Health Awareness blog

This is John Murtagh suggestion how to approach a patient that comes with complaint of palpitation.

Probability diagnosis-the most common causes of palpitation

• Anxiety 
• Premature beats (ectopic)
• Sinus tachycardia
• Drugs, e.g. stimulants

Serious disorders not to be missed-These pathology (or disease) need to be ruled out. Fail to reach for the diagnosis might means fatal.

• Myocardial infarction/angina
• Arrhythmias : ventricular tachycardia; bradycardia; sick sinus syndrome; torsades de pointes
• WPW syndrome
• Electrolyte disturbances ; hypokalemia; hypomagnesaemia; hypoglycemia (IDDM)

 Pitfalls- these diagnoses are often missed.

• Fever/infection
• Pregnancy
• Menopause
• Drugs, e.g. caffeine, cocaine
• Mitral valve disease
• Aortic incompetence
• Hypoxia/hypercapnia

Rarities- rare causes of palpitation

• Tick bites (T1-T5)
• Phaechromocytoma

Seven masquerades checklist-Each of these problems can present with any complaints, so, these diagnosis should always be considered during consultation.

• Depression                          - May present with palpitation
• Diabetes                                – Indirectly cause palpitation         
• Drugs                                     – Commonly cause palpitation
• Anemia                                  – May present with palpitation
• Thyroid disease                    – May present with palpitation
• Spinal dysfunction              – May present with palpitation
• UTI                                          – Possible cause of palpitation

 Is the patient trying to tell me something? – Good doctors should always have this piece of question at the back of their mind. Look for hidden agenda.

Consider cardiac neurosis, anxiety. 

Below is another way how to approach a patient that comes with palpitation. When looking for a diagnosis for palpitation, it is very important to differentiate between cardiac or non cardiac causes because the management is difference. The most important part is cardiac causes often severe and may cause fatal if mistreated or delay in reaching for the diagnosis.

CARDIAC

• Arrhythmias
• Atrial fibrillation/Atrial flutter
• Multifocal atrial tachycardia
• Premature ventricular contractions
• Sick sinus syndrome – sinus tachycardia
• AV nodal re-entrant tachycardia
• Supraventricular tachycardia
• Ventricular tachycardia
• Wolf-Parkinson-White Syndrome
• Cardiac shunts
• Cardiomyopathy
• Pacemaker
• Valvular heart disease
• Ischemia (effect pathway)
• Cardiac structural abnormality
• Cardiomyopathy (HOCM)-heart mass increase
• Ventricular hypertrophy
• Other cardiac causes

NON CARDIAC

Medication:

• Alcohol
• Anticholinergics
• Caffeine
• Illicit drugs
• Nicotine
• Sympathomimetics

Endocrine/metabolic:

• Thyroid disorder: hypothyroidism, hyperthyroidism
• Hypoglycemia
• Phaechromocytoma

Psychiatric:

• Anxiety
• Panic disorder
• Somatization disorder

Others:

• Electrolyte imbalance
• Anemia
• Menopausal symptom
• Fever
• Strenuous physical activity

Reference:

1. Paulman et al. Taylor’s 10-Minute Diagnosis Manual. Lippincott Williams and Wilkins. 2007.
2. John Murtagh. General Practice. 3^rd edition.
3. David S. Smith et al. Field Guide to Bedside diagnosis. 2^nd edition. 2007. Lippincott Williams and Wilkins.

Stroke is a clinical syndrome. It is characterized by rapidly developing clinical symptoms and/or signs of focal/global and loss of cerebral function. The symptoms lasting more than 24 hours and may lead to death. Stroke syndrome has no apparent cause other than vascular origin.

Transient ischaemic attack is another clinical syndrome almost similar like stroke syndromes. It is characterized by an acute loss of focal cerebral or monocular function.  The symptoms are lasting less than 24 hours. It has been thought the symptoms occur due to the inadequate blood supply to cerebral or ocular as a result of arterial thrombosis or embolism.

Differential diagnosis of stroke syndromes:

Other differential diagnosis of “stroke” – the following problems may present like stroke. It should always be considered in unconscious patients or patients presented with muscle weakness or other neurological deficits.

• Metabolic/toxic encephalopathy (hypoglycemia, non ketotic hyperglycemia, Wernicke-Korsakoff syndrome, drug intoxication)
• Epileptic seizures (postictal Todd’s paresis)
• Hemiplegic migraine
• Structural intracranial lesions (e.g.: subdural hematoma, brain tumor, arteriovenous malformation)
• Encephalitis (e.g.: herpes simplex virus), brain abscess, tuberculoma
• Head injury
• Hypertensive encephalopathy
• Relapsing multiple sclerosis
• Conversion disorders
• Hyperviscosity syndrome
• Peripheral nerve lesion (e.g.: Guillaine Barre syndrome)

Related:

• Clinical features of stroke
• Causes of ischemic stroke
• Risk factors of stroke

Reference:

1. Clinical Practice Guidelines. Management of Ischaemic Stroke. June 2006. Ministry of Health Malaysia.
2. David S. Smith et al. Field Guide to Bedside diagnosis. 2^nd edition. 2007. Lippincott Williams and Wilkins.