Diagnostic Tests for Adult respiratory distress syndrome
Adult respiratory distress syndrome Tests: Book Excerpts
- DIAGNOSTIC WORKUP - EDEMA, GENERALIZED
- DIAGNOSTIC WORKUP - PERIORBITAL EDEMA
- DIAGNOSTIC WORKUP - EDEMA, LOCALIZED
- DIAGNOSTIC WORKUP - ALKALOSIS (INCREASED PH)
- History and physical examination - Accessory muscle use
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- History and physical examination - Accessory muscle use
- History and physical examination - Respirations, grunting
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- History and physical examination - Edema of the face
- History and physical examination - Salivation, increased [Polysialia, ptyalism]
- History and physical examination - Tearing, increased [Epiphora]
- Physical examination - Edema
- Physical examination - Epigastric Distress
- Diagnostic Approach - Edema
- Diagnostic Approach - Shock
- Physical assessment - Accessory muscle use
- Physical assessment - Respirations, grunting
- Physical assessment - Edema of the leg
- Physical assessment - Edema, generalized
- Physical assessment - Edema of the arm
- Physical assessment - Edema of the face
- Physical assessment - Salivation, increased
- Physical assessment - Tearing, increased
- Diagnostic Approach Respiratory Distress - Respiratory Distress and Apnea
- Diagnostic Approach - Edema
- History and physical examination - Accessory muscle use
- History and physical examination - Respirations, grunting
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- History and physical examination - Edema of the face
Home Diagnostic Testing
These home medical tests may be relevant to Adult respiratory distress syndrome:
- Child Behavior: Home Testing
- Mental Health (Adults): Home Testing
- Lung & Respiratory Health Tests:
- Mental Health: Home Testing:
- Brain & Neurological Disorders: Related Home Testing:
Adult respiratory distress syndrome Diagnosis: Book Excerpts
- Ask the following questions - EDEMA, GENERALIZED
- Ask the Following Questions - PERIORBITAL EDEMA
- Ask the following questions - EDEMA, LOCALIZED
- Ask the following questions - ALKALOSIS (INCREASED PH)
- Differential Diagnosis - Periorbital Edema
- Differential Diagnosis - Peripheral Edema
- Differential Diagnosis - Periorbital Edema
- Differential Diagnosis - Edema
- Approach to the Diagnosis - HYPOTENSION AND SHOCK
- Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
- Approach to the Diagnosis - ALKALOSIS (INCREASED PH)
- History and physical examination - Accessory muscle use
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- Diagnosis - Infant respiratory distress syndrome
- Diagnosis - Lung cancer
- Diagnosis - Toxic shock syndrome
- Diagnosis - Hypovolemic shock
- Diagnosis - Pulmonary edema
- Diagnosis - Atelectasis
- History and physical examination - Accessory muscle use
- History and physical examination - Respirations, grunting
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- History and physical examination - Edema of the face
- History and physical examination - Salivation, increased [Polysialia, ptyalism]
- History and physical examination - Tearing, increased [Epiphora]
- History - Edema
- History - Epigastric Distress
- Differential Overview - Edema
- Differential Overview - Shock
- Diagnosis - Respiratory distress syndrome
- Diagnosis - Lung abscess
- Diagnosis - Lung cancer
- Diagnosis - Toxic shock syndrome
- Diagnosis - Hypovolemic shock
- Diagnosis - Pulmonary edema
- Diagnosis - Acuterespiratory distress syndrome
- Diagnosis - Atelectasis
- Diagnosis - Cardiogenic shock
- Diagnosis - Electric shock
- History - Respirations, grunting
- History - Edema, facial
- History - Edema, generalized
- History - Accessory muscle use
- History - Respirations, grunting
- History - Edema of the leg
- History - Edema, generalized
- History - Edema of the arm
- History - Edema of the face
- History - Salivation, increased
- History - Tearing, increased
- Clinical Features and Diagnosis Respiratory Distress (Neonatal) - Respiratory Distress and Apnea
- Clinical Features and Diagnosis - Edema
- History and physical examination - Accessory muscle use
- History and physical examination - Respirations, grunting
- History and physical examination - Edema of the leg
- History and physical examination - Edema, generalized
- History and physical examination - Edema of the arm
- History and physical examination - Edema of the face
- Approach to the Diagnosis - HYPOTENSION AND SHOCK
- Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
- Approach to the Diagnosis - ALKALOSIS (INCREASED pH)
Diagnostic Tests for Adult respiratory distress syndrome: Online Medical Books
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for more information about the diagnostic tests for Adult respiratory distress syndrome.
EDEMA, GENERALIZED:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
A CBC should be done to rule out significant anemia that may be the cause of the edema. If there is anemia, we need to determine its source. Liver function tests are done to rule out liver disease, and serum protein electrophoresis and tests for BUN and creatinine should be done to exclude renal disease. The urinalysis is very important both for the routine studies and also to examine the urinary sediment for diseases such as chronic glomerulonephritis and collagen disease. If there is significant loss of protein in the urine, one should be considering nephrosis. An EKG, chest x-ray, and venous pressure and circulation time will be extremely helpful in diagnosing congestive heart failure, but pulmonary function tests can be done as the vital capacity is significantly reduced in this disease. When there is a strong suspicion of congestive heart failure, echocardiography or radionuclide-gated blood pool scintigraphy should be done to determine the left ventricular ejection fraction (LVEF). A value of less than 45% is considered abnormal. A thyroid profile should be done to diagnose myxedema. A CT scan of the chest will help diagnose constrictive pericarditis. Occasionally, the edema is due to an abdominal tumor. A CT scan of the abdomen and pelvis will be helpful in those cases. Contrast lymphangiography may be necessary to diagnose lymphedema.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PERIORBITAL EDEMA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, chest x-ray, VDRL test, and x-ray of the sinuses and orbits. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. A CT scan of the brain and sinuses probably ought to be done in these cases, but why not get an ear, nose, and throat or neurologic consultation first?
If there is generalized edema, the workup should proceed as outlined on
page 138
.
Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. Superior vena cava syndrome may be diagnosed by a chest x-ray in many cases, but a CT scan of the mediastinum may be necessary.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
EDEMA, LOCALIZED:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
A venous ultrasound study, impedance plethysmography, and contrast venography are very useful in the diagnosis of deep vein thrombophlebitis.
d
-dimer testing is also a sensitive indicator of active deep vein thrombophlebitis and the need for anticoagulants. Patients with suspected cellulitis or osteomyelitis should have a CBC, sedimentation rate, and cultures of the blood or any fluid that is available from the site of the lesion, either direct or by aspiration. X-rays and CT scans of the involved area are useful as well. Bone scans are often of value in diagnosing osteomyelitis and fractures. Lymphangiography will be helpful in the diagnosis of carcinomatosis or lymphedema from other causes. A CT scan of the abdomen or pelvis may also demonstrate the malignant lymph nodes. A thyroid profile will diagnose cases of pretibial myxedema due to thyrotoxicosis. Patients with upper extremity edema should have a chest x-ray and CT scan of the mediastinum to determine the causes of superior vena cava syndrome.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ALKALOSIS (INCREASED PH):
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The workup of alkalosis should include a CBC, chemistry panel, urinalysis, electrolytes, arterial blood gas analysis, flat plate of the abdomen, chest x-ray, and consultation with an endocrinologist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Accessory muscle use:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, or fever.
Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.
Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.
Perform a detailed chest examination, noting an abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Edema of the leg:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.
Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 240.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans' sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Edema, generalized:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the
day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?
Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.
Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Edema of the arm:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.
Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema Pitting or nonpitting? page 240.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Accessory muscle use:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, and fever.
Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.
Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and about occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.
Perform a detailed chest examination, noting abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing. (See Accessory muscle use: Causes and associated findings, page 30.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Respirations, grunting:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After addressing the child’s respiratory status, ask his parents when the grunting respirations began. If the patient is a premature infant, find out his gestational age. Ask the parents if anyone in the home has recently had an upper respiratory tract infection. Has the child had signs and symptoms of such an infection, such as a runny nose, cough, low-grade fever, or anorexia? Does he have a history of frequent colds or upper respiratory tract infections? Does he have a history of respiratory syncytial virus? Ask the parents to describe changes in the child’s activity level or feeding pattern to determine if the child is lethargic or less alert than usual.
Begin the physical examination by auscultating the lungs, especially the lower lobes. Note diminished or abnormal sounds, such as crackles or sibilant rhonchi, which may indicate mucus or fluid buildup. Characterize the color, amount, and consistency of any discharge or sputum. Note the characteristics of the cough, if any.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Edema of the leg:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or any recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.
Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 292.) Because leg edema may compromise arterial blood flow, palpate or use a handheld Doppler device to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Edema, generalized:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?
Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.
Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Edema of the arm:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.
Determine the edema’s severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting? page 292.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare the radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Edema of the face:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.
Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 292.) Next, take vital signs and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Salivation, increased [Polysialia, ptyalism]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
A patient who complains of increased salivation may have overproductive salivary glands or difficulty swallowing. To distinguish these, first test for a gag reflex and observe the patient’s ability to swallow and chew. Is he drooling? Is his chewing uncoordinated? An impaired gag reflex, drooling, and chewing incoordination suggest difficulty swallowing. Does he have related signs and symptoms, such as fatigue, fever, headache, or a sore throat? Ask about exposure to industrial toxins, such as mercury. Is the patient taking any medications? Note especially use of iodides, cholinergics, and miotics.
Inspect the mouth and mucous membranes for lesions. If present, are they painful? Put on gloves and palpate the lesions, which may be suppurative or infectious. Describe them in your notes. Next, inspect the uvula, gingivae, and pharynx. Palpate the lymph nodes, and determine if the parotid glands are swollen or sore.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Tearing, increased [Epiphora]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of increased tearing, begin by fully exploring this sign. When did it begin? Is it constant or intermittent? Minimal or extensive? Is increased tearing accompanied by pain, irritation, or any other eye drainage or discharge? Next, ask about recent eye trauma and about ocular and systemic disorders. Then record which drugs the patient is taking. Note his occupation and the nature of his work. For example, does he read extensively, look at a computer screen frequently, or work with small or fine objects? Is he exposed to any chemicals or dust in the workplace?
After taking vital signs, examine both eyes—unless the history suggests a perforating or penetrating injury. Carefully inspect the external structures. Do the eyelashes contain debris? Examine the eyelids for lesions and edema. Ask the patient to look straight ahead at a fixed object while you check for ptosis. Are the lid margins turned inward or outward? Examine the eyeballs. Do they appear sunken or bulging? Examine the conjunctivae for redness and abnormal drainage. Also, note the color of the sclera. Hold a flashlight at the side of each eye and examine the cornea and iris for scars, irregularities, and foreign bodies. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 245.) Finally, test the patient’s visual acuity.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Edema:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Generalized edema manifests in the most dependent area (e.g., pedal edema in ambulatory patients, presacral edema in bedbound patients).
B. Peripheral edema (3)
1. Sparing of the feet suggests lipedema.
2. Pitting edema present for more than 3 months usually indicates a low serum protein level. Chronic edema can have fibrosis as well.
3. Assessment of color
a. Redness suggests infection or phlebitis.
b. A red-blue color suggests DVT.
c. A slightly cyanotic color bilaterally suggests CHF (Chapter 7.5).
d. The presence of ecchymosis suggests trauma.
Testing
Routine studies can include complete blood count (CBC), urinalysis, chest films, electrocardiogram (ECG), and biochemical screening to include albumin, total protein, total cholesterol, liver function tests, and thyroid function tests (4). Specific tests or imaging studies are indicated in clinical situations listed below.
Diagnostic assessment
A. Edema affecting the arms only
1. Edema exclusively of the upper extremities, caused by increased venous pressure, points to superior vena cava syndrome. A venogram will be useful.
2. If venous obstruction is suspected, obtain a venogram and Doppler or ultrasound studies.
3. If a thoracic outlet syndrome is suggested, computed tomography (CT), magnetic resonance imaging (MRI), or plain films may be helpful.
B. Edema of the arms and legs
1. Cardiac causes include CHF and constrictive pericarditis (Chapter 7.5). Diagnostic studies include a chest x-ray (CXR) study and ECG.
2. A leading hepatic cause is cirrhosis. Liver function tests are indicated.
3. Renal causes
a. Nephrotic syndrome: order 24-hour urine protein and lipids.
b. Glomerulonephritis or acute tubular necrosis: obtain urinalysis with sediment evaluation.
c. Preeclampsia: laboratory tests include urine protein, urate, blood urea nitrogen (BUN), creatinine, and serum bilirubin (5).
4. Other causes of generalized edema and tests that may be useful include hypothyroidism [thyroid-stimulating hormone, (TSH)], aldosteronism (serum potassium), Cushing’s disease (cortisol or dexamethasone test), malnutrition (prealbumin), beriberi (thiamine), malabsorption (total protein), angioedema, inflammatory bowel disease (sigmoidoscopy), serum sickness, malignancies (CT or MRI), and idiopathic edema (6).
C. Unilateral edema of the legs only points to a local peripheral cause such as trauma, venous obstruction, mass, or inflammation.
D. Bilateral chronic edema of the legs only
1. If tenderness is present, consider lipedema if no foot involvement, or varicose veins if the foot is involved.
2. Consider the possibility of a medication-related cause: see above.
3. An elevated TSH may point to a diagnosis of hypothyroidism or Grave’s disease.
4. Unilateral left-sided edema could be caused by iliac compression or pelvic mass obstructing venous outflow. A venogram, CT, or MRI may be helpful.
References
1. Braunwald E. Edema. In: Fauci AS, ed. Harrison’s principles of internal medicine, 14th ed. New York: McGraw Hill, 1998:210–214.
2. Powel AA, Armstrong MA. Peripheral edema. Am Fam Physician 1997;55:1721–1726.
3. Weber R. Leg edema. In: Rakel RE, ed. Saunders manual of medical practice. Philadelphia: WB Saunders, 1996:207–209.
4. Friedman HH. Edema. In: Friedman HH, ed. Problem oriented medical diagnosis, 6th ed. Boston: Little, Brown and Company, 1996:1–4.
5. Taylor RB. Manual of family practice. Boston: Little, Brown and Company, 1997:
497–499.
6. MacGregor GA, deWardner HE. Idiopathic edema. In: Schrier RW, Gottschalk CW, eds. Diseases of the kidney, 5th ed. Boston: Little, Brown and Company, 1993:
2493–2501.>
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Epigastric Distress:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. General assessment. Obtain vital signs. Is the patient febrile—indicating an infectious cause? Tachycardia and hypotension can indicate dehydration or GI bleed. Is the patient in acute distress? Jaundiced?
B. Cardiopulmonary assessment. Evaluate the heart and lungs to rule out any cardiac or pulmonic process that could present with epigastric distress. Is there evidence of an arrhythmia, myocardial infarction, or congestive heart failure? Are there crackles or rales suggesting a pneumonia?
C. Abdominal examination. Are bowel sounds present? Decreased or absent bowel sounds can indicate a small bowel obstruction, acute surgical abdomen (appendicitis, perforated ulcer), or pancreatitis. Rebound tenderness should prompt consideration of an acute surgical abdomen. The right upper quadrant (RUQ) should be palpated. A palpable liver warrants evaluation for other signs of liver disease—jaundice, ascites, skin changes. Murphy’s sign—sudden cessation of the patient’s inspiratory effort during deep palpation of the RUQ—is suggestive of acute cholecystitis (3). Tenderness to palpation of the left upper quadrant can indicate splenic infarct such as seen with sickle cell disease. Tenderness of the midepigastric area can represent peptic ulcer disease, dyspepsia, “nonclassical” presentation of acute appendicitis, or any other of the above-mentioned conditions. A rectal examination with testing for occult blood should be a part of the examination, particularly with any concern about GI bleeding (Chapter 9.7).
Testing
A. Clinical laboratory tests. Laboratory tests should be directed by the history and physical examination. A complete blood count is indicated if signs are seen of infection or bleeding. An elevated white blood cell count is consistent with appendicitis or pneumonia. A decreased hemoglobin or hematocrit warrants further evaluation for GI bleed. Other laboratory tests that might be indicated by the history and physical examination include liver function tests (hepatitis, gallbladder disease), amylase and lipase (pancreatitis—although no single laboratory test is diagnostic for pancreatitis), creatine kinase-MB (CK-MB), and/or troponin (cardiac pathology). Laboratory testing for Helicobacter pylori is controversial except for those with documented PUD. Keep in mind that of patients who have PUD, 90% are infected with H. pylori and only 10% to 20% of patients infected with H. pylori develop PUD (4).
B. Diagnostic imaging. Plain film x-ray studies are helpful only if bowel obstruction or perforation is suspected. RUQ ultrasound is warranted if gallbladder disease or pancreatitis is suspected. Computed tomography scan of the abdomen could be considered in cases of difficulty in differentiating acute abdominal pain or when needed to evaluate for possible complications. Barium studies are not indicated in the acute setting, but can be helpful in the diagnostic workup for gastric ulcer, GERD, and esophagitis.
C. Endoscopy. Esophagogastrodoudenoscopy in the setting of an upper GI bleed may help to identify the source of the bleeding, assuming the patient is sufficiently stable to tolerate the procedure (Chapter 9.7). The diagnoses of PUD, gastritis, and esophagitis are best made using endoscopy, which also allows evaluation for the presence of H. pylori (5).
D. Other tests. Other tests useful in the evaluation of epigastric distress include an electrocardiogram to assess for possible cardiac disease and chest radiographs and a pulmonary function test to evaluate for possible pulmonary disease.
Diagnostic assessment
The key to the successful approach to a patient presenting with epigastric distress begins with a careful history. If the distress is of acute onset, a more urgent and directed evaluation is needed. Vital signs and physical examination should be directed to evaluate for fever (infection), hypotension (GI bleed), and non-GI causes (MI, ruptured aneurysm). Epigastric distress of a chronic nature can be evaluated using history, directed laboratory testing, and diagnostic imaging.
References
1. Scott M, Gelhot AR. Gastroesophageal reflux disease: diagnosis and management. Am Fam Physician 1999;59(5):1161–1169.
2. Isselbacher KJ, Podolsky DK. Approach to the patient with gastrointestinal disease. In: Fauci AS, ed. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1998:1579–1583.
3. Swartz MH. Textbook of physical diagnosis, history and examination. Philadelphia: WB Saunders, 1994:324.
4. NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease. JAMA 1994;
272(1):65–69.
5. Rank JM, Vennes JA. Gastrointestinal endoscopy. In: Bennet JC, Plum F, eds. Cecil textbook of medicine. Philadelphia: WB Saunders, 1996:636–642.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Edema:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
The degree of edema is influenced by membrane permeability, hydrostatic pressure, and/or oncotic pressure. Edema implies an increase in interstitial volume of several liters. Low protein fluids (hypoalbuminemia, cardiac, and venous edema) pit easily and recover quickly on release. High protein fluids (cellulitis, lymphedema) resist pitting and recover slowly.
The distribution of the edema combined with an estimation of the jugular venous pressure (JVP) can help differentiate heart failure, cirrhosis, renal sodium retention and nephrotic syndrome. Anasarca suggests cardiac, renal, or hepatic disease. Splenomegaly is found more often in patients with cirrhosis than those with congestive heart failure.
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Source: Field Guide to Bedside Diagnosis, 2007
Shock:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A patient in shock will lie still, paying little attention to events around him. If agitated, he will answer in a weak voice. The pupils are dilated and react slowly to light. The coloration is gray and pale, with marbling of the skin on the back or the hands and legs, and cyanosis of the lips. The pulse is rapid and thready; temperature and blood pressure are low. Emergence of these findings corresponds to a 20% to 25% reduction in volume in low preload shock, a fall in the cardiac index to below 2.5 L/min/M 2 or activation of mediators of the sepsis syndrome.
Clues to the underlying cause should be carefully searched for on physical examination. HEENT exam may reveal dilated or pinpoint pupils, dry conjunctivae, or scleral icterus. In the neck, jugular venous distension, delayed carotid upstroke, carotid bruits, or meningeal signs may be observed. Lung exam may show tachypnea, shallow breaths, rales, unilateral tympany or absent breath sounds. The cardiovascular exam may reveal tachycardia, bradycardia, irregular rhythm, S3 gallop, right or left ventricular heave, murmurs, distant heart sounds, pulsus paradoxus, or rub. On abdominal exam, tenderness, guarding or rebound, high-pitched or absent bowel sounds, distension, pulsatile mass, hepatosplenomegaly, or ascites may be found. Rectal exam can reveal evidence of bleeding (occult positive, melena, or bright red blood) or decreased tone. The extremities can show a swollen calf or unequal pulses or blood pressures between the arms. Neurologic exam could exhibit agitation, confusion, delirium, obtundation, or coma. Finally, skin exam can reveal cool and clammy skin, warm and hyperemic skin, rashes, petechiae, urticaria, or cellulitis.
Prognosis in cardiogenic shock can be accurately stratified by Killip class, using observable clinical criteria:
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Source: Field Guide to Bedside Diagnosis, 2007
Accessory muscle use:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a detailed chest assessment, noting abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Respirations, grunting:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by auscultating the lungs, especially the lower lobes. Note diminished or abnormal sounds, such as crackles or sibilant rhonchi, which may indicate mucus or fluid buildup. Also, characterize the color, amount, and consistency of any discharge or sputum. Note the characteristics of the cough, if any.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Edema of the leg:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by examining each leg for pitting edema. (See Differentiating between pitting and nonpitting edema, page 245.) Because leg edema may compromise arterial blood flow, palpate or use Doppler ultrasonography to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Edema, generalized:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Edema of the arm:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Determine the edema’s severity by comparing the size and symmetry of the arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Differentiating between pitting and nonpitting edema, page 245.) Next, examine and compare the color and temperature of the arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Edema of the face:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Differentiating between pitting and nonpitting edema, page 245.) Next, take the patient’s vital signs, and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Salivation, increased:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
A patient who complains of increased salivation may have overproductive salivary glands or difficulty swallowing. To distinguish these, first test for a gag reflex and observe the patient’s ability to swallow and chew. Is he drooling? Is his chewing uncoordinated? An impaired gag reflex, drooling, and chewing incoordination suggest difficulty swallowing.
Inspect the mouth and mucous membranes for lesions. If present, are they painful? Put on gloves and palpate the lesions, which may be suppurative or infectious. Describe them in your notes. Next, inspect the uvula, gingivae, and pharynx. Palpate the lymph nodes, and determine if the parotid glands are swollen or sore.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Tearing, increased:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
After taking vital signs, examine both eyes — unless the history suggests a perforating or penetrating injury. Carefully inspect the external structures. Do the eyelashes contain debris? Examine the eyelids for lesions and edema. Ask the patient to look straight ahead at a fixed object while you check for ptosis. Are the lid margins turned inward or outward? Examine the eyeballs. Do they appear sunken or bulging? Examine the conjunctiva for redness and abnormal drainage. Also, note the color of the sclera. Hold a flashlight at the side of either eye and examine the cornea and iris for scars, irregularities, and foreign bodies. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. Finally, test the patient’s visual acuity.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Respiratory Distress and Apnea:
Diagnostic Approach: Respiratory Distress
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
In preterminfants, most common cause of respiratory distress is respiratorydistress syndrome. In term infants, transient tachypnea, meconiumaspiration, pneumonia, and pneumothorax are most common lower respiratorytract disorders causing respiratory distress. Other nonpulmonarycauses of respiratory distress in neonates are congenital heartdisease, persistent fetal circulation, and septicemia. In infancyand childhood, most common causes of respiratory distress are bronchiolitis,croup, asthma, pneumonia, foreign body aspiration, and congenitalor acquired heart disease with cardiac failure.History and physical exam suggest mostlikely cause for respiratory distress. Oxygen saturation in roomair indicates degree of hypoxemia. Certain tests should be considereddepending on clinical circumstances:Airway radiography or endoscopy for upperairway obstructionChest radiography for lower respiratorydisorders or cardiac diseaseCBC for anemiaSerum electrolytes and creatinine;blood urea nitrogen; and venous/capillary pH for metabolicacidosisECG and 2-D echocardiography for cardiacfailureChest CT for any airway, lung, or mediastinal mass
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Edema:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Age of onset is important in determiningcause of edema. Other distinguishing features are presence of hypoalbuminemia ± proteinuria.
Fetal and Neonatal Onset
Hydropsfetalis should be suspected in either second or third trimesterof pregnancy, when discrepancy exists between size of fetus andpresumed gestational age.Polyhydramnios occurs in ≥50% ofcases, and this can be confirmed by U/S.First step in diagnosis of fetal hydropsis to perform prenatal antibody screen to exclude any kind of isoimmunization.Other tests include CBC and RBC indicesin both parents to screen for alpha-thalassemia; hemoglobin electrophoresis;Kleihauer-Betke test for fetomaternal transfusion; and maternalrapid plasma reagin, appropriate serology, and cultures for congenitalinfection.U/S can detect multiple pregnancies(twin-twin transfusion), chondrodysplasias (limb length measurements),and many congenital anomalies.Fetal movement studies also can bedone using real-time U/S.Fetal echocardiography may detect cardiacstructural defects and fetal arrhythmias.If these tests fail to reveal causeof fetal hydrops, amniocentesis can be performed. Several testsare commonly performed on amniotic fluid: fetal karyotype, culturesand polymerase chain reaction for infection, specific metabolictests for storage diseases, and alpha-fetoprotein (congenital nephrosis).Fetal blood can be obtained by cordocentesisfor other tests: CBC, blood type, hemoglobin electrophoresis, serumalbumin, cultures and polymerase chain reaction, karyotype, andspecific tests for metabolic disorders.After infant's birth, physicalexam as well as exam of umbilical cord and placenta narrow diagnosticpossibilities and suggest most appropriate investigations.Several testsshould be considered depending on clinical circumstances: infant's bloodgroup and Rh type; CBC; hemoglobin electrophoresis; UA; chest, longbone, abdominal, and spine radiography; ECG; 2-D echocardiography;maternal and infant rapid plasma reagin; urine culture for cytomegalovirus;serology for toxoplasmosis; serum electrolytes, creatinine, glucose,and liver function tests; blood urea nitrogen; analysis of fluidfrom effusion or ascites for chyle, protein, or culture; chromosomalkaryotype; metabolic studies; and exam of placenta including histology.Other investigations depend on resultsof these tests and suspected diagnosis. Postneonatal Onset
UA screensfor proteinuria and renal disease.In absence of significant proteinuriaor cardiac failure, serum albumin should be measured. Fluid overloadand allergic reactions are common causes of edema with normal serumalbumin. Decreased serum albumin without proteinuria suggests liverdisease, protein-losing enteropathy, or protein-caloric malnutrition.Jaundice, hepatomegaly, and abnormalliver function tests are manifestations of liver disease.Elevated fecal alpha1-antitrypsinlevel indicates increased protein loss in stool and is seen withvarious causes of protein-losing enteropathy.Protein-calorie malnutrition can beassessed by plotting weight and height on growth charts developedby CDC (2001).U/S or MRI may help diagnosecauses of lymphedema.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Accessory muscle use:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, sputum production, or fever.
Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.
Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.
Perform a detailed chest examination, noting an abnormal respiratory rate, pattern, or depth. Assess the patient's chest for equal expansion during inspiration. Check the trachea for midline position. Assess the color, temperature, and turgor of the patient's skin, and check for clubbing. Auscultate the lungs for adventitious breath sounds.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Respirations, grunting:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
After addressing the child's respiratory status, ask his parents when the grunting respirations began. If the patient is a premature infant, find out his gestational age. Ask the parents if anyone in the home has recently had an upper respiratory tract infection. Has the child had signs and symptoms of such an infection, such as a runny nose, cough, low-grade fever, or anorexia? Does he have a history of frequent colds or upper respiratory tract infections? Does he have a history of respiratory syncytial virus? Ask the parents to describe changes in the child's activity level or feeding pattern to determine if the child is lethargic or less alert than usual.
Begin the physical examination by auscultating the lungs, especially the lower lobes. Note diminished or abnormal sounds, such as crackles or sibilant rhonchi, which may indicate mucus or fluid buildup. Characterize the color, amount, and consistency of any discharge or sputum. Note the characteristics of the cough, if any. Note the respiratory rate. Assess accessory muscle use for breathing and cyanosis.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Edema of the leg:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.
Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting?page 226.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans'sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Edema, generalized:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?
Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.
Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Edema of the arm:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.
Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting?page 226.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Edema of the face:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.
Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting?page 226.) Next, take the patient's vital signs, and assess his neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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