Clinical Challenge: Young Woman With Arm Numbness and Shortness of Breath

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An electrocardiograph (EKG) recording revealed tachycardia with premature ventricular contractions.
An electrocardiograph (EKG) recording revealed tachycardia with premature ventricular contractions.

Ms J, a 30-year-old African American woman, presented to her school's infirmary with an increased heart rate that skipped a beat, shortness of breath, and tingling and numbness down her right arm. The increased heart rate and skipping heartbeat began earlier that day during class. The shortness of breath also began earlier that day while walking from the parking lot to class and was relieved with less exertion. 

Ms J had no history of injury, strenuous activity, or trauma. She had not ingested any medication or caffeine that morning to trigger an increased heart rate or skipping heartbeat. 

All symptoms appeared abruptly and caused immediate discomfort. Decreasing activity improved the shortness of breath, but Ms J found no relief from the racing and skipping heartbeat or tingling sensation in the arm. She felt slight chest pain on deep inhalation after strenuous exercise. Ms J also reported radiating pain to her right shoulder but denied having a fever, coughing, arrhythmia, edema, orthopnea, and paroxysmal nocturnal dyspnea.

History and examination 

Ms J was a moderately active student with a history of childhood asthma and seasonal allergies. She reported regular consumption of a healthy diet, including adequate fruits and vegetables, but admitted a periodic overindulgence in sweets. Ms J consumed alcohol socially and a moderate amount of caffeine, but she denied tobacco and illicit drug use.

Ms J denied any past surgeries or hospitalizations. Though sexually active, she denied any past pregnancies and was not taking oral contraceptives.

Ms J's family history was positive for hypertension, diabetes, cancer, anemia, and cardiac abnormalities. Her mother died at 52 years of age from a heart arrhythmia associated with mitral valve prolapse. Her father's comorbidities included hypertension, diabetes, and prostate cancer. The family history was negative for hyperlipidemia and stroke.

Ms J was alert and responsive to all questions, but she appeared worried and mildly uncomfortable. She also appeared younger than her stated age. Her blood pressure was 126/69 mg/dL, heart rate was 180 beats per minute, temperature was 36.6° C, respiratory rate was 16 breaths per minute, weight was 84 kg, and O2 saturation was at 98%. 

An electrocardiograph (EKG) recording revealed tachycardia with premature ventricular contractions (PVCs). The cardiac examination revealed a rapid rate, irregular rhythm, and an inconsistent regularity. No lifts, thrills, heaves, murmurs, rubs, or clicks were found. No jugular venous distention or edema was found. No crackles or rhonchi were present, but wheezing was found on expiration. All skin was of good color, with adequate turgor and texture. No visible rashes, exudates, lesions, ulcers, indurations, nevi, petechial, spider angioma, telangiectasia, ecchymosis, or hemangiomas were present. All lymph nodes were non-tender and non-palpable. Extraocular movements were intact with pupils equal, round, and reactive to light. No nystagmus, icterus, or rhinorrhea was present upon evaluation. The neck was supple without lymphadenopathy, and there were no bruits or thyromegaly. Oral mucosa was found to be pink and of good quality, with all teeth intact. No masses or lesions were seen in the mouth. Postnasal drip tracts were visible down the palpate. There was no pain in any joints during active and passive movement, and there was no pain in the bones of extremities. No edema was present in the pretibial area, and the patient had difficulty with right side shoulder shrug only.

Differential and follow-up

Ms J's differential included anxiety and mild heart attack. The most likely diagnosis was heart arrhythmia, due to a positive family history, racing heart rate, and skipping heartbeats. Cardiac enzyme testing and EKG ruled out a mild heart attack. 

At a subsequent visit with a cardiologist, an echocardiogram was performed, with caffeine, exercise, and strenuous activity restrictions. A 48-hour Holter monitor and stress test were ordered, and the latter was found to be negative. The echocardiogram revealed no abnormal heart findings. The Holter monitor recorded over 20,000 premature ventricular contractions in 2 days, which supported a patient referral to an electrophysiologist.

The cardiologist and electrophysiologist determined a diagnosis of supraventricular tachycardia. The electrophysiologist discussed pharmacologic intervention or cardiac ablation as available treatment options with the patient. Dependent on Ms J's age, academic obligations, and the desire to pursue pregnancy in the next few years, cardiac ablation was pursued for treatment.

The cardiac ablation required a greater area of focus than expected, but was successful in eliminating the PVCs. Post-procedure patient expectations included gradual resumption of exercise, embracing a heart-healthy lifestyle, monitoring caffeine intake, and limiting the consumption of salt and sugar.

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