Causes of Arthritis

• Fracture
  –Radial head fracture is most common: Usually due to a fall on an outstretched arm, resulting in pain with supination
  –Olecranon fracture: Pain with extension
  –Distal humerus fractures are less common
• Dislocation
  –Nursemaid's elbow (subluxation of the radial head) occurs in young children who were pulled by an outstretched arm; children will refuse to move the arm
  –In adults, dislocations generally occur secondary to falling on an outstretched arm; 80% are associated with an olecranon fracture
• Bursitis: Due to trauma, inflammation, infection

• Epicondylitis
  –Degeneration of the tendinous insertion at the lateral or medial epicondyles
  –Lateral epicondylitis (“tennis elbow”): Due to extensor muscle overuse (results in pain with pronation and wrist dorsiflexion)
  –Medial epicondylitis (“golfer's elbow”): Due to flexor muscle overuse (results in decreased grip strength and pain with pronation or wrist flexion)
• Ulnar nerve entrapment
  –Usually in the groove of the posterior aspect of the medial epicondyle
  –Occurs acutely after direct trauma or with prolonged pressure or overuse
  –Causes acute medial aching with numbness and tingling in fourth and fifth digits

• TMJ disorders
  –Associated with unilateral or bilateral achy pain and diffuse tenderness of the masseter and temporalis muscles
  –Exaggerated by jaw use
  –Joint may be tender to palpation
  –“Clicking” sounds are often present
  –More common in females age <50

• Giant cell (temporal) arteritis
  –Unilateral pain in older patients
  –Headache, jaw claudication, and vision loss
• Mucosal lesions (buccal mucosa, hard and soft
  palate, floor of mouth, or oropharynx)
  –Aphthous ulcers
  –Herpes simplex or coxsackievirus B
  –Cancer
  –Tongue or lip lesions
• Paranasal sinus pathology
  –Most common pathology is maxillary
  sinusitis secondary to viral URI
  –Pain is often referred to the upper molars
• Salivary gland pathology, including inflammation (e.g., parotiditis), ductal stone, or neoplasm
• Headache with radiation to the jaw
• Referred pain from cardiac, cervical spine, pulmonary, or throat disease
• Neuralgias (e.g., trigeminal, glossopharyngeal)
• Neuropathies
  –Systemic neuropathies (e.g., HIV, diabetes)
  –Dental/alveolar neuropathies, usually
  subsequent to extrinsic trauma (e.g., blow to face, dental surgical intervention)
• Behavioral disorders
• Primary neoplasms of the maxilla, mandible, or major salivary gland
• Metastases to mandible, maxilla, or TMJ
• Herpes zoster or post-herpetic neuralgia
• Fibromyalgia
• Rheumatologic disease (e.g., Sjögren's syndrome)
• Systemic arthritis (e.g., rheumatoid arthritis)

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Knee Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Degenerative joint disease (osteoarthritis)
• Ligamentous injury
  –ACL: Positive Lachman (more sensitive) and anterior drawer test
  –PCL: Positive thumb sign (more sensitive) and posterior drawer test
  –MCL: Pain and/or increased laxity with valgus stress
  –LCL: Pain and/or increased laxity with varus stress
• Meniscus tear
  –Patient may complain of pain and locking; positive McMurray circumduction test
• Patellofemoral syndrome
• Iliotibial band syndrome
  –Pain along the lateral aspect of the knee accompanied by a palpable or audible snapping
  –Occurs almost exclusively in runners
• Pes anserine bursitis
  –Patients complain of pain along the medial aspect of the knee (at pes anserinus insertion)
  –Caused by repetitive movement that creates an inflammatory response
• Joint effusion
  –May be secondary to osteoarthritis, inflammatory arthritis, ligament injury, gout, pseudogout, or infection
• Joint infection (septic joint)
  –Staphylococcus aureus is most common
  –Neisseria gonorrhoeae is common in adolescents and young adults
  –Salmonella is common in sickle cell patients
  –Haemophilus influenzae is common in children
• Osteochondritis dissecans (OCD)
  –Osteonecrosis of subchondral bone
  –Most commonly seen in the knee
  –Patient reports a gradual onset of pain
  –Exam reveals tenderness of the affected area with manipulation
• In the pediatric population, consider Osgood-Schlatter disease, physeal injury, and discoid meniscus
• Hip or foot/ankle disease with referred pain to the knee
• Malignancy
• Osteomyelitis

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Arthritis – Single Joint: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthritis
  –Rapid diagnosis critical: Untreated septic arthritis causes irreversible joint and bone destruction
  –Usually presents hyperacutely with very tender, swollen, warm, red joint with severely restricted range of motion
  –Usual pathogens: Haemophilus influenzae type b, Staphylococcus aureus, group B strep in neonates, and Neisseria gonorrhoeae in adolescents; fungal and mycobacterial arthritis are seen rarely, may have chronic course

• Lyme arthritis
  –Second most common manifestation of Lyme disease (after erythema migrans)
  –Monoarthritis of a knee occurs in about two-thirds of children with Lyme disease
• Reactive arthritis
  –Probably the most common etiology of childhood rheumatic diseases
  –Transient sterile arthritis following a bacterial GI infection
  –Usually full resolution, but a few children have a chronic course
• Trauma, overuse, fracture
  –Often acute onset with significant pain
• Malignancy such as leukemia, neuroblastoma and osteogenic sarcoma
• Pauciarticular juvenile rheumatoid arthritis (JRA)
• Spondyloarthropathies (SpA)
• Congenital hip dysplasia
• Slipped capital femoral epiphysis (SCFE)
  –Most common adolescent hip disorder
  –Separation of the femoral growth plate
  –More common in obese males
• Spontaneous osteonecrosis of the joint
  –Mostly in hip (Legg-Calvé-Perthes disease), shoulder, and knee
  –More common in males
• Internal structural abnormality
  –Discoid meniscus, osteochondritis dissecans, synovial chondromatosis
• Hemarthrosis due to trauma, bleeding disorder such as hemophilia, or benign tumors such as hemangiomas and pigmented villonodular synovitis
• Periodic fever syndromes such as familial Mediterranean fever

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Arthritis – Multiple Joints: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Infectious
  –Reactive arthritis (postenteric or genital including Reiter syndrome, postviral, poststreptococcal)
  –Acute rheumatic fever (ARF): Migratory, painful; usually affects large joints; diagnosis is based on Jones criteria, which includes five major (arthritis, carditis, Sydenham chorea, erythema marginatum, subcutaneous nodules) and several minor (fever, arthralgia, elevated ESR or CRP, prolonged P-R interval) manifestations
  –Lyme disease: Arthritis is monoarticular or oligoarticular, is rarely symmetric, and is the second most common manifestation of Lyme disease after erythema migrans
  –SBE-related arthritis
  –Septic polyarthritis (unusual)

• Rheumatic
  –Polyarticular JRA: Arthritis in five or more joints in first 6 months of disease, insidious onset, symmetric involvement, may be RF+ (erosive, similar to adult RA) or RF-
  –Systemic-onset JRA: Presents with severe systemic involvement (fever, rash, serositis), which may precede the arthritis, usually oligoarticular
  –Juvenile ankylosing spondylitis (JAS): Initially affects lower extremity joints; later affects axial skeleton, also affects tendons
  –Psoriatic arthritis
  –Arthritis of IBD: Usually more transient than JRA
  –SLE: May present only with arthritis, may be misdiagnosed as JRA
  –Other connective tissue diseases (scleroderma)
  –Vasculitis (HSP, Kawasaki disease)

• Malignancy such as leukemia
• Other systemic disorders: Serum sickness, sarcoidosis, Behçet disease, Ehler-Danlos syndrome, mucopolysaccharidoses, Noonan syndrome, Turner syndrome
• Medications (minocyline, carbamazapine)
• Sickle cell disease

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Otalgia (Ear Pain): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

External ear

• Otitis externa
  –Pinnae and especially tragus, are exquisitely tender
• Impacted cerumen
  –Hearing loss and aural fullness
• Foreign body
  –Items such as beads, toys, and even extruded tympanostomy tubes
• Trauma
  –Any object inserted into the ear canal may cause trauma, including Q-tips
• Perichondritis
  –Inflammation or infection of the cartilage of the pinna and canal, sparing the lobule (since there is no cartilage there)
• Myringitis
  –Tympanic membrane granulation or de-epithelialization

Middle ear/mastoid
• Acute otitis media
  –Otalgia may precede middle ear effusion
• Otitis media with effusion
  –May occur in the absence or presence of an active infection
• Eustachian tube dysfunction
  –Negative intratympanic pressure
• Barotrauma
  –Pretreatment with topical nasal decongestants may be effective prophylaxis
• Mastoiditis
  –Associated with postauricular pain and normal tympanic membrane/middle ear

Non-otologic (secondary)
• Cranial nerve referred pain
  –III: Dental infection, temporal-mandibular joint (TMJ) syndrome
  –VII: Herpes zoster oticus (Ramsay Hunt syndrome)
  –IX: Tonsillitis, pharyngitis
  –X: Laryngitis, GERD, thyroiditis
• Cervical nerve referred pain
  –Neck infections, lymph nodes, cysts
  –Cervical spine disorders
• Paranasal sinusitis
• Migraines
• Neuralgias

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Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Epigastric pain

• Peptic ulcer disease/GERD
  –May be due to Helicobacter pylori or NSAID use
• Gallbladder disease
  –Most commonly with hemolytic disorders
• Pancreatitis
  –Trauma and idiopathic are common causes

Periumbilical pain
• Functional abdominal pain/IBS
  –Most common cause of nonorganic pain
  –Occurs in children 3–15 years old
• Appendicitis
  –Periumbilical pain moves to RLQ
• Gastroenteritis (virus, bacteria, parasite)
• Carbohydrate intolerance
  –Lactase, fructase, trehelase deficiency
• Abdominal migraine
• Drugs
  –Antibiotics, anticonvulsants, bronchodilators
• Small bowel bacterial overgrowth
• Streptococcal pharyngitis
  Suprapubic pain
• Urinary tract infection
  –With dysuria, fever, foul-smelling urine
  –Pyelonephritis may have CVA tenderness
• Constipation
  –Accounts for 3% of visits to pediatrician
  –May have a palpable fecal mass
• Urinary retention
• Hydrometrocolpos
  –Associated with imperforate hymen
  –Cyclic pain with onset of menstrual cycle

Right lower quadrant pain
• Appendicitis
• Ovarian torsion
• Pelvic inflammatory disease
• Ectopic pregnancy
• Mittelschmerz
  –Pain midcycle with ovulation
• Inflammatory bowel disease
  –Classic for terminal ileal Crohn disease
• Iliopsoas abscess
• Inguinal hernia
• Right lower lobe pneumonia

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Back Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Muscular strain, disk herniation
  –Most common in adolescents who are involved in competitive or contact sports; may be occupational
• Spondyloarthropathy
  –Ankylosing spondylitis is found primarily in boys, characterized by sacroiliitis, LE oligoarthritis, and may be associated with IBD
  • Malalignment
    –Scoliosis: Idiopathic form is most common in girls, may be familial, may be secondary to neurologic disorder
    –Hyperlordosis
  • Infectious
    –Diskitis: Characterized by spine stiffness and muscular spasm, Staphylococcus aureus is the usual pathogen, blood culture may be positive
    –Vertebral osteomyelitis: Exquisite point tenderness, pathogen may be S. aureus, Streptococcus pneumoniae, or others such as tuberculosis or brucellosis
    –Acute transverse myelopathy: Generally follows an upper respiratory tract infection; characterized by back pain, distal weakness and paresthesias at the midthoracic level
  • Urinary tract
    –Urinary tract infection: Most common in postpubertal girls, occurrence in boys or prepubertal girls may require evaluation for urinary tract anomalies, especially if recurrent
    –Urolithiasis: Associated with hypercalcuria, cystinuria, Lesch-Nyhan; characterized by intense flank pain and hematuria
  • Malignancy
    –Primary spinal cord or column tumors (osteogenic sarcoma, neuroblastoma)
    –Metastatic tumors (neuroblastoma)
    –Bone marrow infiltration (leukemia, lymphoma)
  • Gynecologic
    –Menstrual cramps
    –PID
    –Endometriosis

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Chest Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Musculoskeletal
  –Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
  –Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
  –Injury to chest wall

• Pulmonary
  –Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
  –Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
  –Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
  –Pneumonia: Chest pain secondary to cough or pleural involvement
  –Pneumothorax can occur spontaneously, especially in tall, thin athletes

• Gastrointestinal
  –GERD and PUD: Burning, substernal pain with eating, worse at night
  –Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis

• Cardiac: Rare in children
  –Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
  –Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
  –MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
  –Aortic dissection: Consider if features or history of Marfan syndrome is present

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Hip Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthitis
  –Surgical emergency due to irreversible chondrolysis and epiphyseal injury
  –Acute process leading to decreased hip range of motion, severe pain with passive range of motion
• Slipped capital femoral epiphysis (SCFE)
  –Typically in obese, adolescent males with aching groin, hip, or knee
  –May have externally rotated hip position and gait
• Legg-Calvé-Perthes
  –Presents at younger age than SCFE (3–8 years old)
  –Five times greater incidence in boys than girls
  –Pain in hip or knee, decreased active and passive ROM, and Trendelenburg gait
• Developmental dysplasia of the hip (DDH)
  –Early diagnosis with newborn exam finding of easily dislocatable hip
  –Older infants have limited hip abduction
• Osteomyelitis
  –Vague symptoms may make this a difficult diagnosis
  –Limp, fever, pain in the proximal thigh or pseudoparalysis of an extremity in an infant may be the only sign
• Fracture
  –Consider accidental and nonaccidental trauma
  –Pain, limited ambulation, limited active and passive ROM, or inability to bear weight
• Transient monoarticular synovitis
  –Often preceded 1–2 weeks by upper respiratory infection
  –Antalgic gait, moderate pain in hip, groin, or knee, and uncomfortable range of motion
• Neoplasia
  –Although primary bone disorders do not generally present with hip pain, other malignancies such as acute leukemia may initially present with bone or joint pain
• Vertebral osteomyelitis/diskitis
  –Referred pain from lumbrosacral region may present as hip pain

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Knee Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthritis
  –Characterized by redness, swelling or effusion, warmth, pain with active and passive ROM, fever or chills
  –Requires urgent evaluation and diagnosis

• Osgood-Schlatter disease (OSD)
  –Repetitive microtrauma to the bone-tendon junction where patellar tendon inserts into the secondary ossification center of the tibial tubercle
  –Onset at early adolescence, more often in athletes

• Sinding-Larsen-Johansson disease
  –Similar to OSD, except localized to distal pole of the patella

• Meniscal pathology
  –Meniscal tears are usually associated with acute trauma, and involve pain and swelling with mechanical symptoms such as popping, clicking, or locking
  –Discoid meniscus: Mechanical symptoms and plain X-rays show squaring, widening, and cupping

• Ligamentous injury
  –Medial collateral ligament sprain via overuse injury or valgus force to knee
  –Anterior cruciate ligament tear associated with sport noncontact pivoting injury, associated with a “pop” and immediate swelling
  –Posterior cruciate tear associated with direct trauma to anterior tibia or hyperflexion with plantar flexed foot
  –Lateral collateral ligament injury is rare

• Osteochondritis dissecans
  –Trauma resulting in separation of subchondral bone and cartilage at lateral aspect of medial femoral condyle
• Patellar subluxation/dislocation
  –Lateral displacement of patella associated with increased Q angle, genu valgum, and femoral anteversion (more common in women)
• Bursitis
  –Chronic friction over pes anserine, iliotibial band, or capsular bursa leads to inflammation and thickening of the bursa
• Bipartite patella
  –Common variant of patellar ossification

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Scrotal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Testicular torsion
  –Twisting of the spermatic cord and vessels, resulting in testicular ischemia
  –Patients present with an excruciatingly painful swollen testicle with or without a history of previous milder episodes (intermittent torsion)
  –May occur at any age (including in utero)

• Torsion of the appendix testis
  –May be difficult to distinguish clinically from testicular torsion
  –Typically, pain is less severe and the onset less acute (over several days as opposed to several hours)
  –Most common ages 7–12 years

• Testicular trauma
  –Blunt trauma occurs as saddle injuries, in sports such as soccer and baseball, and during altercations

• Epididymitis
  –Inflammation of the epididymis usually secondary to bacteria
  –Rare before puberty and often seen in sexually active young men with acutely swollen and painful testis
  –Pain is usually less acute in onset than torsion

• Inguinal hernia
  –Incarcerated inguinal hernia may present as a painful, edematous scrotum
• Orchitis
  –Inflammation of the testes due to viral infection; classically mumps
  –Patient presents with an acutely swollen, red testicle(s)
  –Uncommon since widespread vaccination
• Henoch-Schönlein purpura
  –Vasculitis characterized by palpable purpura usually in the lower half of the body
  –Painful testicular swelling can be a sign of this disorder
  • Varicocele
    –A collection of dilated veins in the scrotum
    –Usually painless, but occasionally patients may complain of chronic nagging pain and discomfort (especially during physical activity)
    –Presents after puberty

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Scrotal Swelling: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Hydrocele
  –Fluid surrounding the testicle
  –Typically seen in infancy
  –Results from remnant of testicular descent from the abdomen through the inguinal canal into the scrotum
  –May be communicating or noncommunicating; communicating hydroceles have retained patency of the tract of descent, and noncommunicating hydroceles do not
  –Communicating hydroceles may be reducible and are likely to fluctuate in size depending on the amount of fluid within the scrotal sac; crying or any increase in intra-abdominal pressure results in an increase in size
  –Usually is noncommunicating; i.e., not reducible, and does not change in size with crying
  –Testes may be difficult to palpate because surrounded by the hydrocele

• Hernia
  –Protrusion of a loop of bowel into the scrotum
  –Direct hernias represent a channel directly through the musculature of the pelvic floor; indirect hernias have proceeded through the inguinal canal
  –Usually painless unless incarcerated
  –Usually reducible and changes in size with changes in intra-abdominal pressure
  –Testes usually palpable below the hernia

• Varicocele
  –A collection of dilated veins in the scrotum
  –Usually painless, but patients may complain of heaviness
• Edema
  –Generalized edema often is accompanied by scrotal edema
• Tumor
  –Presents as painless nodule on testes
  –May be accompanied by sexual precocity or gynecomastia secondary to hormone production by the tumor
• Leukemia
  –Patients may present with unilateral scrotal swelling (common site for relapse)

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Breast pain [Mastalgia]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Areolar gland abscess. Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also occur.

❑ Breast abscess (acute). In the affected breast, local pain, tenderness, erythema, peau d'orange, and warmth are associated with a nodule. Malaise, fever, and chills may also occur.

❑ Breast cyst. A breast cyst that enlarges rapidly may cause acute, localized, and usually unilateral pain. A palpable breast nodule may be present.

❑ Fat necrosis. Local pain and tenderness may develop in fat necrosis, a benign disorder. A history of trauma usually is present. Associated findings include ecchymosis; erythema of the overriding skin; a firm, irregular, fixed mass; and skin retraction signs, such as skin dimpling and nipple retraction. Fat necrosis may be hard to differentiate from cancer.

❑ Fibrocystic breast disease. Fibrocystic breast disease is a common cause of breast pain that's associated with the development of cysts that may cause pain before menstruation and are asymptomatic afterward. Later in the course of the disorder, pain and tenderness may persist throughout the cycle. The cysts feel firm, mobile, and well defined. Many are bilateral and found in the upper outer quadrant of the breast, but others are unilateral and generalized. Signs and symptoms of premenstrual syndrome — including headache, irritability, bloating, nausea, vomiting, and abdominal cramping — may also be present.

❑ Mammary duct ectasia. Burning pain and itching around the areola may occur, although ectasia is commonly asymptomatic at first. The history may include one or more episodes of inflammation with pain, tenderness, erythema, and acute fever, or with pain and tenderness alone, which develop and then subside spontaneously within 7 to 10 days. Other findings include a rubbery, subareolar breast nodule; swelling and erythema around the nipple; nipple retraction; a bluish green discoloration or peau d'orange of the skin overlying the nodule; a thick, sticky, multicolored nipple discharge from multiple ducts; and axillary lymphadenopathy. A breast ulcer may occur in late stages.

❑ Mastitis. Unilateral pain may be severe, particularly when the inflammation occurs near the skin surface. Breast skin is typically red and warm at the inflammation site; peau d'orange may be present. Palpation reveals a firm area of induration. Skin retraction signs — such as breast dimpling and nipple deviation, inversion, or flattening — may be pres-ent. Systemic signs and symptoms — such as high fever, chills, malaise, and fatigue — may also occur.

❑ Sebaceous cyst (infected). Breast pain may be reported with sebaceous cyst, a cutaneous cyst. Associated symptoms include a small, well-delineated nodule, localized erythema, and induration.

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Abdominal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Initially, this life-threatening disorder may produce dull lower abdominal, lower back, or severe chest pain. Usually, abdominal aortic aneurysm produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

❑ Abdominal cancer. Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and abdominal mass and distention.

❑ Abdominal trauma. Generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

❑ Adrenal crisis. Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

❑ Anthrax, GI. An acute infectious disease, GI anthrax is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in any of the following forms: cutaneous, inhaled, or GI.

GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

❑ Appendicitis. With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

❑ Cholecystitis. Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

❑ Cholelithiasis. Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

❑ Cirrhosis. Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

❑ Crohn’s disease. An acute attack in Crohn’s disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

❑ Diverticulitis. Mild cases of diverticulitis usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, a low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

❑ Duodenal ulcer. Localized abdominal pain — described as steady, gnawing, burning, aching, or hunger like — may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it may also produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

❑ Ectopic pregnancy. Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

❑ Endometriosis. Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

❑ Escherichia coli O157:H7. E. coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of normal intestinal flora of healthy humans and animals. However, E. coli O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin and can cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop, and this may ultimately lead to acute renal failure.

❑ Gastric ulcer. Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

❑ Gastritis. With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

❑ Gastroenteritis. Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

❑ Heart failure. Right upper quadrant pain commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

❑ Hepatitis. Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

❑ Intestinal obstruction. Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in an intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

❑ Irritable bowel syndrome. Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

❑ Listeriosis. A serious infection, listeriosis is caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in the level of consciousness.

GENDER CUE: Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

❑ Mesenteric artery ischemia. Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

❑ Ovarian cyst. Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

❑ Pancreatitis. Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

❑ Pelvic inflammatory disease. Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

❑ Perforated ulcer. With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

❑ Peritonitis. With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

❑ Prostatitis. Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop with prostatitis. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

❑ Pyelonephritis (acute). Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize this disorder. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

❑ Renal calculi. Depending on the location of calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

❑ Sickle cell crisis. Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

❑ Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites for the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

❑ Splenic infarction. Fulminating pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration. Pain usually radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

❑ Ulcerative colitis. Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Other causes

❑ Drugs. Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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Arm pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Angina. Angina may cause inner arm pain as well as chest and jaw pain. Typically, the pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators such as nitroglycerin.

❑ Biceps rupture. Rupture of the biceps after excessive weight lifting or osteoarthritic degeneration of bicipital tendon insertion at the shoulder can cause pain in the upper arm. Forearm flexion and supination aggravate the pain. Other signs and symptoms include muscle weakness, deformity, and edema.

❑ Cellulitis. Typically, cellulitis affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or insect bite.

❑ Cervical nerve root compression. Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

❑ Compartment syndrome. Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome. It may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and an absent pulse.

❑ Fractures. In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, felt and heard from bone ends rubbing together (don’t attempt to elicit this sign); deformity, if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

❑ Muscle contusion. Muscle contusion may cause generalized pain in the area of injury. It may also cause local swelling and ecchymosis.

❑ Muscle strain. Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

❑ Myocardial infarction (MI). An MI is a life-threatening disorder in which the patient may complain of left arm pain as well as the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

❑ Neoplasms of the arm. Neoplasms of the arm produce continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

❑ Osteomyelitis. Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

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Back pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Life-threatening dissection of this aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, however, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

❑ Ankylosing spondylitis. Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn't relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.

❑ Appendicitis. Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney's point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney's point), and rebound tenderness. Some patients also have painful, urgent urination.

❑ Cholecys