Episodic palpitations

A 35-year-old woman presented to the outpatient clinic with a 2-week history of episodic palpitations. She noted that each episode was abrupt in onset and would last approximately 1 to 2 hours before abating gradually. She denied chest pain, shortness of breath, and light-headedness and had no history of similar symptoms.

The patient’s medical and psychiatric history were unremarkable, and her only medication was an oral contraceptive (OC). She had been taking OCs since age 21 years and was currently taking 3 mg of drospirenone and 0.2 mg of ethinyl estradiol (Yasmin 28, Bayer Healthcare Pharmaceuticals, Wayne, NJ). The patient was a smoker and had smoked 1 pack of cigarettes per day since the age of 18 years. She denied alcohol or illegal drug use.

On examination, the patient appeared comfortable and in no distress. Vital signs were as follows: temperature, 36.8°C; blood pressure, 135/95 mm Hg; heart rate (HR), 102 beats/min and regular; respiratory rate (RR), 18 breaths/min; and oxygen saturation (Spo2), 91% while breathing room air. Cardiovascular examination revealed tachycardia but no murmurs, S3, or S4; jugular venous pressure was normal. Pulmonary examination showed clear lung fields and no signs of effusion. The patient had no goiter, palpable thyroid nodules, or asymmetry. Findings on examination of the skin, eyes, extremities, neurologic system, and peripheral arterial systems were normal.

Which one of the following is the most likely etiology for the patient’s symptoms of palpitations?

Given the case information up to this point, which one of the following is the most likely precipitant of this patient’s sinus tachycardia?

Which one of the following is the most appropriate next step in the management of this patient’s condition?

Which one of the following tests would be the least helpful if the patient was evaluated for thrombophilia at this time?

Which one of the following oral contraceptives would be most reasonable to consider in the long-term management of this patient?

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