest pain, shortness of breath, pre-syncopePrevious episodes terminated by vagal manoeuvres, e.g. blowing the nose See Chapter 65 on ECGs
Ventricular tachycardia Symptoms of compromise, e.g. chest pain, shortness of breath, pre-syncope, cold peripheries, sweatingHistory of recent myocardial infarctionPast medical history of ischaemic heart diseaseFamily history of sudden death, known long QT syndrome See Chapter 65 on ECGs
Thyrotoxicosis (causing sinus tachycardia or atrial fibrillation) Weight loss, increased appetite, heat intolerance, diarrhoea, tremor, mood disturbancePast medical history of thyroid diseasePast medical history of other autoimmune disease (insulin-dependent diabetes mellitus, vitiligo, Addison’s disease, pernicious anaemia, etc.) Follow protocol for atrial fibrillationMedical/surgical correction of thyrotoxicosis
Hypertrophic obstructive cardiomyopathy (HOCM) Family history of sudden deathCollapse while playing sportfamily history of HOCM AmiodaroneAnticoagulate if paroxysmal atrial fibrillationImplantable defibrillatorSeptal myomectomy
Excess caffeine intake History of excessive caffeine intake (definition of ‘excessive’ varies from patient to patient)No symptoms suggesting compromisePalpitations self-limitingPast medical history of cardiac or thyroid disease Decrease caffeine intakeRule out cardiac and thyroid-related causes
Phaeochromocytoma Triad of episodic headache, sweating, fast palpitationsWeight lossSymptoms of anxietyNB. This must be ruled out before ascribing symptoms to generalised anxiety disorder Urgent referral to endocrine surgeonsInvestigate for multiple endocrine neoplasia type 2, neurofibromatosis, von Hippel–Lindau syndrome
Simple anxiety Associated with important/stressful eventNo symptoms of compromiseNo history of cardiac or thyroid disease ReassuranceBehavioural therapy/cognitive-behavioural therapyBeta-blockers if severe symptoms
Fever Localising symptoms of infection (e.g. cough, earache)First episode or episodes only coincide with febrile illness Antipyrexial medication (e.g. paracetamol)
Generalised anxiety disorder Associated with important/stressful eventNo symptoms of compromiseNo history of cardiac or thyroid diseasePast medical history of depressionAvoidance of predisposing situations Referral to psychiatryBeta-blockers for symptom control
Ventricular ectopics Recent myocardial infarctionPast medical history of ischaemic heart diseaseDescription of missed beat followed by heavier beat Usually no treatment required if asymptomatic and infrequentAmiodarone if >10/min or symptomatic
Pacemaker failure Past medical history of pacemaker insertion Replacement/repair of pacemaker
Hypoglycaemia Associated with sweating, anxiety, hunger, tremor, dizzinessPast medical history of diabetes mellitusDrug history of hypoglycaemic medication (not metformin)History of liver disease, Addison’s disease Oral sugar followed by slow-release carbohydrateIntravenous dextrose (if unable to swallow)

Relevant Investigations You May Need to Discuss at This Station

Investigation Justification
ECG Instant detection of underlying rhythm
Detection of long QT syndrome
Full blood count Anaemia precipitates palpitations
High white cell count suggests infection
Thyroid function tests Diagnosis of thyrotoxicosis
Blood glucose Diagnosis of hypoglycaemia
Risk assessment for cardiovascular disease
Us+Es Hypokalaemia/hyperkalaemia can cause fatal arrhythmias
Mg and Ca Low levels of Ca and Mg predispose to long QT syndrome and therefore polymorphic ventricular tachycardia
24-hour ECG monitoring Identification of paroxysmal arrhythmias
Echo Identification of structural heart disease, e.g. HOCM or mitral stenosis, that may predispose to arrhythmias
Exercise ECG Detection of arrhythmias precipitated by ischaemic heart disease

Hints and Tips for the Exam

Palpitations are an extremely common complaint in general practice and A&E settings so this is a popular station in the OSCE exam. The underlying causes range from being benign (e.g. anxiety prior to an OSCE) to being potentially catastrophic (e.g. paroxysmal ventricular tachycardia after a myocardial infarction). This can make the task of taking a history in 5 minutes challenging. However, your task will be made easier if you remember the following six tips:

 The importance of starting with an open question to get the patient talking cannot be stressed enough. The information from this alone will often go a long way towards formulating a differential diagnosis to guide further history-taking BUT … 

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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Palpitations

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