BIOSOFT HELP FILES

1)      Stress, fear, anxiety states – other symptoms suggestive of somatic anxiety syndrome seen, recent stress may be seen,

2)      Somatic anxiety syndrome – palpitations as a part of somatic anxiety syndrome

3)      Caffeine, nicotine, cocaine, diet pills -

4)      Anemia – fatigue, dyspnea on exertion, pallor, sweating, pica, limb swelling, evidence of CCF later in the course

5)      Sleep apnea syndrome (See under Medically Unexplained Symptoms)

6)      Suprventricular tachyacardia - Dizziness, anxiety, light headedness, chest pain, palpitations fetl at the neck and chest both, dyspnea, syncope, psychologic distress, polyuria, sudden onset and offset, the usual heart rates are in the range of 160-200 beats pr minutes as opposed to ventricular tachycardias the rate is 120-160 beats per minute, Mx – carotid sinus massage (N), referral for further management.

7)      Drug-induced – calcium channel blockers, sympathomimetics, sympathomimetic inhalers and nebulizer solutions

8)      Hyperthyroidism – see under medically unexplained symptoms

9)      Somatic depression syndrome

10)    Palpitations associated with a normal heart rate and rhythm practically exclude heart disease

1)      Hypercholesterolemia

2)      Hypertension

3)      Diabetes

4)      Blackouts or near blackouts with palpitations

5)      Chest pain with palpitations

6)      Dyspnea in palpitations

7)      Past rheumatic fever

8)      Heart murmurs – aortic stenosis, aortic regurgitation, mitral stenosis

9)      Dizziness, anxiety, lightheadedness, chest pain, palpitations felt at the neck and chest both, dyspnea, syncope, psychological distress, polyuria (Supraventricular tachycardia, sudden onset, and offset, )

10)    Elderly, dizziness, bradycardia, tachycardia, alternating bradycardia and tachycardia, fatigue, dyspnea, confusion, chest pain (sick sinus syndrome)

11)    Exclude pulsatile tinnitus and carotid bruit presenting as palpitations

12)    Bradycardia – per se can cause palpitations as it may increase the stroke volume

13)    Palpitations with angina, diaphoresis, presyncope, syncope (underlying heart disease likely)

14)    Palpitations felt at the neck and chest (heart disease likely)

15)    Sensation of heart-stopping, irregular heartbeat, and fluttering (correlated with heart disease)

16)    Palpitations that are frequent, disabling, and symptomatic more urgent evaluation than those that are infrequent and asymptomatic

17)    Associated palpable abnormalitites in the pulse – atrial fibrillation, atrila flutter, bradyarrhythmias

18)    ECG signs – bifascicular heart block, QRS duration > 120 ms, second degree AV block, sinus bradycardia, prolonged QT interval, Q waves, arrhythmogenic right ventricular dysplasia (T inversion in V1-V3, QRS duration > 110 ms in V1-V3)

19)    ECG signs – Brugada pattern – ST elevation in V1-V3, coved appearance of elevated ST segment, T wave inversion, associated with increased risk of ventricular arrythmias, sudden cardiac death (Brugada syndrome), howevere this pattern may also occur in right ventricular infarction, hyperkalemia, drugs,

(Balentine and Eisenhart 2005)

(Balentine and Kassapidis 2006)

(Liu and Sinert 2006)

(Delacretaz 2006)

(Weitz and Weinstock 1995)

1)      CTS – pain and paresthesiae of the median nerve distribution (thumb, index, and middle fingers), paresthesiae particularly nocturnal, symptoms worsen with clenched fists, Tinel’s positive, Phalen’s positive, sensory loss in median nerve distribution, weakness of abductor policies brevis, weakness of opponents policies,

2)      MFPS – See under Myofascial syndromes in the notes or details.

3)      TTS

4)      Radiculopathies

5)      Cubital Tunnel Syndrome – due to entrapment of ulnar nerve at the elbow, point tenderness at the cubital tunnel, pain and paresthesiae in the distribution of the 4^th and 5^th fingers of the hand, sensory loss in the 4^th and 5^th fingers, interossei weakness, Froment’s sign positive (wasting of the 1^st dorsal interosseous muscle and inability to maintain adduction of the thumb so that hyperflexion of the interphalangeal joint occurs while pinching between thumb and the 1^st finger), positive Wartenberg’s sign (inability to abduct the little finger), Tinel’s sign positive (percussion over cubital tunnel causes a shower of paresthesiae in the ulnar distribution), Mx – usually RSI, look for the RSI factors

6)      Pronator Teres Syndrome – activities that require the use of the elbow, forearm supination and grasping, forearm pain, medial aspect of the forearm, point tenderness at the edge of the pronator teres, pain, and paresthesia in the median nerve distribution of the hand, reproduction of symptoms on resisted pronation of the forearm – usually an RSI,

7)      Anterior Interosseous Syndrome – entrapment neuropathy of anterior interosseous nerve branch of the median nerve, pain in the volar aspect of the forearm, weakness of pronator quadratus, flexor policies longus and/or flexor digitus profundus

8)      Posterior Interosseous Syndrome – pain around the elbow joint, pain distal to the lateral epicondyle, tenderness distal to the elbow, weakness of extension of a middle finger, if the entrapment involves sensory branch (which is called radial tunnel syndrome) no weakness nor sensory loss but pain and tenderness at the site of entrapment (this is usually 5-7 cm distal to the  lateral epicondyle), weakness of supination, decreased strength of  ulnar deviation of the wrist,

9)      Hypothenar hammer syndrome – blanching, paresthesiae, pain in the hand, Allen’s test positive

10)    Hyperventilation syndrome – transient paresthesiae of hand and feet, perioral region, lightheadedness, carpopedal spasms, occasionally syncope,

11)    Alcoholic neuropathy – numbness, tingling, burning feet, painful sensations, wekaness of legs, in early and mild cases, when severe and with autonomic involvement muscle cramps, muscle aches, heat intolerance after exercises, impotence, micturition difficulties (incontinence, sensation of incomplete emptying of bladder, hesitancy), constipation, diarrhea, nausea and  vomiting, swallowing difficulty, speech impairment, muscle contractions, muscle atrophy, dyskinesias, symptoms develop gradually, worsen over time, usually bilateral symptoms, lower limb involvement more than upper limb involvement, hyporeflexia, decreased pupillary response to light, Mx -  alcohol cessation and symptomatic management

1)      Vitamin D deficiency – See under Generalized body aches

2)      Vertebrobasilar insufficiency – peioral paresthesiae

(Helliwell 1996)

1)      Hemiparesis

2)      Faciobrachial paresis

3)      Cerebrovascular accident - left carotid - Motor signs - dysarthria, paresis/paralysis of the right extremities or face or both, Blindness in the left eye or loss of vision in the right field of vision, Paresthesiae of the right extremities OR face, Aphasia, Symptoms and signs last more than 24 hrs

4)      Cerebrovascular accident - right carotid - Paresis/paralysis of left extremities, Loss of vision in the right eye or, rarely, the left field of vision, Paresthesiae of the left upper/lower limbs, Symptoms and signs last more than 24 hrs

5)      Cerebrovascular accident – vertebrobasilar - Paresis/paralysis of any 1 or more of any combination of limbs, Paresthesiae of any 1 or more of any combination of limbs, Blindness in 1 or both of visual fields, Imbalance, vertigo, diplopia, dysphagia, dysarthria, Symptoms, and signs last more than 24 hrs           

6)      Gait abnormalities – falls, clumsy gait due to circumduction

7)      Bell’s palsy -

8)      Radial nerve palsy

9)      Peroneal palsy

10)    Ulnar palsy

11)    Migraine aura

1)      Stroke red flags – gradual onset, seizures at the onset of stroke, impaired consciousness, below 50 yrs of age, apparent absence of CAD risk factors (consider alternative diagnosis like migraine, SDH, hypoglycemia, postictal paresis, brain tumors, below 50 yrs of age, absence of apparent cardiovascular risk factors)

2)      Stroke – ptosis and miosis contralateral to the deficit – carotid artery dissection

3)      Stroke, fever, cardiac murmur – SABE

(Manford 2004)

(Solensky 2004)

(Gladstone 2005)

1)      Unexplained petechiae in a child or young person

2)      Newborn

3)      Ill-looking child

4)      Bleeding PR and arthritis

5)      Splenomegaly