Palpitation physical examination

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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

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

Appearance of the Patient

• 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.

Vital Signs

• Tachycardia with regular pulse or irregularly irregular pulse
• 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.

Skin

• Heat intolerance – Hyperthyroidism
• Cold intolerance – Hypothyroidism
• Dry skin with discoloration – Hypothyroidism
• Diaphoresis – Substance abuse,hyperthyroidism
• Pallor – Anemia

HEENT

• Exophthalmos – Hyperthyroidism
• Pupils may be dilated – Indicative of substance abuse ; cocaine, amphetamines

Neck

• Jugular venous distension – secondary to congestive heart failure
• 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

Lungs

• Fine/coarse bibasilar crackles upon auscultation – Congestive heart failure

Heart

• Displaced point of maximal impulse (PMI) suggestive of left ventricular hypertrophy or cardiomegaly.
• Friction rub – Pericarditis
• S2 – fixed splitting of S2 along with a right ventricular heave is indicative of an atrial septal defect
• S3 – Congestive heart failure
• 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

Abdomen

• Ascites – Right heart failure
• Congestive hepatomegaly

Back

• Back examination of patients with palpitations is usually normal.

Genitourinary

• Genitourinary examination of patients with palpitations is usually normal.

Neuromuscular

• Patient is usually oriented to persons, place, and time
• Altered mental status – Myxedema madness, alcohol consumption
• Hyperreflexia – Hyperthyroidism
• Hyporeflexia – Hypothyroidism
• Proximal/distal muscle weakness unilaterally/bilaterally – Hypothyroidism
• Unilateral/bilateral tremor – Hyperthyroidism

Extremities

• Pitting edema – Congestive heart failure