Diagnostic Tests for Anthrax
Anthrax: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Anthrax
includes:
Anthrax Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Anthrax:
- Lung & Respiratory Health Tests:
Anthrax Diagnosis: Book Excerpts
Tests and diagnosis discussion for Anthrax:
Anthrax General: DBMD (Excerpt)
Anthrax is diagnosed by isolating B. anthracis from the
blood, skin lesions, or respiratory secretions or by measuring
specific antibodies in the blood of persons with suspected cases. (Source: excerpt from Anthrax General: DBMD)
Anthrax: NWHIC (Excerpt)
A person can be exposed to anthrax by coming into contact with anthrax
bacteria. However, a person can be exposed without getting the disease.
Actual anthrax disease occurs when there is some sign of illness, such as
the skin lesion that occurs with cutaneous anthrax. A person who is
exposed to anthrax spores but given appropriate antibiotics can avoid
getting anthrax. Anthrax is not a contagious disease and cannot be passed
from person to person. (Source: excerpt from Anthrax: NWHIC)
Anthrax: NWHIC (Excerpt)
Currently used tests for anthrax in an individual can only confirm
an infection, not exposure without infection. The only way exposure can be
determined is through a public health investigation. The tests that you
hear or read about, such as nasal swabs and environmental tests, are not
tests to determine whether an individual should be treated. These kinds of
tests are used only to determine the extent of exposure in a given
building or workplace and are not reliable in determining if an individual
has been exposed to anthrax. When an investigation shows that exposure may
have occurred, prophylactic (preventive) therapy with antibiotics is
provided to those persons. (Source: excerpt from Anthrax: NWHIC)
Anthrax: NWHIC (Excerpt)
Anthrax is diagnosed by isolating the anthrax bacteria from the blood,
skin lesions, or respiratory secretions or by measuring specific
antibodies in the blood of persons with suspected cases. (Source: excerpt from Anthrax: NWHIC)
Diagnostic Tests for Anthrax: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Anthrax.
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
Pustular rash:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
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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
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
Introduction: Gastrointestinal Disorders:
Accurate assessment vital
(Professional Guide to Diseases (Eighth Edition))
Your assessment of the patient with suspected GI disease must begin with a careful history that includes occupation, family history, and recent travel. The medical history should include previous hospital admissions; surgical procedures (including recent tooth extraction); family history of ulcers, colitis, or cancer; and current medications, whether prescribed, over-the-counter, or herbal remedies, with particular attention to aspirin, steroids, or anticoagulants.
Have the patient describe his chief complaint in his own words. Does he have abdominal pain, indigestion, heartburn, or rectal bleeding? How long has he had it? What relieves these symptoms or makes them worse? Has he experienced nosebleeds or difficulty in swallowing recently? Has he had recent weight loss or gain? Is he on a special diet? Does he drink alcoholic beverages or smoke? If yes to either, how much and how often? Ask about bowel habits. Does he regularly use laxatives or enemas? If he experiences nausea and vomiting, what does the vomitus look like? Does changing his position relieve nausea?
Next, try to define and locate any pain. Ask the patient to describe the pain. Is it dull, sharp, burning, aching, spasmodic, or intermittent? Where is it located? Does it radiate? How long does it last? When does it occur? What triggers it? What relieves it?
Visual assessment
Observe how the patient looks and note appropriateness of behavior. Changes in fluid and electrolyte balance, severe infection, drug toxicity, and hepatic disease may cause abnormal behavior. Your visual examination should check:
❑ Skin: loss of turgor, jaundice, cyanosis, pallor, diaphoresis, petechiae, bruises, edema, and texture (dry or oily)
❑ Head: color of sclerae, sunken eyes, dentures, caries, lesions, tongue (color, swelling, dryness), and breath odor
❑ Chest: shape (asymmetrical, barrel, or sunken)
❑ Lungs: rate, rhythm, and quality of respirations
❑ Abdomen: size and shape (distention, contour, visible masses, and protrusions), abdominal scars or fistulae, excessive skin folds (may indicate wasting), and abnormal respiratory movements (inflammation of diaphragm).
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pustular rash:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
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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.
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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
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.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Gastrointestinal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Vital signs. The single most important aspect of the initial physical examination is determining the patient’s hemodynamic stability. Unstable patients should be managed as trauma patients. Placement of a nasogastric (NG) tube is considered the “fifth vital sign” in patients with acute GI bleeding (2).
B. Focused physical examination. After ensuring hemodynamic stability, the initial physical examination should eliminate a nasal or oropharyngeal source of bleeding. Examine the skin and abdomen carefully for clues to an underlying cause. A rectal examination is mandatory.
1. Skin examination. Ecchymoses, petechiae, and varices should be noted. Conjunctival pallor is a sign of chronic anemia. Numerous mucosal telangiectasias can point to an underlying vascular abnormality.
2. Abdominal examination. Look for stigmata of chronic liver disease (hepatosplenomegaly, spider angiomata, ascites, palmar erythema, caput medusae, gynecomastia, and testicular atrophy) (Chapter 9.9).
3. Rectal examination. Rectal varices, hemorrhoids, and fissures should be noted.
Laboratory evaluation
A. Basic laboratory studies should include a complete blood count with particular attention to the hematocrit, coagulation studies [prothrombin time (PT) and partial thromboplastin time (PTT)], liver function tests (LFTs), serum chemistries (blood urea nitrogen is elevated disproportionately to creatinine in patients with GI blood loss), electrocardiogram (ECG), and NG aspirate analysis. Acutely, the hematocrit is a poor indicator of blood loss; however, serial hematocrits can be useful in assessing ongoing blood loss. A prolonged PT or PTT suggests an underlying coagulopathy. Elevated LFTs suggest underlying liver disease. An ECG is important, especially in elderly patients, to search for evidence of cardiac ischemia. Finally, the NG aspirate is essential. If the aspirate is bright red, or “coffee grounds” in appearance, an upper GI source is likely.
B. Endoscopy plays a central role in the diagnosis and management of GI bleeding. Fiberoptic endoscopy is 90% accurate in pinpointing the source of upper GI bleeding. In addition, the endoscope can also be used to deliver therapy directly.
C. Anoscopy can be used to identify the source of lower GI bleeding; however, the yield is poor (5). Often the site of bleeding cannot be directly visualized or the volume of bleeding is sufficiently heavy to obscure clear visualization.
D. Nuclear medicine studies are useful in grossly localizing bleeding sources to the small intestine, right colon, or left colon. Nuclear scanning is also useful in detecting Meckel’s diverticulae. These images can detect ongoing GI bleeding with a sensitivity of blood loss at 0.05 to 0.1 ml/minute.
E. Angiography can also identify the source of lower GI bleeding. It is not as sensitive as nuclear scanning, requiring a blood loss of more than 0.5 ml/minute.
Diagnostic assessment
The key to the successful approach to GI bleeding is ensuring the hemodynamic stability of the patient. Once done, a systematic search for the source of the bleeding should be undertaken. Although often unreliable, a careful patient history can provide valuable clues to factors that may predispose the patient to hemorrhage from a particular site within the GI tract. Physical examination (including placement of a NG tube) can further delineate whether an upper source or a lower source is most likely. The key diagnostic modality in GI bleeding is fiberoptic endoscopy. Following the clues provided by a careful history and physical examination, targeted endoscopy is then used to definitively identify the source of bleeding. In the rare cases where endoscopy is unable to adequately identify the source of GI bleeding, specialized nuclear medicine and angiographic studies can be used.
References
1. Zimmerman HM, Curfman K. Acute gastrointestinal bleeding. AACN Clin Issues 1997;8(3):449–458.
2. Laine L. Acute and chronic gastrointestinal bleeding. In: Feldman M, Sleisinger MH, Scharschmidt BF, eds: Gastrointestinal and liver disease: pathophysiology, diagnosis, and management. Philadelphia: WB Saunders, 1998:198–218.
3. McGuirk TD, Coyle WJ. Upper gastrointestinal tract bleeding. Emer Med Clin N Am 1996;14(3):523–545.
4. Zuccaro G. Management of the adult patient with acute lower gastrointestinal bleeding. Am J Gastroenterol 1998;93(8):1202–1208.
5. Bono MJ. Lower gastrointestinal bleeding. Emer Med Clin N Am 1996;14(3):547–556.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
Gastrointestinal Bleeding:
DIagnostic Approach
(Field Guide to Bedside Diagnosis)
With overt bleeding, determining whether a source is proximal or distal to the ligament of Treitz is key to the further diagnostic evaluation. Hematemesis confirms an upper GI source, and suggests loss of more than a quarter of blood volume. Melena (black, tarry stool) also comes from an upper source unless the bleeding is brisk or large volume and transit is rapid. Melena without hematemesis usually results from a lesion distal to the pylorus (e.g., duodenal ulcer) or to slow bleeding. Tarry stools may be produced by as little as 100 mL of blood. Lower sources produce hematochezia (maroon or clots from the right colon and bright red from the left colon). A small amount of blood only on the toilet tissue nearly always comes from a bleeding hemorrhoid or fissure. Silver stool is said to arise from acholic stools combined with luminal bleeding in an ampullary cancer.
Determine the hemodynamic significance of the bleeding by looking for postural lightheadedness or changes in pulse or blood pressure. Early symptoms of thirst and lightheadedness occur with loss of more than 15% of intravascular volume. An orthostatic blood pressure drop of 10 mm Hg indicates a loss greater than or equal to 20% of volume. Shock with hypotension and pallor develops with 25% to 40% volume loss.
Stools may be falsely colored by ingestants such as bismuth subsalicylate, iron, licorice or charcoal, which turn it black, or beets, which turn it red. These stools are not sticky. A negative stool test for occult blood will usually resolve this.
Hemoccult screening detects blood loss down to 1 to 10 ml/day. Evaluation of a heme positive stool will reveal colon cancer in 5% to 14% of patients, and large adenomatous polyps in another 15% to 35%. Any single positive stool should be evaluated. Hemoccult screening reduces colon cancer mortality by 15% to 33%. An asymptomatic patient with a negative Hemoccult has only a 0.2% chance of having colon cancer (compared with 1.4% prevalence in this population). Using Hemoccult alone as a screening strategy will miss 50% to 60% of colon cancers.
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Source: Field Guide to Bedside Diagnosis, 2007
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
Vesicles/Bullae/Pustules:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Vesicles are less than 5 mm in diameter, and bullae are larger. If bullae, petechiae, purpura, or necrosis are present, look for an “allergen” such as HSV, strep, deep fungal infection, collagen disease (especially lupus), or occult neoplasm.
Erythema multiforme can be differentiated from a drug reaction by a dusky violet color and petechiae at the center of the lesion. A target or iris lesion is also characteristic of erythema multiforme.
Staphylococcal scalded skin syndrome can be differentiated from toxic epidermal necrolysis by superficial blisters and absence of oral lesions.
Multidermatomal or disseminated zoster in a young adult should suggest HIV infection.
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Source: Field Guide to Bedside Diagnosis, 2007
Pustular rash:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Assess the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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
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
Gastrointestinal Bleeding:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Determination of Gastrointestinal Bleeding
Determinewhether reddish color of vomitus or stool is blood (e.g., raspberries,beets, and food colorings can give reddish color).Gastroccult (Smith Kline Diagnostics,San Jose, CA) test may be used to detect presence of blood in vomitusor gastric aspirate. Hemoccult test can be used to confirm presenceof blood in stool. Severity of Bleeding
If GI bleedingis obvious, most important task is to determine severity.Important to quantitate amount of bleeding:1–2 drops, 1 teaspoonful, 1 cupful, or massive bleedingwith clot formation. Passage of clots via rectum or vomiting of >1cupful of bright red blood is indicative of significant bleeding.In such cases, first note vital signsand perform any necessary resuscitation.Immediate fluid replacement is requiredto stabilize BP. Site of the Bleeding
Determinethe site of bleeding—whether it is from the upper or lowertract or both. Blood from nose or mouth can be swallowed and subsequentlyvomited or passed in stool. Retching from vomiting also can producesome blood-stained vomitus but is rarely severe.Except in these instances, NG tubeshould be placed to document level and rate of bleeding.Gastric aspirate that is positive forblood is highly specific for upper tract bleeding. Negative aspiratesuggests lower tract bleeding but does not totally preclude uppertract bleeding, especially from duodenum. Specific Diagnosis
Importantfactors to consider in diagnosis areAgeClinical findings (e.g., vomiting,diarrhea, fever, constipation, abdominal pain, hepatomegaly, splenomegaly,abdominal distension, weight loss, and jaundice)History of aspirin, NSAID, or alcoholingestionPresence of known diseases (e.g., IBDor liver disease) Diagnostic studies that may identifysource of acute bleeding include endoscopy, radionuclide scanning,and selective angiography.If upper tract bleeding has stoppedor is intermittent, upper endoscopy can be performed to diagnoseesophagitis, gastritis, gastric or duodenal ulcer, Mallory-Weisstear, and esophageal varices.If endoscopic exam is impossible to performbecause of continuous bleeding, radionuclide scan or selective angiographycan be performed. Technetium sulfur colloid scan can detect slow ongoingbleeding, whereas technetium red cell scan can detect slow intermittentbleeding. These techniques help localize site of bleeding, so thatother diagnostic studies can be performed.Sulfur colloid scan can detect bleedingat rate as low as 0.1 mL/min, but only if bleeding is occurringat time of injection because half-life of tracer is <2.5mins. Labeled red cells remain in blood for 24 hrs, so technetiumred cell scan can detect intermittent bleeding.If these scans fail to disclose siteof bleeding or bleeding is brisk, selective angiography should beperformed—angiography of celiac axis and superior mesentericartery for suspected upper tract bleeding, and superior mesentericand inferior mesenteric artery angiography for suspected lower tract bleeding.Another advantage of angiography isthat therapeutic measures (e.g., vasopressin infusion and embolization)can be used if necessary.If the bleeding is massive or uncontrolled,immediate surgery should be considered. In stable child with lower tract bleeding,anus should be examined for anal fissure and rectum for polyp.With bloodydiarrhea, bacterial stool culture should be performed, and examof stool for ova and parasites should be considered.Technetium 99m–pertechnetatescan to identify ectopic gastric mucosa in Meckel diverticulum orintestinal duplication also should be considered. If diagnosis remainsuncertain, proctosigmoidoscopy should be performed. This may befollowed by colonoscopy or contrast studies.Colonoscopy with biopsy may diagnosepolyps, colitis, IBD, hemangiomas, and malignant lesions. Air-contrastenema may diagnose intussusception. With persistent undefined bleeding,upper tract endoscopy may be useful to identify ulcer, esophagealor gastric varices, or vascular lesion.Upper GI radiographic series with smallbowel follow-through may diagnose lesions of esophagus, stomach,and duodenum as well as lesions of small bowel, including CrohndiseaseSelective angiography may not revealsite of bleeding if bleeding is too slow, but it may suggest angiodysplasticlesion or tumor by revealing abnormal vascular pattern. >
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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
Pustular rash:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.
Examine the entire skin surface, noting if it's dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.
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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.
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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.
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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
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