BOARDS AND BEYOUND STEP 2 CS: Palpitations PRESENTATION RELEVANT HISTORY 67 yo F with palpitation and diphoresis event, takes

insulin for DM Onset, gradual or acute Precipitatiors, anxiety, caffeine, activity Associated symptoms, dizzy, 45 yochest pain, F with weight loss, heat intolerance, nervousness, Medical hx, bleeding, increased bowel frequency anemia, heart dx

EXAMS TO PREFORM Vitals Endocrine/thyroid exam, exophthalmos, lid retraction, lid lag, bruits, tremor, Heart Lungs Vitals Endocrine/thyroid exam, exophthalmos, lid retraction, lid lag, bruits, tremor, Heart Lungs Vitals Endocrine/thyroid exam, exophthalmos, lid retraction, lid lag, bruits, tremor, Heart Lungs

ASSESSMENT W/ DIFF. PLAN Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation Panic attack Pheochromocytoma Carcinoid Hyperthyroidism Hypoglycemia Cardiac arrhythmias Angina Panic attack Pheochromocytoma Carcinoid Panic attack Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation Pheochromocytoma Carcinoid Glucose CBC Electrolytes TSH BUN/Cr ECG Holter monitor Glucose CBC Electrolytes TSH BUN/Cr ECG Holter monitor Glucose CBC Electrolytes TSH ECG

25 yo M with discrete periods of intense fear that peaks in 10 minutes, during event, chest pain, palpitations, nausea, feeling like hes choking, occurs at least once a month and is afraid to go out in public for fear hell have an attack

PRESENTATION

RELEVANT HISTORY

EXAMS TO PREFORM Vitals Endocrine/thyroid exam, exophthalmos, lid retraction, lid lag, bruits, tremor, Heart Lungs

ASSESSMENT W/ DIFF. PLAN Pheochromocytoma Panic attack Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation Carcinoid CT or MRI to look for supra renal mass 24 hour urninary catecholamine metabolites (VMA, HVA) Glucose CBC Electrolytes TSH BUN/Cr ECG Urine 5-HIAA 24 hour urninary catecholamine metabolites, (VMA, HVA) CT chest and abdomen CBC TSH ECG

30 yo F with intermittent tachycardia, palpitations, chest pain, diaphoresis, HTN, headache, tremor and anxiety

35 yo F with cutaneous flushing, diarrhea, wheezing and palpitations, worse after eating or activity

Vitals Endocrine/thyroid exam, exophthalmos, lid retraction, lid lag, bruits, tremor, Heart Lungs Abdomen

Carcinoid Panic attack Hypoglycemia Cardiac arrhythmias Angina Hyperthyroidism Hyperventilation 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.