Five MD’s respond to my questions about the believability of symptom-report phenomenology

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Q-As a doctor, when a patient tells you they are experiencing “palpitations” or “racing heart” or “skipped beats”, what affects whether or how much you believe them? What else would they have to say for you to think they are accurately reporting on their physiological state?

1: “Regarding patients reporting palpitations. I almost always believe them about that. It’s pretty easy to tell when you have palpitations, and when they are significant they scare the shit out of people, so they notice, remember, and report. If I see a patient in atrial fibrillation, and they say they’ve noticed palpitations for 3 months, I will take that as fairly strong evidence that they have had atrial fib with a rapid ventricular rate for approximately 3 months. It’s not a commonly misperceived experience, I don’t think. There’s not many things that masquerade as ‘palpitations’ that aren’t. Maybe gastroesophageal reflux could make people feel that like they are having palpations when in fact they are refluxing, in which case taking a careful medical history would clear this up.
so what effects how much I believe them…
-the patient’s medical history: does the patient have a history of cardiac arrhythmias? Do they know what tachycardia feels like? If yes, then it makes the subjective report very reliable. for example, if a patient is having chest pain and says “this feels just like my last heart attack” then I would take the complaint very seriously.
-the history of present illness: the details of the patient’s chief complaint can be very useful in the interpretation of their “palpitations”. for example, what was the onset? if suddenly the patient noticed (felt) their heart racing, that would be more consistent with an ectopic cardiac foci suddenly misbehaving than if the patient described a gradual increase in awareness of a racing heart (maybe they were getting stressed out, and developed a gradual sinus tachycardia, or maybe they were exercising and developed a physiological tachycardia).
-patient’s mental status: this prolly goes without saying, but is the patient alert and oriented to person, place, time? do they understand why they are in the hospital? do they make sense? can you believe anything they say? are they rational and coherent in they’re descriptions of other physiological processes?”

2 “Even though they are generally synonymous…I take “palpitations” and “racing heart” more seriously because both connote speed and a rhythm problem; whereas, “skipped beats” can mean a normal rate but with an arrhythmia. As for accuracy and belief, I tend to find patterns or repetition of symptoms more believable (which is not accuracy but precision). If it happens once, it is easier to shrug it off.”

3. “I think I generally believe that complaint since there’s no reason to lie about that sensation- not like they’re looking for narcotics. Things that would make me more concerned would be light headedness, loss of consciousness, chest pain, family history of arrhythmia or sudden cardiac death. “

4 “I tend to believe the patient. Whether there is real disease or not it’s a concern and it’s real to them- I rather not assume the patient is just histrionic or borderline. Then I check their vitals, evaluate their risk factors (age, gender, etc.) for the different etiologies. Then based on the possibilities I order studies if necessary (TSH, EKG, Holter, etc.). If work up is negative then reassure, reassure, reassure. “

5 “I would rank my reliance on phrases as: 1) racing heart, 2) palpitations, 3) skipped beats. Mainly because palpitations is such a low-frequency word in general usage. Although I do interpret them all as palpitations per history with equal reliance on patient accuracy. “

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One thought on “Five MD’s respond to my questions about the believability of symptom-report phenomenology

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