The etiology can vary from benign premature atrial ectopic activity to more worrisome ventricular arrhythmias. Although substances such as nicotine that increase adrenergic tone or diminish vagal activity could be a cause of palpitations, such palpitations would not usually present acutely and intermittently if the substances had been used long-term, as they were in this patient.Īrrhythmias are a common cause of palpitations. 2 Although anxiety-related disorders are in the differential diagnosis for the patient's symptoms, it would be premature to accept this as the sole etiology, especially without the usual accompanying symptoms and before further diagnostics. However, in a retrospective study of 107 patients experiencing reentrant paroxysmal supraventricular tachycardia, approximately 70% fulfilled DSM-IV criteria for panic disorder as well. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV), palpitations are one of the multiple cardiopulmonary symptoms suggestive of a panic attack. Psychiatric disorders can often coexist with somatic symptoms such as palpitations. In the absence of risk factors for bleeding, this would be uncommon. In the setting of a significant anemia, palpitations can be perceived secondary to compensatory increases in HR and stroke volume in order to maintain adequate tissue oxygenation. 1 However, in the absence of characteristic skin findings (diaphoretic and warm) and ocular signs (stare and lid lag), overt hyperthyroidism is less likely. Atrial fibrillation, present in 10% to 20% of hyperthyroid patients, could lead to palpitations. Common signs include an increased heart rate, a widened pulse pressure, and an elevated systemic blood pressure. Thyrotoxicosis (hyperthyroidism) will often manifest with alterations in cardiac physiology. Findings on examination of the skin, eyes, extremities, neurologic system, and peripheral arterial systems were normal. The patient had no goiter, palpable thyroid nodules, or asymmetry. Pulmonary examination showed clear lung fields and no signs of effusion. Cardiovascular examination revealed tachycardia but no murmurs, S 3, or S 4 jugular venous pressure was normal. Vital signs were as follows: temperature, 36.8☌ blood pressure, 135/95 mm Hg heart rate (HR), 102 beats/min and regular respiratory rate (RR), 18 breaths/min and oxygen saturation (Spo 2), 91% while breathing room air. On examination, the patient appeared comfortable and in no distress. The patient was a smoker and had smoked 1 pack of cigarettes per day since the age of 18 years. She had been taking OCs since age 21 years and was currently taking 3 mg of drospirenone and 0.2 mg of ethinyl estradiol (Yasmin 28, Bayer Healthcare Pharmaceuticals, Wayne, NJ). The patient's medical and psychiatric history were unremarkable, and her only medication was an oral contraceptive (OC). She denied chest pain, shortness of breath, and light-headedness and had no history of similar symptoms. She noted that each episode was abrupt in onset and would last approximately 1 to 2 hours before abating gradually. A 35-year-old woman presented to the outpatient clinic with a 2-week history of episodic palpitations.
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