The patient is a 36-year-old woman that sought medical aid due to heart palpitations. The patient lives a sedentary lifestyle with significant stress at work. No medical history, diagnostic test results, or other symptoms are provided. The three differential diagnoses, in this case, are arrhythmia, pregnancy, and thyroiditis.
Arrhythmia is also called irregular heartbeat; it occurs when the sequence of electrical impulses in the heart is disrupted due to natural causes or pathological conditions. To rule out arrhythmia, it is necessary to ask the patient about the family history of heart disease, a family history of heart conditions increases the patient’s risk for cardiovascular pathology. Heart auscultation is the critical component of a physical exam here, as it enables the care provider to determine any abnormalities in the heart rhythm. Pregnancy can also cause heart palpitations due to the increased blood supply required to support the fetus and the consequent increase in the heart rate. To rule out pregnancy, it would be essential to ask about the patient’s level of sexual activity, previous pregnancy testing, and the use of contraception; the patient’s answers would help to establish a possibility of pregnancy. In addition, palpation could help to establish swelling in the abdomen or legs, which could also suggest pregnancy. Finally, thyroiditis is an inflammatory disease of the thyroid that can be linked to palpitations due to hormonal imbalance. To rule out thyroiditis, the medical specialist should ask about the previous history of thyroid disease and weight changes in the past few months. Thyroid disease is often accompanied by weight loss and connected to the previous history of thyroid issues. Thyroiditis is often linked to abnormal body temperature, as well as dry skin and hair, which can be noted during a physical inspection.
Based on the primary information included in the case, an arrhythmia is the most likely diagnosis. In this case, heart rate abnormalities would be evident during the physical exam. Besides, a family history of heart disease could help to confirm the diagnosis. To rule in arrhythmia, it is necessary to conduct further diagnostic tests, such as electrocardiography (ECG) (Hofman et al., 2013). Also, given that the symptoms had probably started due to increased stress, it would be useful to perform a Holter monitoring test, which is also recommended for diagnosing arrhythmia (Priori et al., 2013). The results of the Holter monitoring would help in pinpointing heart palpitations during the day and connect them to stressful situations or other conditions (exercise, sleep, eating, etc.). Apart from establishing the presence of arrhythmia, these tests would help to determine the type of condition, which is crucial to prescribing treatment. If the ECG shows the signs of long QT syndrome, which causes arrhythmias due to exercise or stress, the treatment should include beta-blockers to stabilize the heart rate and reduce blood pressure (Priori et al., 2013). An example of a beta-blocker used to control arrhythmia is Toprol XL, and the dosage should be determined based on the patient’s age and weight.
Although the prescribed medication is the main step in regulating the heart rate and avoiding complications resulting from arrhythmia, patient education is nonetheless important when it comes to cardiovascular conditions. Firstly, it is necessary to explain the diagnosis and how the medication could help to contain the symptoms. Secondly, as the patient lives a sedentary lifestyle and experiences a lot of stress from work, it is important to provide education about the impact of lifestyle on the heart. As noted by the Heart Rhythm Society (2018), to reduce the risk of complications or further heart disease, it is vital to ensure that the patient maintains a healthy weight, follows a low-fat diet, and performs light to moderate exercise regularly. A follow-up visit should be scheduled in 4-6 weeks to repeat ECG and confirm the effect of beta-blockers.
Heart Rhythm Society. (2018). Risk factors & prevention. Web.
Hofman, N., Tan, H. L., Alders, M., Kolder, I., de Haij, S., Mannens, M.,… & Wilde, A. A. (2013). Yield of molecular and clinical testing for arrhythmia syndromes: Report of a 15 years’ experience. Circulation, 12(1), 1-41.
Priori, S. G., Wilde, A. A., Horie, M., Cho, Y., Behr, E. R., Berul, C.,… Kannankeril, P. (2013). HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: Document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm, 10(12), 1932-1963.