DAVAO MEDICAL SCHOOL FOUNDATION, INC.

– COLLEGE OF MEDICINE
Department of Internal Medicine
Name: Vanessa Olga J. Dagondon
Batch/Section: NMD4 Date: May 1, 2022

PALPITATIONS
Instructions:
 Use Harrison’s Principles of Internal Medicine 20th edition, Bate’s Guide to Physical Examination and History Taking, or Clinical Practice Guidelines as your reference in answering this activity. You may
also use the official textbooks used by other departments.
 Indicate the name of the book, chapter and page number in the reference column.

Key Terminologies Definition Reference (Source, page no.)

Harrison’s Principles of
Internal Medicine 20th edition
Chapter 39 Page 249
 defined as a “thumping,” “pounding,” or “fluttering” sensation in the chest
Palpitations The Patient History: An
 an awareness of one’s own heartbeats
Evidenced Based Approach to
Differential Diagnosis Chapter
28 page 273
The Patient History: An
Evidenced Based Approach to
Arrhythmia  a heart rhythm that results from abnormal or disorganized cardiac conduction
Differential Diagnosis Chapter
28 page 273
 Conduction block from the atrium to the ventricle Harrison’s Principles of
AV Block  manifests as slow conduction in its mildest forms and failure to conduct, either intermittent or persistently, in Internal Medicine 20th edition
more severe varieties Chapter 240 Page 1727-1728
The Patient History: An
Evidenced Based Approach to
Syncope  Transient loss of consciousness with spontaneous recovery
Differential Diagnosis Chapter
28 page 273
The Patient History: An
Evidenced Based Approach to
Presynscope  Sensation that one may lose consciousness
Differential Diagnosis Chapter
28 page 273
The Patient History: An
 A psychiatric disorder characterized by episodic panic attacks about which there may be persistent concern or Evidenced Based Approach to
Panic disorder
anxiety Differential Diagnosis Chapter
28 page 273

PREPARED BY: M. PLATERO, RN, MD, FPCP 1

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
 Palpitations associated with syncope or presyncope The Patient History: An
 Family history of sudden cardiac death or known arrythmia Evidenced Based Approach to
Alarm symptoms associated with
 Use of medications known to prolong the QT interval (methadone, antiarrhythmic agents, or antipsychotics) Differential Diagnosis Chapter
palpitations
 A personal history of heart disease, including coronary artery disease, congenital or valvular heart disease, 28 page 275
hypertrophic cardiomyopathy, or dilated cardiomyopathy
 Catheter-based therapy for reentrant arrhythmias designed to disrupt the anatomic circuit or alter the Harrison’s Principles of
relationship between the wavelength and path length of the arrhythmia circuit, eliminating pathologic Internal Medicine 20th edition
conduction. Chapter 238 page 1719, 1721
Ablation  One of the first line therapies for arrythmia
o use of catheter ablation is based on the principle that there is a critical anatomic region of impulse
generation or propagation that is required for the initiation and maintenance of cardiac arrhythmias.
Destruction of such a critical region results in the elimination of the arrhythmia.
Harrison’s Principles of
 procedure used to return an abnormal heartbeat to a normal rhythm
Cardioversion Internal Medicine 20th edition
 used to manage very irregular wide-complex tachycardia that is most likely preexcited AF or flutter
Chapter 244 page 1734
 use of freezing as an energy source for catheter ablation of cardiac arrythmias Harrison’s Principles of
 At temperatures just below 32°C, membrane ion transport is disrupted, producing depolarization of cells, Internal Medicine 20th edition
Cryoablation
decreased action potential amplitude and duration, and slowed conduction velocity (resulting in local Chapter 238 page 1721-1722
conduction block)—all of which are reversible if the tissue is rewarmed in a timely fashion.
 Records all arrythmias during the recording period Harrison’s Principles of
Holter Monitor  Typically used for 24-48 hours Internal Medicine 20th edition
 Useful for frequent arrythmias (daily) or when quantitation of an arrythmia is needed Chapter 247 page 1753

Write in full the meaning of the acronyms given and define or describe this : May use other sources.
ACRONYM MEANING DESCRIPTION/DEFINITION
 originate from or are dependent on conduction through the
atrium or atrioventricular (AV) node to the ventricles
 most produce narrow QRS-complex tachycardia (QRS duration
SVT  Supraventricular Tachycardia
<120 ms) characteristic of ventricular activation over the
Purkinje system

 chaotic rapid atrial electrical activity with variable ventricular

AF  Atrial Fibrillation rate; the most common sustained cardiac arrhythmia in older
adults
Vtach  Ventricular tachycardia  presents as a wide QRS tachycardia that has the same QRS
 configuration from beat to beat indicating an identical sequence

PREPARED BY: M. PLATERO, RN, MD, FPCP 2

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
of ventricular depolarization for each beat
 Decreased CNS dopaminergic activity with relative excess of
cholinergic activity
EPS  Extrapyramidal Syndrome  Caused by antipsychotics, some cyclic antidepressants and
antihistamines
 Manifests as Akathisia, dystonia, parkinsonism
 consists of the use of chest compressions and artificial
CPR  Cardiorespiratory Resuscitation ventilation to maintain circulatory flow and oxygenation during
cardiac arrest 
 single ventricular beats that fall earlier than the next anticipated
PVC  Premature Ventricular Contraction
supraventricular beat
 medical device designed to analyze the heart rhythm and deliver
AED  Automated External Defibrillator an electric shock to victims of ventricular fibrillation to restore
the heart rhythm to normal
 indicated for individuals who have had unexplained syncope or
been resuscitated from cardiac arrest
 Implantable Cardioverter Defibrillator  usually indicated for arrhythmias associated with a sudden death
ICD
risk as it will provide a “safety-net” to terminate life-threatening
VT or VF, preventing sudden death, but without preventing the
arrhythmia
 defined as a preexcited QRS during sinus rhythm and episodes of
WPW  Wolff-Parkinson-White (WPW) syndrome
PSVT
 Intrinsic impairment of conduction in the right bundle system
(intraventricular conduction disturbances) that leads to
RBBB  Right Bundle Branch Block prolongation of the QRS interval.
 In RBBB, the terminal QRS vector is oriented to the right and
anteriorly (rSR′ in V1 and qRS in V6, typically).
 Intrinsic impairment of conduction in the left bundle system
(intraventricular conduction disturbances) that leads to
prolongation of the QRS interval.
LBBB  Left Bundle Branch Block
 In LBBB, both early and later phases of ventricular depolarization
are altered. The major QRS vector is directed to the left and
posteriorly.

Palpitations with associated features Suggested diagnosis

Palpitation in younger patients Panic Disorder

PREPARED BY: M. PLATERO, RN, MD, FPCP 3

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
Arrythmia due to bypass tract
Palpitation in older patients Arrythmia associated with structural heart disease (Atrial fibrillation or ventricular tachycardia)
Palpitation + Hx of panic disorder or anxiety or emotional Sinus tachycardia or perception of sinus rhythm
distress
Palpitation + Hx of heart disease Arrhythmia
Palpitation during exercise Ventricular tachycardia or sinus tachycardia
Palpitation + stimulant drugs Sinus tachycardia
Palpitation + use of QT-prolonging medications Torsades de pointes
Ventricular tachycardia
Palpitation + heat intolerance/tremor/thyromegaly AVNRT

A 25 yo female, no known comorbidities came in because of on and off palpitations for the past month associated with episodes of breathlessness during episodes .

TASK: Write down the questions that you need to ask your patient to come up with a complete medical history. You are given a maximum of 20 questions to ask.

Questions that you will need to ask : You may write down in English
RULE – OUT
1 Can you recall what you were doing before you felt the first episode of your palpitations? (answer in sentence format) (answer in sentence format)
2 For how many minutes do you feel the palpitations in one episode?
3 Do you have any other symptoms such as chest pain, shortness of breath, excessive sweating, nausea, vomiting, or light headedness?
4 Was there any instance that you fainted or felt like fainting?
5 Did you take any medications for your symptoms?
6 Were there anything you did that made your palpitations worse or better?
7 What time of the day would you usually have episodes pf palpitations?
8 Did you notice a deterioration of your symptoms overtime? What was the breaking point that made you seek consultation?
9 Do you have history of cardiac illnesses such as coronary heart disease, congestive heart failure, or hypertension?
10 Do you have any history of panic attacks, anxiety disorders, or hypochondriasis (worrying too much of having a serious illness?)
11 Have you ever consulted a medical professional about your problem or is this the first time? If yes, were they able to request for any diagnostic tests such as
ECG? If yes, may I know the results of these tests?
12 Do you take any medications such as methadone, antiarrhythmic agents, or any antipsychotics, any antibiotics, antiemetics, protease inhibitors, or
diuretics?
13 When was your last menstrual period? Do you have a regular or irregular menstrual cycle?
14 Do you have any family history of hypertension, cardiac diseases, diabetes, or thyroid problems?
15 Do you smoke cigarettes or drink alcohol? If yes, when did you start and how many sticks per day can you consume? What type of alcohol do you drink and
how much and how often do you drink?
16 Do you have any history of illicit drug use or any recreational or prescription stimulant use?
17 Do you drink caffeine? How much do you drink in one day?
18 What do you usually eat in a day?

PREPARED BY: M. PLATERO, RN, MD, FPCP 4

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine
19 Have you been under a lot of stress lately? Do you have any recurrent negative thoughts in your mind?
20 If you are overwhelmed by your thoughts or emotions, do you have someone you can talk to or confide in?

TASK 2 Make an algorithm on how you will approach a patient coming to you with Palpitations as presented in your short case above . NO other details are given

Make an algorithm on how you approached the chief complaint of this patient to arrive in your diagnosis. Include 5 differential diagnoses in the algorithm. See sample below.

To maintain the organization of the diagrams, you may follow one of these options:
 save the document as PDF file (recommended) ;
 write it in a clean white sheet of paper(s), take a picture, then paste it here in the document;
 do a screen shot of your output, paste it back in this document, then crop as needed

PREPARED BY: M. PLATERO, RN, MD, FPCP 5

 DAVAO MEDICAL SCHOOL FOUNDATION, INC. – COLLEGE OF MEDICINE
Department of Internal Medicine

PREPARED BY: M. PLATERO, RN, MD, FPCP 6