Boards and Beyound Step 2 Cs Palpitations

BOARDS AND BEYOUND STEP 2 CS: Palpitations
PRESENTATION RELEVANT HISTORY EXAMS TO PREFORM ASSESSMENT W/ DIFF. PLAN

67 yo F with palpitation and • Vitals • Hypoglycemia Glucose
diphoresis event, takes insulin • Endocrine/thyroid exam, • Cardiac arrhythmias CBC
for DM exophthalmos, lid • Angina Electrolytes
retraction, lid lag, bruits, • Hyperthyroidism TSH
• Onset, gradual or tremor, • Hyperventilation BUN/Cr
acute • Heart ECG
• Panic attack
• Precipitatiors, • Lungs Holter monitor
• Pheochromocytoma
anxiety, caffeine, • Carcinoid
activity
• Associated • Vitals • Hyperthyroidism Glucose
symptoms, dizzy, • Endocrine/thyroid exam, • Hypoglycemia CBC
45 yochest
F with weight loss, heat
pain, exophthalmos, lid • Cardiac arrhythmias Electrolytes
• Medicalnervousness,
intolerance, hx, bleeding, retraction, lid lag, bruits, • Angina TSH
increased bowel
anemia, heartfrequency
dx tremor, • Panic attack BUN/Cr
• Heart ECG
• Pheochromocytoma
• Lungs Holter monitor
• Carcinoid
• Vitals • Panic attack Glucose
• Endocrine/thyroid exam, • Hypoglycemia CBC
exophthalmos, lid • Cardiac arrhythmias Electrolytes
retraction, lid lag, bruits, • Angina TSH
25 yo M with discrete periods tremor, • Hyperthyroidism ECG
of intense fear that peaks in 10 • Heart • Hyperventilation
minutes, during event, chest • Lungs • Pheochromocytoma
pain, palpitations, nausea, • Carcinoid
feeling like he’s choking,
occurs at least once a month
and is afraid to go out in public
for fear he’ll have an attack
PRESENTATION RELEVANT HISTORY EXAMS TO PREFORM ASSESSMENT W/ DIFF. PLAN
• Vitals • Pheochromocytoma CT or MRI to look for supra
• Endocrine/thyroid exam, • Panic attack renal mass
exophthalmos, lid • Hypoglycemia 24 hour urninary
retraction, lid lag, bruits, • Cardiac arrhythmias catecholamine metabolites
30 yo F with intermittent tremor, • Angina (VMA, HVA)
tachycardia, palpitations, chest • Heart Glucose
• Hyperthyroidism
pain, diaphoresis, HTN, • Lungs CBC
headache, tremor and anxiety • Hyperventilation Electrolytes
• Carcinoid TSH
BUN/Cr
ECG
• Vitals • Carcinoid Urine 5-HIAA

• Endocrine/thyroid exam, • Panic attack 24 hour urninary
35 yo F with cutaneous exophthalmos, lid • Hypoglycemia catecholamine metabolites,
flushing, diarrhea, wheezing retraction, lid lag, bruits, • Cardiac arrhythmias (VMA, HVA)
and palpitations, worse after tremor, • Angina CT chest and abdomen
eating or activity • Heart CBC
• Hyperthyroidism
• Lungs TSH
• Hyperventilation ECG
• Abdomen • Pheochromocytoma
Hypoglycemia
o Hypoglycemia is considered present when serum glucose level is less than 50 mg/dL. An alternative definition is a decrease in the
blood glucose level or its tissue utilization that results in demonstrable signs or symptoms. These signs or symptoms usually
include altered mental status and/or sympathetic nervous system stimulation. The glucose level at which an individual becomes
symptomatic is highly variable.
Cardiac arrhythmias
o group of conditions in which the electrical activity of the heart is irregular or is faster or slower than normal.
o Some arrhythmias are life-threatening medical emergencies that can cause cardiac arrest and sudden death. Others cause
aggravating symptoms, such as an awareness of a different heart beat, or palpitation, which can be annoying. Some are quite minor
and can be regarded as normal. In fact, most people have felt a skip of a beat or a sudden tachycardia, which are usually not a cause
for alarm[1]. Sinus arrhythmia is the mild acceleration followed by slowing of the normal rhythm that occurs with breathing. In
adults the normal resting heart rate ranges from 60 beats per minute to 100 beats per minute. The normal heart beat is controlled by
a small area in the upper chamber of the heart called the sinoatrial node or sinus node. The sinus node contains specialized cells
that have spontaneous electrical activity that starts each normal heart beat.
Angina
• Angina pectoris, chest pain due to ischemia (a lack of blood and hence oxygen supply) of the heart muscle
• Abdominal angina, postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet visceral demands
• Ludwig's angina, a serious, potentially life-threatening infection of the tissues of the floor of the mouth
• Prinzmetal's angina, a syndrome typically consisting of cardiac chest pain at rest that occurs in cycles
• Vincent's angina, trench mouth, infection of the gums leading to inflammation, bleeding, deep ulceration and necrotic gum tissue
• Angina tonsillaris, an inflammation of the tonsils
• One common form of Angina is chest pain or discomfort that occurs when your heart isn't getting enough oxygen because of reduced
blood flow to the heart. It is usually a symptom of coronary heart disease.
Hyperthyroidism
o Hyperthyroidism is a condition caused by an overactive thyroid gland. The gland makes too much T4 and T3 hormones. Hormones
are substances that affect and control many important functions in the body.
Hyperventilation
o In psychiatry, hyperventilation syndrome (HVS) is an episodic disorder that often presents with chest pain and a tingling
sensation of the fingertips (paresthesia) and around the mouth, as well as deep and labored breathing (causing hyperventilation),
although chronic but subtle hyperventilation can cause these symptoms too.
o HVS can be part of a panic attack but, despite all the stigma, most people are not putting on a show but are in true distress.
o People with HVS feel like they can't get enough air, but the opposite is actually true: they have too much oxygen and too little
carbon dioxide in their blood. The hyperventilation is self-promulgating as rapid breathing causes carbon dioxide (CO2) levels to
fall, and respiratory alkalosis (high blood pH) develops. This makes the symptoms worse, which causes the person to try breathing
even faster, which further exacerbates the problem.
o The respiratory alkalosis leads to changes in the way the nervous system fires and leads to the paresthesia, dizziness, and
perceptual changes that often accompany this condition.
o Other mechanisms may also be at work, and some people are physiologically more susceptible to this phenomenon than others
Panic attack
o Panic attacks are sudden, discrete periods of intense anxiety, mounting physiological arousal, fear and discomfort that are
associated with a variety of somatic and cognitive symptoms.[1] The onset of these episodes is typically abrupt, and may have no
obvious triggers. Although these episodes may appear random, they are considered to be a subset of an evolutionary response
commonly referred to as fight or flight that occur out of context, flooding the body with hormones (particularly adrenalin) that aid
in defending itself from harm.[2] Experiencing a panic attack is said to be one of the most intensely frightening, upsetting and
uncomfortable experiences of a person's life. (Bourne 2005).
o According to the American Psychological Association the symptoms of a panic attack commonly last approximately ten minutes.
However, panic attacks can be as short as 1-5 minutes, while sometimes panic attacks may form a cyclic series of episodes, lasting
for an extended period, sometimes hours. Often those afflicted will experience significant anticipatory anxiety and limited
symptom attacks in between attacks, in situations where attacks have previously occurred, and in situations where they feel
"trapped". That is, where escape would be obvious and/or embarrassing.
o Panic attacks also affect people differently. Experienced or hardcore sufferers may be able to completely 'ride out' a panic attack
with little to no obvious symptoms or external manifestations. Others, notably first-time sufferers, may even call for emergency
services; many who experience a panic attack for the first time fear they are having a heart attack or a nervous breakdown
Pheochromocytoma
o Pheochromocytoma is a rare catecholamine-secreting tumor derived from chromaffin cells. Tumors that arise outside the adrenal
gland are termed extra-adrenal pheochromocytomas or paragangliomas. Because of excessive catecholamine secretion,
pheochromocytomas may precipitate life-threatening hypertension or cardiac arrhythmias. If the diagnosis of a pheochromocytoma
is overlooked, the consequences could be disastrous, even fatal; however, if a pheochromocytoma is found, it is potentially curable.
Carcinoid
o slow-growing but often malignant type of neuroendocrine tumour, originating in the cells of the neuroendocrine system. Carcinoid
tumours are apudomas that arise from the enterochromaffin cells throughout the gut. They are most commonly found in the foregut
(35.6% cases) with lung, bronchus and trachea constituting 27.9% cases from where they rarely metastasise (except in case of
pancreas). The next most common affected area is the small intestine especially the midgut (32.1% cases) with the highest
proportion from ileum at 14.9% of all cases [as per the PAN-SEER data (1973-1999)]. In cases of metastases it can lead to
carcinoid syndrome. This is due to the production of serotonin,[citation needed] which is released into the systemic circulation, which
leads to symptoms of cutaneous flushing, diarrhea, bronchoconstriction and right-sided cardiac valve disease.

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BOARDS AND BEYOUND STEP 2 CS: Palpitations

PRESENTATION RELEVANT HISTORY EXAMS TO PREFORM ASSESSMENT W/ DIFF. PLAN

• Vitals • Carcinoid Urine 5-HIAA

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