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1. GENERAL EXAMINATION AND
SYSTEMIC EXAMINATION IN A
CASE OF PALPITATION

2. PALPITATION
 Definition:
„an awareness of ones heartbeat that is thought
inappropriate to the circumstances

3. GENERAL EXAMINATION
 PATIENT PANIC / NOT PANIC
 BUILT AND NOURISHMENT
 PALLOR
 ICTERUS
 CYANOSIS
 CLUBBING
 LYMPHADENOPATHY
 EDEMA

4. GENERAL EXAMINATION
 VITALS
PULSE-
RATE- tachycardia/bradycardia
Heart rate >120 beats/min or < 45 beats/min
while at rest
RHYTHM-
Regular-
occasional-SVT/VT
continuous-sinus tachycardia
high output states
Irregular- Atrial Fibrillation / Ectopics
sustained and irregularly irregular /chaotic -AF

5. GENERAL EXAMINATION
Intermittent and irregular/ felt as
missed beats- Ectopics
Volume-high/low
character-normal/abnormal
Condition of vessel wall-thickened/not
thickend
Radiofemoral delay-present/absent
peripheral pulsations-felt normal/not

6. GENERAL EXAMINATION
 BP
Hypotension / Hypertension

7. SYSTEMIC EXAMINATION
 INSPECTION
 shape of precodium
 Position of apex beat
 Visible pulsations-jvp elevated/not
 Visible scars

8. SYSTEMIC EXAMINATION
 Palpation
 Palpation of the apcal impulse
 Left parasternal heave
 Sub xiphoid pulsations
 Palpation of the pulmonary arterial pulsation
 Thrills – palpable murmurs

9. SYSTEMIC EXAMINATION
 Percussion
 Identfy whether heart is enlarged or not

10. SYSTEMIC EXAMINATION
 Auscultation
 S1
 S2
 Ejection sounds
 murmurs

11. Resting ECG
• Features to check
Sinus rhythm / arrhythmia
PR interval
QRS duration
QT Intervals
ST segment shape (LVH/Brugada)
T waves (? Cardiomyopathy)

12. KEY CLINICAL FINDINGS WITH PALPITATIONS AND
SUGGESTED DIAGNOSES
 Finding  Suggested diagnosis
 Single “skipped” beats  Benign ectopy
 Feeling of being unable to  Ventricular premature
catch one‟s breath contractions
 Single pounding sensations  Ventricular premature
 Rapid, regular pounding in contractions
neck  Supraventricular
 Palpitations that are worse arrhythmias
at night  Benign ectopy or atrial
 Palpitations associated with fibrillation
emotional distress  Psychiatric etiology or
 Palpitations associated with catecholamine-sensitive
activity arrhythmia
 General anxiety  Coronary heart disease
 Panic attacks

13. KEY CLINICAL FINDINGS WITH PALPITATIONS AND
SUGGESTED DIAGNOSES
 Finding  Suggested diagnosis
 Medication or recreational drug use  Drug-induced palpitations
 Rapid palpitations with exercise  Supraventricular arrhythmia, atrial
fibrillation
 Positional palpitations  Atrioventricular nodal tachycardia,
pericarditis
 Heat intolerance, tremor, thyromegaly
 Hyperthyroidism
 Palpitations since childhood
 Rapid, irregular rhythm
 Supraventricular tachycardia
 Atrial fibrillation, tachycardia with
 Palpitations terminated by vagal variable block
maneuvers
 Supraventricular tachycardia
 Heart murmur
 Midsystolic click
 Heart valve disease
 Friction rub
 Mitral valve prolapse
 Pericarditis

14. EVALUATING A PATIENT WITH PALPITATIONS

15. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 ARRHYTHMIAS
 Atrial fibrillation/flutter
 Bradycardia caused by advanced arteriovenous block or
sinus node dysfunction
 Bradycardia-tachycardia syndrome(sick sinus
syndrome)
 Multifocal atrial tachycardia
 Premature supraventricular or ventricular contractions
 Sinus tachycardia or arrhythmia
 Supraventricular tachycardia
 Ventricular tachycardia
 Wolff-Parkinson-White syndrome

16. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Psychiatric causes
 Anxiety disorder
 Panic attacks
 Drugs and medications
 Alcohol
 Caffeine
 Certain prescription and over-the-counter agents
(e.g., digitalis, phenothiazine, theophylline, beta
agonists)
 Street drugs (e.g., cocaine)
 Tobacco

17. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Nonarrhythmic cardiac causes
 Atrial or ventricular septal defect
 Cardiomyopathy
 Congenital heart disease
 Congestive heart failure
 Mitral valve prolapsed
 Pacemaker-mediated tachycardia
 Pericarditis
 Valvular disease (e.g., aortic insufficiency, stenosis)

18. DIFFERENTIAL DIAGNOSIS OF
PALPITATIONS
 Extracardiac causes
 Anemia
 Electrolyte imbalance
 Fever
 Hyperthyroidism
 Hypoglycemia
 Hypovolemia
 Pheochromocytoma
 Pulmonary disease
 Vasovagal syndrome