Case History

Personal Details:
Ms. Anjali Sharma, 28-year-old female, software engineer

Presenting Complaint:

• Palpitations for 3 weeks

History of Presenting Illness:
Ms. Anjali reports experiencing episodes of “racing heartbeats” for the past 3 weeks. The palpitations have a sudden onset, last for a few minutes, and occur 2–3 times per week. She describes them as fast and regular, sometimes accompanied by a mild sense of chest discomfort and occasional lightheadedness, but no syncope. The episodes are often triggered by emotional stress at work or after consuming coffee, and are relieved by sitting quietly or taking deep breaths. She denies any associated chest pain, breathlessness, sweating, or tremors. She has not noticed any irregularity or skipped beats.

She has not experienced similar episodes in the past and has not sought medical attention before. There is no history of fever, weight loss, or symptoms of hyperthyroidism such as heat intolerance or tremor.

Past Medical History:

• No known heart disease, hypertension, diabetes, or thyroid disorder

• No previous hospitalizations

Drug History:

• Not on any regular medications

• Occasionally takes over-the-counter painkillers for headaches

• Drinks 2–3 cups of coffee daily

• No history of recreational drug use

Personal History:

• Diet: Vegetarian, regular meals

• Appetite: Normal

• Sleep: Often disturbed due to work stress

• Physical activity: Sedentary lifestyle

• Alcohol: Does not consume

• Smoking: Non-smoker

Family History:

• No family history of sudden cardiac death, arrhythmias, or heart disease

Socioeconomic History:

• Works as a software engineer in a private firm

• Lives with parents in an urban area

• Middle-class socioeconomic status

• Access to regular healthcare

Systemic Enquiry:

• No symptoms of hyperthyroidism (no tremor, heat intolerance, or weight loss)

• No symptoms of anemia (no fatigue or pallor)

• No symptoms of anxiety or panic attacks apart from work-related stress

Case Summary

Ms. Anjali Sharma, a 28-year-old software engineer with no significant past medical or family history, presents with 3 weeks of sudden-onset, brief, regular palpitations triggered by stress or caffeine and relieved by rest. There are no associated symptoms suggestive of structural heart disease, hyperthyroidism, or systemic illness.

Differential Diagnosis

1. Sinus Tachycardia (due to anxiety or stress):

   • Likely, given the association with emotional stress and absence of other symptoms.

2. Supraventricular Tachycardia (SVT):

   • Possible, as episodes are sudden in onset and regular, though usually more symptomatic.

3. Caffeine-induced Palpitations:

   • Possible, given regular coffee intake and temporal relation to episodes.

4. Panic Attacks/Anxiety Disorder:

   • Could present with palpitations, but she does not report other anxiety symptoms.

5. Premature Atrial or Ventricular Contractions (PACs/PVCs):

   • Less likely as she does not describe “skipped beats” or irregularity.

6. Hyperthyroidism:

   • Unlikely, as there are no other supporting symptoms.

7. Other Arrhythmias:

   • Less likely in the absence of structural heart disease, but should be considered if symptoms worsen or persist.

Viva Questions and Answers on Palpitations

1. What are palpitations?
Palpitations are an abnormal awareness of one’s own heartbeat, described by patients as a sensation of pounding, fluttering, racing, or irregular heartbeats.

2. What are the common causes of palpitations?

• Cardiac arrhythmias (e.g., atrial fibrillation, supraventricular tachycardia, ectopic beats)

• Anxiety or panic attacks

• Excessive caffeine, alcohol, or stimulant use

• Hyperthyroidism

• Fever, anemia, hypoglycemia

• Structural heart disease (e.g., mitral valve prolapse)

3. What important features should you elicit in the history of palpitations?

• Onset (sudden or gradual)

• Duration and frequency

• Character (regular or irregular, fast or slow)

• Triggers (exertion, stress, caffeine, position)

• Relieving factors

• Associated symptoms (chest pain, breathlessness, syncope, dizziness, sweating, tremor)

• Past history of heart disease or thyroid disorder

• Family history of arrhythmias or sudden cardiac death

4. What are red flag symptoms associated with palpitations?

• Syncope or near-syncope

• Chest pain

• Severe breathlessness

• Family history of sudden cardiac death

• Palpitations at rest or during sleep

5. How do you differentiate between regular and irregular palpitations clinically?
Ask the patient to “tap out” the rhythm of their palpitations. Regular tapping suggests a regular arrhythmia (e.g., SVT), while irregular tapping suggests an irregular rhythm (e.g., atrial fibrillation, ectopic beats).

6. What investigations would you order for a patient with palpitations?

• ECG (resting and, if possible, during symptoms)

• Holter monitoring (24–48 hours)

• Thyroid function tests

• Complete blood count (for anemia)

• Blood glucose

• Echocardiography (if structural heart disease is suspected)

7. What is the significance of caffeine and stress in palpitations?
Both caffeine and stress stimulate the sympathetic nervous system, which can increase heart rate and trigger palpitations, especially in susceptible individuals.

8. How do you manage a patient with benign palpitations?

• Reassure the patient if no serious cause is found

• Advise reduction of caffeine and stimulants

• Encourage stress management and adequate sleep

• Treat any underlying cause (e.g., anemia, hyperthyroidism, anxiety)

9. What is supraventricular tachycardia (SVT) and how does it present?
SVT is a rapid heart rhythm originating above the ventricles, presenting with sudden-onset, regular, rapid palpitations, sometimes associated with dizziness or chest discomfort, and often terminating abruptly.

10. When should you refer a patient with palpitations to a cardiologist?

• If there are red flag symptoms (syncope, chest pain, breathlessness)

• If arrhythmia is detected on ECG

• If there is suspicion of structural heart disease

• If symptoms are severe, frequent, or unresponsive to initial management