Case scenario
28 year old female presents to the ED reporting heart palpitations for the past 20 minutes
Responses to appropriate history questions
Onset: Suddenly while on the subway, 1 hr after waking up this morning
Location: Left side of chest without radiation
Duration: For the past hour
Character: “Feel my heart beating in my chest”
Aggravating: Denies
Relieving: Deep breathing with some relief
Timing: Denies
Severity: Worst palpitations she’s ever had – reports intermittent palpitations for the past 2 weeks, but all have lasted no longer than 2 minutes and were not as debilitating
Also reporting associated constant chest pain described as “pressure” and shortness of breath described as “I feel like I can’t catch my breath”
Noted 10 lb weight loss since last visit (1 yr ago)
No past medical history. On OCPs.
Drinks coffee, drinks alcohol socially, smokes marijuana socially; Denies tobacco smoking or other illicit drug use
Denies recent illness or injury
Denies recent travel or sick contacts
Full-time student, started PA school last month
Physical Exam
Vital Signs: P 131, BP 104/64, R 30, T 98.7, SpO2 100% on RA
In summary, aside from regularly regular tachycardia and hyperventilation, the rest of the physical exam is unremarkable
Gen – alert, oriented, breathing quickly and shifting positions frequently in her chair
Skin: no suspicious lesions, warm and dry , moist, no rash
Eyes: PERRL, EOMI, sclera non-icteric, upper eyelids normal, lower eyelids normal
Neck/Thyroid: trachea midline, no LAD, FROM, supple, nontender, no masses
CV: regular tachycardia, normal S1 and S2 with no murmurs, rubs, or gallops, 2+ radial pulses corroborated with heartbeat B/L
Resp: hyperventilation CTA B/L, no adventitious sounds
Gastrointestinal: soft, non-tender/non-distended, BS present, no guarding or rigidity, no masses palpable.
Neurologic Exam: nonfocal, alert and oriented; gait steady and normal, strength 5/5 x 4 limbs, sensations intact, speech normal, no facial droop
Extremities: no clubbing, cyanosis, or edema. Capillary refill <2s on UE B/L.
Differential Diagnosis
1. PE: Aside from the tachycardia and hyperventilation, this patient’s generally unremarkable history and exam is possibly consistent with the nonspecific presentation of PE. She takes OCPs, which is a risk factor.
2. Tachyarrhythmia (ex. SVT): Patients with tachyarrhythmias often present with abrupt onset palpitations with the potential for associated chest discomfort and/or shortness of breath.
3. Hyperthyroidism: Initial presenting symptoms of hyperthyroidism can be AFib or other tachyarrhythmias. The patient’s recent weight loss would also be consistent.
4. Panic/Anxiety disorder → Panic/Anxiety attack: The tachycardia and hyperventilation with an otherwise generally unremarkable history and exam is consistent with possible anxiety/panic attack. She recently started PA school, which may result in high stress levels and other potentially triggering lifestyle changes, which could also explain her weight loss.
5. DKA/New-onset diabetes
Lower suspicion, but this patient has recent weight loss and hyperventilation that could be consistent with a diabetic acidosis
There are likely many other possible DDx to be considered, but given this patient’s age, unremarkable PMH, and relatively unremarkable exam, I would have a lower suspicion for other diagnoses (such as ACS, PTX, etc), but they are still important to rule out
Labs/tests that should be ordered and their results
ECG: sinus tachycardia
CBC: unremarkable
CMP: unremarkable
UA: unremarkable
BGL: WNL
Magnesium: WNL
Thyroid Panel: WNL
Cardiac Enzymes: WNL
ABG: mild hypercarbia without pH abnormality
PERC criteria → PE cannot be ruled out → Wells Criteria = ~4.5 → CTPA=Negative for PE
Urine Drug Panel: Positive for marijuana, negative for everything else
Any other lab tests ordered: unremarkable
Any psychiatric questionnaires or questions: Pt endorses recent feelings of overwhelming stress/anxiety, responses also consistent with mild depression. She denies all other psychiatric symptoms (including that she denies any feelings of wanting to harm herself or others)
Treatment
1st Line: Guided Breathing Retraining (Abdominal/Diaphragmatic Breathing Exercises)
Instruct the patient to place one hand on her abdomen, the other on her chest, and to adjust her breathing so that the hand on the abdomen moves with greater excursion than the hand on the chest, which should barely move at all
Ask the patient to breathe in slowly over four seconds, pause for a few seconds, and then breathe out over a period of eight seconds, repeating
2nd Line: If severe symptoms persist with breathing retraining, give a small dose of a short acting benzodiazepine (ex. lorazepam 0.5 mg PO)
Consider psych consult if symptoms are severe/refractory, otherwise, the patient may be discharged with an outpatient psych referral
Pt. counseling
Social: Evaluate and address stressors/triggers
Reach out to school, family, classmates, for support
Minimize caffeine intake, make sure to nourish and hydrate properly every day
Emotional: Practice self-care techniques, consider practices like journaling or meditation
The breathing exercise as described above should be practiced whenever the patient feels the onset of anxiety/panic
Although it’s often depicted in media, avoid rebreathing into a paper bag as it can cause more harm than good
Follow-up with outpatient psych for likely initiation of therapy and possibly medication
Family: The patient is under increased stress that is affecting her mental health, the social and emotional support of her family could be of benefit
Encourage the patient to follow up for further care, practice self-care, take frequent breaks, etc.
