MODUL 3 - PALPITATION

SCENARIO 2

GROUP 14:
PRIDINA SYADIRA : 110 2011 0006
SITI ABDILLAH MULIADI : 110 2014 0015
AKHMAD FADHIEL NOOR : 110 2014 0033
A.EKA OKTAVIANA B. PUTRI : 110 2014 0049
PRAMULIANSYAH HAQ : 110 2014 0053
ALIFA FAWZIA : 110 2014 0082
NURRAHMAH KADIR : 110 2014 0102
M. RHEZA RIVALDI SALAM : 110 2014 0114
SITI ADANI AYUNDI : 110 2014 0098
MUH. NUR ANSHARI SYAKIR : 110 2014 0150
CASE 2

A woman 25 yro came to the hospital with chief complain of palpitation. She has suffered
from this symptom for quite awhile, and sometimes accompanied with dizzines. Lately when
doing activities, the palpitation get more severe alongside with shortness breath and
exhaustion. In The physical examination we attained BP: 100/60 mmHg, cardiac pulse:
120x/min irreguler, respiration Ade: 28x/min, and body temp: 37 C. There is mid sistolyc click
and holosystolic murmur 3/6 degre in the intersection between 5th left rib and left axillaris
anterior line. ECG shows axis deviation to the left, LVH and p-mitral.
KEY WORDS

 A woman, 25 yro
 Palpitation, sometimes accompanied with dizzines.
 when doing activities, the palpitation get more severe alongside with shortness breath and
exhaustion.
 BP: 100/60 mmHg,
 cardiac pulse: 120x/min irreguler,
 respiration rate: 28x/min
 body temp: 37 C.
 mid sistolyc click and holosystolic murmur 3/6 degre in the intersection between 5th left rib and left
axillaris anterior line.
 ECG shows axis deviation to the left, LVH and p-mitral.
 1. What is the etiology of palpitation?
 Serious cardiac causes include myocardial ischemia or other myocardial disorders, congenital
heart disease (eg, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy,
congenital long QT syndrome), valvular heart disease, and conduction system disturbances
(eg, disturbances that cause bradycardia or heart block). Patients with orthostatic hypotension
commonly sense palpitations caused by sinus tachycardia upon standing.
 Noncardiac disorders that increase myocardial contractility (eg, thyrotoxicosis,
pheochromocytoma, anxiety) may cause palpitations.
 Some drugs, including digitalis, caffeine, alcohol, nicotine, and sympathomimetics (eg,
albuterol, amphetamines, cocaine, dobutamine, epinephrine, ephedrine, isoproterenol,
norepinephrine, and theophylline), frequently cause or exacerbate palpitations.
 Metabolic disturbances, including anemia, hypoxia, hypovolemia, and electrolyte
abnormalities (eg, diuretic-induced hypokalemia), can trigger or exacerbate palpitations

Reference:
Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. The clinical course of palpitations in medical outpatients. Arch Intern Med 1995;155:1782-8.
Zimetbaum P, Josephson ME. Evaluation of patients with palpitations. N Engl J Med 1998;338:1369-73.
Lessmeier TJ, Gamperling D, Johnson-Liddon V, Fromm BS, Steinman RT, Meissner MD, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder.
Arch Intern Med 1997;157:537-43.
 2. What is the relation between dizzines and palpitation?

Suply O2 to the
Dizzyness Compenzation
brain ↓

Miokard
PALPITATION Cardiac Output ↑ Contractility and
Heart Rate ↑

Reference:
1. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. Am J Med 1996;100:138-48.
2. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medical outpatients complaining of palpitations. J Gen Intern Med 1994;9:306-13.
 3. What is the relation between physical
activity and palpitation?

Physical activity Body’s need O2 ↑ Compensation

Miokard
PALPITATION Cardiac Output ↑ Contractility and
Heart Rate ↑

Reference:
1. 1. Lauralee, Sherwood. 2011. Fisiologi Manusia dari Sel Ke Sistem. Jakarta:EGC.
2. 2. Sylvia, et al. Patofisiologi Kadokteran. Jakarta:EGC.
 4. What relationship the results of vital signs with symptoms?

Hypotention:
• Blood pressure is low because the volume enter the cor is less. So the blood pressure diminish. The hypotension
caused by:
• The stroke volume diminish, because the cardiac pulse is abnormal.
• The blood volume is less
• Increasing blood vessel capacity. In this scenario, because the valve has damage. So the stroke volume is diminish and
oxygen need is less make the blood pressure is less

Takipneu
• incresing frequent of breath. Because of Cardac output is less than before  hipoxia in artery vessel  pulls the breath
nerve center because the perifer kemoreceptor do not give the respon to the oxigen in the blood vessels but how much
blood in vessels and make increasing of breath frequent

Takicardi
• cardiac pulse increasing. Stroke volume low  compensation of cor  increasing the power of blood pomp 
dilatation atrium as a compensation  dilatation of the ventricle and increasing power  palpitation.

Reference:
1. www.bit.lipi.go.id>tekanandarah.com. Hal 2. Diakses 11 april 2016
 5. What relationship the results of auscultation with symptoms?

Midsystolic Clic

• Mid systolic does not start at the beginning of ventricular systole (s1) for contractions occur before
semilunaris valve open, which at that time there was no movement of blood. As soon as the valve
opens semilunaris, murmur gradually increases in intensity and then declined, ending just before
a2 or p2. Causes include aortic stenosis and pulmonary stenosis, ventricular outflow tract
obstruction, high current situation (ie pulmonary flow past the left to right shunt)

Murmur Holosystolic

• Noisy holosystolic start at the beginning of ventricular systole (s1) and ends or immediately after
s2. This happens with other rich throughout systole. Holosystolic term used more often than the
pan- because the last word pressing panintensitas (same intensity during systole)

Reference:
1. www eatham, audrey. kardiologi edisi 4, erlangga, Jakarta. 2003. Hal 26
 6. What cause LAD picture, LVH and p-mitral on EKG?

LAD
• Left Anterior Hemiblock
• Left Bundle-Branch Block
• Left Ventricular Hypertrophy (caused by Left Anterior Hemiblock)
• The position of the heart that pushed to the left (Ascites, Abdominal Tumor, emphysema etc.)

LVH
• Both hypertrophy and dilatation of both ventricular depolarization produces large currents and provide an overview
of the QRS complex amplitude is large, especially in the precordial leads.

P-MITRAL
• P mitral is P wave shaped with a width more than 3mm (0.12 seconds). This picture is characteristic of hypertophy
or left atrial enlargement caused by diseases of the mitral or aortic valve.

Reference:
1. Kabo, Prof. Dr. Peter. 2014. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. Ed 1. Balai Penerbit FKUI: Jakarta. Halaman 242, 255,272-275
 DIFFERENTIAL DIAGNOSIS
ADDITIONAL
DISEASE DEFINITION ETIOLOGY PHYSICAL EXAMINATION
EXAMINATION
MITRAL Blood regurgitation because • Progresive LV dilatation • Anamnesis: cresendo shortness of • EKG: non-specific but
REGURGTA incompentence of mitral valve • Rematic fever breath, otopneu, PND, angina, and atrial fibrilation is often
TION • Mitral valve prolaps physical tolerance↓. found
• Ruptur cordae cause • Murmur pansistolic • MR e.c ischemic: Q
iskemia • LVH sign: gallop, ronki pulmonal, patologis
takikardi • LAD and RAD can be
found if there is high
pulmonal hipertensi
STENOSIS Aortic stenosis is a disease in Degenerative calcification of • Anamnesis: angina, shortness of EKG: LVH
AORTA which the leaflets of the valve valve breath, syncope
become stiff, thick and narrow – • S2 soft and single (A2 delayed)
preventing it from opening fully.
ATRIUM atrial septal defect means all of Kongenital heart disease •Second heart sound (S2) exist in two EKG:
SEPTAL defect that exist at atrium septum components, they are A2 and P2 • RAD, RVH
DEFECT except foramen ovale separeted,
•Sistolic sound ejection type level 2-3/6
and diastolic rumble at the bottom left
sternum.
Fibrillasi Disorganisation electrical from CHF, ischemic miocard, Anamnesis: palpitation, takipneu, EKG: chaotic atrial rhythm
Atrium atrium with inefectivity of atrium cardiac valve disease,right dizzyness without ventricular rhythm P
contraction atrium dilatation, etc PemFis: ↑ JVP, ronki paru, hepato wave narrow and irregular
megali, edema perifer.
 9. What is the treatment of the patient in this scenario?
(Regurgitation Mitral)

Farmako Terapy

• Nitrat, diuretic, ACEI, ARB

Non Invasive Surgical Treatment

• Non invasive surgical treatment of mitral valve reconstruction using the percutaneous mitral clip.

Surgical Therapy

• Surgery on an act of choice to cut down the symptoms and prevent worsening of the condition of
the patients towards heart failure. This type of surgery can include repair or replacement of the
valve, the valve indications affected by the condition, age, and desire.

Reference:
1. 1. Rilantono, I Lily. 2012. 5 Rahasia Penyakit Kardiovaskular hal.294 FK-UI