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Palpitations
Causes of Sinus Tachycardia and Clinical notes: Causes of
Sinus Bradycardia, respectively.
Noncardiac causes of palpitations include:
• thyrotoxicosis: may cause sinus tachycardia,
paroxysmal atrial tachycardia and atrial flutter/atrial
fibrillation (AF);
• hypothyroidism (myxoedema): may be responsible for
sinus bradycardia;
• anxiety: a very common cause of palpitations.
CLINICAL NOTES
NONCARDIAC CAUSES OF SINUS
TACHYCARDIA
• Exercise
• Fever
• Anaemia
• Thyrotoxicosis
• Pregnancy
• Arteriovenous fistulae
• Anxiety
• Pain
• Cigarettes, alcohol, caffeine
• Sympathomimetic drugs (e.g. cocaine)
CLINICAL NOTES
CAUSES OF SINUS BRADYCARDIA
• Physiological (e.g. athletes)
• Hypothyroidism
• Obstructive jaundice
• Raised intracranial pressure
• Hypopituitarism
• Hypothermia
• Cardiac causes: including ischaemia, drugs
(e.g. digoxin, β-blockers), inflammation and
degeneration/fibrosis
required. Changes in rate may be more serious,
compromising coronary blood supply and leading
to symptoms of myocardial ischaemia or cardiac
failure.
Tachycardia or bradycardia may lead to a reduction
in cardiac output and cause dizziness or collapse
(e.g. Stokes–Adams attacks in complete heart
block). Ventricular tachycardia is potentially
life-threatening.
Examination
A guide to examining the patient with palpitations is given
in Fig. 7.2. Look for signs of systemic diseases. Feel the
pulse. Note:
• Rate: beats per minute.
• Rhythm: regular, regularly irregular (e.g. Wenckebach
second-degree heart block), irregularly irregular (e.g.
multiple ectopic beats or AF).
• Volume/character: e.g. a collapsing pulse of
hyperdynamic circulation or aortic regurgitation
or a low-volume pulse of shock or aortic stenosis.
Remember this may be positional, so raising the arm
above the heart may exaggerate a collapsing pulse.
If the patient is symptom-free at the time of examination,
the pulse may be normal.
The blood pressure will be low if the arrhythmia leads
to a reduction in cardiac output. Hypertension may predispose to AF.
The jugular venous pressure may be elevated if cardiac
failure is present. Irregular cannon ‘a’ waves are visible with
complete heart block but are absent in AF.
A displaced apex beat may indicate cardiomyopathy.
Feel for heaves and thrills with associated right ventricular
enlargement and valvular heart disease. Assess the rate and
rhythm by auscultation. The pulse rate felt at the radial artery may be slower than the apical rate in AF (pulse deficit).
Listen for cardiac murmurs.
HINTS AND TIPS
CLINICAL NOTES
CONSEQUENCES OF PALPITATIONS
Palpitations can cause a range of problems, from
minor anxiety to syncope or sudden death. If a
benign arrhythmia is present, reassurance that
the condition is not serious is often all that is
58
An irregularly irregular pulse is irregular in both
rhythm and volume.
INVESTIGATIONS
The following tests should be considered.
• Bedside observations: pulse, blood pressure, respiratory
rate and saturations.
• Full blood count: anaemia.
Eyes
in hypothyroidism
Lungs
−
J
ugular vein
−
−
Blood pressure
Temperature
Hands
−
Cannon wave—CHB
Absent ‘a’ waves—atrial
fibrillation
−
Thyrotoxicosis
−
Lid lag
−
Exophthalmos
−
Anaemia
Investigations
77
Crepitations due
to pulmonary
congestion
Tremor due to
hyperthyroidism or βagonist drugs
Fig.7.2 Examining the patient with palpitations. CHB, Complete heart block.
• Urea and electrolytes: disturbances of potassium or, less
commonly, magnesium and calcium may contribute to
refractory arrhythmias.
• Thyroid function tests: hypothyroidism/hyperthyroidism.
• Drug concentration if appropriate (e.g. digoxin levels in
suspected toxicity).
• ECG: although this is mandatory for everyone with
palpitations, paroxysmal events may not be caught
on a resting 12-lead ECG. Wolff–Parkinson–White
syndrome will be seen at rest, as will atrial fibrillation.
Ectopic beats may be seen.
• Twenty-four-hour ECG: for intermittent symptoms.
It should be performed with a diary of symptoms to
see if they correlate with any rhythm disturbances
found.
• Echocardiogram: to exclude any underlying structural
heart disease.
• Exercise test: the induction of symptoms under
controlled conditions with ECG monitoring may be
appropriate.
• Electrophysiological studies: more rarely, patients
may be referred for specialized studies. These can be
used to induce arrhythmias, locate the origin of any
arrhythmic foci, assess the response to drug treatment
or destroy any aberrant pathway via radiofrequency
ablation.
Heart
−
Rate
−
Rhythm
−
Heart sounds
−
Added sounds
−
Murmurs
−
Heaves/thrills
Peripheral pulses
−
Rate
−
Rhythm
−
Volume
−
Pulse deficit
−
Character
Pretibial
myxoedema
Reflexes
−
Slow relaxing
59
Palpitations
Chapter Summary
• Make sure that both you and the patient have the same understanding of the word
‘palpitations’.
• Palpitations can be of cardiac or noncardiac origin. They can be a manifestation of a
sinister disease, and therefore need to be investigated.
• Worrying symptoms include dizziness, syncope, chest pain and shortness of breath.
• Palpitations can be of regular or irregular character. The most common cause of regular
palpitations is sinus tachycardia. The most common cause of irregular palpitations is
atrial fibrillation.
60
Pyrexia of unknown origin
8
INTRODUCTION
Fever is a common symptom, and a cause is often obvious
(e.g. upper respiratory tract infection, gastroenteritis).
Pyrexia of unknown origin (PUO) is defined as a temperature above 38.3°C measured on multiple occasions and
present with illness lasting at least 3weeks. This is where
a diagnosis has not been reached despite at least 1week of
inpatient investigations.
HISTORY AND EXAMINATION FINDINGS
The history and examination are vital when one is considering PUO and must be thorough. Systematic enquiry should
be rigorous, and every symptom should be explored in detail. It is important to pay attention to:
• Symptoms such as sweats, weight loss, itch, lumps and
rash.
• Past medical history, particularly recurrent infection
and immunosuppression.
• Surgical history, including complications and trauma.
• Travel and contact with animals. Has there been
exposure to endemic diseases or disease-carrying
vectors (e.g. malaria, toxoplasmosis, borreliosis)?
• Sexual history.
• Drug history, including immunizations.
• Family history (may point to inherited disorders such
as familial Mediterranean fever).
INVESTIGATIONS
Investigations are best directed by the history and examination. Frequently there will be few clues, and the best
way to proceed is to request general nonspecific screening tests, the results of which may direct more specific
investigations.
Bedside investigations
Blood tests
The full blood count may yield useful information, and although it is often nonspecific, it may show:
• Neutrophilia: bacterial infections, myeloproliferative
disease, malignancy or connective tissue disease.
• Lymphocytosis: acute viral infection, chronic bacterial
infection (e.g. tuberculosis (TB) and brucellosis) or
protozoal infection. Atypical lymphocytosis can suggest
infectious mononucleosis (Epstein–Barr virus) or
cytomegalovirus infection.
• Monocytosis: subacute bacterial endocarditis,
inflammatory disease such as Crohn disease,
connective tissue disease, Hodgkin lymphoma or TB.
• Eosinophilia: helminth infection (e.g. schistosomiasis,
filariasis), malignancy (especially Hodgkin disease), or
drug reaction.
• Leucopoenia: viral infections, lymphoma, systemic
lupus erythematosus, TB or drugs.
Inflammatory markers such as C-reactive protein level
(CRP) and erythrocyte sedimentation rate (ESR) are raised
in many conditions and can be unspecific. CRP can be par-
COMMUNICATION
A thorough sexual history is important and
becomes easier to elicit with practice.
Examination of a patient with PUO should include all systems (Fig.8.1). The most common signs and symptoms are:
• teeth and throat signs (e.g. periodontal disease/dental
abscess);
• joint signs and temporal artery tenderness;
• eye signs (e.g. conjunctival petechiae);
• skin lesions (e.g. rashes, petechiae, vasculitic infarction);
• lymphadenopathy and organomegaly;
• heart murmurs and stigmata of endocarditis;
• rectal and vaginal examinations findings (abscesses,
masses, retained tampon).
can suggest:
• multiple myeloma;
• connective tissue disease (e.g. systemic lupus
erythematosus, giant cell arteritis, polymyalgia
rheumatica);
• Still disease;
• rheumatic fever;
• lymphoma.
Renal and liver function tests are useful in narrowing
down the cause of fever. Liver function tests showing
raised alkaline phosphatase level can point to bone disease, myelo proliferative disorder or connective tissue
disease, whereas raised γ-glutamyltransferase level can be
seen in hepatitis.
Many specific serological blood tests are available. They
should be directed by clinical assessment. You should always ask for an HIV test, with the patient’s consent.
61
Pyrexia of unknown origin
Legs
— Deep vein
thrombosis
Rectum/vagina
— Rectal/vaginal
Nervous system
— Abnormalities of
central and peripheral
nervous system
Liver
— Hepatomegaly
— Hepatic bruit
Lung
— Respiratory
Mout
— Dental/pharyngeal
Ears
— Otitis media
stigmata of endocarditis
Head
— Temporal artery
tenderness
h
sepsis
s
examination
masses and
infections
Eyes
— Conjunctival petechiae
— Jaundice
Lymph nodes
— Lymphadenopathy
Heart
— Murmurs and other
Spleen
— Splenomegaly
Kidneys
— Renal cell carcinoma
Hands
— Nail-fold infarcts:
rash, nodules, papules
Joints
— Active infection or
inflammation
Skin
— Rashes
Fig.8.1 Examining the patient with pyrexia of unknown origin.
Microbiology tests
Samples for microbiology testing should be taken from
multiple sites, including:
• urine for infections (e.g. TB and sexually transmitted
disease or haematuria);
• blood cultures for septicaemia;
• faeces for microorganisms and inflammatory bowel
conditions;
• genital swabs;
• throat and nose swabs, and sputum;
• bone marrow and cerebrospinal fluid.
Further investigations
Simple investigations including chest X-ray and ultrasound
scan are first-line investigations. Further imaging including
CT, MRI scans or echocardiogram can help.
When you are considering PUO, sometimes further
investigations need to proceed ‘blindly’ rather than be directed by the clinical picture, simply because of lack of an
62
apparent diagnosis. Noninvasive tests should be performed
first, and can involve autoimmune antibody screening, immunoglobulins and protein electrophoresis and tumour
markers.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis associated with PUO is very wide
ranging (Table 8.1). Infections including undiagnosed ab-
scesses, TB, endocarditis, hepatobiliary infections (cholangitis) and osteomyelitis are common. Viral causes include
herpes viruses and HIV. The likely neoplasm which causes
fever is lymphoma, although PUO can also be attributed
to solid tumours, particularly renal cell and gastrointestinal carcinoma. Drug fever can be caused by antibiotics and
is usually associated with rash. Rarer causes include hyperthyroidism, peripheral pulmonary emboli and familial
Mediterranean fever.
Differential diagnosis
88
HINTS AND TIPS
Remember to go over the history and examination
findings repeatedly, even when investigations are in
progress.
Table8.1 Causes of pyrexia of unknown origin
Causes Percentage of cases
Infections 25–40
Autoimmune disorders 10–20
Malignancy 10–30
Miscellaneous (e.g. drugs,
thyroid disorders)
Undiagnosed 15–20
5–14
Chapter Summary
• Persistent fever can prove very problematic for medical professionals to diagnose when
• When assessing pyrexia of unknown origin (PUO), ensure you conduct a thorough,
systematic history and examination and that appropriate investigations are conducted to
aid in diagnosis.
• The most common causes of PUO include infectious disease and malignancy, and
therefore their prompt diagnosis will improve disease management and patient survival.
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Abdominal pain
9
INTRODUCTION
Abdominal pain is a common presenting complaint. The
differential diagnosis for abdominal pain is multiple, and
ranges from benign disease such as mesenteric adenitis to
Table. 9.1 Differential diagnosis of abdominal pain
Site of pain Causes
Epigastric Lower oesophagus: oesophagitis, malignancy, perforation
Right
hypochondrium
Left
hypochondrium
Central
abdomen
Right iliac fossa Terminal ileum: Crohn disease, infection (e.g. tuberculosis),
Left iliac fossa Sigmoid/descending colon: diverticulitis, paracolic abscess, ulcerative colitis, malignancy
Loin Kidneys: malignancy, pyelonephritis, polycystic disease
Suprapubic Bladder: UTI, acute urinary retention
Other causes of
abdominal pain
HSP, Henoch–Schönlein purpura; IBS, irritable bowel syndrome; PAN, polyarteritis nodosa; UTI, urinary tract infection.
Stomach: peptic ulcer, gastritis
Pancreas: pancreatitis, malignancy
See Chapter29
Biliary tree: biliary colic, cholecystitis, cholangitis
Liver: hepatitis, malignancy, abscess, right ventricular failure
Subphrenic space: abscess
See Chapters27 and 29
Spleen: traumatic rupture, infarction (sickle cell disease)
Pancreas: pancreatitis, malignancy
Subphrenic space: abscess
See Chapter29
Pancreas: pancreatitis, malignancy
Small/large bowel: obstruction, perforation, intussusception, ischaemia, Crohn disease, lymphoma,
IBS, adhesions, early appendicitis
Lymph nodes: mesenteric adenitis, lymphoma
Abdominal aorta: ruptured aortic aneurysm
See Chapter29
Meckel diverticulum
Appendix: appendicitis, tumour (including carcinoid)
Caecum/ascending colon: diverticulitis, paracolic abscess, ulcerative colitis, malignancy
Ovary/fallopian tubes: malignancy, ectopic pregnancy, pelvic inflammatory disease, cyst (bleeding or torsion)
See Chapter29
Ovary/fallopian tube: malignancy, ectopic pregnancy, pelvic inflammatory disease, cyst (bleeding or torsion)
See Crash Course: Obstetrics and Gynaecology
Ureters: colic due to stone or clot
See Chapter30
Uterus/adnexa: pelvic inflammatory disease, endometriosis (see Crash Course: Obstetrics and
Gynaecology)
Anxiety (see Crash Course: Psychiatry)
Myocardial infarction (especially inferior causing epigastric discomfort) (see Chapter27)
Lower lobe pneumonia (causing hypochondrial or loin pain) (see Chapter28)
Vasculitis (especially HSP and PAN) (see Chapter34)
Diabetic ketoacidosis (see Chapter33)
Addison disease (see Chapter33)
Sickle cell crisis (see Chapter36)
Very rarely: lead poisoning, porphyria, familial Mediterranean fever
life-threatening causes, such as a ruptured abdominal aortic aneurysm. Consideration of the anatomical structures
at the site of the pain will often provide clues to its cause.
Table. 9.1 summarizes the common causes of abdominal
pain.
65
Abdominal pain
HISTORY AND EXAMINATION FINDINGS
History
‘Acute abdomen’ describes sudden-onset, severe abdominal
pain that may signify a life-threatening condition. It requires urgent assessment.
The SOCRATES approach is a commonly used approach
for taking a patient’s history concerning any type of pain
(see Hints and Tips).
HINTS AND TIPS
SOCRATES
S – site: where is the pain?
O – onset: when did the pain start? Was it sudden/
gradual?
C – character: is it an ache? Is the pain sharp,
crushing, stabbing, etc.?
R – radiation.
A – associations: signs or symptoms associated
with the pain.
T – time course: is there a pattern to the pain?
E – exacerbating/alleviating factors.
S – severity.
HINTS AND TIPS
CHARACTERISTICS OFPAINAND ASSOCIATED
CONDITIONS
• Sudden onset of sustained severe pain is often
due to perforation or rupture of a viscus.
• Gradual onset with sustained pain can be seen in
inflammatory conditions, such as ulcerative colitis
or Crohn disease, infection, including abscess
formation or gastroenteritis, and malignancy.
• Colicky pain is a gripping pain that comes and
goes. It is due to muscular spasm in a viscus
wall, such as the bowel, ureters and gallbladder.
• The site and radiation of pain may help to
determine the organ involved. Pancreatic and
aortic pain may radiate to the back (these are
retroperitoneal structures), ureteric pain often
radiates from ‘loin to groin’ and diaphragmatic
irritation caused by subphrenic disease (e.g. an
abscess) may cause pain which is referred to
the shoulder tip.
• Haematemesis is seen in upper gastrointestinal
tract bleeding, projectile vomiting is seen in
pyloric stenosis and feculent vomiting results from
severe large bowel obstruction. Ask specifically
about the content of the vomit (bilious, feculent).
• Change in bowel habit is an important symptom.
Absolute constipation (no faeces or wind
passed rectally) indicates complete bowel
obstruction; gastroenteritis or diverticulitis often
causes diarrhoea. Constipation alternating with
diarrhoea is a feature of colonic malignancy
but is also seen in irritable bowel syndrome or
irritable bowel disease.
• Rectal bleeding may indicate malignancy,
inflammatory bowel disease, diverticulitis,
dysentery and angiodysplasia. Dark red
bleeding is a feature of bowel infarction.
• Dysuria, haematuria and urinary frequency
indicate urinary infection.
COMMUNICATION
It may be challenging to elicit a history from
a patient who is in pain. Offer analgesia and
antiemetics early. This will not only help build
rapport between you and the patient but will also
facilitate communication.
Examination
The first question that must be asked is ‘Is the patient acutely
ill?’ Signs of shock and peritonism should be looked for. The
examination should then focus on specific signs. Fig. 9.1
summarizes the examination approach.
Signs of shock include tachypnoea, tachycardia and hypotension, delayed capillary refill (beware that in early sepsis the peripheries may be warm because of vasodilation)
and reduced urine output. Consider sepsis (particularly
gram-negative), severe bleeding (ruptured abdominal aortic
aneurysm, splenic rupture), significant fluid loss (vomiting,
diarrhoea, third spacing in bowel obstruction and pancreatitis) and, rarely, acute Addisonian crisis.
Peritonism is inflammation of the peritoneum. This can
be localized or generalized. The patient often lies still, as
movement exacerbates the pain. Look for rebound tenderness and guarding (involuntary spasm of the abdominal
wall on palpation). When peritonism becomes generalized,
the abdomen will be rigid and bowel sounds may be scanty
and high pitched or absent because of paralysis of peristalsis. Causes of peritonism are summarized in Table9.2.
66
Blood pressure
— Shock
Pulse
— Tachycardia
Urogenital
— Hernial orifices
— Rectal examination
— Vaginal examination
— Pregnancy test
— Urine dipstick
Fig.9.1 Examining the patient with abdominal pain.
Table9.2 Causes of peritonism
Cause Examples
Infection Spread from paracolic/subphrenic
Chemical
irritation
Transmural
inflammation
abscess following surgery or paracentesis
Bowel perforation
Bile
Faeces
Gastric acid
Pancreatic enzymes
Crohn disease
Salpingitis
Abdomen
— Surgical scar
— Distension
— Grey Turner
and
Cullen signs
— Tenderness
— Guarding
— Mass
— Ascites
— Bowel sounds
Hands
— Clubbing
— Anaemia
General
— Unwell
— Pyrexia
— Dehydration
— Jaundice
— Cachexia
— Lymphadenopathy
Ascertaining the underlying causes of abdomnal pain
• Pyrexia: high temperature indicates infection; lowgrade pyrexia can be found in malignancy, bowel
infarction, inflammatory bowel disease or pancreatitis.
• Rigors, visible shaking accompanied by fever, are a
feature of sepsis, and are particularly common with
gram-negative infection.
• Cachexia: suggests a chronic disease, particularly
malignancy.
• Clubbing: inflammatory bowel disease, small bowel
lymphoma, chronic liver disease.
History and examination findings
• Lymphadenopathy: lymphoma; metastases (e.g.
Virchow node).
• Jaundice: hepatitis, gallstones or pancreatitis (causing
periampullary oedema).
• Recent surgical scar: may indicate a source of
peritoneal sepsis, such as an anastomotic leak.
• Older surgical scar: may indicate the presence of adhesions.
• Abdominal distension: generalized peritonitis, bowel
obstruction (examination findings include resonant
percussion, quiet or absent bowel sounds and,
occasionally, visible peristalsis).
• Tenderness: consider what structures lie at the site of
tenderness.
• Pain from peritoneal irritation is made worse by
movement and relieved by keeping still, whereas patients
with colic often curl into a ball and may roll around.
• Mass: this can be neoplastic or inflammatory as in
Crohn disease.
• Ascites: malignancy, peritoneal sepsis, pancreatitis,
portal hypertension.
• Bowel sounds: high-pitched (tinkling) sounds suggest
obstruction; absence indicates an ileus (paralysis of
bowel) of whatever cause.
• Dehydration.
• Cullen sign (periumbilical or central bruising) and Grey
Turner sign (bruising in the flanks): severe haemorrhagic
pancreatitis, rarely leaking abdominal aortic aneurysm.
Both are due to retroperitoneal bleeding.
• Carnett sign: worsening of pain on tensing the
muscles of the anterior abdominal wall. It suggests the
abdominal wall as the origin of pain.
• Hernial orifices (inguinal and femoral): these must be
examined, particularly if obstruction is suspected.
• Pelvic and rectal examination: pelvic inflammation,
cervical excitation, ectopic pregnancy, rectal mass or
bleeding, stool consistency. Vaginal discharge will often
be present in pelvic inflammatory disease.
• Cardiorespiratory examination: consider myocardial
infarction and pneumonia.
HINTS AND TIPS
Murphy sign: classically associated with
cholecystitis; place two fingers just inferior to the
liver border and ask the patient to take a deep
breath in. The patient reports pain, and inspiration is
limited, as the inflamed gallbladder descends onto
your fingers. A similar examination in the left upper
quadrant does not halt inspiration or cause pain.
Rovsing sign: a sudden release of pressure in the
left iliac fossa causes pain in the right iliac fossa in
appendicitis.
Both are common examination questions.
99
67