Consult - Palpitations & Presyncope 

HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart