What Is Making This Man’s Heart Skip a Beat?

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BR 51: What Is Making This Man's Heart Skip a Beat?

Session 51

As always, we’re joined by Dr. Mike Natter from BoardVitals. If you are looking for some more help with your board prep, check out everything they have to offer. Their massive QBank database will help you prepare for Step 1 or Level 1, and even in the future as well for your Shelf exams. Use the promo code BOARDROUNDS to save 15% off.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:47] Question of the Week

A 36-year-old male presents to the hospital because he fears his heart may be “skipping a beat.” He denies any palpitations but is convinced his heartbeat is abnormal. The patient’s EKG 24-hour telemetry and echocardiogram indicate normal results. The patient remains convinced that he has a life-threatening arrhythmia despite a normal workup and other normal evaluation from a neighboring hospital six months ago. He checks his pulse countless times a day to see if his rhythm is irregular.

Psychiatry is counseled that after the patient has an outburst at the medical team demanding more tests, he is currently working part time until he “gets to the bottom of this.” He admits to exaggerating symptoms, but remains confident about having an arrhythmia. What is the most likely diagnosis?

(A) somatic symptom disorder

(B) pain disorder

(C) conversion disorder

(D) illness anxiety disorder, formerly known as hypochondriasis

[02:55] Thought Process Behind the Correct Answer and the Incorrect Choices

A medically related issue here. This is really nothing physical. There’s nothing testing-wise that shows anything other than the patient’s claim. 

So the correct answer here is (D) illness anxiety disorder.

This is a gentleman who believes there is something wrong. He has affirmed fixed false belief. Test results show nothing. There’s no objective data to suggest anything’s wrong, but he is still firmly in fixed belief that there is something going on even though it’s false. This actually is a kind of a mental disorder.

Conversion disorder is a mental condition. It’s where the patient can be blind or paralyzed or other kinds of neurologic symptoms that can’t be explained by medical evaluation. They believe they can’t move their leg or they feel that they can’t see when there’s really nothing wrong. They actually can but they just think they can’t.

Somatic symptom disorder is more of a somatic complaint. They’re nauseous and their belly hurts all the time but there is no medical reason for it. It’s kind of the anxiety manifesting as nausea, vomiting or headaches or whatever that may be.

It’s not a pain disorder either because the patient is not complaining of any pain.

[05:59] How to Approach These Patients

Just reassuring them is really the best way to approach these patients because that’s what they need. Oftentimes, there’ll be answer choices for how you would approach these patients. And if there’s ever an answer choice in these types of questions that says something along the lines of frequent visits to your office in a week or two weeks. Those are usually the right answers in these cases because they just need this. They have to feel as though you’re on their side. 

“The worst thing you can do is confront them and tell them that they're wrong and they're lying and all these things and you don't believe them.”Click To Tweet



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