What is the approach to a patient presenting with palpitations?

History and Physical Examination Template for Palpitations

The most effective approach to a patient presenting with palpitations requires a structured history and physical examination focused on identifying the pattern, onset, duration, frequency, and associated symptoms to guide diagnostic evaluation and management.

Chief Complaint

• Patient presents with palpitations described as [sensation of racing/fluttering/pounding/skipped beats]

History of Present Illness

Characteristics of Palpitations

• Onset and termination pattern: Sudden onset and termination suggests AVRT or AVNRT 1
• Duration: [seconds/minutes/hours/days]
• Frequency: [daily/weekly/monthly]
• Description: How patient describes sensation (racing, fluttering, pounding, irregular beats)
• Position when symptoms occur: [sitting, standing, lying down]
• Termination: Spontaneous or with specific maneuvers (Valsalva, coughing)
  • Termination by vagal maneuvers suggests re-entrant tachycardia involving AV nodal tissue 1

Associated Symptoms

• Syncope or near-syncope: Present in approximately 15% of patients with SVT 1
• Dyspnea: [present/absent]
• Chest pain: [present/absent]
• Polyuria: Suggests sustained supraventricular arrhythmia 1
• Dizziness/lightheadedness: [present/absent]

Precipitating Factors

• Exercise: Exertional palpitations may require stress testing 2
• Emotional stress/anxiety: [present/absent]
• Caffeine/alcohol/nicotine consumption: [amount/frequency]
• Medications: [current medications, recent changes]
• Illicit drug use: [type/frequency]

Past Medical History

• Cardiac conditions: Previous arrhythmias, structural heart disease, valvular disease
• Pre-excitation syndromes: Previous diagnosis of WPW syndrome
• Endocrine disorders: Thyroid disease, pheochromocytoma
• Psychiatric conditions: Anxiety, panic disorder, depression

Family History

• Sudden cardiac death: [age of occurrence, relationship]
• Arrhythmias: [type, relationship]
• Structural heart disease: [type, relationship]

Impact on Quality of Life

• Driving concerns: 57% of patients with SVT experience episodes while driving 1
• Work/daily activities: Limitations due to symptoms
• Sleep disturbances: [present/absent]
• Psychological impact: Anxiety about symptoms

Physical Examination

• Vital signs: Heart rate, blood pressure, respiratory rate, temperature
• Cardiovascular:
  • Regular/irregular rhythm
  • Murmurs (especially midsystolic click suggesting MVP) 1
  • Extra heart sounds
  • Variation in S1 intensity (suggests ventricular origin if irregular) 1
• Respiratory: Signs of heart failure or pulmonary disease
• Thyroid: Enlargement, nodules, tenderness
• Neurological: Signs of autonomic dysfunction

Initial Diagnostic Impression

• Suspected mechanism: [SVT, AF, VT, non-arrhythmic cause]
• Risk stratification: [low/moderate/high risk based on associated symptoms]
• Plan for further evaluation: 12-lead ECG, ambulatory monitoring, laboratory tests

Plan for Diagnostic Workup

• 12-lead ECG: Initial test for all patients with palpitations 2
• Laboratory studies: CBC, electrolytes, thyroid function, cardiac enzymes if indicated
• Ambulatory monitoring:
  • 24-48 hour Holter for frequent (daily) episodes 2
  • Event recorder for less frequent episodes 2
  • Implantable loop recorder for very infrequent but severe symptoms 2
• Echocardiogram: To exclude structural abnormalities 2
• Exercise stress testing: For exertional palpitations 2

Follow-up Plan

• Return visit timing: [days/weeks] based on severity and frequency
• Referral considerations: Cardiology/electrophysiology referral for:
  • Patients with WPW syndrome
  • Severe symptoms (syncope, dyspnea)
  • Drug resistance or intolerance
  • Desire to be free of drug therapy 1

This template provides a comprehensive framework for documenting the history and physical examination of patients presenting with palpitations, focusing on the most critical elements that will guide diagnosis and management according to current guidelines.