Question

Please Write Succinct:   Palpitations

• Review of Systems: Associated symptoms and Risk Factors
• Findings on Focused Physical Ex
• Five Differential Diagnosis

See example below for question #1:

1. Sore Throat

ROS:

Associated symptoms: fever, redness or eye discomfort, sneezing, wheezing, cough, runny nose, postnasal drip, GERD like symptoms, fatigue, muscle ache, n/v, and diarrhea.

Risk Factors:

Smoking, new sexual partners, irritant exposure, medications, and chronic health problems.

Red flags:

drooling, unable to swallow, unable to lie down, restless, unable to stay still, and unable to talk.

PE findings:

Epiglottis- severe illness with signs of upper airway obstruction such as restlessness, stridor, difficulty breathing, drooling, inability to swallow and high fever signals epiglottis and requires immediate referral. Further examination with a tongue blade could trigger laryngospasms and lead to airway obstruction.

Peritonsillar retropharyngeal abscess- orthopnea, dyspnea, symmetrical swelling, abscess, trismus.

Viral pharyngitis: Erythema, edema of throat, tender posterior cervical nodes.

GAS: temp more than 101.5, exudate anterior cervical lymphadenopathy.

Mononucleosis: presence or absence of pharyngeal exudate, posterior cervical lymphadenopathy, splenomegaly.

Gonococcal pharyngitis: pharyngeal exudate bilateral cervical lymphadenopathy

Inflammation: sinus tenderness, pale or swollen pharynx, postnasal drainage visible, no fever or lymphadenopathy.

Aphthous Stomatitis: shallow ulcers, no vesicles; indurated papules that progress to 1 cm ulcers; ulcer has yellow membrane and red halo; no fever or nodes.

Herpes simplex Lesions: perioral lesions; lymph adenitis; vesicles on palate, pharynx gingiva.

Herpetic pharyngitis: vesicles, ulcers, or exudate of the oral and pharyngeal mucosa.

Candidiasis: curd like white plaques that bleed when scraped off.

Differential diagnosis:

Viral Pharyngitis, Streptococcal Pharyngitis, peritonsillar or retropharyngeal abscess, Mononucleosis, Epiglottis, gonococcal pharyngitis, Herpangina, Vincent angina, Aphthous stomatitis, HSV type 1, Candidiasis, GERD.

Answer 1

PALPITATION ;(Noticeably rapid,strong/irregular heartbeat due to agitation,exertion/illness.)

Associated symptoms:

chest discomfort/pain,fainting,severe shortness of breath,severe dizziness.

Risk factors:

highly stressed,anxiety,pegnant,stimulants such as asthma medications,hyperthyroidism,arrhythmia,heart problems,previous heart attack/heart surgery.

Red flag:

associated syncope/palpitation triggered during excise,or evidence of sturctural heart disease,accessory pathway or channelopathy/family history of sudden death /cardiomyopathy.

Physical examination:

3 irregular pulse with no repeating pattern suggest atrial fibrillation.A cannon wave noted when observing for jugular venous pulse often occurs in ventricular tachycardia.Mitral valve prolapse in the most common structural heart disease resulting in palpitation.

Differential diagnosis:

Non arrhythmic cardiac problems such as mitral valve prolapse,pericarditis and congestive heart failure,and non cardiac problems such as hyperthyroidism,vasovagal syncope,hypoglycimia,can cause palpitation.palpitation also can result from stimulant drugs and over the counter and prescribtion medication.NO cause for the palpitations can be found in upto 16%of patients.ECG monitoring is usually indicated if the etiology of palpitations cannot be determined from the patients history,physical examination and resting ECG.When palpitation occurs unpreditably/do not occur daily an initial 2 week corse of continues closed loop event recording is indicated.Holter monitoring for 24 to 48 hours may be appropriate in patients with daily palpitations.Trans-telephonic event monitors are more effective and cost effective than holter moniters for most patients. standard test for assesing palpitations is a 12 lead electrocardiogram(ECG) which measures heart rate and rhythm parameters through electrical tracing.The doctor may also conduct blood tests ,echocardiography,exercise stress test/electro physiology study depending on the symotoms.An increased /abnormal awarness of the heart beat ,palpitations are the common symptoms in patients to family physicians.palpitations can be symptomatic of life threatening cardiac arrhythmias.However most palpitation /benign in one retrospective study in a family practice setting ,no difference in the rates of morbidity /mortality among patients with compared with matched control subjects