Palpitation physical examination: Difference between revisions

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==Overview==
==Overview==
Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].


OR
[[Palpitations]] are typically a [[transient]] [[symptoms]]. Patients may or may not be in [[physical distress]] and may even present with [[altered mental status]] secondary to [[substance abuse]]. During a [[physical examination]] one must look for [[signs]] and [[symptoms]] of [[hyperthyroidism]], [[hypothyroidism]], [[congestive heart failure]], [[rhythm disturbances]] and [[structural heart disease]].


Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].
==Physical Examination <ref name="pmid10458728">{{cite journal| author=Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A | display-authors=etal| title=ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). | journal=Circulation | year= 1999 | volume= 100 | issue= 8 | pages= 886-93 | pmid=10458728 | doi=10.1161/01.cir.100.8.886 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10458728  }} </ref> <ref name="pmid8629647">{{cite journal| author=Weber BE, Kapoor WN| title=Evaluation and outcomes of patients with palpitations. | journal=Am J Med | year= 1996 | volume= 100 | issue= 2 | pages= 138-48 | pmid=8629647 | doi=10.1016/s0002-9343(97)89451-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8629647  }} </ref>  <ref name="pmid8629647">{{cite journal| author=Weber BE, Kapoor WN| title=Evaluation and outcomes of patients with palpitations. | journal=Am J Med | year= 1996 | volume= 100 | issue= 2 | pages= 138-48 | pmid=8629647 | doi=10.1016/s0002-9343(97)89451-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8629647  }} </ref> <ref name="pmid29995805">{{cite journal| author=Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L | display-authors=etal| title=Benefits of an early management of palpitations. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 28 | pages= e11466 | pmid=29995805 | doi=10.1097/MD.0000000000011466 | pmc=6076186 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29995805  }} </ref> <ref name="pmidhttps://www.ncbi.nlm.nih.gov/pubmed/29995805">{{cite journal| author=Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L | display-authors=etal| title=Benefits of an early management of palpitations. | journal=Medicine (Baltimore) | year= 2018 | volume= 97 | issue= 28 | pages= e11466 | pmid=https://www.ncbi.nlm.nih.gov/pubmed/29995805 | doi=10.1097/MD.0000000000011466 | pmc=6076186 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29995805  }} </ref> <ref name="pmid9426932">{{cite journal| author=Fraser S, Evans MF| title=Diagnosis and prognosis of patients with palpitations. | journal=Can Fam Physician | year= 1997 | volume= 43 | issue=  | pages= 2131-2 | pmid=9426932 | doi= | pmc=2255099 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9426932  }} </ref>==


OR


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
[[Physical examination]] of patients with [[palpitations]] may be normal or have [[findings]] suggestive of [[thyroid dysfunction]], [[congestive heart failure]], [[structural heart disease]], [[substance abuse]] or [[psychiatric disorders]].  


OR
=== Appearance of the Patient ===


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
* Patients with [[palpitations]] may or may not be in [[distress]] as it is typically a [[transient]] [[symptom]].
* Patient may exhibit [[aggressive/aberrant behavior]] suggestive of possible [[substance abuse]].
* Patients with a [[psychiatric  disorder]] such as [[generalized anxiety disorder]] may present with [[psychomotor agitation]] or an [[anxious demeanor]].


==Physical Examination==
=== Vital Signs ===
Physical examination of patients with [disease name] is usually normal.


OR
* [[Tachycardia]] with [[regular pulse]] or [[irregularly irregular pulse]] {{cite web |url=https://www1.racgp.org.au/ajgp/2019/april/approach-to-palpitations/ |title=RACGP - Approach to palpitations |format= |work= |accessdate=}} {{cite web |url=https://www.sciencedirect.com/topics/medicine-and-dentistry/palpitations |title=Palpitations - an overview &#124; ScienceDirect Topics |format= |work= |accessdate=}} {{cite web |url=https://www.msdmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/palpitations |title=Palpitations - Cardiovascular Disorders - MSD Manual Professional Edition |format= |work= |accessdate=}} {{cite web |url=https://www.msdmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/palpitations |title=Palpitations - Cardiovascular Disorders - MSD Manual Professional Edition |format= |work= |accessdate=}}
* An [[irregular pulse]] may indicate [[atrial fibrillation]] or [[atrial flutter]].
* A [[regular pulse]] may indicate [[sinus tachycardia]] or [[paroxysmal supraventricular tachycardia]].
* [[Bradycardia]] with [[regular pulse]] or [[irregularly irregular pulse]] – very rarely seen
* [[Pulse discrepancy]] / [[Radio-femroal delay]]  - [[Coarctation of aorta]]
* [[Tachypnea]] –  [[Hyperventilation]] seen in [[panic disorder]]
* [[Bradypnea]] – [[Respiratory depression]] secondary to [[substance abuse]]
* Possible signs of [[orthostatic hypotension]] – [[Dehydration]] or [[electrolyte imbalance]].


Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
=== Skin ===


OR
* Heat intolerance – [[Hyperthyroidism]]
* Cold intolerance – [[Hypothyroidism]]
* Dry skin with discoloration – [[Hypothyroidism]]
* [[Diaphoresis]] – [[Substance abuse]],[[hyperthyroidism]]
* [[Pallor]] – [[Anemia]]


The presence of [finding(s)] on physical examination is diagnostic of [disease name].
=== HEENT ===


OR
* [[Exophthalmos]] – [[Hyperthyroidism]]
* [[Pupils]] may be [[dilated]] – Indicative of [[substance abuse]] ; [[cocaine]], [[amphetamines]]


The presence of [finding(s)] on physical examination is highly suggestive of [disease name].
=== Neck ===


===Appearance of the Patient===
* [[Jugular venous distension]] – secondary to [[congestive heart failure]]
*Patients with [disease name] usually appear [general appearance].
* [[Thyromegaly]] / [[thyroid nodules]] – causing [[hyperthyroidism]]/ [[hypothyroidism]]
* [[Hepatojugular reflux]] – Indicative of [[constrictive pericarditis]], [[restrictive cardiomyopathy]] or [[right heart failure]].
* [[Pounding pulsations]] – may be seen in AV nodal re-entry [[tachycardia]]  


===Vital Signs===
=== Lungs ===


*High-grade / low-grade fever
* [[Fine/coarse bibasilar]] [[crackles]] upon [[auscultation]] – [[Congestive heart failure]]  
*[[Hypothermia]] / hyperthermia may be present
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
=== Heart <ref name="pmid21766757">{{cite journal| author=Wexler RK, Pleister A, Raman S| title=Outpatient approach to palpitations. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 1 | pages= 63-9 | pmid=21766757 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21766757  }} </ref><ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=28613787 | doi= | pmc= | url= }} </ref> <ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=28613787 | doi= | pmc= | url= }} </ref> <ref name="pmid28613787">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=28613787 | doi= | pmc= | url= }} </ref> <ref name="pmid29431371">{{cite journal| author=Wexler RK, Pleister A, Raman SV| title=Palpitations: Evaluation in the Primary Care Setting. | journal=Am Fam Physician | year= 2017 | volume= 96 | issue= 12 | pages= 784-789 | pmid=29431371 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29431371  }} </ref> <ref name="pmid31256490">{{cite journal| author=McLellan AJ, Kalman JM| title=Approach to palpitations. | journal=Aust J Gen Pract | year= 2019 | volume= 48 | issue= 4 | pages= 204-209 | pmid=31256490 | doi=10.31128/AJGP-12-17-4436 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31256490  }} </ref>===
* Skin examination of patients with [disease name] is usually normal.
OR
*[[Cyanosis]]
*[[Jaundice]]
* [[Pallor]]
* Bruises


<gallery widths="150px">
* Displaced [[point of  maximal impulse]] (PMI) suggestive of [[left ventricular hypertrophy]] or  [[cardiomegaly]].
* [[Friction rub]] – [[Pericarditis]]
* [[Heart sounds#Second heart tone S2 the %22dub%22(components A2 and P2)|S2]] – [[fixed splitting of S2]] along with a [[right ventricular heave]] is indicative of an [[atrial septal defect]]
* [[Heart sounds#Third heart sound S3|S3]] – [[Congestive heart failure]]
* [[Heart sounds#Fourth heart sound S4|S4]] –  [[Chronic valvular heart disease]]
* A harsh [[pansystolic murmur]] best heard over the left [[sternal border]] and increases with [[Vasalva]] –  [[Hypertrophic cardiomyopathy]].
* [[Mid systolic click]] - [[Mitral valve prolapse]]
* [[Systolic murmur]] best heard  over the [[pulmonic area]] – [[Pulmonic stenosis]]


UploadedImage-01.jpg | Description {{dermref}}
=== Abdomen ===
UploadedImage-02.jpg | Description {{dermref}}


</gallery>
* [[Ascites]] – [[Right heart failure]]
* [[Congestive hepatomegaly]]


===HEENT===
=== Back ===
* HEENT examination of patients with [disease name] is usually normal.
OR
* Abnormalities of the head/hair may include ___
* Evidence of trauma
* Icteric sclera
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
* Back examination of patients with [[palpitations]] is usually normal.
* Neck examination of patients with [disease name] is usually normal.
OR
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]


===Lungs===
=== Genitourinary  ===
* Pulmonary examination of patients with [disease name] is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]


===Heart===
* [[Genitourinary examination]] of patients with [[palpitations]] is usually normal.
* Cardiovascular examination of patients with [disease name] is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope


===Abdomen===
=== [[Neuromuscular]] ===
* Abdominal examination of patients with [disease name] is usually normal.
OR
*[[Abdominal distension]]  
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test


===Back===
* Patient is usually [[oriented]] to persons, place, and time
* Back examination of patients with [disease name] is usually normal.
* [[Altered mental status]] – [[Myxedema madness]], [[alcohol]] consumption
OR
* [[Hyperreflexia]] –  [[Hyperthyroidism]] {{cite web |url=https://www.ahajournals.org/doi/full/10.1161/circulationaha.105.566760 |title=Palpitations &#124; Circulation |format= |work= |accessdate=}} {{cite web |url=https://doi.org/10.1016/j.amjmed.2010.01.012 |title=Redirecting |format= |work= |accessdate=}} {{cite web |url=+https://doi.org/10.1002/joa3.12358 |title=Isolated palpitations and ventricular pre‐excitation - Arias - 2020 - Journal of Arrhythmia - Wiley Online Library |format= |work= |accessdate=}} {{cite web |url=https://www.aafp.org/afp/2017/1215/p784.html |title=Palpitations: Evaluation in the Primary Care Setting - American Family Physician |format= |work= |accessdate=}}
*Point tenderness over __ vertebrae (e.g. L3-L4)
* [[Hyporeflexia]] –  [[Hypothyroidism]]
*Sacral edema
* [[Proximal/distal muscle weakness]] [[unilaterally]]/[[bilaterally]] – [[Hypothyroidism]]
*Costovertebral angle tenderness bilaterally/unilaterally
* [[Unilateral]]/[[bilateral]] [[tremor]] – [[Hyperthyroidism]]
*Buffalo hump


===Genitourinary===
=== [[Extremities]] ===
* Genitourinary examination of patients with [disease name] is usually normal.
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge


===Neuromuscular===
* [[Pitting edema]] – [[Congestive heart failure]]
* Neuromuscular examination of patients with [disease name] is usually normal.
OR
*Patient is usually oriented to persons, place, and time
* Altered mental status
* Glasgow coma scale is ___ / 15
* Clonus may be present
* Hyperreflexia / hyporeflexia / areflexia
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)
 
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
OR
*[[Clubbing]]  
*[[Cyanosis]]  
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==
{{reflist|2}}
{{reflist|2}}
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Latest revision as of 17:57, 31 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Overview

Palpitations are typically a transient symptoms. Patients may or may not be in physical distress and may even present with altered mental status secondary to substance abuse. During a physical examination one must look for signs and symptoms of hyperthyroidism, hypothyroidism, congestive heart failure, rhythm disturbances and structural heart disease.

Physical Examination [1] [2] [2] [3] [4] [5]

Physical examination of patients with palpitations may be normal or have findings suggestive of thyroid dysfunction, congestive heart failure, structural heart disease, substance abuse or psychiatric disorders.

Appearance of the Patient

Vital Signs

Skin

HEENT

Neck

Lungs

Heart [6][7] [7] [7] [8] [9]

Abdomen

Back

  • Back examination of patients with palpitations is usually normal.

Genitourinary

Neuromuscular

Extremities

References

  1. ↑ Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A; et al. (1999). "ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography)". Circulation. 100 (8): 886–93. doi:10.1161/01.cir.100.8.886. PMID 10458728.
  2. ↑ 2.0 2.1 Weber BE, Kapoor WN (1996). "Evaluation and outcomes of patients with palpitations". Am J Med. 100 (2): 138–48. doi:10.1016/s0002-9343(97)89451-x. PMID 8629647.
  3. ↑ Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L; et al. (2018). "Benefits of an early management of palpitations". Medicine (Baltimore). 97 (28): e11466. doi:10.1097/MD.0000000000011466. PMC 6076186. PMID 29995805.
  4. ↑ Clementy N, Fourquet A, Andre C, Bisson A, Pierre B, Fauchier L; et al. (2018). "Benefits of an early management of palpitations". Medicine (Baltimore). 97 (28): e11466. doi:10.1097/MD.0000000000011466. PMC 6076186. PMID https://www.ncbi.nlm.nih.gov/pubmed/29995805 Check |pmid= value (help).
  5. ↑ Fraser S, Evans MF (1997). "Diagnosis and prognosis of patients with palpitations". Can Fam Physician. 43: 2131–2. PMC 2255099. PMID 9426932.
  6. ↑ Wexler RK, Pleister A, Raman S (2011). "Outpatient approach to palpitations". Am Fam Physician. 84 (1): 63–9. PMID 21766757.
  7. ↑ 7.0 7.1 7.2 "StatPearls". 2020. PMID 28613787.
  8. ↑ Wexler RK, Pleister A, Raman SV (2017). "Palpitations: Evaluation in the Primary Care Setting". Am Fam Physician. 96 (12): 784–789. PMID 29431371.
  9. ↑ McLellan AJ, Kalman JM (2019). "Approach to palpitations". Aust J Gen Pract. 48 (4): 204–209. doi:10.31128/AJGP-12-17-4436. PMID 31256490.
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