CONFIRMING DIAGNOSIS Confirmation requires these characteristic X-ray findings:
❑ blurring of the bony margins of joints in the early stage
❑ bilateral sacroiliac involvement
❑ patchy sclerosis with superficial bony erosions
❑ eventual squaring of vertebral bodies
❑ bamboo spine with complete ankylosis.
Erythrocyte sedimentation rate and alkaline phosphatase and serum immunoglobulin A levels may be elevated. A negative rheumatoid factor helps rule out rheumatoid arthritis, which produces similar symptoms.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Juvenile rheumatoid arthritis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Persistent joint pain and the rash and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA. Disease activity and response to therapy can also be monitored through laboratory results.
❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.
❑ Erythrocyte sedimentation rate and C-reactive protein, haptoglobin, immunoglobulin, and C3 complement levels may be elevated.
❑ ANA test may be positive in patients who have pauciarticular JRA with chronic iridocyclitis.
❑ RF is present in 15% of JRA cases, compared with 85% of rheumatoid arthritis cases.
❑ Positive HLA-B27 antigens may forecast later development of ankylosing spondylitis.
❑ X-rays in early stages reveal changes, including soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Rheumatoid arthritis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Typical clinical features suggest this disorder, but a definitive diagnosis is based on laboratory and other test results:
❑ X-rays — in early stages, show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; finally, cartilage and bone destruction and erosion, subluxations, and deformities
❑ rheumatoid factor test — positive in 75% to 80% of patients as indicated by a titer of 1:160 or higher
❑ synovial fluid analysis — reveals increased volume and turbidity but decreased viscosity and complement (C3 and C4) levels; white blood cell count usually exceeds 10,000/µl
❑ erythrocyte sedimentation rate — elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation commonly parallels disease activity)
❑ complete blood count — usually reveals moderate anemia and slight leukocytosis.
A C-reactive protein test can help monitor response to therapy.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Neck pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.
Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there is not a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings, pages 548 to 551.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Neck Pain:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. General. Patient age and occupation are important. An individual’s job can involve awkward or prolonged body positioning (1). Some of the conditions listed in Table 12.8 can present with fever or with constitutional or other musculoskeletal symptoms. More diagnosis-specific symptoms may be present (e.g., chest pain with a myocardial infarction).
B. Pain characteristics. What is the character, location, frequency, and duration of pain? Tumors of the cervical spine can present with unremitting neck pain that is worse at night. Referred neck pain from intrathoracic pathology is more often located anteriorly.
C. Precipitating factors. Any prior history of neck problems? Has there been any preceding neck trauma or change in work or avocational activities? A history of collision trauma may warrant consideration of concurrent head injury. Is there any relationship of the pain to a particular neck position or movement? Careful questioning may be needed to uncover this latter information, but it is crucial to determining the mechanism of pain production. Have there been any emotional stressors?
D. Associated symptoms. Is headache present? Any paresthesia, dyskinesia, or weakness of the trunk or upper or lower extremities? Bladder dysfunction can occur with a central spinal cord injury. What is the distribution of any radicular pain? An increase in radicular symptoms with coughing or sneezing suggests nerve root impingement (2).
Physical examination
A. General. After any cervical spine injury, order an x-ray study first to rule out an unstable injury. Assess gait, which can be impaired with a cervical myelopathy. Notice neck posture (3). Torticollis can occur secondary to trauma, muscle strain, vertebral subluxation, viral infection or from a psychogenic cause. Examine other head and neck structures (e.g., lymph nodes) and the temporomandibular joints (1). Look for meningeal signs, if appropriate.
B. Musculoskeletal examination. Palpate for muscle tenderness or spasm in the neck and head. Tender trigger points may be found in fibromyalgia. Assess active and passive range of motion (ROM) of the neck and shoulders. ROM is not affected with referred sources of pain. Decreased passive ROM may be seen in rheumatoid arthritis (RA), ankylosing spondylitis (AS), disseminated idiopathic skeletal hyperostosis (DISH), compression fractures, and cervical spondylosis. Active contraction or stretching of strained muscles or ligaments will precipitate pain.
C. Neurologic examination. Include the examination of cranial nerves, motor function, tone, and reflexes of the upper and lower extremities. Look for muscle atrophy. Check pinprick and light touch sensation in the upper extremities, looking for a dermatomal pattern of loss. Evaluate cerebellar, vibration, and position sense in the legs. The exact level of nerve root involvement cannot be precisely known from the physical examination because of overlapping innervation (2) (Table 12.9). A Spurling’s test (extension and rotation of the head and neck while applying downward pressure to the top of the head) that precipitates radicular symptoms is very suggestive of nerve root pathology (1).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Neck Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
Posterior
❑ Musculoligamentous strain
❑ Cervical spondylosis
❑ Cervical root compression
❑ Posterior cervical lymphadenopathy
❑ Meningeal inflammation
❑ Cervical fracture
❑ Atlantoaxial subluxation
Anterior
❑ Anterior cervical lymphadenopathy
❑ Thyroiditis
❑ Myocardial ischemia
Diagnostic Approach
With neck pain after trauma, a cervical fracture must always be ruled out and the patient’s neck immobilized until this is ascertained.
Assess radicular signs of nerve compression as a marker for more serious pathology. The Spurling sign, production of radicular pain with extension and lateral neck rotation, suggests narrowing of the neural foramen. The Lhermitte sign, an electrical sensation radiating down the spine with neck flexion, is a sign of a spinal cord lesion.
With neck pain in the presence of headache or fever, actively consider meningitis.
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Source: Field Guide to Bedside Diagnosis, 2007
Ankylosing spondylitis:
Diagnosis
(Handbook of Diseases)
Typical symptoms, a family history, and the presence of HLA-B27 strongly suggest ankylosing spondylitis. However, confirmation requires these characteristic X-ray findings:
blurring of the bony margins of joints in the early stage
bilateral sacroiliac involvement
patchy sclerosis with superficial bony erosions
eventual squaring of vertebral bodies
“bamboo spine” with complete ankylosis.
Erythrocyte sedimentation rate and alkaline phosphatase and creatine kinase levels may be slightly elevated. A normal test result for rheumatoid factor helps rule out rheumatoid arthritis, which produces similar symptoms.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Juvenile rheumatoid arthritis:
Diagnosis
(Handbook of Diseases)
Persistent joint pain, rash, and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA and for monitoring disease activity and response to therapy.
❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.
❑ Erythrocyte sedimentation rate, complement (C)-reactive protein, haptoglobin, immunoglobulin, and C3 levels may be elevated.
❑ Test results may be positive for ANAs in patients who have pauciarticular JRA with chronic iridocyclitis.
❑ RF is present in 15% of patients with JRA, as compared with 85% of patients with RA.
❑ Positive HLA-B27 test may forecast later development of ankylosing spondylitis.
❑ Early X-ray changes include soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Rheumatoid arthritis:
Diagnosis
(Handbook of Diseases)
Typical signs and symptoms suggest RA, with a firm diagnosis supported by laboratory and other test results:
❑ X-raysin early stages show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.
❑ RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.
❑ Synovial fluid analysisshows increased volume and turbidity but decreased viscosity and elevated white blood cell counts (often greater than 10,000/µl).
❑ Serum protein electrophoresis may show elevated serum globulin levels.
❑ Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation typically parallels disease activity).
❑ Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.
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Source: Handbook of Diseases, 2003
Neck pain:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the patient hasn’t sustained trauma, inquire about the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there a particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.
Physical examination
Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion (ROM) in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings.)
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Neck pain:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Neck pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient hasn't sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Does any particular event precipitate the pain? Also, ask about other symptoms, such as headaches or back pain. Next, focus on the patient's current and past illnesses and injuries, diet, drug history, and family health history.
Thoroughly inspect the patient's neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion (ROM) in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski's and Kernig's signs if there isn't a history of neck trauma, and palpate the cervical lymph nodes for enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
NECK PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The patient who presents with neck pain most commonly has a cervical
sprain or muscle contraction headache. However, we must rule out more
serious pathology such as meningitis, subarachnoid hemorrhage, herniated
disks, and neoplasms before we send the patient home with a collar and a bag
of pills. This means checking for nuchal rigidity, doing a thorough
neurologic examination, and checking for a thyroid or lymph node mass. If
the neurologic examination is abnormal, referral to a neurologist or a
neurosurgeon is indicated before ordering expensive diagnostic tests.
If the neurologic examination is normal and there are no neck masses or
other significant findings, conservative treatment may be initiated without
ordering expensive diagnostic tests. However, most physicians consider it
wise to at least do plain films of the cervical spine. Careful and close
follow-up is necessary so that something serious is not missed in these
cases. When the pain persists despite adequate medical therapy, an MRI of
the cervical spine should be done as well as an Electromyogram (EMG). Again,
it is wise to consult a neurologist first. Always keep in mind that the pain
may be referred from the heart, lungs, esophagus, or gallbladder. Act
accordingly.
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Source: Differential Diagnosis in Primary Care, 2007
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