Rahaf Wardeh Internal Medicine 2016-2017

History Taking in Palpitations (this is how our patient presented, could be other complaint)

Element Components Details

Chief complaint *Palpitations*  When did it start?
 Is it fast or slow?
 Continuous all the time/intermittent?
 Anything that increases it? Reduces it?
*activity/position/medication…*
 Is it regular or irregular? *let the patient tap the
beat/rhythm*
 Is it the first time to happen?
Associated Cardio  Chest pain?
Symptoms  Cough?
 Shortness of Breath?
CNS  Headache?
 Any problems with your eyes/vision?
 Any problems with your ears/hearing?
 Any weakness in any limb?
Pulmonary  Reassure no cough, breathing problems, …
Gastro  Diarrhea/constipation?
 Nausea/vomiting?
 Abdominal Pain?
Urinary  Any problem with urine?
 Amount? Color? Burning sensation?
MSK  Joint/Muscle pain?
 Joint problems?
Skin  Any change in color? Itching? Patches? Rashes?
Blood  Do you have any blood diseases? Anemia?
Bleeding problems? Recurrent infections?
Past Medical Hx Any chronic illness from
Past Surgical Hx before?
HTN?
Diabetes?
Heart Problem?
Any previous surgeries?
Drugs Taking any medications? Names, doses, frequency, compliance
Mood-enhancing drugs?
Allergies Don’t forget drug allergies
Family Hx HTN, DM, Heart problems,
Blood problems, others?
Personal Hx Nutrition Eating home/fast food? Eats meat/vegetables/…?
Smoking Vegetarian?
Alcohol
Rahaf Wardeh Internal Medicine 2016-2017

Exercise
Occupation? Occupational exposure?
Beliefs? What the patient thinks it is? Anything else the patient would like to add?
Concerns? What is important for you to
know?

Additional notes:
- Think about the causes of your clinical suspicion and ask accordingly. In this case, the
complaint was very generalized (not specific to any system) so we were considering anemia
 causes: familial, hereditary, acquired (decreased intake or increased loss). Ask specifically
in systems review, family and personal histories.
- Difference between fatigue & weakness: patient can not initiate movement in weakness,
but in fatigue patient can initiate the action but can’t complete it.
- Shortness of breath in Anemia patients is characterized by relief when lying down (increase
blood return and improve circulation), in contrast to other causes of SOB that are relieved
when the patients sit up straight (to reduce congestion or breathing difficulty).
- With such a vague complaint, you should do full Physical Examination, but without going
deep in each system. Since we were suspecting Anemia, focus on hematopoietic system:
tonsils, spleen, Lymph nodes. Other than that, auscultate chest and heart, perform gross
neurological examination.

Differential Diagnosis of Palpitations/Tachycardia

Keep this scheme in mind for any DDx

Infectious

Congenital Inflammation
DDx

Hereditary
Acquired Malignancy
Non-Hereditary
Trauma

Drugs

Autoimmune

Follow same scheme for ‘palpitations’ :

Congenital: Heart Valvular problems, ASD, VSD, conduction defects in babies whose mothers
had SLE…
Rahaf Wardeh Internal Medicine 2016-2017

Acquired – Hereditary: None

Acquired – Non hereditary: exercise, pregnancy, fever of any cause (1 increment in the temp
will increase HR by 15-20 bpm), Anxiety, caffeine, nicotine, alcohol, Anemia, thyrotoxicosis,
heart diseases (heart failure, arrhythmias), drugs (always dig behind drugs!), many autoimmune
diseases, many endocrine problems…

Physical Examination (suspecting Anemia)

Element Components Details
Before Physical Position and Exposure  Explain what you’ll do to patient
Examination  Position patient
 Proper exposure
 Adjust the height of the bed to your comfort
(student should be comfortable examining)
 Stand on RIGHT side of the patient
 Wash hands!
Physical General Appearance  Lying supine? Sitting upright? Standing?
Examination  Calm? Comfortable? Alert? Ill? Distressed?
Surrounding of the Patient  Comment on any: Identification tag (name band
on wrist), O2 mask, IV lines (& what solutions
infused), cannula color, cannula insertion site,
ECG leads, CV lines, urinary catheter (+ urine
bag content), drainage tubes, chest tubes, NG
tubes, walking aids, pathological specimens
(Gallstones, aspirated fluid….) *make sure
belongs to the patient* …
Hands  Koilonychia
 Leukonychia
 Clubbing
 Pallor in the palm of the hand
 Tendon xanthoma (may indicate heart disease)
 Tremor and palmar erythema (thyrotoxicosis)
Face & Neck  Face:
o Loss of outer 1/3 of eyebrows
(hypothyroidism)
o Exophthalmos (hyperthyroidism)
o Pallor in conjunctiva
o Cyanosis
o Jaundice (examine Under DAY LIGHT)
o Xanthelasma
o Cheeks (rosy or pale)
o Angles of the mouth (ulcerations,
Rahaf Wardeh Internal Medicine 2016-2017

fissures; do NOT say angular stomatitis)

o Tongue (hydrated or bald tongue); do
NOT say glossitis.
o Central cyanosis below tongue
o Check thyroid by inspection
 Neck:
o Virchow’s LN
Chest  Lungs: inspect, palpate, percuss, auscultate
 Heart: inspect, palpate, auscultate
Lymph Nodes  submental, submandibular, preauricular,
Spleen postauricular, occipital, anterior cervical,
Tonsils posterior cervical, supraclavicular, axillary, groin,
& popliteal
Abdomen  Inspect, palpate, percuss, auscultate
*don’t forget spleen if you haven’t done it yet*
Lower limb  Edema
Summary &  Thank + Drape & cover
conclusion the patient

Additional notes:
- Every 1 ml = 15 microdrops IV. Another device called “microdropper” makes those 15
microdrops into 60 microdrops. This is important when administering medications at
specific speeds. Ex. 100 ml of medication in 10 minutes. So 10 ml in 1 min  600
microdrops/min, I enter this into the device and now the drug administration is controlled.
- Acute means <2 weeks ; chronic means >2 weeks
- Cyanosis = more than 5 g of deoxygenated blood. So if a patient has SEVERE anemia, they
will NOT have cyanosis. Let’s say a patient with severe anemia who has Hb 5 – 7, cyanosis
means 5 g of those are deoxygenated; the patient wouldn’t be alive in this case. Hence, we
can NOT have cyanosis and pallor at the same time. We can see cyanosis with mild anemia.