How should I evaluate and manage a 60-year-old man with continuous hiccups for 8 hours after a febrile illness three days ago, who has no current fever, vomiting, abdominal or chest pain, and is not taking any regular medications?

Evaluation and Management of Persistent Hiccups Following Febrile Illness

This 60-year-old man with 8 hours of continuous hiccups following a recent febrile illness requires urgent evaluation for serious underlying pathology—particularly central nervous system, cardiovascular, or gastrointestinal causes—before initiating symptomatic treatment with chlorpromazine or baclofen. 1

Immediate Risk Stratification

Red Flag Assessment

You must immediately evaluate for life-threatening causes that can present with persistent hiccups:

• Cardiovascular: Check for myocardial infarction signs (chest pain, dyspnea, diaphoresis, ECG changes) as MI commonly causes chronic hiccups 1
• Neurological: Assess for confusion, focal deficits, headache, or altered consciousness suggesting brain tumor, stroke, or posterior fossa lesions 1, 2
• Metabolic/Renal: Evaluate for uremia (renal failure is a common cause of persistent hiccups) 1
• Post-infectious complications: Given the recent fever, consider COVID-19 or other viral infections that can cause persistent hiccups even in the post-acute period 3, 4

Critical Physical Examination Findings

Perform targeted examination looking for:

• Vital signs: Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation 3
• Cardiovascular exam: Signs of acute coronary syndrome or pericarditis 1
• Neurological exam: Cranial nerve assessment, particularly vocal cord function (unilateral paralysis suggests serious pathology) 2
• Abdominal exam: Gastric distention, organomegaly, or peritoneal signs 1

Diagnostic Workup

Essential Initial Testing

Order the following investigations systematically:

• Laboratory: Complete blood count, comprehensive metabolic panel (particularly BUN/creatinine for uremia), C-reactive protein, D-dimer if COVID-19 suspected 3, 1
• ECG: Rule out myocardial infarction 1
• Chest X-ray: Evaluate for pneumonia, mediastinal masses, or diaphragmatic pathology 3
• COVID-19 testing: Both rapid antigen and PCR given the recent febrile illness 3, 4

Secondary Investigations Based on Initial Findings

If initial workup is unremarkable, proceed with:

• Upper GI evaluation: Endoscopy, pH monitoring, and manometry should be included systematically as gastric/duodenal ulcers, gastritis, esophageal reflux, and esophagitis are commonly observed in chronic hiccup patients 1
• Abdominal ultrasound: Assess for gastric distention, hepatobiliary pathology, or masses 3, 1
• Brain imaging (CT or MRI): If any neurological signs present or if hiccups persist despite treatment 1, 2

Treatment Algorithm

First-Line Pharmacological Management

Once serious pathology is excluded or being addressed:

Chlorpromazine 25 mg orally every 8 hours is the classical first-line treatment with proven efficacy 3, 1

• Response typically occurs within 24 hours (often after 4 doses) 3
• Monitor for sedation and extrapyramidal side effects 1

Alternative: Baclofen has emerged as a safe and often effective treatment 1, 4

• Consider if chlorpromazine is contraindicated or ineffective 1
• Particularly useful in COVID-19-associated hiccups 4

Adjunctive Therapies

Consider adding:

• Metoclopramide: Useful when gastric distention or reflux is suspected 1
• Oral lidocaine 2% viscous solution: Swallow 10-15 mL for immediate relief, particularly effective in refractory cases 5

Critical Pitfalls to Avoid

Do Not Dismiss as Benign

Persistent hiccups (>48 hours) are never normal and require thorough investigation—they can be the harbinger of serious disease including myocardial infarction, brain tumor, renal failure, or malignancy 1, 2

Do Not Delay Cardiac Evaluation

Given the patient's age (60 years) and recent systemic illness, myocardial infarction must be actively excluded with ECG and cardiac biomarkers 1

Do Not Overlook Post-Viral Syndromes

Recent fever raises concern for COVID-19 or other viral infections that can cause persistent hiccups even 35 days after acute illness 3, 4

• Test for COVID-19 even if the patient appears recovered 3
• Consider post-acute COVID-19 syndrome in the differential 3

Do Not Start Symptomatic Treatment Without Investigation

While chlorpromazine is effective, starting it before excluding serious pathology may mask important diagnostic clues 1

Disposition Decision

Outpatient Management Appropriate If:

• Vital signs stable and no red flags identified 3
• No evidence of acute cardiac, neurological, or metabolic emergency 1
• Patient can tolerate oral medications and follow-up 3
• Reliable for 24-48 hour reassessment 1

Hospital Admission Required If:

• Any signs of respiratory distress, altered consciousness, or hemodynamic instability 3
• Severe dehydration or inability to maintain oral intake 1
• Suspected myocardial infarction, stroke, or other acute emergency 1
• Hiccups causing significant sleep deprivation, weight loss, or depression 1