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Chapter 23 • Palpitations 291
https://t.me/med1917
Note General Appearance
Observe the patient entering the room. Note signs of
stress or anxiety. Tremors may indicate hyperthyroidism or pheochromocytoma. Flushing or sweating may
occur with pheochromocytoma. Pallor suggests anemia
or pheochromocytoma.
Take Vital Signs
Vital signs can provide information on cardiac function. Atrial brillation is suggested by an irregular
pulse that has no repeating pattern (irregularly irregular). The presence of a pulse decit (obtaining
a lower pulse rate at the wrist than at the apex) or
the auscultation of a variable intensity of the rst
heart sound suggests atrial brillation. These ndings are due to beat-to-beat variation in stroke
volume that occurs during atrial brillation. Hypertension may indicate underlying CAD or
pheochromocytoma.
Assess Jugular Venous Pressure
The presence of cannon A waves on the jugular
venous pressure (JVP) suggests an arrhythmia that
is associated with atrioventricular dissociation, such
as ventricular tachycardia. Cannon A waves are
prominent waves in the JVP that occur with the
contraction of the right atrium against a closed tricuspid valve. Cannon A waves are perceived as neck
pulsations and, when rapid and regular, may be
seen as a bulging in the neck, sometimes termed a
frog sign.
Auscultate the Heart
A displaced and enlarged cardiac point-of-maximal
impulse suggests the presence of dilated cardiomyopathy and increases the likelihood of ventricular tachycardia and atrial brillation. Cardiomegaly may be
present with pheochromocytoma.
An irregular heartbeat, both in rhythm and strength,
that begins and terminates abruptly suggests atrial
brillation.
Listen for murmurs. The midsystolic click of
mitral valve prolapse suggests a preventricular
arrhythmia. The harsh holosystolic murmur of hypertrophic cardiomyopathy, which occurs along the
left sternal border and increases with the Valsalva
maneuver, suggests atrial brillation or ventricular
tachycardia.
Assess Mental Status
Assess general behavior. Irritability may occur in patients with anxiety. Note body posture, movement, and
facial expressions. Assess thought content for delusions that may occur with substance abuse or psychoses. Young infants may exhibit poor feeding or be
irritable when palpitations are present.
Inspect the Head and Neck
Substance users may have chronic rhinorrhea, frequent
nosebleeds, or lesions in the nose or around the nostrils.
Pupils may be dilated secondary to substance use. The
patient may have dry lips, halitosis, or an odor of alcohol
or tobacco. Patients with hyperthyroidism may display
exophthalmos and thinning hair. Patients with anemia
may have pale mucous membranes.
Examine the Thyroid
In patients with hyperthyroidism, the thyroid may be
enlarged and a bruit may be present.
Examine the Extremities
Look for onycholysis and localized myxedema (edematous skin thickening) of legs (pretibial) or dorsa of
feet if you suspect hyperthyroidism.
Check Reflexes
Hyperthyroidism can produce overly brisk reexes.
LABORATORY AND DIAGNOSTIC
STUDIES
12-Lead Electrocardiogram
A standard 12-lead electrocardiogram (ECG) is the initial
test in patients with palpitations and may identify the
arrhythmia or provide insight into underlying structural
and electrical abnormalities that may be causing the
arrhythmia. Patients with electrical or structural abnormalities on 12-lead ECG require further evaluation.
ECG exercise testing is appropriate in patients who
have palpitations with physical exertion and patients
with suspected coronary artery disease or myocardial
ischemia (see Chapter 7).
Cardiac Monitoring:
Event or Continuous-Loop
These measures are used in patients with suspected
cardiac arrhythmias as the cause of the palpitations.
Holter monitoring or long-term (weeks, months) event
292 Chapter 23 • Palpitations
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monitoring is used to document ECG recordings.
Holter monitoring is a continuous 24- or 48-hour ECG
recording to evaluate the type and amount of irregular
heartbeats during regular activities, exercise, and sleep.
The patient keeps a diary to record daily activities and
any symptoms experienced. At the end of the monitoring period, the data are analyzed for arrhythmias and
are correlated with symptoms recorded by the patient.
Cardiac event monitoring is a continuous-loop, digital
memory recorder worn for extended periods of time
(up to 30 days or longer) that saves and records transient events felt by the patient. These monitors are
patient-activated as symptoms occur. Loop monitors
save information for a predetermined period prior to
the patient trigger, and can help identify the initiation
sequence for arrhythmias. These stored events can be
transmitted through a telephone for review.
Echocardiogram
An echocardiogram is a noninvasive ultrasound test for
examining the heart that provides information about the
position, size, and movements of the valves and chambers, as well as the velocity of blood ow. This test is
used to determine, detect, or rule out structural abnormalities; to evaluate velocity and direction of blood ow;
and to provide direction for further diagnostic evaluation.
Complete Blood Count
A complete blood count (CBC) with differential can be
done to establish the presence of a systemic infection.
An increase in white blood cells and bands is seen with
systemic infection. Hemoglobin and hematocrit levels
are useful if anemia is suspected as an underlying
cause of palpitations.
blood. If levels are greater than two times the reference
range, imaging studies are usually performed to evaluate the adrenal glands.
DIFFERENTIAL DIAGNOSIS
Cardiac Arrhythmias
Cardiac arrhythmias that result in palpitations include
atrial brillation or utter; supraventricular and ventricular tachycardia; premature ventricular and atrial
contractions; sick sinus syndrome; and advanced atrioventricular block. The causes are primary electrical
abnormality or electrical abnormality secondary to
structural cardiac disease or comorbid conditions. The
association of palpitations with other symptoms that
indicate hemodynamic compromise, including presyncope, syncope, or lightheadedness, may signify a lifethreatening cardiac arrhythmia. Chest pain and dyspnea may be the result of sustained tachyarrhythmias.
Physical ndings such as a pulse decit, irregular
heartbeat, or cannon A waves on JVP measurement indicate a cardiac arrhythmia as the cause of the palpitations.
ECG and cardiac monitoring may reveal the arrhythmia.
Box 23-1 lists arrhythmias that can cause palpitations.
Psychological Causes
The most common psychological causes of palpitations
are anxiety and panic disorder. The release of catecholamines during a panic attack or signicant stress can
trigger an arrhythmia. Patients with psychological
causes more commonly report a longer duration of the
sensation (.15 min) and accompanying symptoms
than do patients with other causes. It is essential to rule
out clinically signicant arrhythmias before attributing
palpitations to psychological causes.
Electrolytes
Evaluation of electrolytes is useful when the palpitation is from a suspected electrolyte imbalance.
Thyroid-Stimulating Hormone
Thyroid-stimulating hormone (TSH) level is used to
detect hyperthyroidism. An abnormal level requires
further testing. An undetectable level is diagnostic of
hyperthyroidism.
Catecholamines/Metanephrines
Catecholamines and metanephrines are measured in a
24-hour urine collection to rule out pheochromocytoma. Metanephrines may also be measured in the
Box 23-1
Arrhythmias That Can Cause
Palpitations
Atrial fibrillation/flutter
Bradycardia caused by advanced arteriovenous block or
sinus node dysfunction
Bradycardia-tachycardia syndrome (sick sinus syndrome)
Multifocal atrial tachycardia
Premature supraventricular or ventricular contractions
Sinus tachycardia or arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Wolff-Parkinson-White syndrome
From Abbott AV: Diagnostic approach to palpitations, Am Fam Physician
71:743, 2005.
Chapter 23 • Palpitations 293
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Panic Disorder
Panic disorder is manifested by sudden attacks of fear
accompanied by symptoms that may resemble a heart
attack (e.g., palpitations, chest pain, dizziness). Often the
symptoms develop rapidly and without an identiable
stressor. The individual may have had periods of high
anxiety in the past, or may have been involved in a recent
stressful situation; however, the underlying cause is typically subtle. Panic attacks subside as abruptly as they
begin, typically lasting a few minutes, although they can
last several hours. Asking a single question, “Have you
experienced brief periods, for seconds or minutes, of an
overwhelming panic or terror that was accompanied by
racing heartbeats, shortness of breath, or dizziness?” can
help identify patients with panic disorder.
Generalized Anxiety Disorder
Chronic anxiety, also referred to as generalized anxiety
disorder (GAD), manifests as persistent worries, fears,
and negative thoughts lasting at least 6 months. Excessive worry over daily activities and a tendency toward
headache and nausea are seen. Typically GAD develops over a period of time and may not be noticed until
it is signicant enough to cause problems with functioning. Anxiety is persistent, pervasive, and occurs in
many different settings.
Drugs and Medications
Palpitations that coincide with the use of a medication or
drug suggest them as a probable cause. Drugs that commonly cause palpitations include alcohol, caffeine, tobacco, digitalis, phenothiazine, theophylline, ß-agonists,
and cocaine.
On physical examination, look for telltale signs of
stimulant use: chronic rhinorrhea, frequent nosebleeds,
and lesions in the nose or around the nostrils. Pupils
may be dilated secondary to substance use. Notice if
the patient has an odor of alcohol or tobacco.
Nonarrhythmic Cardiac Causes
Nonarrhythmic cardiac causes of palpitations include
valvular heart diseases, such as aortic insufciency or
stenosis; atrial or ventricular septal defect; cardiomyopathy; congenital heart disease; and pericarditis.
Positional palpitations may reect a structural process within the heart (e.g., atrial myxoma), adjacent
to the heart (e.g., mediastinal mass), atrioventricular
nodal tachycardia, or pericarditis. Echocardiogram
can be useful in detecting nonarrhythmic cardiac
causes of palpitations. Box 23-2 lists some nonarrhythmic cardiac causes of palpitations.
Noncardiac/Systemic Causes
Noncardiac causes of palpitations include exercise,
fever, dehydration, hypoglycemia, anemia, electrolyte imbalance, hypovolemia, hyperthyroidism, and
pheochromocytoma.
A CBC may identify anemia, infection, or hypovolemia as possible underlying causes. Electrolytes can
identify electrolyte imbalance.
Anemia
Fatigue and pallor may indicate anemia. Hemoglobin
and hematocrit levels will be low.
Pheochromocytoma
Pheochromocytomas are rare catecholamine-producing
tumors of the adrenal glands. In addition to palpitations,
patients with pheochromocytoma often report severe,
pounding and paroxysmal headaches; sweating; nausea
and vomiting; visual problems; ushing; weight loss;
diarrhea; nervousness; abdominal or chest pain; panic
attacks; ank pain; pallor; tremor; fatigue; anxiety;
weakness; dyspnea; warmth; fever; dizziness; constipation; paresthesias; painless hematuria; and anorexia. On
physical examination, patients may exhibit hypertension, tremors, postural (orthostatic) hypotension, and
pallor. The heart may be enlarged.
Hyperthyroidism
Patients with hyperthyroidism may report nervousness,
emotional lability, fatigue, muscle weakness, weight
loss with good appetite, hyperdefecation, heat intolerance, menstrual changes (oligoamenorrhea), increased
Box 23-2
Nonarrhythmic Cardiac
Causes of Palpitations
Atrial or ventricular septal defect
Cardiomyopathy
Congenital heart disease
Congestive heart failure
Mitral valve prolapse
Pacemaker-mediated tachycardia
Pericarditis
Valvular disease (e.g., aortic insufficiency, stenosis)
From Abbott AV: Diagnostic approach to palpitations, Am Fam Physician
71:743, 2005.
294 Chapter 23 • Palpitations
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appetite, insomnia, and tremors. On physical examination, exophthalmos, warm skin, onycholysis, increased
sweating, and thinning hair may be evident. Patients
may have localized myxedema (edematous skin thickening) of the legs (pretibial) or dorsa of the feet. The
thyroid may be enlarged and a bruit may be present.
Deep tendon reexes (DTRs) may be brisk. High fever,
congestive heart failure, and mental status changes suggest thyroid storm. TSH level will be low or undetectable. Elderly patients have less obvious symptoms and
signs than younger patients, and a higher prevalence of
cardiac manifestations, such as atrial brillation.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Palpitations
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Cardiac Arrhythmias
CAD, lightheadedness, syncope,
chest pain, dyspnea
Psychological Causes
Panic disorder Panic attacks, terror None ECG, continuous event or
Stress/anxiety Persistent worries, fears, and negative
thoughts
Drugs and Medications
Use of alcohol, caffeine, tobacco,
digitalis, phenothiazine, theophylline,
ß-agonists, and recreational drugs
such as cocaine and amphetamines
Nonarrhythmic Cardiac Causes
May have positional palpitations Murmur may be present ECG, continuous event
Noncardiac/Systemic Causes
Anemia Fatigue Pallor; pale mucous
Pheochromo-
cytoma
Severe pounding and paroxysmal
headaches, sweating, nausea, visual
problems, flushing, weight loss,
diarrhea, nervousness, abdominal
or chest pain, panic attacks, flank
pain, pallor, tremor, fatigue, anxiety,
emesis, weakness, dyspnea, warmth,
fever, dizziness, constipation, paresthesias, painless hematuria, anorexia;
may report familial syndrome
Pulse deficit, irregular
heartbeat, cannon A
waves on JVP
None ECG, continuous event or
Substance users may
have chronic rhinorrhea,
frequent nosebleeds, or
lesions in the nose or
around the nostrils; pupils
may be dilated secondary
to substance use; dry lips,
halitosis; odor of alcohol,
or tobacco
membranes
Sweating, tremors
hypertension, postural
hypotension, heart may
be enlarged
ECG, continuous event or
loop monitoring
loop monitoring
loop monitoring
ECG, continuous event
or loop monitoring;
toxicology screen
or loop monitoring;
echocardiogram
ECG, continuous event or
loop monitoring;
Hct/Hgb
ECG, continuous event or
loop monitoring; 24-hour
urine; catecholamines
and metanephrines;
plasma metanephrines;
abdominal imaging
Chapter 23 • Palpitations 295
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Palpitations—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Hyperthyroidism Nervousness, emotional lability,
fatigue, muscle weakness, weight
loss with good appetite, hyperdefecation, heat intolerance, menstrual
changes (oligoamenorrhea), increased
appetite, insomnia, and tremors
CAD, coronary artery disease; DTR, deep tendon reflex; ECG, electrocardiogram; JVP, jugular venous pressure; TSH, thyroid-stimulating hormone.
Exophthalmos, warm skin,
onycholysis, increased
sweating and thinning
hair, localized myxedema
of legs (pretibial) or dorsa
of feet; enlarged thyroid,
bruit may be present;
brisk DTRs
ECG, continuous event or
loop monitoring; TSH
REFERENCES AND READINGS
Abbott AV: Diagnostic approach to palpitations, Am Fam Physician
71:743, 2005.
Barsky AJ, Ahern DK, Delamater BA, Clancy SA, Bailey ED:
Differential diagnosis of palpitations: preliminary development
of a screening instrument, Arch Fam Med 6:241, 1997.
Batra A, Hohn A: Consultation with the specialist: palpitations,
syncope, and sudden cardiac death in children: who’s at risk?
Pediatr Rev 24:269, 2003.
Dubois RW, Goodnough LT, Ershler WB, Van Winkle L, Nissenson
AR: Identication, diagnosis, and management of anemia in
adult ambulatory patients treated by primary care physicians:
evidence-based and consensus recommendations, Curr Med Res
Opin 22:385, 2006.
Lenders JW, Eisenhofer G, Mannelli M, Pacak K: Phaeochromocytoma,
Lancet 366:665, 2005.
Reid ER, Wheeler SF: Hyperthyroidism: diagnosis and treatment,
Am Fam Physician 72:623 2005.
Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK:
Does this patient with palpitations have a cardiac arrhythmia?
JAMA 302:2135, 2009.
Thiene G, Carturan E, Corrado D, Basso C: Prevention of sudden
cardiac death in the young and in athletes: dream or reality?
Cardiovasc Pathol 19:207, 2010.
Zimetbaum P, Josephson ME: Evaluation of patients with palpitations,
N Engl J Med 19:1369, 1998.
C H A P T E R
https://t.me/med1917
24
Penile Discharge
enile discharge results from an infectious or inammatory process secondary to exposure or
P
contact with organisms that enter and ascend the
urethra. Males infected with Chlamydia trachomatis
may be asymptomatic 25% of the time, and symptoms
may be absent with gonorrhea infections. Coinfections
with both Neisseria gonorrhoeae and Chlamydia organisms may be present in up to 25% of heterosexual
males.
Urethritis in males related to a sexually transmitted
infection (STI) that is acquired during unprotected
sexual contact is classied as either gonococcal urethritis or nongonococcal urethritis (NGU). It is not possible
to determine the causative organism based on symptoms or physical examination alone. Although patients
may be tentatively classied clinically, laboratory tests
are used to direct diagnosis and treatment. The most
frequently identied organism (40%) in nongonococcal
infection is Chlamydia trachomatis. Other organisms
identied in NGU include Ureaplasma urealyticum
and, less frequently, Trichomonas.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this likely a sexually transmitted infection?
Key Questions
n Are you sexually active? How many sexual partners
do you have?
n Do you have any new partners?
n When was the last time you had unprotected sex?
n When did you rst notice the symptoms?
Sexual History
A history of multiple sexual partners signies a risk
of exposure to STIs. The incidence of Ureaplasma
urealyticum increases with the number of sexual partners. A new partner also is a risk factor, as is a sexual
partner who has other sexual partners. Sexually active
296
adolescents are at risk for STIs because of impetuous
sexual activities, lack of barrier protection use, and
use of alcohol or drugs. STIs are a serious health
problem, occurring in about 25% of sexually active
adolescents.
Unprotected Sex
Unprotected sex that is vaginal, oral, or anal increases
the chances of STIs.
Number of Days Between Exposure
and Symptom Onset
For patients with a single exposure, a shorter incubation
period (2 to 6 days) is characteristic for N. gonorrhoeae
and a longer period (2 to 3 weeks) for C. trachomatis.
For patients with multiple or unknown exposures, the
time interval may not be useful.
Are there any risk factors that point me
in the right direction?
Key Question
n Have you used street or illicit drugs?
History of Drug or Substance Abuse
Substance or drug abuse is a risk factor for unprotected
and indiscriminate sexual activity.
What do the characteristics of the discharge
tell me?
Key Questions
n What color is the discharge?
n How much discharge are you having?
n What is the consistency of the discharge?
Color, Consistency, and Amount of Discharge
The presence of copious amounts of spontaneous
yellow-greenish drainage is indicative of a gonococcal
infection. A scant mucoid discharge is characteristic
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of a nongonococcal infection. Substance or drug abuse
may produce a scant, whitish penile discharge.
Is this a local infection or process?
Key Questions
n Is the tip of your penis red and inamed?
n Can you describe how you clean yourself?
Red, Inflamed Glans Penis
A beefy-red, inamed glans penis is indicative of a
yeast infection or a xed drug reaction often caused by
tetracycline. Lubricated condoms or spermicidal gel
can cause contact dermatitis.
Hygienic Practices
Poor hygiene or aggressive hygiene with inappropriate
or harsh cleansers can cause local irritation and result
in inammation.
Is this complicated urethritis?
Key Questions
n Do you have frequency, urgency, or nocturia?
n Do you have rectal, testicular, or low back pain?
n Do you have pain in any joints or muscles?
n Do you have any skin sores or lesions?
Symptoms That May Indicate Complicated
Urethritis
Symptoms of urinary frequency, urgency, and nocturia
may indicate complications of a urethral infection
caused by spreading of the infection to other urinary
tract structures, such as the prostate (see Chapter 17).
Symptoms of perirectal, testicular, or low back pain
indicate involvement of the vas deferens and the epi-
didymis, which can lead to acute epididymitis and/or
the involvement of the testicles and the development of
orchitis.
Symptoms That May Indicate Reiter
Syndrome
Reiter syndrome is a complication of NGU that
follows urogenital infection and classically includes
arthritis, conjunctivitis, oral mucosal ulcers, and der-
matitis. More common is the joint and tendon involve-
ment after C. trachomatis infection. This complication
has also been reported in HIV-positive patients. It is
less common in non-Caucasian populations, and the
incubation period is usually 1 to 4 weeks after the
onset of urethritis.
Disseminated Systemic Urethral Infection
A disseminated gonococcal infection can produce papules or petechiae that progress to pustules on the skin
surfaces of the hands, arms, and legs.
Is this an upper urinary tract problem?
Key Questions
n Have you had a fever or chills?
n Have you noticed any blood in your urine?
n Are you having any acute pain?
n Where is the pain?
Fever
The presence of fever indicates an ascending infection
of the upper urinary tract (e.g., pyelonephritis) or a
descending infection of the lower urinary tract (e.g.,
prostatitis, epididymitis). A fever with a temperature of
greater than 101º F (39º C) should be cause for concern
and aggressive treatment.
Hematuria
Blood in the urine signies renal involvement—
specically, pyelonephritis or lithiasis. Painless hematuria in the elderly is characteristic of bladder
tumor or is a late symptom of carcinoma of the
kidney.
Acute Pain
Abdominal pain, ank pain, and costovertebral angle
(CVA) pain are characteristic of bladder, ureter, and
kidney involvement. Urinary tract pain is usually perceived locally in the area where sensory bers of
nerves are located. However, pain can be referred to a
site distant from the area that is affected because sensory nerves of the lower body are concentrated in
the same segments of the spinal cord. Most pain in the
urinary tract is referred pain and may not be perceived
by the patient in the site where the problem actually
occurs. A dull ache may be felt at the CVA or ank.
Pain may be elicited by applying tension to the renal
capsule, pelvis, or ureter. Ureter pain may be perceived
in the bladder, penis, scrotum, or perineum. Testicular
pain may be a result of renal calculi. Pain may vary in
intensity from a dull ache to a sharp, stabbing, colicky
pain that is unbearable.
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What else could this be?
Key Questions
n Do you have scrotal pain and/or fever?
n Have you had recent instrumentation in the urethra
(e.g., catheterization)?
n Have you been treated recently for an STI?
n Are you or your partner an immigrant, or have you
recently engaged in foreign travel?
Scrotal Pain or Fever
Epididymitis usually presents with scrotal pain that
developed over a period of several hours. The patient
often is also febrile.
Recent Treatment or Instrumentation
Recent treatment or instrumentation of the urethra produces a risk of infection. Elderly males are especially
at risk because they often undergo urinary tract treatment or instrumentation secondary to benign prostatic
hypertrophy.
Recent Treatment for an STI
Recent treatment for an STI may indicate treatment
failure, a coinfection that was not covered by the prescribed drug, or recent exposure. The appropriate laboratory test may not have been done or was not available, or treatment may have been empirically based on
presenting symptoms. Infection with more than one
organism or a coinfection may take place. Urethritis
can also develop from a nongonococcal organism that
has a longer incubation period and was not sensitive to
the drug prescribed. The urethritis episode may also
represent a recent exposure after treatment. Another
possibility could be lack of patient compliance with
treatment. The patient does not take the medication as
directed or stops taking the medication when the symptoms disappear but before the causative organism is
eliminated from the urethra.
Immigrant Patient/Partner or Recent Foreign
Travel
Immigrants, partners of foreigners, and patients with a
history of foreign travel may have exposure to STIs that
are not seen frequently in the United States but have a
higher incidence and prevalence in foreign countries.
Resistant strains of common organisms are also prevalent in foreign countries. Referral or infectious disease
consultation with urologists, infectious disease departments, or public health departments may be necessary
to identify and treat patients with unusual STIs.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Note General Appearance
If the patient appears systematically ill, a more aggressive and immediate approach should be taken and
an expanded examination becomes appropriate. An
ascending infection is usually limited to the anterior
portion of the male urethra and is most likely to cause
local signs and symptoms in the male patient. The
patient who appears to be in acute pain from sites
other than the urethra warrants more than a focused
physical examination.
Examine skin surfaces, exposed orices, and eyes,
as well as mucous membranes and bordering areas
around sites that may have been exposed during sexual
activity.
Note eyes for discharge or infection. Check around
nares and lips for signs of infection or lesions. Inspect
the chest, back, palms, and bottoms of the feet for
rashes or lesions. Secondary syphilis produces typical
rashes and lesions in these areas, as does Reiter syndrome. Spontaneous greenish-yellow discharge from
the eyes is indicative of gonococcal infections.
Inspect the skin of the abdomen, inguinal areas, and
thighs for lesions or rashes. Disseminated gonococcal
infections may produce papules, petechiae, and pustules
on the hands, arms, and feet. Chlamydia may produce
hyperkeratotic lesions on skin surfaces and a rash on the
penis in the uncircumcised male.
Palpate Lymph Nodes
Palpate the cervical, axillary, inguinal, and femoral
lymph nodes for adenopathy. Although a nonspecic
indicator of infection, lymph nodes may enlarge in
response to exposure from several organisms. Virus
exposure may cause lymph node enlargement, or there
may be extension of bacterial organisms into adjacent
lymph chains, indicating regional infections. It is important to ascertain how long the nodes have been
enlarged and what symptoms have appeared during
the course of enlargement. Assess the state of the
nodes, such as any redness, swelling, heat, or pain, or
if they are rm, mobile, or boggy. Sexually active
males may have some inguinal lymph node enlargement, and the patient may or may not be aware of the
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enlargement. Lymph node enlargement should be documented and described.
Examine Body Hair
Examine hair on the head and in the pubic area and
inspect underlying skin areas. Hair shafts can be
infected with lice and nits. Hair follicles can be irritated from scratching and from secondary infection
by other organisms.
Examine the Penis and Urethral Meatus
Inspect penile skin surfaces for lesions, especially the
underside of the head of the penis around the area of
the frenulum, where viral lesions may be found. Palpate
the shaft of the penis for tenderness or for strictures
of the urethra. Retract the foreskin if present and inspect the glans penis, corona, and frenulum for lesions.
Inspect the meatus for redness, discharge, patency, or
growths. If there is discharge, note if it is spontaneous
or produced by milking or stripping the penis. Document a tender urethra and describe the character of any
discharge. Note whether the discharge is profuse and
yellow-green, which indicates gonococcal infection,
or scant and mucoid-like, which is characteristic of
C. trachomatis and nongonococcal infection.
Examine the Scrotum and Testicles
Inspect and palpate the scrotum for lesions. Palpate the
testicles and epididymis for tenderness and any signs
of inammation. Elevating a tender testicle may alleviate pain and reduce discomfort in epididymitis. The
testicle may not be dened when there is an acute
infection present because of examiner-produced pain
with palpation. The borders of the testicle may also be
obliterated from swelling and edema.
Inspect and Examine Other Sites
for Lesions and Discharge
Inspect other sites, such as the mouth and pharynx,
using a tongue depressor to visualize buccal skinfolds
for any lesions. The pharyngeal area may be asymptomatic. Depending on the patient’s sexual practices
and preferences, other sites exposed to sexual contact,
such as the rectum, need to be examined. Rectal bleeding, pus, and mucus may indicate proctitis and require
further anoscopic examination and special cultural and
laboratory consideration (see Chapter 26). Examine
any joints or tendons that are inamed or tender or
have limited range of motion.
LABORATORY AND DIAGNOSTIC
STUDIES
To improve the probability of identifying the caus-
ative organism, the patient should be examined and
specimens obtained at least 1 hour after the last
voiding, ideally up to 4 hours after voiding. Manufac-
turer directions should be followed for all materials
used to collect specimens, and policies and proce-
dures should be followed to obtain valid and reliable
results from laboratory and diagnostic tests.
Urine Dipstick
Urine dipstick is used as a screening test for urethri-
tis. The leukocyte esterase (LE) strip is calibrated to
turn purple in 60 seconds, indicating 5 or more white
blood cells (WBCs) in the urine. LE detects esterase,
an enzyme released by WBCs, and a positive LE re-
sult is indicative of urethritis (75% to 90% sensitiv-
ity, 95% specicity). The nitrite strip is calibrated to
turn pink within 30 seconds and signies nitrites
produced by 105 or more organisms per milliliter.
Urine that tests positive for leukocyte esterase and
nitrites should be cultured for bacteria. However,
note that some organisms that cause UTIs do not
convert nitrate to nitrites (e.g., Staphylococcus and
Streptococcus).
Urinalysis with Microscopic Examination
Look for proteinuria and glycosuria, which suggest
kidney involvement. The presence of casts, red
blood cells (RBCs), and bacteria is also important.
Casts indicate hemorrhage or pathological condi-
tions of the nephrons. RBCs indicate acute inam-
matory or vascular disorders of the glomerulus.
More than 1 or 2 RBCs/high-power eld (HPF) is
abnormal and can indicate renal or systemic disease
or kidney trauma. Microscopic examination of the
urine resulting in 20 or more organisms/HPF
indicates urinary tract infection. Fewer than 20
organisms/HPF merits further study, such as culture
and sensitivity.
Segmented Urine Collection for Culture
and Sensitivity
Obtaining segmented urine specimens is a procedure
used to identify the site along the urinary tract where
the colonization of organisms is occurring and is useful
in diagnosing prostatitis (see Chapter 17).
300 Chapter 24 • Penile Discharge
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Gram Stain of Specimens
The Gram stain has 95% specicity in gonococcal
urethritis. Sensitivity in urethritis is nearly 100%.
Gram stain of urethral discharge should be performed to determine inammation (WBCs) and the
presence of either gram-negative or gram-positive
bacteria.
If the stain is positive for polymorphonuclear neutrophils (PMNs), then the smear is examined for
gram-negative intracellular diplococci (GNICDCs).
If diplococci are found, the smear is considered
positive for gonococcal urethritis. A smear that is
equivocal or atypical indicates a mixed gonococcal
and NGU. If there are no GNICDCs, then an NGU is
indicated.
Culture and Sensitivity
Culture and sensitivity should be performed on specimens to conrm the identity of the causative organism
and its sensitivity to antibiotics. This is especially important in populations with resistant organisms. Cultures are necessary in cases of suspected rectal or
pharyngeal infection, as well as a typical urethral
swab.
DNA Testing for Infectious Organisms
DNA testing using a rst-void sample or a sample
taken from the urethra or rectum provides rapid, sensitive, and specic results. A number of products are
available. Follow manufacturer directions to collect
and transport the sample. Nucleic acid amplication
tests (NAATs) are available to test for C. trachomatis
and N. gonorrhoeae. Single or dual organism tests are
available.
Doppler Blood Flow
Doppler blood ow studies can be performed to support
the diagnoses of testicular torsion and epididy mitis.
Testicular torsion results in a lack of blood ow to
the testicle, whereas in epididymitis the blood ow is
intact. Color Doppler ow studies also provide information concerning blood ow to the testicles and identify hot areas of infection.
Complete Blood Count
A complete blood count with differential can be performed to indicate a systemic response to infection.
Serology for Syphilis
Serological tests are used for screening and diagnosing syphilis and are recommended if other STIs
are found or suspected. The screening tests are
nontreponemal and include Venereal Disease Research Laboratory (VDRL), rapid plasma reagin
(RPR), and enzyme immunoassay (EIA) tests. Diagnostic tests are Treponema pallidum–specic and
include uorescent treponemal antibody absorption
test (FTA-ABS) and Treponema pallidum particle
agglutination assay (TPPA).
Human Leukocyte Antigen
The human leukocyte antigen (HLA) test is done to
determine antigens that are present for specic diseases. Histocompatibility locus A (HLA-B27) tissue
haplotype is associated with sexually acquired reactive arthritis seen in Reiter syndrome. This test is not
specic but is used to conrm the diagnosis.
DIFFERENTIAL DIAGNOSIS
Urethritis
Urethritis presents with itching, burning, or pain
around the urethral opening. Symptoms vary in severity. Discharge may range from copious amounts of
greenish-yellow discharge to scant mucoidlike discharge that may only be visible before the rst voiding
of the day. Patients commonly present with complaints
of urinary frequency, urgency, and/or burning with
urination, as well as penile discharge. Patients may
also report a known sexual partner or that the public
health department has contacted them indicating that
they need to be checked for an STI. If you are unable
to make a diagnosis based on history and physical ndings, diagnostic testing is necessary for specic organism identication.
N. gonorrhoeae and NGU caused by C. trachomatis
are the two most common infectious causes of urethritis. A coinfection with both organisms is found in up
to 25% of the cases.
Gonococcal Urethritis
Gonococcal STIs are usually the easiest to diagnose
because the patient often presents with complaints of
a yellow-green discharge and burning on urination.
Unprotected sexual relations increase the risk for contracting this STI. Gonococcal infection often becomes
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