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Chapter 25 • Nasal Symptoms and Sinus Congestion
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309
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Nasal Symptoms and
Sinus Congestion—cont'd
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Obstruction History of asthma, aspirin intoler-
ance; foreign body in children;
tumor in adults; infants with
choanal atresia: difficulty
Nasal polyposis History of asthma, aspirin
Osteomyelitis of
frontal bone
CT, Computed tomography; URI, upper respiratory infection.
feeding; cyanosis if bilateral
intolerance
History of head trauma, diving Appears severely ill; periorbital
References and Readings
Brook L: Acute sinusitis in children, Pediatr Clin North Am 60:409,
2013.
DeMuri G, Wald ER: Acute bacterial sinusitis in children, Pediatr
Rev 34:429, 2013.
Gargiulo KA, Spector ND: Stuffy nose, Pediatr Rev 31:320, 2010.
Gendo K, Larson EB: Evidence-based diagnostic strategies for
evaluating suspected allergic rhinitis, Ann Intern Med 140:278,
2004.
Marple BF, Stankiewicz JA, Baroody FM, et al: Diagnosis and man-
agement of chronic rhinosinusitis in adults, Postgrad Med
121:121, 2009.
Novelline RA: Squire’s fundamentals of radiology, ed. 6, Cambridge,
Mass, 2004, Harvard University Press.
Increased pain with forward
motion or Valsalva; pain with
percussion and palpation
of sinuses; no transillumination; septal deviation
Presence of polyps Nasal endoscopy;
and frontal edema
Rose A, Thorp B, Zanation AM, Ebert CS: Chronic rhinosinusitis in
children, Pediatr Clin North Am 60:976, 2013.
Rosenfeld RM, Andes D, Bhattacharyya N, et al: Clinical practice
guideline: Adult sinusitis, Otolaryngol Head Neck Surg 137:S1,
2007.
Ryan MW: Evaluation and management of the patient with “sinus,”
Med Clin North Am 94:881, 2010.
Skoner DP: Allergic rhinitis: Denition, epidemiology, pathophysi-
ology, detection and diagnosis, J Allergy Clin Immunol 108:S2,
2001.
Wallace DV, Dykewicz MS, Berstein DL, et al: The diagnosis and
management of rhinitis: An updated practice parameter, J Allergy
Clin Immunol, 122:S1, 2008.
Zacharisen M, Casper R: Pediatric sinusitis, Immunol Allergy Clin
North Am 25:313, 2005.
Sinus radiographs;
CT scan
may require biopsy
Sinus and skull radiographs;
blood culture
CHAPTER
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26
alpitations are dened as an unpleasant awareness
P
of the forceful, rapid, or irregular beating of
the heart. It is a common presenting symptom that is
usually benign; however, occasionally palpitations can
indicate a life-threatening arrhythmia.
Palpitations are described by patients as a thumping, pounding, or uttering sensation in the chest.
This sensation can be either intermittent or sustained,
and either regular or irregular. Patients often note
palpitations when quietly resting, a time when other
stimuli are minimal.
Causes of palpitations can be of cardiac or noncardiac origin. Cardiac causes include arrhythmias;
structural abnormalities such as mitral valve prolapse,
valvular disease, cardiomyopathy; and congenital
heart lesions. Noncardiac causes include psychological conditions such as anxiety; systemic conditions
including thyroid disorders, anemia, and hyperdynamic cardiovascular states; and drugs, medications,
and stimulants. In children, fever, anxiety, exercise,
and anemia are common causes of palpitations.
The principal goals in assessing patients with palpitations is to distinguish cardiac from noncardiac causes
and determine if the symptom is caused by a lifethreatening arrhythmia.
Palpitations
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Could this patient have a life-threatening arrhythmia?
Key Questions
l
Do you have a history of coronary artery disease
(CAD)?
l
Are you lightheaded or have you had episodes of
passing out?
l
Are you having chest pain?
l
Have you had difculty breathing?
l
Do you have a family history of sudden cardiac
death?
l
Have you had heart surgery?
Coronary Artery Disease
Patients with risk factors for or preexisting coronary
artery disease (CAD) are at greater risk for ventricular
arrhythmias as a cause for palpitations. Risk factors
include smoking, hypertension, diabetes, a history of
myocardial infarction (MI), and a family history of
heart attack or stroke before age 60.
Lightheadedness/Syncope
Palpitations associated with other symptoms suggestive
of hemodynamic compromise, including lightheadedness
or syncope, may signify a life-threatening cardiac
arrhythmia.
Chest Pain, Dyspnea
Palpitations caused by sustained tachyarrhythmias in
patients with CAD can be accompanied by angina
pectoris or dyspnea (shortness of breath). Palpitations
associated with chest pain suggest ischemic heart disease; if the chest pain is relieved by leaning forward,
pericardial disease is suspected. Exertional palpitations
associated with chest pain, lightheadedness, or both in
the athlete may indicate an underlying cardiovascular
disorder.
Sudden Cardiac Death
A family history of sudden cardiac death (SCD) may
indicate an inherited cardiac problem.
Cardiac Surgery
Children and adults who have had cardiac surgery are
at risk for arrhythmias and palpitations.
What else do I need to know about the palpitation?
Key Questions
l
How would you describe the palpitation/sensation?
l
When do the palpitations occur? Are they associated
with rest or activity?
l
How long do the palpitations last?
l
Do the palpitations start or stop abruptly?
310
Chapter 26 • Palpitations
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311
Description of Palpitations
Flip-flopping
Single skipped beats or a sensation of the heart stop-
ping and then starting with a pounding, ipping, or
jumping sensation, especially while sitting quietly
or lying in bed and lasting only for brief periods, are
typically attributed to premature contraction of the
atria or ventricles. The sensation that the heart has
stopped results from the pause following the prema-
ture contraction, and the pounding or ipping sensa-
tion results from the forceful contraction following
the pause.
Rapid Fluttering in the Chest
A feeling of rapid uttering in the chest may result
from atrial or ventricular arrhythmias, including sinus
tachycardia.
Pounding in the Neck
A pounding feeling in the neck is caused by the dis-
sociation of atrial and ventricular contractions so that
the atria contract against closed tricuspid and mitral
valves, producing cannon A waves, which are large
pressure waves seen in the neck as a result of the si-
multaneous contraction of the atria and ventricles.
The sensation of rapid and regular pounding in the
neck is typical of reentrant supraventricular arrhyth-
mias, particularly atrioventricular nodal tachycardia.
Occurrence of Palpitations
Palpitations that start during sleep or states of increased
vagal tone (e.g., at termination of exercise) may be associ-
ated with vagal-mediated atrial brillation or certain sub-
types of long QT syndromes. Palpitations that are worse at
night may be caused by benign ectopy or atrial brillation.
Palpitations that start and stop abruptly suggest
supraventricular or ventricular tachycardias. Palpitations
that can be stopped using patient-initiated vagal
maneuvers, such as the Valsalva maneuver, suggest
supraventricular tachycardia.
Rapid palpitations during catecholamine excess,
such as during exercise, suggest ventricular tachycardia, sinus tachycardia, or atrial brillation. Palpitations
that occur regularly with exertion suggest hypertrophic cardiomyopathy or CAD. Palpitations at rest
that are exacerbated by exercise suggest anemia. Persistent palpitations at rest may indicate a systemic
condition.
Positional palpitations may reect atrioventricular
nodal tachycardia, pericarditis, or a structural process
within the heart (e.g., atrial myxoma) or adjacent to the
heart (e.g., mediastinal mass).
Could this be related to stress or a psychological
condition?
Key Questions
l
Have you experienced panic attacks (brief periods
[seconds or minutes] of an overwhelming panic or
terror accompanied by racing heartbeats, shortness
of breath, or dizziness)?
l
Can you describe your stress level and how you cope
with stress in your life?
l
Do you or anyone in your family have a problem
with panic attacks, anxiety, or depression?
l
What other symptoms are you having?
Panic Disorder/Stress/Anxiety
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 minutes) and accompanying
EVIDENCE-BASED PRACTICE
This systematic review included 23 studies. Seven studies
examined the utility of the patient history in diagnosing an
arrhythmia as the cause of palpitations. A slightly increased
likelihood of a cardiac arrhythmia was associated with a history of cardiac disease and palpitations affected by sleeping
or while at work. A history of panic disorder or having palpitations lasting less than 5 minutes made the presence of cardiac arrhythmia slightly less likely. A regular rapid-pounding
Reference: Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK: Does this patient with palpitations have a cardiac arrhythmia? JAMA
302:2135, 2009.
Can Patient History Predict Arrhythmias?
sensation in the neck that occurred with the palpitations increased the likelihood that the palpitations were due to a
specific arrhythmia (i.e., atrioventricular node reentry tachycardia). Likewise, the absence of that symptom made the
likelihood of atrioventricular tachycardia unlikely. The authors
concluded that patient history cannot exclude clinically significant arrhythmias in most patients, and electrocardiographic monitoring is required.
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Chapter 26 • Palpitations
symptoms than patients with other causes. It is essential to rule out clinically signicant arrhythmias before
attributing palpitations to psychological causes. Panic
attacks, however, may also indicate pheochromocytoma, a rare tumor of the adrenal tissue, resulting in the
release of too much epinephrine and norepinephrine.
Other Symptoms
Palpitations associated with hyperventilation, hand
tingling, nervousness, shortness of breath, or dizziness
are common when anxiety or panic disorder is the underlying cause. Children with serious arrhythmias may
not report palpitations. Young infants may exhibit poor
feeding or be irritable when palpitations are present.
Could this be secondary to a systemic condition?
Key Questions
l
What other symptoms are you having?
l
Have you been ill?
l
Are you pregnant?
Symptoms/Illness
Noncardiac symptoms should be elicited because the
palpitations may be caused by a normal heart responding to a metabolic or inammatory condition. Palpitations can be precipitated by vomiting or diarrhea that
lead to electrolyte disorders and hypovolemia. Other
systemic causes of palpitations include exercise, fever,
dehydration, hypoglycemia, anemia, anorexia, hyperthyroidism, and pheochromocytoma.
A complete blood count may identify anemia, infection, or hypovolemia as possible underlying causes.
Evaluation of electrolytes can identify an imbalance.
Fatigue and shortness of breath can suggest anemia. Weight loss and heat intolerance may indicate
hyperthyroidism. Patients with hyperthyroidism also
report nervousness, emotional lability, fatigue, muscle
weakness, increased sweating, menstrual changes
(oligomenorrhea), increased appetite, insomnia, thinning hair, tremors, and anxiety. A fever with hypotension may indicate myocarditis.
A pheochromocytoma, although rare, can lead to
palpitations. Patients typically report headache (usually
severe, pounding, and paroxysmal), sweating, nausea
and vomiting, visual problems, episodic ushing,
weight loss, diarrhea, nervousness, abdominal or chest
pain, panic attacks, ank pain, pallor, tremor, fatigue,
anxiety, weakness, dyspnea, warmth, fever, dizziness,
constipation, paresthesias, hematuria, and anorexia.
Pregnancy
Pregnancy produces a hyperdynamic cardiovascular
state which may cause palpitations.
Are drugs, medications, or other stimulants implicated?
Key Questions
l
What prescription and over-the-counter (OTC) medi-
cations are you taking?
l
What recreational drugs do you use?
l
Are the palpitations associated with caffeine or
tobacco use?
Medications
Palpitations can result from OTC and prescription
medications. Medications that prolong the QT interval
and predispose patients to arrhythmias include antidysrhythmics, antimicrobials, antihistamines, psychotropic drugs, and other medications, such as motility
medications, electrolyte-depleting diuretics, and protease inhibitors for human immunodeciency virus.
Palpitations may occur with the use of sympathomimetic agents, vasodilators, anticholinergic drugs, or
b-agonists. In children, cold medicines may cause
palpitations.
Stimulants
Stimulants such as caffeine, cocaine, amphetamines,
and nicotine enhance the strength of myocardial contraction and may cause palpitations. Energy drinks and
workout supplements marketed to increase endurance,
concentration, and performance also have a high caffeine content and may therefore lead to the occurrence
of palpitations.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Most patients with episodic palpitations are asymptomatic on physical examination. Typically, the purpose of
the physical examination is to identify structural heart
abnormalities to help conrm or rule out the presence
of an arrhythmia.
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.
Chapter 26 • Palpitations
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313
Take Vital Signs
Vital signs can provide information on cardiac function.
Blood pressure and pulse should be taken in the supine,
sitting, and standing positions. Atrial brillation is sug-
gested 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 at-
tributable to beat-to-beat variation in stroke volume that
occurs during atrial brillation. Hypertension may indi-
cate underlying CAD or pheochromocytoma. Weight
loss from anorexia nervosa or bulimia nervosa may cause
palpitations as a result of dehydration. In addition, the
possible use of appetite suppressants, diuretics, and/or
vomiting may result in an electrolyte imbalance. A fever
with hypotension and the presence of a murmur may
indicate myocarditis or pericarditis.
Assess Jugular Venous Pressure
The presence of cannon A waves on the jugular venous
pressure (JVP) examination of the jugular veins sug-
gests an arrhythmia that is associated with atrioven-
tricular dissociation, such as complete heart block or
ventricular tachycardia. Cannon A waves are promi-
nent 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 left ventricular hyper-
trophy or cardiomyopathy. Hypertrophic and dilated
cardiomyopathies can increase the likelihood of ven-
tricular tachycardia and atrial brillation.
An irregular heartbeat, both in rhythm and strength, that
begins and terminates abruptly suggests atrial brillation.
Listen for murmurs. A midsystolic click suggests
mitral valve prolapse. Mitral valve prolapse has an association with supraventricular arrhythmias. The harsh
holosystolic murmur of hypertrophic cardiomyopathy,
which occurs along the left sternal border and increases with the Valsalva maneuver, can be associated
with 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
Intranasal substance users may have chronic rhinorrhea,
frequent nosebleeds, or lesions in the nose and around
the nostrils. Pupils may be dilated secondary to substance
use. The patient may have dry lips, halitosis, and 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 thyroid disease, the thyroid may be
enlarged and a bruit may be present in hyperthyroidism.
Examine the Extremities
Look for onycholysis (detachment of the nail from the
nail bed) and localized myxedema (edematous skin
thickening) of the legs (pretibial) or dorsa of the feet if
you suspect hyperthyroidism. The nail beds should be
examined for cyanosis and clubbing.
Check Reflexes
Hyperthyroidism can produce overly brisk reexes.
LABORATORY AND DIAGNOSTIC STUDIES
Twelve-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 a 12-lead ECG require
further evaluation.
ECG exercise stress testing is appropriate in patients who have palpitations with physical exertion and
patients with suspected CAD or myocardial ischemia
(see Chapter 8).
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
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
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Chapter 26 • Palpitations
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 patientactivated as symptoms occur or can be automatically
triggered by a predened high or low heart rate.
Implantable loop monitors save information for a predetermined period before the patient trigger and can
help identify the initiation sequence for arrhythmias.
These stored events can be transmitted for review.
Echocardiogram
An echocardiogram is a noninvasive ultrasound test for
examining the heart that provides information about the
ventricular function and position, size, and movements
of the valves and chambers, and velocity of blood ow
through the heart. This test is used to determine, detect,
or rule out structural abnormalities or hypertrophy; 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.
Electrolytes
Evaluation of electrolytes is useful when the palpitation is from a suspected electrolyte imbalance.
Thyroid-Stimulating Hormone and Free T
4
Thyroid-stimulating hormone (TSH) and free T4 (fT4)
levels are used to detect thyroid disease. An abnormal
level requires further testing. An undetectable TSH
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
blood. If levels are greater than two times the reference
range, imaging studies are usually performed to evaluate the adrenal glands.
DIFFERENTIAL DIAGNOSIS
Cardiac Causes
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
abnormalities or electrical abnormalities secondary to
structural cardiac disease or comorbid conditions. The
association of palpitations with other symptoms that
indicate hemodynamic compromise, including syncope or lightheadedness, may signify a life-threatening
cardiac arrhythmia, and referral to a cardiologist is
warranted. 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 26-1 lists arrhythmias that can cause
palpitations.
EVIDENCE-BASED PRACTICE
This systematic review included 28 studies, both descriptive
and experimental, which compared the yield of two or more
devices or diagnostic strategies in detecting cardiac arrhythmias. With the continuous event recorder (CER), a diagnosis
was established in 21% to 62% of the studied patients,
compared with a maximum of 30% diagnosed with Holter
monitoring. The CER was better at excluding arrhythmias
during symptoms than the Holter monitor (34% and 2%, respectively). Automatically triggered recorders detected more
Data from Hoefman E1, Bindels PJ, van Weert HC: Efficacy of diagnostic tools for detecting cardiac arrhythmias: Systematic literature search. Neth
. 18:543, 2010.
Heart J
What Diagnostic Device is Best to Use?
arrhythmias (72% to 80%) than patient-triggered devices
(17% to 75%). Implantable devices are used for prolonged
monitoring periods in patients with infrequent symptoms or
unexplained syncope. The authors concluded that the choice
of the device depends on the characteristics of the symptoms
and the patient. As a result of methodological shortcomings
of the included studies, no evidence-based diagnostic strategy was proposed.
Chapter 26 • Palpitations
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315
Box 26-1
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 complexes
• Premature ventricular complexes
• Sinus tachycardia or arrhythmia
• Supraventricular tachycardia
• Ventricular tachycardia
• Wolff-Parkinson-White syndrome (AV-nodal reentrant
tachycardia)
From Abbott AV: Diagnostic approach to palpitations, Am Fam Physician
71:743, 2005.
Structural Abnormalities
Structural 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) or adjacent to
the heart (e.g., mediastinal mass), atrioventricular
nodal tachycardia, or pericarditis. An echocardiogram
can be useful in detecting structural cardiac causes of
palpitations. Box 26-2 lists some structural cardiac
causes of palpitations.
Noncardiac Causes
Psychological Causes
Panic disorder. Panic disorder is manifested by sud-
den attacks of fear accompanied by symptoms that
may resemble a heart attack (e.g., palpitations, chest
pain, dizziness). Often the symptoms develop rapidly
Box 26-2
Structural 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.
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 to have symptoms
of 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.
Systemic Causes
Anemia. Fatigue and pallor may indicate anemia.
Hemoglobin and hematocrit levels will be low.
Hyperthyroidism. Patients with hyperthyroidism
may report nervousness, emotional lability, fatigue,
muscle weakness, weight loss with good appetite,
hyperdefecation, heat intolerance, menstrual changes
(oligomenorrhea), increased 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. DTRs may be
brisk. High fever, congestive heart failure, and mental
status changes suggest thyroid storm. TSH level will
be low or undetectable. Older adult patients have less
obvious signs and symptoms than younger patients and
a higher prevalence of cardiac manifestations such as
atrial brillation.
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,
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Chapter 26 • Palpitations
painless hematuria, and anorexia. On physical examination, patients may exhibit hypertension, tremors, postural (orthostatic) hypotension, and pallor. The heart
may be enlarged.
that commonly cause palpitations include alcohol, caffeine, tobacco, digitalis, phenothiazine, theophylline,
b-agonists, and cocaine.
On physical examination, look for telltale signs of
stimulant use: chronic rhinorrhea, frequent nosebleeds,
Drugs and Stimulants
Palpitations that coincide with the use of a drug suggest them as a probable cause. Drugs and stimulants
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
CARDIAC CAUSES
Cardiac arrhythmias CAD, lightheadedness,
syncope, chest pain,
dyspnea
Structural causes May have positional
palpitations
NONCARDIAC CAUSES
Psychological Causes
Panic disorder Panic attacks, terror None ECG, continuous event or loop
Stress/anxiety Persistent worries, fears,
and negative thoughts
Common Causes of Palpitations
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.
Pulse deficit, irregular
heartbeat, cannon A waves
on JVP
Murmur may be present ECG, continuous event or loop
None ECG, continuous event or loop
ECG, continuous event or loop
monitoring, CAD evaluation
(stress test)
monitoring; echocardiogram
monitoring
monitoring
Systemic Causes
Anemia Fatigue
Hyperthyroidism Nervousness, emotional lability,
fatigue, muscle weakness,
weight loss with good
appetite, hyperdefecation,
heat intolerance, menstrual
changes (oligomenorrhea),
increased appetite, insomnia,
and tremors
Pheochromocytoma Severe pounding and paroxysmal
headaches, sweating, nausea,
visual problems, flushing,
weight loss, diarrhea,
nervousness, abdominal
or chest pain, panic attacks
Drugs and Stimulants
Use of alcohol, caffeine,
tobacco, digitalis,
phenothiazine, theophylline,
b-agonists, and recreational
drugs such as cocaine
and amphetamines
CAD, Coronary artery disease; DTR, deep tendon reflex; ECG, electrocardiogram; JVP, jugular venous pressure; TSH, thyroid-stimulating hormone.
Pallor; pale mucous
membranes
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
Sweating, tremors hypertension,
postural hypotension,
heart may be enlarged
Nasal substance users may
have chronic rhinorrhea,
frequent nosebleeds, and
lesions in the nose or around
the nostrils; pupils may be
dilated secondary to substance
use; dry lips, halitosis; odor
of alcohol, or tobacco
ECG, continuous event or loop
monitoring; Hct/Hgb
ECG, continuous event or loop
monitoring; TSH, Free T
ECG, continuous event or loop
monitoring; 24-hr urine;
catecholamines and
metanephrines; plasma
metanephrines; abdominal
imaging
ECG, continuous event
or loop monitoring;
toxicology screen
4
Chapter 26 • Palpitations
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References and Readings
Abbott AV: Diagnostic approach to palpitations, Am Fam Physician
71:743, 2005.
Dubois RW, Goodnough LT, Ershler WB, et al: Identication, diag-
nosis, 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.
Hoefman E, Boer KR, van Weert HC, et al: Predictive value of
history taking and physical examination in diagnosing arrhythmias
in general practice, Fam Pract 24:636, 2007.
Lenders JW, Eisenhofer G, Mannelli M, Pacak K: Pheochromocytoma,
Lancet 366:665, 2005.
Reid ER, Wheeler SF: Hyperthyroidism: Diagnosis and treatment,
Am Fam Physician 72:623, 2005.
Rivera R, Chambers P, Ceresnak S: Evaluation of children with
palpitations, Clin Ped Emerg Med 12:4, 2011.
Sedaghat-Yazdi F, Koenig P: The teenager with palpitations,
Ped Clin North Am 16:1, 2014.
Thavendiranathan P, Bagai A, Khoo C, et al: 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.
Wexler RK, Pleister A, Raman S: Outpatient approach to palpitations,
Am Fam Physician 84:63, 2011.
Zimetbaum P, Josephson ME: Evaluation of patients with palpitations,
N Engl J Med 19:1369, 1998.
CHAPTER
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27
enile discharge results from an infectious or in-
P
ammatory process secondary to exposure and
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 as well. Coinfection 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) 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 necessary to direct diagnosis and treatment. The most frequently identied
organism (40%) in nongonococcal infection is
C. trachomatis. Other organisms identied in NGU
include Ureaplasma urealyticum, and less frequently,
Trichomonas species.
Penile Discharge
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 sexual intercourse, whether 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
l
Have you used street or other drugs?
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is this likely a sexually transmitted infection?
Key Questions
l
Are you sexually active? How many sexual partners
do you have?
l
Do you have any new partners?
l
When was the last time you had unprotected sex?
l
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 is also a risk factor, as is a sexual
partner who has other sexual partners. Sexually active
adolescents are at risk for STIs because of impetuous
318
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
l
What color is the discharge?
l
How much discharge are you having?
l
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 of a nongonococcal infection. Substance or
drug abuse may produce a scant, whitish penile
discharge.
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