Palpitations
Palpitations are the subjective awareness of one's own heartbeat, often perceived as rapid, irregular, or forceful cardiac contractions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Anxiety / panic disorder | Palpitations + anxiety/fear + hyperventilation + no cardiac abnormality | 「你發作嗰陣有冇覺得好驚、好似就嚟死咁、透唔到氣？」(Do you feel terrified / like you're about to die / can't breathe during episodes?) | ~30% |
| Ectopic beats (APB/VPB) | "Skipped" or "thumping" beats, brief, often at rest, relieved by exercise | 「係咪覺得心跳漏咗一下，之後大力跳一下？行下路會唔會好啲？」 | ~25% | |
| Sinus tachycardia (secondary cause) | Regular, fast, gradual onset/offset; look for underlying cause (caffeine, fever, anaemia, thyrotoxicosis) | 「心跳係慢慢快起嚟，定突然間快起嚟？」 | ~20% | |
| Serious Not To Miss | Atrial fibrillation | Irregularly irregular pulse; risk of stroke | 「心跳係完全冇規律、亂咁跳？」/ Irregularly irregular pulse on examination | ~5% |
| SVT (AVNRT/AVRT) | Discrete bouts, very rapid (>120 bpm), sudden onset/offset, may respond to vagal manoeuvres [2] | 「發作嗰陣谷氣或者飲凍水會唔會停？」 | ~3% | |
| Ventricular tachycardia | Regular very fast + syncope/presyncope + structural heart disease | 「有冇暈低過？以前有冇心臟病？」/ Haemodynamic compromise | <1% | |
| Inherited arrhythmia (LQTS, Brugada, HCM) | Young patient + syncope on exertion + FHx sudden death [4][6] | 「屋企人有冇人後生時突然過身？你做運動時暈過未？」 | <1% | |
| Pitfalls | Thyrotoxicosis | Sinus tachycardia or AF + weight loss, heat intolerance, tremor, goitre [3][7] | 「有冇瘦咗？怕唔怕熱？」/ Goitre, tremor, lid lag on exam | ~5% |
| Hypoglycaemia | DM on insulin/SU + adrenergic symptoms: palpitation, sweating, tremor [9] | 「你有冇糖尿病？食藥未食嘢之後有冇出現呢啲症狀？」 | ~2% | |
| Phaeochromocytoma | Paroxysmal HT + headache + sweating + palpitations [10] | 「有冇突然頭好痛加大汗加心跳快一齊嚟？」 | <1% | |
| Masquerades | Caffeine / substance-induced | Heavy coffee/energy drink intake, stimulant use, β-blocker withdrawal | 「一日飲幾多杯咖啡？有冇食減肥藥或者興奮劑？」 | ~15% |
| Depression with somatic symptoms | Low mood, anhedonia, sleep disturbance; palpitations as somatic complaint | 「心情點呀？有冇覺得咩都唔想做？」 | ~10% | |
| Iron-deficiency anaemia | Pallor, fatigue, tachycardia; menorrhagia in young women [1] | 「面色有冇白啲？月經量多唔多？」/ Conjunctival pallor | ~5% | |
| Trying to Tell Me Something? | Psychosocial stress / health anxiety | Work/family stress, fear of heart attack, recent bereavement | 「你最擔心係咩嘢？最近生活有冇咩大改變？」 | ~20% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, introduce self, build rapport | 「你好呀！我係陳醫生，今日由我同你傾下。請問點稱呼你？」「今日咩風吹你嚟睇醫生呀？」 | Sets patient-centred tone; scores interpersonal marks from the first second. |
| 0:30–1:30 | Chief complaint & HPI: onset, duration, frequency, character (ask patient to tap rhythm), triggers, offset, associated symptoms (chest pain, SOB, dizziness, syncope) | 「你話心跳唔正常，可唔可以用手指篤枱面學下你心跳嘅節奏畀我睇？」「幾時開始㗎？突然間嚟定慢慢嚟？」「每次大約維持幾耐？」「做嘢嗰陣發作定休息嗰陣發作？」「有冇頭暈、眼前發黑、暈低過？有冇胸口痛、氣喘？」 | Character / tapping rhythm is a key discriminator between ectopics, AF, SVT, VT [1][2]. Syncope / near-syncope = red flag for haemodynamic compromise. |
| 1:30–2:30 | Systematic screening: thyroid Sx, anaemia Sx, caffeine/drug/alcohol use, menstrual Hx, mood/anxiety | 「有冇覺得特別怕熱、出汗多、瘦咗？」「有冇覺得人好攰、面青、經期流量多？」「平時飲唔飲咖啡、濃茶、酒？一日幾多？」「有冇食緊任何藥或者保健品？」「最近壓力大唔大？訓唔訓得好？」 | Screens metabolic & psychiatric causes — commonly tested DDx [1][3]. |
| 2:30–3:30 | PMHx, FHx, DHx, allergy, social Hx | 「以前有冇心臟病、甲狀腺病、糖尿病？」「屋企人有冇心臟問題或者突然猝死？」「而家食緊咩藥？有冇藥物敏感？」「你做咩工作㗎？」 | FHx of sudden death = inherited arrhythmia red flag [4]. Drug history picks up sympathomimetics, β-blocker withdrawal [1]. |
| 3:30–4:30 | ICE (Ideas, Concerns, Expectations) — the hidden agenda | 「你自己覺得係咩原因呢？」(Ideas) 「最擔心係咩嘢？」(Concerns) 「你嚟睇醫生最想我幫到你啲咩？」(Expectations) | ICE is directly marked on the Case Report Form. Explores hidden agenda — e.g. fear of heart attack, worry about sudden death, work stress causing anxiety. |
| 4:30–5:15 | Summarise back to patient, check understanding | 「等我總結返：你大約兩個禮拜前開始覺得心跳好快，冇規律，有時覺得頭暈…我有冇理解錯？」 | Summarising earns interpersonal marks; ensures nothing is missed. |
| 5:15–5:45 | Brief plan & safety-net | 「我會安排幫你做心電圖同埋驗血，睇下有冇問題。」「如果你突然暈低、胸口好痛或者透唔到氣，要即刻打999去急症。」 | Safety-netting for syncope / haemodynamic compromise = must-do in FM exam. |
| 5:45–6:00 | Empathic close | 「多謝你今日嚟同我講，我哋會跟進嘅，唔使太擔心。」 | Professional closure; scores final interpersonal marks. |
Hidden agenda tip: A patient with "palpitations" may actually be presenting because of anxiety about a family member's sudden death, work stress, or fear of cancer/heart attack. Always ask ICE explicitly — the RFC may not be "diagnose my arrhythmia" but "reassure me I won't die suddenly."
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Character | Can you tap out the rhythm on the table? | 「可唔可以用手指篤枱面學下你心跳嘅節奏？」 | Key discriminator between ectopics (skipped beats), AF (irregular), SVT/VT (regular fast) [1][2] | Regular fast → SVT/VT; Irregular → AF; Missed beats → ectopics |
| Onset/Offset | Does it start and stop suddenly? | 「係突然間嚟又突然間停，定慢慢嚟慢慢走？」 | Sudden onset/offset = re-entrant tachycardia (AVRT/AVNRT); gradual = sinus tachycardia [2][5] | Sudden → AVNRT/AVRT/VT; Gradual → sinus tachycardia |
| Duration/Frequency | How long does each episode last? How often? | 「每次大概維持幾耐？幾密發作？」 | Brief seconds → ectopics; minutes-hours → SVT/AF; sustained → VT | — |
| Triggers | At rest or during exercise? Stress? Bending? | 「做運動嗰陣定休息嗰陣發作多啲？」 | Rest → ectopics, AF; Exercise → SVT, VT, sinus tachycardia [2] | Exercise-induced → structural heart disease, catecholamine-sensitive VT |
| Termination | Does anything stop it — coughing, bearing down? | 「有冇試過谷氣、咳或者飲凍水會停？」 | Terminated by vagal manoeuvres → nodal re-entrant tachycardia [5] | AVNRT/AVRT |
| Red flag: Syncope | Have you ever fainted or blacked out? | 「有冇試過暈低或者眼前發黑？」 | Syncope with palpitations → haemodynamically significant arrhythmia, urgent referral [6] | VT, severe SVT, HCM, LQTS, Brugada |
| Red flag: Chest pain | Any chest pain during episodes? | 「發作嗰陣有冇胸口痛？」 | Chest pain + palpitations → ACS, HCM, valvular disease | ACS, aortic stenosis, HCM |
| Red flag: FHx sudden death | Any family member died suddenly or young? | 「屋企人有冇人年紀輕輕突然過身或者猝死？」 | Family history of unexplained death at young age → inherited arrhythmia syndrome [4][6] | LQTS, Brugada, HCM, ARVC |
| Thyroid symptoms | Heat intolerance, weight loss, tremor, sweating? | 「有冇特別怕熱、出汗多、手震、瘦咗？」 | Classical symptoms of hyperthyroidism: weight loss, palpitations, nervousness, sweating [3][7] | Graves' disease, thyrotoxicosis |
| Anaemia symptoms | Tiredness, pallor, heavy periods, GI bleeding? | 「有冇覺得好攰、面青？女仔嘅話月經量多唔多？」 | High-output state causing sinus tachycardia [1] | Iron-deficiency anaemia, menorrhagia |
| Caffeine/Substances | Coffee, tea, energy drinks, alcohol, smoking, recreational drugs? | 「一日飲幾多杯咖啡、茶？飲唔飲酒？有冇食其他嘢，例如減肥藥？」 | Caffeine, nicotine, alcohol, cocaine, amphetamine are drug-related causes of palpitations [1] | Substance-induced arrhythmia |
| Drug history | Current medications? Recently stopped anything? | 「而家食緊咩藥？最近有冇停咗咩藥？」 | Sympathomimetics, anticholinergics, β-blocker withdrawal, thyroxine [1] | Drug-induced palpitations |
| Psychiatric screen | Anxiety, panic, stress, sleep problems? | 「最近壓力大唔大？有冇突然好驚、心跳好快、手震、覺得透唔到氣？」 | Panic attack / anxiety disorder is a common DDx and a pitfall [1][8] | Panic disorder, GAD |
| Hypoglycaemia | Diabetic? Skipped meals? Tremor + sweating? | 「有冇糖尿病？有冇試過唔食嘢之後手震出汗心跳快？」 | Adrenergic symptoms of hypoglycaemia: palpitation, sweating, tremor [9] | Hypoglycaemia (in DM patients on SU/insulin) |
| Phaeochromocytoma screen | Episodic headache + sweating + palpitations? | 「有冇試過突然頭痛加出汗加心跳好快一齊嚟？血壓高唔高？」 | Classic triad: headache + sweating + tachycardia [10] | Phaeochromocytoma |
| Functional impact | Does this affect work, sleep, daily life? | 「呢個問題有冇影響你返工、瞓覺、日常生活？」 | Captures social/functional problem for biopsychosocial model | — |
| Menstrual Hx (if female) | Regular periods? Could you be pregnant? | 「月經正唔正常？有冇機會懷孕？」 | Pregnancy → high-output state; perimenopause → palpitations [1] | Pregnancy, perimenopause |
Case Report Form Answer Builder
Write: "Palpitations for [duration]" High-yield HPI points:
- Onset (sudden vs gradual), duration, frequency of episodes
- Character (patient's description / tapped rhythm — regular fast, irregular, skipped beats)
- Triggers (exercise, rest, caffeine, stress, bending)
- Termination (spontaneous, vagal manoeuvres)
- Associated symptoms: chest pain, SOB, dizziness, syncope, polyuria (SVT)
- Relevant negatives: no weight loss/heat intolerance (rules out thyrotoxicosis), no syncope (rules out haemodynamic compromise)
Likely RFC examples:
- "To find out the cause of palpitations"
- "Worried about having a heart attack / heart disease"
- "Fear of sudden death (especially if FHx)"
- "Symptoms affecting work / sleep / daily function"
- "Recurrent episodes causing anxiety"
Phrasing tip: Choose the single most important reason from the patient's ICE. If the patient says "I'm scared I have a heart problem," the RFC = "Concern about underlying heart disease" — not just "palpitations."
| Component | Likely Example Wording |
|---|---|
| Ideas | "I think I might have a heart problem" / "Maybe it's stress" / "Could it be my thyroid?" |
| Concerns | "I'm worried I might have a heart attack" / "I'm scared of dying suddenly like my uncle" / "Worried it's something serious" |
| Expectations | "I want to get an ECG / blood test" / "I want medication to stop the palpitations" / "I want reassurance that nothing is wrong" |
In a young, otherwise healthy patient in FM: most commonly anxiety/panic disorder or ectopic beats (benign premature beats). In a middle-aged/older patient or with systemic symptoms: consider AF, thyrotoxicosis, sinus tachycardia secondary to anaemia.
Minimum supporting evidence:
- Anxiety/panic: episodic palpitations with fear, hyperventilation, no structural heart disease, normal ECG
- Ectopic beats: brief "skipping" sensation, worse at rest, relieved by exercise, no red flags
- AF: irregularly irregular rhythm on pulse check, may have polyuria, SOB
| DDx | Key Discriminator |
|---|---|
| 1. Anxiety / Panic disorder | Palpitations with hyperventilation, fear, perioral tingling; no arrhythmia on ECG |
| 2. Thyrotoxicosis | Weight loss, heat intolerance, tremor, goitre; elevated free T4, suppressed TSH |
| 3. Atrial fibrillation | Irregularly irregular pulse; risk of stroke; ECG shows absence of P waves |
(Adjust based on stem clues — if stem suggests young female with weight loss → thyrotoxicosis as most likely; if elderly with irregular pulse → AF.)
| Domain | Problem |
|---|---|
| Biological | Underlying arrhythmia / thyrotoxicosis / anaemia requiring investigation (ECG, TFT, CBC) |
| Psychological | Anxiety about having a serious heart condition; possible underlying anxiety disorder / panic disorder |
| Social/Functional | Palpitations affecting work productivity / sleep quality / exercise tolerance / quality of life |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| Anxiety / Panic disorder | Normal resting heart rate and regular rhythm with signs of anxiety (hyperventilation, sweaty palms, tremor) | Take resting pulse; observe patient's demeanour; check respiratory rate | Normal cardiac examination makes primary arrhythmia unlikely; anxiety features point to psychiatric cause |
| Ectopic beats (APB/VPB) | Occasional irregular "extra" or "dropped" beat on pulse palpation | Palpate radial pulse for ≥30 sec; auscultate apex for premature beats | Intermittent irregularity with compensatory pause = ectopic; overall rate normal |
| Atrial fibrillation | Irregularly irregular pulse | Palpate radial pulse and compare with apex rate (check for pulse deficit) | Irregularly irregular pulse is the hallmark of AF [1]; pulse deficit suggests rapid AF |
| Thyrotoxicosis | Fine tremor + goitre + tachycardia | Ask patient to extend hands with paper on top (fine tremor); inspect and palpate neck for goitre; note lid lag / lid retraction [3] | Goitre + tremor + tachycardia = thyrotoxicosis until proven otherwise |
| SVT (AVNRT) | Tachycardia during episode; normal examination between episodes | Difficult to catch in FM station; if currently tachycardic, note regular fast rate ~150 bpm | In between episodes, examination is usually entirely normal — state this explicitly; ECG (Holter) is the key investigation |
| Ventricular tachycardia | Haemodynamic instability: hypotension, cannon A waves in JVP | Check BP, inspect JVP for cannon A waves (AV dissociation) | VT is unlikely to present stably in FM; if it does, cannon A waves + independent atrial rhythm = VT |
| Phaeochromocytoma | Paroxysmal hypertension | Check BP (may be markedly elevated during episode; normal between) | Paroxysmal HT + classic triad (headache, sweating, palpitations) [10] |
| Anaemia | Conjunctival pallor | Pull down lower eyelid, inspect palpebral conjunctiva | Pallor suggests anaemia → high-output state causing sinus tachycardia |
Top Traps That Lose Marks
- Not asking patient to tap the rhythm — this is the single best bedside discriminator and is explicitly taught in CFB cardiovascular history taking [2].
- Forgetting ICE — many students take a complete medical history but score zero on Q3 because they never asked "What do you think is going on? What worries you most?"
- Missing the hidden agenda — "palpitations" may be the ticket of entry; the real reason may be anxiety about a relative's sudden death, work stress, or relationship problems.
- Not screening for thyrotoxicosis — a classic pitfall. Always ask about weight loss, heat intolerance, tremor [3][7].
- Not asking FHx of sudden cardiac death — misses inherited arrhythmia syndromes (LQTS, HCM, Brugada) [4][6].
- Writing "arrhythmia" as diagnosis without specifying type — be specific: "paroxysmal AF," "benign ventricular ectopics," "AVNRT."
- Confusing RFC with chief complaint — chief complaint = "palpitations for 2 weeks"; RFC = "worried about heart disease."
Must-Not-Miss Red Flags → Urgent Referral
- Syncope or near-syncope during palpitations → possible VT, severe SVT, structural heart disease
- Palpitations on exertion + FHx sudden death → inherited arrhythmia, HCM → urgent cardiology referral
- Haemodynamic instability (hypotension, altered consciousness) → emergency
- Associated chest pain → rule out ACS
- New irregular pulse in patient on no rate control → new AF → stroke risk assessment needed
Safety-Net Closing Line (Cantonese)
「如果你突然暈低、胸口好痛、透唔到氣、或者心跳好快停唔到，要即刻打999去急症室。」 (If you suddenly faint, get severe chest pain, can't breathe, or your heart races and won't stop, call 999 and go to A&E immediately.)
High-yield from GC lecture slides [1]: Palpitations DDx is classified into 4 categories: Cardiac causes (arrhythmia, valvular disease, cardiomyopathy, high-output states), Drug-related causes (sympathomimetics, anticholinergics, vasodilators, β-blocker withdrawal, caffeine, cocaine, alcohol, nicotine), Metabolic causes (thyrotoxicosis, phaeochromocytoma, hypoglycaemia, electrolyte disturbance), and Psychiatric causes (panic, anxiety, stress, depression, somatisation).
High-yield from GC CVS history taking slides [2]: The SOCRATES framework for palpitations distinguishes extrasystoles (skipped beats, brief, worse with fatigue/caffeine/alcohol, relieved by walking), sinus tachycardia (gradual onset, regular fast pounding), SVT (sudden onset with "jump," polyuria, relieved by vagal manoeuvres), AF (irregular, sudden, polyuria, breathlessness), and VT (regular fast, presyncope/syncope).
High-yield from GC CVS investigations slides [6]: Ambulatory cardiac monitoring (Holter) is indicated for diagnosis of arrhythmias presenting as palpitations, syncope, chest pain, or stroke.
High Yield Summary
What to ASK: Character (tap rhythm!), onset/offset (sudden vs gradual), triggers, vagal manoeuvre response, syncope, chest pain, thyroid symptoms, caffeine/drugs, FHx sudden death, anxiety/stress, ICE.
What to WRITE: Chief complaint with duration → HPI using SOCRATES → RFC (patient's real reason, often fear-based) → ICE verbatim → Most likely Dx with supporting evidence → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign (irregularly irregular pulse for AF; goitre/tremor for thyrotoxicosis; normal exam for anxiety/ectopics).
What NOT TO MISS: Syncope (→ urgent referral), FHx sudden death (→ inherited arrhythmia), thyrotoxicosis (classic pitfall), hidden psychiatric agenda, and always specify the arrhythmia type — never write just "arrhythmia."
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Block A - Syncope and irregular heartbeat: Cardiac arrhythmia; Heart blocks, Bradycardia (Differential diagnosis of palpitation section) [2] GC Lecture slides: CFB (MED05) Cardiovascular (I) Physical Examination (History Taking) (Palpitation SOCRATES table) [3] Senior notes: Block A - I am losing weight and sweating all the time: causes of severe weight loss; thyrotoxicosis; hypothyroidism (Symptoms/Signs of hyperthyroidism) [4] Senior notes: Block A - Inherited Cardiac conditions (HCM, LQTS clinical presentation and Schwartz score) [5] Senior notes: Ryan Ho Fundamentals (Section 3.1.3 Palpitations) [6] GC Lecture slides: General Clerkship Introduction to CVS Investigations 2026 Yiu (Indications for ambulatory cardiac monitoring; Clinical features of syncope) [7] Past papers: 2023 Fourth Summative SAQ (Q6 — Graves' disease with palpitations) [8] GC Lecture slides: GC 167. I feel very nervous Anxiety disorders [9] Senior notes: Block A - Polyuria and polydipsia: glucose metabolism; diabetes mellitus; diabetic ketoacidosis (Symptoms of hypoglycaemia) [10] Senior notes: Block A - I have fluctuating BP: cushing syndrome; adrenal diseases and tumours (Phaeochromocytoma symptoms and signs); MBBS Final MB Medicine Felix PY Lai (5Ps of Phaeochromocytoma)
Hand Pain
Hand pain is a symptom arising from injury, overuse, or disease affecting the bones, joints, tendons, nerves, or soft tissues of the hand, commonly caused by conditions such as carpal tunnel syndrome, osteoarthritis, tendinitis, or trauma.
General Malaise
General malaise is a nonspecific symptom of overall bodily discomfort, weakness, or feeling of being unwell that often accompanies the onset of various acute or chronic illnesses.