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Diseases » Arthralgia » Tests
 

Diagnostic Tests for Arthralgia

Contents
  1. Arthralgia: Introduction
  2. Symptoms of Arthralgia
  3. Diagnosis
  4. Home Diagnostic Testing

Arthralgia Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Arthralgia:

Arthralgia Diagnosis: Book Excerpts

Diagnosis of Arthralgia: medical news summaries:

The following medical news items are relevant to diagnosis of Arthralgia:

Diagnostic Tests for Arthralgia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Arthralgia.

JOINT PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine studies include a CBC, sedimentation rate, ASO titer, ANA, cross-reacting protein (CRP), urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joints. It is also wise at times to order a bone survey. Synovial fluid analysis and culture should be done if there is sufficient joint effusion. A trial of therapy may be initiated at this point and will assist in the diagnosis. For example, a course of colchicine may be given to rule out gout.

If there is still doubt, a rheumatology consultation should be made. Other tests that may be done include a gonococcal antibody titer and a coagulation profile. If there is a urethral discharge, a smear and culture of the material should be made. If there is fever, febrile agglutinins, serologic tests for Lyme disease, brucellin antibody titer, blood cultures, and a Monospot test may be done. If collagen disease is suspected, antinuclear antibodies and anti-DNA antibodies may be sought. If sickle cell anemia is suspected, a sickle cell preparation should be done. A bone scan will help diagnose rheumatoid spondylitis and ochronosis. A urine for homogentisic acid will diagnose ochronosis also. An MRI may diagnose a torn meniscus and other condition.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

JOINT SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests include a CBC, sedimentation rate, ASO titer, CRP, ANA, urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joints. It is also wise to do a bone survey when there is multiple joint involvement. A synovial fluid analysis and culture may be done if there is sufficient joint fluid. A trial of therapy can be initiated and may be diagnostic. At this point, it is wise to refer the patient to a rheumatologist for further evaluation. Additional tests that may be ordered are found on page 279 . Polarized microscopy may reveal positive birefringent crystals of pseudogout.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SCROTAL SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, and urethral smear. If prostatic disease is suspected, a PSA should be ordered. If intestinal obstruction is suspected, a flat plate of the abdomen and lateral decubiti should be ordered. A radionuclide testicular scan with technetium-99m is useful in differentiating between testicular torsion and epididymitis. Scrotal ultrasound may be done to evaluate any kind of testicular or scrotal mass. However, it is much less costly to refer the patient to a urologist.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PULSATILE SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

In cases of suspected abdominal aortic aneurysms, abdominal ultrasound will help differentiate the normal aorta or a tumor from a true aneurysm. When in doubt, CT scan or aortography should be done. It will be necessary before surgery anyway.

All other cases of pulsatile masses suggesting an aneurysm should receive angiography of the artery or arteries supplying the area.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Scrotal swelling: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?

Take the patient’s vital signs, especially noting a fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient supine and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Scrotal swelling: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?

Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Arthralgia: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Joint examination. Inspect the joint for evidence of trauma, breaks in the skin, swelling, erythema, deformity (e.g., bony changes, tophi), and asymmetry with contralateral joints. Palpate the joint and surrounding tissues for warmth, tenderness, effusion, edema, and crepitus. Perform joint range of motion (ROM). Pain with active, but not passive ROM is more consistent with a periarticular problem.

B. Examination of other systems. Conjunctivitis, oral lesions, urethritis, genital or extremity ulcers, rash, tophi, and nail pitting can indicate a more systemic problem. Rheumatic disease can affect other organs (e.g., pleural effusion, splenomegaly, Raynaud’s phenomenon).

Testing

A. Laboratory tests. Perform arthrocentesis of an isolated, acutely inflamed joint and examine synovial fluid for cell count and differential, crystals, Gram’s stain, and culture (2). Suspected cases of gonococcal disease warrant culture of the pharynx, urethra, cervix, and rectum to increase the likelihood of a positive culture. Potentially useful blood tests include an erythrocyte sedimentation rate (ESR), antinuclear antibody, rheumatoid factor, syphilis, Lyme disease and other serologies, blood culture, uric acid, thyroid-stimulating hormone, calcium, liver function tests, blood urea nitrogen, and creatinine (2). The ESR is often elevated with inflammatory or infectious conditions, and can be mildly increased in primary generalized OA (Chapter 16.3).

 B. Diagnostic imaging. Perform an x-ray study with a history of significant trauma or focal bone pain (2). In adults, x-ray findings of degenerative changes are more prevalent than symptomatic disease at all ages. Soft tissue swelling and erosive changes can be seen with rheumatic disease. Disruption of joint integrity is most clearly seen on magnetic resonance imaging (MRI). Radiographs and MRI are more helpful in the evaluation of trauma than in other situations, but can be used to follow the progression of a chronic process. Plain radiographs of the chest looking for lung nodules, infiltrates, interstitial processes, and cardiac enlargement may be helpful if rheumatic disease is suspected.

Diagnostic assessment

Arthralgia has many causes. Trauma and infection are the most serious problems in the acute setting where the history and physical examination will be the key to the diagnosis. Chronic or recurrent mon- or polyarticular arthralgia more likely indicates an arthritic process; further testing may be needed to narrow the differential diagnosis. Arthralgia without physical findings may suggest an overuse syndrome, viral infection, vaccine or other medication side effect, or metabolic bone disease (2). Keep in mind that arthralgia can be caused by disease in the surrounding soft tissue structures.


References

1. Johnson BE. Adult rheumatic disease. AAFP home study self assessment. Kansas City: American Academy of Family Physicians July, 1997.

2. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Guidelines for the initial evaluation of the adult patient with acute musculoskeletal symptoms. In: Kelley WN, Ruddy S, Harris ED, Jr, Sledge CB, eds. Textbook of rheumatology, 5th ed. Philadelphia: WB Saunders, 1997.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Monarticular Joint Pain: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Is discomfort apparent? Is fever present? Assess the patient’s gait and note if a mobility aide is used. Inspect the joint for surgical or traumatic scars, muscle atrophy, deformity, joint swelling, and erythema. Palpate for warmth, tenderness, and effusion. Evaluate joint range of motion (ROM). If active ROM is full and normal, evaluation of passive ROM is unnecessary. Pain with active, but not passive ROM suggests a periarticular process. Depending on the joint involved, palpate the relevant periarticular structures and perform the appropriate provocative maneuvers. Examine for rash.

Testing

 No studies are routinely indicated for all cases of monarticular joint pain.

 A. Imaging studies. Radiographs may be warranted if evaluation suggests degenerative joint disease, but they are not necessarily indicated at initial presentation. Radiographic findings of OA, which are more prevalent than symptomatic disease, can be found in 85% of patients aged 65 years (1). Radiographic study is clearly indicated if the pain is chronic, or if there is a history of recent trauma, night pain, or childhood joint disease. In cases of acute inflammatory arthritis, radiographs will likely reveal soft tissue swelling and not provide diagnostic certainty, but could exclude other diseases. Bone scans are not helpful, as they will be positive in all forms of arthropathy. Computed tomography or magnetic resonance imaging scans are not indicated in the routine initial evaluation of monarticular joint pain.

B. Laboratory testing. In the presence of an inflamed joint, a complete blood count and erythrocyte sedimentation rate (ESR) may help distinguish a septic or inflammatory condition from crystal-induced arthritis. Rheumatoid factor or antinuclear antibody may be positive in inflammatory arthritis (Chapters 16.3 and 17.3). Serologic testing for syphilis should be done when gonococcal infection is suspected. Serum uric acid, Lyme titers, and human immunodeficiency virus testing may be warranted. The uric acid level may be normal during an acute gouty attack.

C. Joint aspiration. Fluid analysis is necessary in all cases of suspected septic arthritis, and for the definitive diagnosis of presumed crystal-induced arthropathy at initial presentation. Fluid should be analyzed for cell count and crystals and sent for Gram’s stain, culture, and sensitivity. Patients with immune compromise or tuberculosis require culture for mycobacteria and opportunistic organisms. In suspected septic arthritis, Gram’s stain and culture of the blood, skin lesions, cervix, urethra, pharynx, and rectum may be indicated.

Diagnostic assessment

The history and physical examination usually determine whether the cause of joint pain is inflammatory or degenerative. Occasionally, an acute, inflammatory appearing monarthritis, with a mildly elevated ESR, can be the initial presentation of degenerative disease. OA typically presents with a slow, insidious progression of symptoms over months to years. The pain is achy, brought on by joint use, and relieved by rest. Short-lived (<30 minutes) stiffness may be apparent in the morning and after inactivity.

Gouty arthritis is seen most frequently in men aged more than 30 years. Of patients, 50% present classically with inflammation in the first metatarsal joint of the foot. In women, upper extremity joint involvement predominates. Synovial fluid analysis will reveal monosodium urate crystals or calcium pyrophosphate crystals in the case of pseudogout. Synovial white blood cell (WBC) count suggests inflammation (3,000–50,000 cells/µL). Synovial fluid should be cultured, even if crystals are identified, as bacterial infection can coexist. When in doubt, a diagnostic or therapeutic trial of colchicine can be considered.

Infectious arthritis should be considered with any inflamed joint. Risk factors include an immunocompromised state, a damaged or prosthetic joint, sexual promiscuity, and alcohol or intravenous drug abuse. Onset is usually rapid, over hours to days. Gonococcal arthritis can present with a few days of migratory polyarthralgias. In septic arthritis, the joints commonly affected are the knees, hips, and shoulders. Severe joint pain, swelling, and limited ROM suggest the diagnosis, especially if high fever is present. An elevated WBC count, with a left shift, is present in more than 50% of cases. Definitive diagnosis is dependent on arthrocentesis. Synovial fluid WBC count of greater than 50,000 is supportive of infection. A negative Gram’s stain finding does not rule out infection. Gonococcal arthritis can present with a lower synovial fluid WBC count and the synovial fluid culture is positive in only 25% of cases (2).

Lyme arthritis has an acute, oligoarticular onset and especially affects large joints, most commonly the knee. Symptoms tend to be episodic and are associated with marked swelling, often disproportionate to the amount of pain. Presentation can be weeks to months after the initial infection, and the patient may be unable to give a history of tick bite or the erythema chronicum migrans rash (3). Serology and Western blot testing for Lyme disease should be positive.


References

1. Baker DG, Schumacher HR. Acute monoarthritis. N Engl J Med 1993;329:1013–1020.

2. Zimmerman B, Lally EV, Liu NYN. Infectious agents and the musculoskeletal system. In: Noble J, ed. Textbook of primary care, 2nd ed. St. Louis: Mosby, 1996.

3. Sigal LH. Musculoskeletal manifestations of Lyme arthritis. Rheum Dis Clin North Am 1998;24:323–351.>

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Acute Monoarticular Arthritis: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Ascertain that arthritis (joint inflammation) is present by eliciting pain on joint motion. A hot, swollen joint with constitutional symptoms such as fever, weight loss, and malaise suggests infection. The skin may hold clues to psoriasis, systemic lupus, viral exanthems, Lyme disease, and others. Erythema nodosum occurs with sarcoidosis or inflammatory bowel disease. Urethritis suggests gonorrhea or Reiter syndrome. A monoarticular presentation of a polyarticular disease may be rarely seen in rheumatoid arthritis, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, and sarcoidosis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Polyarticular Arthritis: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Ascertain that the pain is articular; that is, it is exacerbated by the function of the joint. Detecting synovitis limits the differential to inflammatory arthridites and systemic rheumatic diseases. Findings of synovitis include palpable soft tissue bogginess around a joint, warmth over a joint, or effusion. Involvement of the wrists, elbows, or metacarpophalangeal joints implies inflammatory disease rather than osteoarthritis. Morning stiffness persisting for as long as 1 to 2 hours, relieved by NSAIDs, is typical for inflammatory arthritis, as is a history of a red joint.

Differentiating features include the following: Erythema nodosum: sarcoidosis, inflammatory bowel disease-related arthritis, or Behçet disease. Rash: lupus, Still disease, vasculitis, dermatomyositis, endocarditis, disseminated gonorrhea, or Behçet disease. Fever greater than 40˚C: Still disease, bacterial arthritis, or lupus. Fever preceding arthritis: viral arthritis, Lyme, reactive arthritis, Still
desease, or bacterial endocarditis. Spiking fever: bacterial infection or Still
disease. Splenomegaly: rheumatoid arthritis and lupus. Raynaud: scleroderma, mixed connective tissue disease, or lupus. Oral ulcers: lupus, Behçet disease, or viral arthritis. Dry eyes and mouth: Sjögren syndrome, mixed connective tissue
disease, or lupus. Ocular findings: lupus, Behçet disease, sarcoidosis, or reactive arthritis. Migratory arthritis: gonococcemia, rheumatic fever, meningococcemia, viral arthritis, lupus, acute leukemia, or Whipple disease. Episodic recurrences: Lyme, crystal-induced arthritis, inflammatory bowel disease, Still disease, or lupus. Morning stiffness: rheumatoid arthritis, polymyalgia rheumatica, Still
disease, or viral arthritis. Symmetric small-joint synovitis: rheumatoid arthritis, lupus, or viral arthritis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Scrotal Pain/Swelling: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.

Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.

Referred pain can be differentiated from scrotal pathology by a normal testicular examination.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Scrotal swelling: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Scrotal swelling: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?

Take the patient's vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in a supine position and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles'position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can't be transilluminated.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T, 38.9°C; RR, 36/min; HR, 130 bpm; BP, 115/55 mm Hg; SpO2, 99% in room air
Weight, 18.0 kg (greater than the 95th percentile)
The child appeared uncomfortable and refused to stand. The eyes, nose, and oropharynx were clear. The neck was supple. The abdomen was mildly distended and diffusely tender, particularly in the right lower quadrant. However, there was no rebound tenderness or involuntary guarding. There was no costovertebral angle tenderness. There was discomfort with passive flexion of the right hip. There was mild edema and tenderness to percussion along the right paraspinous muscle at the level of the L1 vertebra. There was no kyphosis, scoliosis, or abnormal lordosis. There were no apparent sensory or motor neurologic deficits, although the degree of back and abdominal pain made assessment of muscle strength in the lower extremities difficult. There was no muscle atrophy. Rectal tone was normal. The deep tendon reflexes were symmetric and appropriately brisk. The remainder of the examination was normal.

IV. Diagnostic Studies

Complete blood count revealed the following: 19,700 white blood cells (WBCs)/mm3, with 67% segmented neutrophils, 29% lymphocytes, and 3% monocytes; hemoglobin, 11.4 g/dL; and platelets, 390,000/mm 3. Serum electrolytes were remarkable for a bicarbonate level of 19 mEq/L, a blood urea nitrogen level of 7 mg/dL, and a creatinine level of 0.3 mg/dL. Urinanalysis revealed a specific gravity of 1.020 and 3+ ketones but the microscopic examination was normal. Serum albumin and transaminases were normal. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were elevated at 7.9 mg/dL and 65 mm/hour, respectively. Abdominal obstruction series revealed scattered air –fluid levels and a small amount of stool in the rectum.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-2: 2-Year-Old Boy: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T, 37.3°C; RR, 34/min; HR, 104 bpm; BP, 98/43 mm Hg
Height and weight, both 25th percentile for age
On examination, the child was pale and tired-appearing. His sclerae were anicteric. The heart and lung sounds were normal. The spleen tip was palpable just below the left costal margin. The liver edge was palpable 3 cm below the right costal margin. There was mild discomfort with passive flexion of the right hip, but the range of motion was normal. There was no overlying erythema or warmth. Examination of the left hip was unremarkable. The testes were in normal position and were not enlarged, swollen, or tender. Numerous petechial lesions were scattered on his lower extremities bilaterally. Small lymph nodes were palpable in the anterior cervical and inguinal regions.

IV. Diagnostic Studies

The complete blood count revealed 4,300 WBCs/mm3, with 3% band forms, 8% segmented neutrophils, and 85% lymphocytes, giving an absolute neutrophil count of 473/mm 3. The hemoglobin was 8.0 g/dL, with a reticulocyte count of 1.3%. The platelet count was 31,000/mm 3. CRP and ESR were 2.6 mg/dL and 60 mm/hour, respectively. Serum lactate dehydrogenase (LDH), uric acid, transaminases, and electrolytes were normal. The hip radiographs performed earlier were reviewed (Fig. 5-2A).

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-3: 14-Year-Old Boy: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T, 37.1°C; RR, 24/min; HR, 105 bpm; BP, 125/80 mm Hg
Weight, 101 kg
Physical examination revealed an obese boy without visible evidence of head trauma. He was alert and cooperative. Heart and lung sounds were normal. The abdomen was soft without organomegaly. There was no deformity of either lower extremity. Passive flexion of the left hip accompanied by internal and external rotation significantly worsened the left knee pain. Internal rotation of the left hip was limited compared with that of the right hip. There was no tenderness, swelling, or erythema of the left knee. There was full range of motion of the left knee without discomfort when this joint was tested in isolation. There was no sign of knee ligament instability. The right lower extremity was normal. He was able to ambulate but clearly preferred not to place too much weight on the left leg.

IV. Diagnostic Studies

The complete blood count revealed the following: 8,600 WBCs/mm3 (65% segmented neutrophils, 30% lymphocytes, and 5% monocytes); hemoglobin, 13.1 g/dL; and 204,000 platelets/mm 3. The CRP concentration was 0.7 mg/dL, and the ESR was 12 mm/hour. Serum electrolytes and calcium were normal.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-4: 16-Year-Old Girl: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T, 35.8°C; RR, 18/min; HR, 93 bpm; BP, 123/66 mm Hg
Weight, 40 kg; Height, 162 cm (50th percentile); weight-for-height ratio, less than 5th percentile
Physical examination revealed a thin girl. Her palpebral conjunctivae were slightly pale. There were several superficial but actively bleeding erosions on the left medial nasal septum. There were no oral ulcers. Heart and lung sounds were normal. The abdomen was soft with mild right lower-quadrant tenderness to palpation. There were no peritoneal signs. Bright red blood mixed with stool was detected on rectal examination. There was a small left knee effusion and bilateral ankle effusions. All joints had a normal range of motion.

IV. Diagnostic Studies

Complete blood count revealed 8,900 WBCs/mm3; hemoglobin, 9.6 mg/dL; and 463,000 platelets/mm3. MCV was 70 fL. The reticulocyte count was 1.5%. ESR was 89 mm/hour. Prothrombin time, partial thromboplastin time, and serum transaminases were normal. Serum albumin was 3.0 mg/dL. Urine pregnancy test was negative. There were no red blood cells (RBCs) or WBCs on urinanalysis. Stool was sent for bacterial culture, ova and parasite examination, and Clostridium difficile toxin detection. Abdominal radiography revealed stool in the rectal vault.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-5: 13-Year-Old Boy: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T 37.7°C; RR 24/min; HR 110 bpm; BP 105/70 mm Hg; Weight 35kg.
The patient was a well-developed, well-nourished male crying in pain. Head, eyes, ears, nose, and throat were normal. There was no lymphadenopathy. There was no thoracic wall tenderness. The heart and lung sounds were normal. His abdomen was soft and nontender without hepatomegaly or splenomegaly. He had no point tenderness of his back; however, he complained of “inside pain” over his sacrum. The rectal examination revealed normal sphincter tone and no palpable masses. His extremities were warm with good peripheral pulses, and he had full range of motion of all four extremities.

IV. Diagnostic Studies

Complete blood count revealed 8,400 WBCs/mm3 (81% segmented neutrophils, 17% lymphocytes, 2% basophils, 1% eosinophils, and no bands); hemoglobin, 10.4 g/dL; MCV, 72fL; mean corpuscular hemoglobin content (MCHC), 23.4 g/dL; red cell distribution width (RDW), 15.1; platelets 241,000/mm 3; and a reticulocyte count of 3%. Blood smear showed anisocytosis, poikilocytosis, and polychromasia. Electrolytes, blood urea nitrogen, creatinine, and glucose were normal. ESR was 20 mm/hour. Urinalysis revealed small amounts of urobilinogen.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Back, Joint, and Extremity Pain - Case 5-6: 9-Year-Old Boy: III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)

T, 38.6°C; RR, 18/min; HR, 112 bpm; BP, 112/60 mm Hg
Weight, 60th percentile (down 3 kg from his preparticipation physical examination 4 months earlier); height, 75th percentile (up by 1.0 cm from the earlier measurements)
The patient was a cooperative boy in no acute distress. He was slender, and his clothes hung loosely from his frame. Eyes, nose, ears, and oropharynx were not inflamed. His tonsils were 3+ and symmetric without erythema or exudates. His neck was supple with only shotty anterior cervical adenopathy. His thyroid was not enlarged. His lungs were clear with good aeration. His heart had a regular rhythm but was tachycardic, with a soft systolic murmur at the apex that was audible throughout systole. His abdomen was soft, nontender, nondistended, and without hepatosplenomegaly. The left ankle demonstrated a small effusion with increased warmth and mild erythema. There was exquisite pain with active and passive range of motion and with gentle palpation of the joint. All other joints were normal on examination.

IV. Diagnostic Studies

A complete blood count revealed 12,200 WBCs/mm3 (74% neutrophils, 20% lymphocytes, 5% monocytes, and 1% eosinophils); hemoglobin, 9.5 g/dL; and a platelet count of 556,000/mm 3. A basic metabolic panel was normal, but inflammatory markers were elevated, with an ESR of 120 mm/hour and a CRP concentration of 8.3 mg/dL. A rapid streptococcal test and culture of his throat were both negative. Radiographs of both ankles were obtained and were normal.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


 » Next page: Diagnosis of Arthralgia

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