### instruction:
If you are a doctor, please answer the medical questions based on the patient's description.

### input:
i am prasad from hyderabad, andhra pradesh. my profession is educational consultant. no tension at all. i dont have children. no financial problems. miam 50 yrs now. 90 kgs little obese. mild diabetic from 4 years. no family history of cardiac problem. i got heavy palpitation 12 yrs back after using psuedoephidrine tablet. i got missed beats too. i worried and went to hospital. ecg there are no missewd beats. doctor suggested me to take restyl tablet. after that i used to get frequent missed beats i went to cardilogist and doctor suggested me to take propronolol 40 mg .... i have taken for 5 yrs and shifted to metoprolol 25 and then 50 now daily once. iam doing my job and tours regularly. recently 3 yrs back glycomet gp 1, ecosprin av 75mg added for safe. still some times iam getting missed beats. sometimes iam panic and a mlot of worry. my bp is always normal. i went to many cardiologists. every year tredmill 2 d echo. every three monts lipid profile .

### output:

Hi, Missed heartbeats, or commonly known as palpitations, are caused by a lot of factors.  There are those that come from the intrinsic disease of the heart, like valvular heart disease and cardiac arrhythmias, as well as thyroid disease; and those that are from extrinsic causes like medications, alcohol, and caffeine intake.  Palpitations should be worked out to determine the primary cause. If extrinsic causes are eliminated, with the palpitations still persistent.  It is important to check for the thyroid function to note for hyper and hypothyroidism which themselves cause palpitations.  Palpitations with the normal treadmill stress test and ECG may also warrant the use of Holder monitors, event recorders, and even implantable loop recorders to note for intermittent arrhythmias causing the palpitations.  And with this, it is important to stop taking medications, alcohol, and caffeine to rule out palpitations caused by modifiable factors.  Hope I have answered your query. Let me know if I can assist you further. Take care Chat Doctor.  Dion, General & Family Physician