What is the diagnosis and management for a patient of unknown age and medical history experiencing intense pulsations in the upper back, abdomen, and occasionally eyelids without associated pain?

Evaluation and Management of Intense Pulsations Without Pain

This patient is most likely experiencing heightened awareness of normal physiologic pulsations (benign palpable pulsations), but you must systematically exclude life-threatening vascular pathology—particularly abdominal aortic aneurysm, aortic dissection, and cardiac arrhythmias—before attributing symptoms to anxiety or somatization. 1

Immediate Assessment Required

Vital Signs and Physical Examination

• Measure blood pressure in both arms to detect differences >15 mmHg systolic that suggest aortic dissection or subclavian stenosis 1
• Palpate all peripheral pulses (radial, femoral, pedal) bilaterally and assess for symmetry, as asymmetry indicates vascular pathology 1
• Perform abdominal examination specifically palpating for a pulsatile abdominal mass >3 cm in diameter, which indicates abdominal aortic aneurysm requiring urgent imaging 1
• Auscultate for bruits over carotid arteries, renal arteries, and abdomen, as these suggest significant vascular stenosis or aneurysm 1
• Check orthostatic vital signs (supine, then standing at 1 and 3 minutes) to identify orthostatic hypotension causing compensatory tachycardia 1, 2

Cardiac Evaluation

• Obtain 12-lead ECG immediately to exclude arrhythmias (atrial fibrillation, supraventricular tachycardia, ventricular tachycardia) and conduction abnormalities 1
• Assess heart rate and rhythm on continuous monitoring, as sinus tachycardia >100 bpm requires identification of underlying cause (fever, anemia, hyperthyroidism, heart failure) 1, 3
• Auscultate heart sounds for murmurs (aortic stenosis, mitral regurgitation), gallops (S3 suggesting heart failure), or rubs (pericarditis) 1

Risk Stratification Based on Clinical Features

High-Risk Features Requiring Urgent Workup

• Abdominal pulsations with back pain suggest expanding or ruptured abdominal aortic aneurysm requiring emergent CT angiography 1
• Chest pain, dyspnea, or syncope with pulsations indicate acute coronary syndrome, heart failure, or arrhythmia requiring immediate cardiac evaluation 1, 4
• Asymmetric pulses or blood pressures suggest aortic dissection requiring emergent CT angiography of chest/abdomen/pelvis 1
• New-onset pulsations in elderly patients (>65 years) with cardiovascular risk factors warrant comprehensive vascular imaging 1, 3

Intermediate-Risk Features Requiring Outpatient Workup

• Pulsations with palpitations suggest arrhythmia requiring 24-48 hour Holter monitoring or event recorder 1
• Pulsations with exertion suggest cardiac ischemia requiring stress testing and echocardiography 1, 4
• History of hypertension or atherosclerotic disease increases likelihood of vascular pathology requiring ultrasound screening 1, 3

Low-Risk Features Suggesting Benign Etiology

• Young patient (<40 years) with no cardiac history and normal vital signs/examination suggests heightened somatic awareness 1, 5
• Pulsations triggered by anxiety or stress with normal cardiac examination suggest psychogenic pseudosyncope or somatization 1, 5
• Long history of similar symptoms without progression suggests benign etiology 1

Diagnostic Testing Algorithm

First-Tier Testing (Perform in All Patients)

• 12-lead ECG to exclude arrhythmias and conduction abnormalities 1
• Complete blood count to exclude anemia causing compensatory tachycardia 3
• Thyroid-stimulating hormone (TSH) to exclude hyperthyroidism causing sinus tachycardia 3
• Basic metabolic panel to assess electrolytes and renal function 3

Second-Tier Testing (Based on Clinical Suspicion)

• Abdominal ultrasound or CT angiography if palpable abdominal mass or risk factors for abdominal aortic aneurysm (age >65, smoking, hypertension) 1
• Transthoracic echocardiography if abnormal cardiac examination, ECG abnormalities, or suspected structural heart disease 1, 2
• 24-48 hour Holter monitor if palpitations or suspected paroxysmal arrhythmia 1
• CT angiography chest/abdomen/pelvis if asymmetric pulses/blood pressures or suspected aortic dissection 1

Third-Tier Testing (If Above Testing Normal)

• Tilt-table testing if suspected neurally-mediated syncope or orthostatic intolerance 1
• Psychiatric evaluation if all cardiac and vascular testing normal and features suggest somatization or anxiety disorder 1, 5

Management Based on Diagnosis

If Vascular Pathology Identified

• Abdominal aortic aneurysm >5.5 cm requires urgent vascular surgery consultation for repair 1
• Aortic dissection requires emergent cardiothoracic surgery consultation and blood pressure control with IV beta-blockers 1

If Cardiac Arrhythmia Identified

• Atrial fibrillation requires rate control, anticoagulation assessment, and cardiology referral 1
• Supraventricular tachycardia may require adenosine or synchronized cardioversion if unstable 1
• Sinus tachycardia requires treatment of underlying cause (fever, anemia, hyperthyroidism, hypovolemia) rather than rate control 1, 3

If All Testing Normal (Benign Pulsations)

• Reassure patient that pulsations represent normal physiologic phenomenon and do not indicate dangerous pathology 1, 5
• Educate about somatic awareness and how anxiety can amplify perception of normal bodily sensations 1, 5
• Consider cognitive behavioral therapy if symptoms significantly impair quality of life or suggest underlying anxiety disorder 1
• Avoid unnecessary repeat testing unless new symptoms develop or clinical status changes 5

Critical Pitfalls to Avoid

• Do not attribute symptoms to anxiety without first excluding life-threatening vascular and cardiac pathology through appropriate testing 1
• Do not miss abdominal aortic aneurysm by failing to palpate abdomen or obtain imaging in high-risk patients (age >65, smoking, hypertension) 1
• Do not treat sinus tachycardia with rate-control medications before identifying and treating the underlying cause 1, 3
• Do not dismiss eyelid pulsations as they can indicate increased intracranial pressure or vascular malformations requiring neuroimaging in specific contexts 1
• Do not delay imaging if any high-risk features present (back pain, chest pain, asymmetric pulses, syncope) 1