Palpitations

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Palpitations are the uncomfortable sensations in the chest associated with a range of arrhythmias. Patients may describe palpitations as ''fluttering,'' ''skipped beats,'' ''pounding,''

Table 14-1

Characteristics of Chest Pain*

Feature

Angina

Not Angina

Location Retrosternal, diffuse

Radiation Left arm, jaw, back

Description ''Aching,'' ''dull,'' ''pressing,'' ''squeezing,'' ''viselike''

Intensity Mild to severe

Duration Minutes

Precipitated by Effort, emotion, eating, cold

Relieved by Rest, nitroglycerin

Left inframammary, localized Right arm

''Sharp,'' ''shooting,'' "cutting" Excruciating Seconds, hours, days Respiration, posture, motion Nonspecific

Location Retrosternal, diffuse

Radiation Left arm, jaw, back

Description ''Aching,'' ''dull,'' ''pressing,'' ''squeezing,'' ''viselike''

Intensity Mild to severe

Duration Minutes

Precipitated by Effort, emotion, eating, cold

Relieved by Rest, nitroglycerin

Left inframammary, localized Right arm

''Sharp,'' ''shooting,'' "cutting" Excruciating Seconds, hours, days Respiration, posture, motion Nonspecific

*Angina and other chest pain may manifest in a variety of ways. The characteristics listed here are the common manifestations. This list, however, is not exhaustive and should be used only as a guide.

*In general, it is best to allow the patient to describe the character of the pain. These descriptions are provided for the interviewer to use only when the patient is unable to characterize the pain.

Coronary Artery Spasms And Mvp

Table 14-2 Common Causes of Chest Pain Organ System Cause

Cardiac

Vascular Pulmonary

Musculoskeletal

Coronary artery disease Aortic valvular disease Pulmonary hypertension Mitral valve prolapse Pericarditis

Idiopathic hypertrophic subaortic stenosis

Dissection of the aorta

Pulmonary embolism Pneumonia Pleuritis Pneumothorax

Costochondritis* Arthritis

Muscular spasm Bone tumor

Neural

Gastrointestinal

Emotional

Herpes zoster{

Ulcer disease Bowel disease Hiatal hernia Pancreatitis Cholecystitis

Anxiety Depression

*Tietze's syndrome, which is an inflammation of the costal cartilages. {Shingles, which is a viral invasion of the peripheral nerves in a dermatomal distribution.

''jumping,'' ''stopping,'' or ''irregularity.'' Determine whether the patient has had similar episodes and what was done to extinguish them. Palpitations are common and do not necessarily indicate serious heart disease. Any condition in which there is an increased stroke volume, as in aortic regurgitation, may be associated with a sensation of ''forceful contraction.'' When a patient complains of palpitations, ask the following questions:

' 'How long have you had palpitations?''

''Do you have recurrent attacks?'' If so, ' 'How frequently do they occur?'' ''When did the current attack begin?'' How long did it last?'' ''What did it feel like?'' Did any maneuvers or positions stop it?'' ''Did it stop abruptly?''

''Could you count your pulse during the attack?'' ''Can you tap out on the table what the rhythm was like?''

' 'Have you noticed palpitations after strenuous exercise? on exertion? while lying on your left side? after a meal? when tired?''

''During the palpitations, have you ever fainted? had chest pain?''

''Was there an associated flush, headache, or sweating associated with the palpitations?''* Have you noticed an intolerance to heat? cold?'' ''What kind of medications are you taking?'' Do you take any medications for your lungs?'' ''Are you taking any thyroid medications?''

Have you ever been told that you had a problem with your thyroid?'' How much tea, coffee, chocolate, or cola sodas do you consume a day?'' ''Do you smoke?'' If yes, ' 'What do you smoke?'' ''Do you drink alcoholic beverages?''

''Did you notice that after the palpitations you had to urinate?''{

In addition to primary cardiovascular causes, thyrotoxicosis, hypoglycemia, fever, anemia, pheochromocytoma, and anxiety states are commonly associated with palpitations. Hyperthyroidism is an important cause of rhythm disturbances that originate outside the cardiovascular system. Caffeine, tobacco, and drugs are also important factors in arrhyth-mogenicity. Sympathomimetic amines used in the treatment of bronchoconstriction are potent stimuli for arrhythmia as well. In patients with panic disorders and other anxiety states, the sensation of palpitations may occur during periods of normal rate and rhythm.

Patients who have had previous attacks of palpitations should be asked the following:

How was your previous attack terminated?''

How often do you get the attacks?''

''Have you ever been told that you have Wolff-Parkinson-White syndrome?''1.

*Symptoms associated with a pheochromocytoma.

{After an attack of paroxysmal atrial tachycardia, patients often have an urge to urinate. The patho-physiologic process is not well understood, but the association is present.

1The use of this technical term is appropriate because a patient having this form of preexcitation may have been told of this condition and may recognize the name.

TABLE 14-3 Common Causes of Palpitations

Extrasystoles

Atrial premature beats*

Nodal premature beats

Ventricular premature beats{

Tachyarrhythmias

Paroxysmal supraventricular tachycardia

Atrial flutter

Atrial fibrillation

Multifocal atrial tachycardia

Ventricular tachycardia

Bradyarrhythmias

Heart block

Sinus arrest

Drugs

Bronchodilators Digitalis

Antidepressants Smoking Caffeine Thyrotoxicosis

*Also known as atrial premature contractions or premature atrial contractions.

{Also known as ventricular premature contractions or premature ventricular contractions.

Table 14-3 outlines the common causes of palpitations. Dyspnea

The complaint of dyspnea is important. Patients report that they have ''shortness of breath'' or that they ''can't get enough air.'' Dyspnea is commonly related to cardiac or pulmonary conditions. The questions relating to dyspnea are discussed in Chapter 13, The Chest. This section further delineates dyspnea as a cardiac symptom.

Paroxysmal nocturnal dyspnea (PND) occurs at night or when the patient is supine. This position increases the intrathoracic blood volume, and a weakened heart may be unable to handle this increased load; congestive heart failure may result. The patient is awakened about 2 hours after having fallen asleep, is markedly dyspneic, is often coughing, and may seek relief by running to a window to ''get more air.'' Episodes of PND are relatively specific for congestive heart failure.

The symptom of PND is often associated with the symptom of orthopnea, the need for using more pillows on which to sleep. Inquire of all patients, ''How many pillows do you need in order to sleep?'' To help quantify the orthopnea, you can state, for example, ''3-pillow orthopnea for the past 4 months.''

Dyspnea on exertion (DOE) is usually caused by chronic congestive heart failure or severe pulmonary disease. Quantify the severity of the dyspnea by asking, ''How many level blocks can you walk now?'' and ''How many level blocks could you walk 6 months ago?'' You can now attempt to quantify the dyspnea: for example, ''The patient has had 1-block DOE for the past 6 months. Before 6 months ago, the patient was able to walk 4 blocks without becoming short of breath. In addition, during the last 3 months, the patient has noted 4-pillow orthopnea.'' Trepopnea is a rare form of positional dyspnea in which the dyspneic patient has less dyspnea while lying on the left or right side. The pathophysiologic process of trepopnea is not well understood.

Table 14-4 Common Causes of Dyspnea Organ System or Condition

Cardiac

Pulmonary

Emotional

High-altitude exposure Anemia

Cause

Left ventricular failure Mitral stenosis

Obstructive lung disease Asthma

Restrictive lung disease Pulmonary embolism Pulmonary hypertension

Anxiety

Decreased oxygen pressure Decreased oxygen-carrying capacity

Table 14-4 lists the common causes of dyspnea.

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With all the stresses and strains of modern living, panic attacks are become a common problem for many people. Panic attacks occur when the pressure we are living under starts to creep up and overwhelm us. Often it's a result of running on the treadmill of life and forgetting to watch the signs and symptoms of the effects of excessive stress on our bodies. Thankfully panic attacks are very treatable. Often it is just a matter of learning to recognize the symptoms and learn simple but effective techniques that help you release yourself from the crippling effects a panic attack can bring.

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