Author: Donald Kasitinon, MD
Co Author #1: Robert J. Dimeff, MD Professor, Orthopedic Surgery, Pediatrics, and Family and Community Medicine The University of Texas Southwestern Medical Center (Dallas, TX)

Patient Presentation:
39 year old male presenting with chief complaint of 4 weeks of intermittent palpitations.

History:
A 39 year old male professional hockey coach and former professional hockey player with PMH significant for anxiety and gastroesophageal reflux presents with intermittent palpitations for 4 weeks. Patient reports that the episodes of palpitations initially occurred once per week, but have recently increased in frequency to 3 to 5 times per week. These episodes typically last 1 to 2 minutes, are accompanied by dyspnea and light-headedness, and only occur while he sits and eats. They never occur while he stands and eats, during or after exercise, or at night. Patient denies associated chest pain or pressure, diaphoresis, nausea, vomiting, headaches, and fevers.

Patient denies medical diseases, current medications or supplements, previous surgeries, and allergies. He did have a possible viral syndrome 4 years ago that presented with headaches, dizziness, neck pain, myalgias, rash, and tremor for which an extensive workup was negative; these symptoms resolved after about a year. Social history is significant for occasional alcohol use, but he denies tobacco and illicit drug use. Patient underwent a divorce 6 months ago and currently shares custody of his 2 daughters with his ex-wife. Last year, his job responsibilities increased, resulting in a significant increase in national and international travel and perceived personal stress.

Physical Exam:
Vitals: Within normal limits.
General: Alert and oriented x3 in no acute distress.
HEENT: Within normal limits.
Neck: Supple; no masses, adenopathy, thyromegaly, or bruits.
Cardiac: Regular rate and rhythm; no murmurs, gallops, or rubs; peripheral pulses normal.
Pulmonary: Clear to auscultation bilaterally; no wheezes, rales, or rhonchi.
Abdomen: Soft, no masses or tenderness.
Neurologic: Cranial nerves II-XII intact, normal strength and sensation.
Dermatologic: Warm and dry, no rashes.

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