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Diseases » Arthritis » Diagnosis
 

Diagnosis of Arthritis

Arthritis Diagnosis: Book Excerpts

Tests and diagnosis discussion for Arthritis:

Questions and Answers About Arthritis and Rheumatic Diseases: NIAMS (Excerpt)

Diagnosing rheumatic diseases can be difficult because some symptoms and signs are common to many different diseases. A general practitioner or family doctor may be able to evaluate a patient or refer him or her to a rheumatologist: a doctor who specializes in treating arthritis and other rheumatic diseases.

The doctor will review the patient’s medical history, conduct a physical examination, and obtain laboratory tests and X rays or other imaging tests. The doctor may need to see the patient more than once to make an accurate diagnosis.

Medical History

It is vital for people with joint pain to give the doctor a complete medical history. Answers to the following questions will help the doctor make an accurate diagnosis:

  • Is the pain in one or more joints?
  • When does the pain occur?
  • How long does the pain last?
  • When did you first notice the pain?
  • What were you doing when you first noticed the pain?
  • Does activity make the pain better or worse?
  • Have you had any illnesses or accidents that may account for the pain?
  • Is there a family history of any arthritis or rheumatic diseases?
  • What medicine(s) are you taking?

It may be helpful for people to keep a daily journal that describes the pain. Patients should write down what the affected joint looks like, how it feels, how long the pain lasts, and what they were doing when the pain started.

Physical Examination and Laboratory Tests

The doctor will examine all of the patient’s joints for redness, warmth, deformity, ease of movement, and tenderness. Because some forms of arthritis, such as lupus, may affect other organs, a complete physical examination including the heart, lungs, abdomen, nervous system, and eyes, ears, and throat may be necessary. The doctor may order some laboratory tests to help confirm a diagnosis. Samples of blood, urine, or synovial

Common Laboratory Tests

  • Antinuclear antibody (ANA)—This test checks blood levels of antibodies that are often present in people who have connective tissue diseases or other autoimmune disorders, such as lupus. Since the antibodies react with material in the cell’s nucleus (control center), they are referred to as antinuclear antibodies. There are also tests for individual types of ANA’s that may be more specific to people with certain autoimmune disorders. ANA’s are also sometimes found in healthy people. Therefore, having ANA’s in the blood does not necessarily mean that a person has a disease.
  • Arthrocentesis—Arthrocentesis or joint aspiration is done to obtain a sample of synovial fluid. The doctor injects a local anesthetic, inserts a thin, hollow needle into the joint, and removes the synovial fluid into a syringe. The test provides important diagnostic information. For example, the test allows the doctor to see whether crystals (found in patients with gout or other types of crystal-induced arthritis) or bacteria or viruses (found in patients with infectious arthritis) are present in the joint.
  • Complement—This test measures the level of complement, a group of proteins in the blood. Complement helps destroy foreign substances, such as germs, that enter the body. A low blood level of complement is common in people who have active lupus.
  • Complete blood count (CBC)—This test determines the number of white blood cells, red blood cells, and platelets present in a sample of blood. Some rheumatic conditions or drugs used to treat arthritis are associated with a low white blood count (leukopenia), low red blood count (anemia), or low platelet count (thrombocytopenia). When doctors prescribe medications that affect the CBC, they periodically test the patient’s blood.
  • Creatinine—This blood test is commonly ordered in patients who have rheumatic diseases to monitor for underlying kidney disease.
  • Erythrocyte sedimentation rate (sed rate)—This blood test is used to detect inflammation in the body. Higher sed rates indicate the presence of inflammation and are typical of many forms of arthritis, such as rheumatoid arthritis and ankylosing spondylitis, and many of the connective tissue diseases.
  • Hematocrit (PCV, packed cell volume)—This test and the test for hemoglobin (a substance in the red blood cells that carries oxygen through the body) measure the number of red blood cells present in a sample of blood. A decrease in the number of red blood cells (anemia) is common in people with inflammatory arthritis and rheumatic diseases.
  • Rheumatoid factor—This test determines whether rheumatoid factor is present in the blood. Rheumatoid factor is an antibody found in the blood of most (but not all) people who have rheumatoid arthritis. Rheumatoid factor may be found in many other diseases besides rheumatoid arthritis, and sometimes in normal, healthy people.
  • Urinalysis—In this test, a urine sample is studied for protein, red blood cells, white blood cells, or casts. These abnormalities indicate kidney disease, which may be seen in several rheumatic diseases such as lupus or vasculitis. Some medications used to treat arthritis can also cause abnormal findings on urinalysis.
  • White blood cell count (WBC)—This test determines the number of white blood cells present in a sample of blood. The number may increase as a result of infection or decrease in response to certain medications, or with certain diseases, such as lupus. Low numbers of white blood cells increase a person’s risk of infections.
(Source: excerpt from Questions and Answers About Arthritis and Rheumatic Diseases: NIAMS)

Questions and Answers About Arthritis and Rheumatic Diseases: NIAMS (Excerpt)

X Rays and Other Imaging Procedures

To see what the joint looks like inside, the doctor may order X rays or other imaging procedures. X rays provide an image of the bones, but they do not show the cartilage, muscles, and ligaments. Other noninvasive imaging methods such as computed tomography (CT or CAT), magnetic resonance imaging (MRI), and arthrography (joint X ray) show the whole joint. The doctor may also use an arthroscope (a small, flexible tube that transmits the image of the inside of a joint to a video screen) to examine damage to a joint. The arthroscope is inserted into the affected joint through a very small incision in the skin. This procedure, called arthroscopy, allows the doctor to see inside the joint. Doctors also use arthroscopy to perform surgery for some types of joint injury. (Source: excerpt from Questions and Answers About Arthritis and Rheumatic Diseases: NIAMS)

Diagnosis of Arthritis: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Arthritis:

Diagnostic Tests for Arthritis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Arthritis.


ABDOMINAL PAIN, CHRONIC RECURRENT: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a family history of migraine or epilepsy? Migraine and epilepsy both present with abdominal pain.
  2. Is the pain colicky or persistent? Chronic colicky abdominal pain may be due to chronic cholecystitis, cholelithiasis, renal calculus, or partial intestinal obstruction.
  3. What is the location of the pain? If the pain is located in the upper abdomen, then one should consider peptic ulcer disease, pancreatitis, cholecystitis, and cholelithiasis. If the pain is located in the flanks, one should consider renal calculus and pyelonephritis. If the pain is located in the lower abdomen, one should consider diverticulitis, salpingitis, endometritis, and chronic appendicitis. Regional ileitis also may be located in the lower abdomen, particularly in the right lower quadrant.
  4. What is the relationship to meals? Abdominal pain relieved by food may be due to a peptic ulcer. Abdominal pain brought on by food may be due to abdominal angina. If the pain comes on 2 to 3 hr after a meal, it may be due to a peptic ulcer. On the other hand, pain that comes on 1 to 2 hr after meals, especially if it's a fatty meal, may be related to cholecystitis and cholelithiasis.
  5. Is there fever associated with the abdominal pain? Fever and abdominal pain may be due to pyelonephritis, diverticulitis, or appendicitis.
  6. Is there a history of chronic alcoholism? The history of chronic alcoholism suggests acute and chronic pancreatitis.
  7. Is there blood in the stool? The presence of blood in the stool would, of course, suggest peptic ulcer disease and diverticulitis.
  8. Is there an abdominal mass? The presence of an abdominal mass, particularly in the midepigastrium, suggests a pancreatic cyst related to chronic pancreatitis. A mass in the right lower quadrant might be related to regional ileitis or salpingitis. A mass in the left lower quadrant may be related to diverticulitis and salpingitis.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, sensitivity, colony count, chemistry panel, serum amylase and lipase, pregnancy test, stool for occult blood, and stools for ovum and parasites. A chest x-ray, EKG, and flat plate of the abdomen should also be done. A urine porphobilinogen will help exclude porphyria.

If these tests are negative, then an upper gastrointestinal (GI) series, esophagogram, and gallbladder ultrasound would be done for upper abdominal pain; an IVP would be done for flank pain; and a barium enema and sigmoidoscopy would be performed for lower abdominal pain.

If these studies are inconclusive, a gastroenterologist should be consulted for endoscopic procedures. If there is upper abdominal pain, esophagoscopy, gastroscopy, and duodenoscopy would be performed. Endoscopic retrograde cholangiopancreatography (ERCP) may be required to diagnose cholangitis or common duct stones. If there is lower abdominal pain, colonoscopy would be performed. A CT scan of the abdomen and pelvis is a useful diagnostic tool also. Gallium scans may detect a diverticular abscess or other localized area of chronic inflammation. Pelvic ultrasound may be useful in lower abdominal pain, especially in females. Aortography and angiography will be useful in abdominal angina. Lymphangiography can be helpful in discovering retroperitoneal tumors. Ultimately, exploratory laparotomy may still be necessary in some cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ABDOMINAL PAIN, ACUTE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Where is the pain located? If it is diffuse, one should consider pancreatitis, mesenteric artery occlusion, or ruptured peptic ulcer. In addition, another viscus may be perforated, such as a ruptured ectopic, and there may be peritonitis. If it is focal, we need to know what quadrant it is in. For example, acute cholecystitis is in the right upper quadrant, whereas diverticulitis is usually in the left lower quadrant.
  2. What is the nature of the pain? Colicky abdominal pain suggests intestinal obstruction, renal calculus, and cholelithiasis or common duct stone, whereas constant pain is typical of pancreatitis, a ruptured peptic ulcer, appendicitis, diverticulitis, and a ruptured ectopic pregnancy.
  3. Does the pain radiate? The pain of acute cholecystitis typically radiates to the right scapular or right shoulder. The pain of a ruptured peptic ulcer may also radiate to the shoulder. The pain of acute renal calculus may radiate to the testicle.
  4. What are the associated signs and symptoms? Shock with generalized tenderness and rebound and diminished or absent bowel sounds should suggest a ruptured peptic ulcer or acute pancreatitis. However, acute right upper quadrant pain with nausea and vomiting should suggest acute cholecystitis. On the other hand, appendicitis is more insidious in onset and is associated with anorexia and nausea, rarely vomiting, as well as constipation. Renal colic presents with hematuria.
  5. Could this patient's abdominal pain be due to an extra-abdominal condition? Remember, lobar pneumonia, myocardial infarction, diabetic acidosis, and porphyria may be responsible for acute abdominal pain. There are numerous other conditions that need to be considered.

DIAGNOSTIC WORKUP

It is wise to consult a general surgeon at the outset. All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!

When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.

If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient's condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

BACK PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the pain of acute onset or gradual onset? If it is acute onset, one must consider the possibility of epidural abscess, pyelonephritis, or other abdominal conditions as the cause of the back pain. If it is gradual onset, one should consider that it may be a tumor, particularly of the spinal cord or cauda equina, a pelvic tumor, or an aortic aneurysm that is compressing one of the nerve roots. In addition, chronic conditions such as lumbar spondylosis, rheumatoid spondylitis, and prostatitis must be considered.
  2. Is there a history of trauma? If there is a history of trauma, one should consider a compression fracture of the spine, a sprain or herniated disk, as well as spondylolisthesis. Without a history of trauma, one should consider a tumor, herpes zoster, or dissecting aneurysm. Lumbar spondylosis might be silent for a while only to cause pain after a significant traumatic event.
  3. Is there radiation of the pain around the trunk or into the extremities? Radiation of the pain would certainly be more likely to signify a space-occupying lesion of the spinal column such as a tumor, an epidural abscess, or a herniated disk. If there is no radiation, one would consider osteoarthritis or lumbar spondylosis and rheumatoid spondylitis.
  4. Finally, are there bladder symptoms associated with the pain? If there are, then one must consider the possibility of a spinal cord tumor, cauda equina tumor, or kidney disease.

DIAGNOSTIC WORKUP

All patients with back pain need to have a CBC, urinalysis, and probably a urine culture, as well as a chemistry panel. A sedimentation rate should be done if rheumatoid arthritis is suspected. All patients should also have plain x-rays of the thoracic and/or lumbar spine. It is very important to get anterior posterior views, as well as oblique and lateral views. At this point it is wise to observe the results of conservative therapy before ordering expensive diagnostic tests. If there is doubt about the diagnosis at this point, a neurologic or orthopedic specialist may be consulted. If there is radiation of the pain into the extremities or around the trunk and definite neurologic findings, one should proceed to a CT scan or MRI immediately. The CT scan costs about half as much as the MRI and usually will show any significant herniated disks, primary or metastatic tumor. Even without radiation of pain into the extremities or definite neurologic findings, a patient with persistent back pain should have a CT scan or MRI. EMG will be useful in identifying radiculopathy.

When all these studies are negative, it might be wise to get a bone scan because this will show the increased uptake of the sacroiliac joints in rheumatoid spondylitis. Also, one should test for the HLA B27 antigen. In the event that all of the above studies are negative, the possibility of a non-neurologic condition or nonorthopedic condition causing the back pain should be considered. Perhaps abdominal ultrasound should be done to rule out an aortic aneurysm. Perhaps a pelvic tumor or prostatic tumor should be reconsidered. Perhaps there is a pancreatic tumor that is causing the back pain. Occasionally, combined myelography and CT scan is the only way to identify a lesion. Exploratory surgery is rarely necessary. Older patients should have a serum protein electrophoresis (for multiple myeloma) and acid phosphatase or PSA to rule out prostatic carcinoma.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

BREAST PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it unilateral or bilateral? Unilateral breast pain should make one think of an infectious process or advanced carcinoma. Bilateral breast pain should make one think of pregnancy. This may be a normal pregnancy or an ectopic pregnancy.
  2. Is there an associated mass? A tender breast mass is most likely a mastitis or abscess, but advanced carcinoma can also produce a tender breast mass. If there are tender masses in both breasts, chronic cystic mastitis should be considered.
  3. Is there a discharge? A bloody discharge associated with a tender breast should make one think of a carcinoma.
  4. Is there fever? Fever associated with a tender breast or tender breast mass is most likely acute mastitis or abscess.

DIAGNOSTIC WORKUP

If there is a fever and discharge, a culture and sensitivity of the discharge should be done before beginning antibiotics. When there is a localized tender mass, referral to a general surgeon should be made. Patients with bilateral breast pain without any masses identified should have a pregnancy test. If this is negative and the pain is associated with the menstrual cycle, they should be treated as having premenstrual tension. A gynecologist may need to be consulted. If there is persistent bilateral breast pain in a young unmarried female, perhaps a psychiatrist should be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

CHEST PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the chest pain acute or chronic? If it is acute, one must consider acute myocardial infarction, pulmonary embolism, pneumothorax, pericarditis, and fractures. If the chest pain is chronic, one must consider chronic coronary insufficiency, esophagitis, hiatal hernia, and various chest wall conditions.
  2. Is the pain constant or intermittent? Constant pain suggests acute myocardial infarction, pulmonary infarction, dissecting aneurysm, and pneumonia. Intermittent pain would suggest coronary insufficiency, Tietze's disease, and DaCosta's syndrome.
  3. Is there associated significant hypertension? Significant hypertension would make one think of dissecting aneurysm, but it is also found occasionally in acute myocardial infarction.
  4. Is the pain relieved by antacids? Relief by antacids should prompt one to consider esophagitis and hiatal hernia.
  5. Is the pain precipitated or increased by breathing? The pain of pleurisy, costochondritis, rib fractures, and pneumothorax is precipitated or increased by breathing.
  6. Is there associated hemoptysis? Hemoptysis should make one consider a pulmonary embolism.
  7. Is there fever and purulent sputum? Fever and purulent sputum should make one consider pneumonia.
  8. Is there dyspnea? Dyspnea should make one consider pneumothorax, pulmonary embolism, and pneumonia, as well as congestive heart failure secondary to acute myocardial infarction.
  9. Is it aggravated by movement? Aggravation of the chest pain by movement should suggest pericarditis. Remember, myocardial infarctions may also have extension into the pericardium and must be considered at times.
  10. Is it relieved by nitroglycerin? Relief by nitroglycerin should suggest a coronary insufficiency, but esophagospasm may be relieved by nitroglycerin also.

DIAGNOSTIC WORKUP

All patients should have a CBC, sedimentation rate, chemistry panel, VDRL test, chest x-ray, and EKG. If there is sputum, a smear and culture should be done as soon as possible.

If a myocardial infarction is suspected, then serial EKGs and tests for the isoenzyme of creatine kinase (CK-MB) should be done if the initial EKG and enzymes do not show any significant changes. Serum cardiac troponin levels may also be diagnostic of a myocardial infarct. Thallium-201 scintigraphy is useful in diagnosing both myocardial infarction and coronary insufficiency. Exercise tolerance tests may help diagnose coronary insufficiency. Immediate coronary angiography should be undertaken if the condition deteriorates. This can be followed by immediate balloon angioplasty, reperfusion therapy, or bypass surgery.

If a pulmonary embolism is suspected, arterial blood gases and a ventilation-perfusion scan should be done. d -dimer testing of whole blood is a sensitive test of pulmonary embolus. Pulmonary angiography may need to be done if these are negative and pulmonary embolism is still strongly suspected.

If esophageal disease is suspected, an upper GI series with esophagogram should be done; this can be followed with esophagoscopy and gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus) may reproduce the exact pain and distinguish esophageal reflux from a cardiac source of the pain. Ambulatory pH monitoring may also diagnose reflux esophagitis.

If pericarditis is suspected, echocardiography and possibly a CT scan of the chest and pericardium may be necessary. Coronary angiography may be necessary to diagnose coronary insufficiency. Echocardiography is also helpful in diagnosing mitral valve prolapse and the various myocardiopathies. Twenty-four-hr Holter monitoring is useful in diagnosing many causes of intermittent chest pain.

Referral to a cardiologist or pulmonologist may be appropriate at any point in this workup. Dissecting aneurysm may be confirmed by a CT scan or MRI of the chest.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EXTREMITY PAIN, LOWER EXTREMITY: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the extremity pain of acute or gradual onset? Acute onset would suggest arterial embolism, deep vein thrombophlebitis, and cellulitis. If there is a history of trauma, it would suggest a fracture, sprain, or torn ligament.
  2. Is there limitation of motion of the joints? A positive Patrick's test would indicate hip pathology, including greater trochanter bursitis. A positive McMurray test would indicate a torn meniscus.
  3. Are there positive neurologic findings? A positive femoral stretch test would suggest a herniated disk at L2-3 or L3-4, whereas a positive Lasčgue's sign would indicate a herniated disk at L4-5 or L5 to S1. Combined motor and sensory deficits may indicate radiculopathy or neuropathy.
  4. Is there a positive Homans' sign? This is a very important examination, as one would not want to miss a deep vein thrombophlebitis.
  5. Is there diminished or absent peripheral pulses? Diminished or absent pulses would suggest arterial embolism, peripheral arteriosclerosis, or Leriche's syndrome (thrombosis of the terminal aorta).
  6. Is there focal tenderness, swelling, or erythema of the extremity? This would suggest cellulitis, superficial thrombophlebitis, osteomyelitis, lymphangitis, and other types of infections. Tenderness without significant swelling or erythema would be suggestive of bursitis or deep vein thrombophlebitis.

DIAGNOSTIC WORKUP

Often bursitis and myofascitis can be diagnosed by the dramatic relief obtained from a lidocaine injection. If there is clear-cut joint pathology, an x-ray of the joints, arthritis profile, and synovial fluid analysis will usually provide a diagnosis. MRI is useful in the diagnosis of a torn meniscus. If a deep-pain thrombophlebitis is suspected, venous Doppler ultrasound, impedance plethysmography, or a contrast venogram may be done. If an arterial embolism or chronic peripheral arterial disease is suspected, femoral angiography can be done. If a herniated disk or other pathology of the lumbar spine is suspected, plain films of the lumbar spine should be obtained. It might be wise at this point also to obtain a CBC, sedimentation rate, and chemistry panel to determine the alkaline phosphatase, calcium, and phosphorus. In older males, tests for acid phosphatase and PSA should be done.

If these tests are unrevealing, it is wise to refer the patient to a neurologic specialist before any more expensive tests are ordered. He will probably order a CT scan of the lumbar spine and may do nerve conduction velocity studies, EMG examinations, or dermatomal SSEP studies as indicated. In difficult neurologic problems, a combined myelography and CT scan is preferred over MRI. Bone scans will help diagnose obscure fractures and osteomyelitis, both of the lumbar spine and the lower extremities.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EXTREMITY PAIN, UPPER EXTREMITY: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there limitation of motion of the joints? Limitation of motion of a joint would suggest not only various types of arthritis, fracture, or torn ligaments, but also inflammation of surrounding structures such as the bursa or tendons. For example, limitation of motion of the shoulder would suggest impingement syndrome, frozen shoulder, rheumatoid or osteoarthritis, subacromial bursitis, and a torn rotator cuff.
  2. Is the limitation of motion both active and passive or active only? If the limitation of motion is only active, one should suspect tendinitis or bursitis. If the limitation of motion is both active and passive, one should suspect the various forms of arthritis, as well as bone tumors, osteomyelitis, and adhesive capsulitis.
  3. Is there weakness or paresthesia? Weakness and especially paresthesia suggest a neurologic origin for the pain, and one should be considering brachial plexus neuritis, carpal tunnel syndrome, ulnar entrapment, and radiculopathy.
  4. Are there vasomotor or trophic changes? Vasomotor changes would suggest Raynaud's phenomena and sympathetic dystrophy. Trophic changes along with vasomotor changes would suggest a peripheral neuropathy also.
  5. Are there positive neurologic signs in the lower extremities? Diffuse hypoactive reflexes with stocking deficits in the lower extremities would suggest a peripheral neuropathy, whereas hyperactive reflexes in the lower extremities would suggest a cervical cord tumor, cervical spondylosis, or multiple sclerosis.
  6. Is there a positive Tinel's sign at the wrist or elbow? Tinel's sign at the wrist would suggest carpal tunnel syndrome, whereas Tinel's sign at the elbow would suggest ulnar entrapment if it is over the ulnar nerve or pronator syndrome if it is over the median nerve.
  7. Are Adson's tests positive? Adson's tests are positive in thoracic outlet syndrome, whether it is due to a cervical rib, scalenus-anticus syndrome, Wright syndrome (pectoralis minor syndrome), or a costoclavicular compression.

DIAGNOSTIC WORKUP

X-rays of the affected joints need to be done if there is tenderness or limitation of motion. Further workup of joint pain can be found on page 279 . When there are abnormal neurologic findings, an x-ray of the cervical spine, nerve conduction velocity studies, and EMG examinations need to be done. Referral to a neurologist should be made for these tests. If there is a typical radicular pain and a herniated cervical disk is strongly suspected, MRI of the cervical spine should be done. This is an expensive test, but when there are obvious signs of radiculopathy, it is worthwhile. Perhaps dermatomal somatosensory studies should be done when there is confusion about whether a herniated disk is pathologic. If a vascular lesion is suspected, angiography and venography should be ordered. ANA and nail fold capillary loop dilation and dropout study may diagnose Raynaud's phenomena; a small injection of lidocaine and steroids locally may be diagnostic in cases of carpal tunnel syndrome.

When there is intermittent pain, an exercise tolerance test should be done to exclude coronary insufficiency. A stellate ganglion block may be helpful in diagnosing reflex sympathetic dystrophy. Remember that other nerve blocks may be done and one should not hesitate to call an anesthesiologist for help in this area. Various forms of bursitis may be diagnosed by a therapeutic trial of lidocaine and corticosteroid injections.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EYE PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there redness of the eye? Redness of the eye suggests definite eye pathology. Without redness, one should suspect disease in the adjacent structures or retrobulbar neuritis.
  2. If there is redness, is there periorbital edema as well? Periorbital edema should suggest a cavernous sinus thrombosis or herpes zoster.
  3. If there is periorbital edema, is there a rash? A rash, particularly vesicular rash, would suggest herpes zoster.
  4. In cases without redness of the eye, is there any abnormality on examination both with the naked eye and with the ophthalmoscope? A dilated pupil would certainly suggest glaucoma; ophthalmoscopic examination may show optic neuritis or retinal detachment. A visual field examination may detect optic neuritis, retrobulbar neuritis, and retinal artery occlusion. A visual acuity check may pick up a refractive error.
  5. Finally, is there headache associated with the eye pain? This would be suggestive of migraine or cluster headache.

DIAGNOSTIC WORKUP

The primary care specialist may want to treat cases of obvious conjunctivitis without a culture and sensitivity. However, a smear and culture is useful especially if Neisseria is suspected. A smear may also reveal eosinophils suggesting allergic conjunctivitis. The primary care specialist may also use fluorescein dye to diagnose a foreign body. Most primary care physicians feel competent to use tonometry to diagnose glaucoma and may feel competent to use a slit lamp. However, when there is any doubt about the diagnosis, the most cost-effective approach is to refer the patient to an ophthalmologist.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FACE PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the pain constant or intermittent? Intermittent pain would suggest trigeminal neuralgia, cluster headaches, or atypical migraine. Constant pain would suggest any local abnormalities in the structures underlying the face such as an abscessed sinus, an abscessed tooth, or a neoplasm in these areas.
  2. Is the pain increased by chewing? Pain that is increased by chewing very often may be related to the temporomandibular joint syndrome, but it could be related to trigeminal neuralgia or dental caries.
  3. Is there an associated nasal discharge? An associated bloody nasal discharge would make one think of a nasopharyngeal carcinoma, but a purulent discharge would make one think of acute or chronic sinusitis. A watery nasal discharge often accompanies cluster headaches or atypical migraine.
  4. Are there abnormal neurologic findings? Face pain sometimes accompanies multiple sclerosis, acute Wallenberg's syndrome, and advanced acoustic neuromas. The pain in the trigeminal distribution associated with multiple sclerosis often is intermittent and suggests trigeminal neuralgia.

DIAGNOSTIC WORKUP

The first thing to determine is whether there is an infectious or neoplastic process in the structures underlying the face. X-rays of the sinuses and teeth and CT scans of the sinuses and brain may be necessary to further elucidate this. An x-ray of the temporomandibular joint may be helpful. An MRI of the temporomandibular joint is the procedure of choice to rule out pathology of this joint. Referral to a dentist to evaluate the patient's teeth or to an ear, nose, and throat specialist to evaluate sinusitis may be necessary.

To rule out cluster headaches or atypical migraine, a histamine test may be done. It may be wise to see the patient during an attack so that superficial temporal artery compression can be done to rule out migraine and/or a shot of sumatriptan succinate can be given, which should provide immediate results in cluster headache and atypical migraine.

A trial of carbamazepine (Tegretol®) can be given in cases of suspected trigeminal neuralgia, but referral to a neurosurgeon for an alcoholic injection of the maxillary or mandibular branches of trigeminal nerve will more likely make the diagnosis and solve the patient's problem.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FLANK PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there associated fever? The presence of fever along with chest pain should make one think of a perinephric abscess or pyelonephritis. Occasionally, however, hypernephroma can cause fever and flank pain, as can bilateral hydronephrosis.
  2. Is there a flank mass? The presence of flank pain along with a flank mass should make one think of a hypernephroma, hydronephrosis, polycystic kidneys, or perinephric abscess.
  3. Is there hematuria? The presence of pain and hematuria should make one think of renal calculus first, but the possibility of a renal infarction, polycystic kidneys, and tuberculosis of the kidneys must be considered also. Hematuria is also found in a hypernephroma.

DIAGNOSTIC WORKUP

Routine tests include a CBC, sedimentation rate, chemistry panel, urinalysis, and urine culture. An intravenous pyelogram is the next logical step. If these fail to make a definitive diagnosis, one should consider ordering an abdominal ultrasound or a CT scan of the abdomen. If a renal infarction is suspected, aortography and renal angiography may be ordered. When the above tests are all negative, one should consider x-rays of the lumbosacral spine and MRI of the thoracic and lumbar spine. Consulting a urologist is prudent before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FOOT AND TOE PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there fever or localized erythema? Localized erythema would suggest phlebitis, gout, osteomyelitis, cellulitis, ingrown toenail, and paronychia. The presence of fever would make one suspect osteomyelitis and cellulitis.
  2. Is there associated deformity of the foot? Hallux valgus, hammertoe, hallux rigidus, arthritis, and displaced fracture are the main causes of a deformity of the foot.
  3. Are the peripheral pulses palpable? Diminished arterial pulses would make one think of arterial embolism, peripheral arteriosclerosis, and diabetes.
  4. Are there associated neurologic findings? The presence of loss of sensation to touch and pain should make one think of peripheral neuropathy and tarsal tunnel syndrome. Numbness or loss of sensation in the 3rd and 4th toes is often associated with a Morton's neuroma.

DIAGNOSTIC WORKUP

Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, VDRL test, and an x-ray of the foot. If the peripheral pulses are diminished, Doppler studies and angiography should be considered. If there is diffuse swelling and erythema, venography may need to be done. If there are neurologic findings, nerve conduction velocity studies and electromyograms (EMGs) may be helpful. Consider bone scans, CT scans, and arthroscopy if the above tests are negative. An MRI may be needed to diagnose stress fractures. Abnormal weight distribution is diagnosed by quantitative scintigraphs. It is wise to refer the patient to an orthopedic surgeon or podiatrist before ordering expensive diagnostic tests.

 

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HEEL PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there abnormalities on inspection of the heel? Inspection of the heel may disclose an ulcer, foreign body, cellulitis, plantar wart, and other disorders.
  2. Is the patient a child? Children often have Sever's disease (osteochondritis of the heel).
  3. Is there tenderness or deformity of the Achilles tendon? Tenderness or deformity of the Achilles tendon should suggest Achilles tendinitis, rupture, or bursitis.
  4. Are there abnormalities on x-ray examination? An x-ray may disclose a calcaneal fracture, osteomyelitis, a tumor, or calcaneal spur. If the x-ray is negative, plantar fasciitis is the most likely diagnosis, but one should also consider gout.

DIAGNOSTIC WORKUP

In addition to a plain x-ray of the foot, a CBC, sedimentation rate, chemistry panel, and arthritis panel should be done. A bone scan may disclose an occult fracture. Response to a trigger point injection should be evaluated. If the diagnosis is still in doubt, referral to an orthopedic surgeon or podiatrist should be made before ordering expensive diagnostic tests such as a CT scan or MRI.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HIP PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a positive straight-leg raising test or other neurologic signs? The presence of positive straight-leg raising tests or other neurologic signs would suggest a herniated disk, a cauda equina tumor, or other neurologic disorders of the lumbar spine. Meralgia paresthetica will cause characteristic loss of sensation in the distribution of the lateral femoral cutaneous nerve.
  2. Is there a positive Patrick's test or limitation of the range of motion of the hip? These findings suggest a greater trochanter bursitis or hip joint pathology such as fracture, osteoarthritis, rheumatoid arthritis, metastasis, slipped femoral epiphysis, Legg-Perthes disease, rheumatic fever, or transient synovitis.
  3. Is there tenderness of the greater trochanter bursa? Tenderness of the greater trochanter bursa will help differentiate greater trochanter bursitis. It is also seen in hysteria.
  4. Is the patient a child or an adult? If the patient is a child, transient synovitis, slipped femoral epiphysis, Legg-Perthes disease, and rheumatic fever should be considered. If the patient is an adult, it is more likely that the problem is osteoarthritis, a fracture, rheumatoid arthritis, metastasis, or avascular necrosis.
  5. Is there a history of trauma? A history of trauma would suggest that there is a fracture or a sprain of the hip joint, but the clinician should remember that a fracture in the elderly often occurs with no history of trauma.

DIAGNOSTIC WORKUP

A CBC, sedimentation rate, chemistry panel, arthritis panel, tuberculin test, and x-rays of the lumbosacral spine and hip will diagnose 90% of the cases. These are relatively expensive in comparison to MRI. A bone scan may be necessary to diagnose occult fractures. A serum protein electrophoresis will help diagnose multiple myeloma. A trigger point injection of the greater trochanter bursa or ischiogluteal bursa will assist in the diagnosis of these conditions. An orthopedic surgeon should be consulted before ordering MRI of the lumbar spine or hip. However, MRI is especially important if the diagnosis of avascular necrosis is suspected.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

JAW PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there abnormalities on examination of the teeth or gums? A thorough examination of the teeth and gums may disclose dental caries, gingivitis, oral tumors, or alveolar abscess.
  2. Is the pain intermittent? Intermittent pain should suggest a trigeminal neuralgia or glossopharyngeal neuralgia.
  3. Is there a rash? The presence of a rash would suggest herpes zoster. Be sure to examine the eardrum for Ramsay Hunt's syndrome.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, chemistry panel, arthritis panel, and an x-ray of the teeth and jaw. X-ray of the sinuses may be helpful. At this point referral to a dentist or oral surgeon should be made if there is still diagnostic difficulty. He may order an MRI of the temporomandibular joint, which is the procedure of choice in evaluating this joint. If all tests are negative or equivocal, perhaps a psychiatric referral is in order.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

KNEE PAIN: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it transient? Transient knee pain may be due to rheumatic fever, sarcoidosis, palindromic rheumatism, or trauma.
  2. Is it unilateral or bilateral? Unilateral knee pain would suggest gout, septic arthritis, bursitis, hemophilia, pseudogout, osteogenic sarcoma, and traumatic conditions such as torn meniscus, hemarthrosis, sprain of collateral ligaments, and fracture.
  3. Is there a history of trauma? History of trauma would suggest a sprain, torn meniscus, bruise, or fracture.
  4. Are there prominent systemic symptoms? If there are prominent systemic symptoms, one should consider lupus erythematosus, Reiter's disease, rheumatoid arthritis, other collagen disease, scurvy, and rheumatic fever.
  5. What is the age of the patient? Younger patients are more likely to have traumatic conditions such as fracture, sprains, bruises, or a torn meniscus. Osgood-Schlatter disease would be more typical of patients in their early teens. Patients in their twenties are more likely to have rheumatoid arthritis, Reiter's disease, and lupus erythematosus, whereas patients in the fourth or fifth decade and older would be more likely to have osteoarthritis, gout, and pseudogout.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, ASO titer, ANA, CRP, urinalysis, chemistry panel, arthritis panel, and x-rays of the involved joint. X-rays may show a fracture, osteoarthritic changes, and punched-out lesion of gout or chondrocalcinosis (suggesting pseudogout). It is also wise to do a bone survey. 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.

If further diagnostic workup needs to be done at this point, it is most cost-effective to refer the patient to a rheumatologist or orthopedic surgeon before ordering MRI or other studies. He may want to do an arthroscopic examination before proceeding with other tests for arthritic conditions. For further workup of knee pain, see page 279 .

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Abdominal Pain in Lower Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right lower quadrant

  • Appendicitis
  • Diverticulitis
  • Salpingitis/Pelvic inflammatory disease
  • Endometritis
  • Endometriosis
  • Ectopic pregnancy
  • Hemorrhage or rupture of ovarian cyst
  • Renal calculus
  • Intussusception
    Pelvic/hypogastric region
  • Cystitis
  • Salpingitis/Pelvic inflammatory disease
  • Ectopic pregnancy
  • Diverticulitis
  • Strangulated hernia
  • Endometriosis
  • Appendicitis
  • Ovarian cyst
  • Ovarian torsion
  • Testicular torsion
  • Bladder distension
  • Nephrolithiasis
  • Prostatitis
  • Malignancy
  • Abdominal aortic aneurysm
    Left lower quadrant
  • Diverticulitis
  • Intestinal obstruction
  • Colitis
  • Strangulated hernia
  • Inflammatory bowel disease
  • Gastroenteritis
  • Pyelonephritis
  • Nephrolithiasis
  • Mesenteric lymphadenitis or thrombosis
  • Aortic aneurysm
  • Volvulus
  • Salpingitis/Pelvic inflammatory disease

Workup and Diagnosis

  • Complete history and examination
    –Note progression of symptoms (duration, rapidity of onset, intensity), associated complaints (e.g., anorexia, diarrhea, fever), urinary complaints, exposure to illness and medication, and past medical history including prior episodes
    –Note body positioning that tends to relieve pain; signs of dehydration or fever
    –Vitals and full pulmonary, cardiac, abdominal, back, pelvic, and rectal examinations
    –Abdominal examination should include bowel sounds, distension, tympany, tenderness, palpation for masses and organomegaly, rebound tenderness, and guarding
  • Initial evaluation includes CBC with differential cell counts, electrolytes, BUN/creatinine, glucose, calcium, urinalysis, urine culture, and β-hCG level
  • Abdominal/pelvic ultrasound and/or CT, obstructive series, and KUB may be indicated
  • Consider endocervical gonorrhea/chlamydia cultures in sexually active females, laparoscopy, barium enema, intravenous pyelogram, stool cultures, and/or fecal fat

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Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain in Upper Quadrants: Differential Diagnosis
(In a Page: Signs and Symptoms)

Right upper quadrant pain

  • Cholecystitis
  • Fatty liver or NASH
  • Congested liver (e.g., secondary to heart failure)
  • Cholangitis
  • Hepatitis
  • Gastritis or pancreatitis (see below)
  • Pneumonia
  • Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis secondary to pelvic inflammatory disease)

    • Epigastric pain
  • Gastritis
  • PUD
  • Pancreatitis
  • Gastroenteritis
  • Intestinal obstruction
  • Myocardial infarction
  • Aortic aneurysm
    Left upper quadrant pain
  • Peptic ulcer disease
  • Gastritis
  • GERD
  • Splenic infarct
  • Pulmonary embolism
  • Pancreatitis
  • Acute splenomegaly (e.g., mononucleosis)
  • Left lower lobe pneumonia
    Nonfocal pain
  • Herpes
  • Sickle cell crisis
  • Irritable bowel
  • Mesenteric ischemia
  • Peritonitis
  • Pleurisy
  • Uremia
  • Lead poisoning
  • Porphyria
  • Toxin ingestion

Workup and Diagnosis

  • History of associated symptoms; relation of pain to eating; anorexia; alcohol use; and location, quality, and intensity of pain
  • Physical exam should focus on heart, lungs, abdomen, and back examinations
  • Initial laboratory tests may include CBC with differential, electrolytes, urinalysis, BUN/creatinine, liver function tests, LDH, amylase/lipase, magnesium, and PT/PTT/INR
  • Chest and abdominal X-rays
  • Abdominal ultrasound and/or CT scan
  • Hepatitis viral serology
  • Percutaneous transhepatic cholangiography (PTCA) and/or ERCP
  • Upper GI endoscopy (EGD) or upper GI series with barium swallow
  • Cultures of blood, urine, and trachea/gastric aspirates
  • Evaluation of possible cardiac and pulmonary etiologies may require ECG (pulmonary embolus may show S in I, Q in III, inverted T in III), cardiac isoenzymes, pleural tap, echocardiogram, and stress test

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Source: In a Page: Signs and Symptoms, 2004

Abdominal Pain with Rebound Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Appendicitis is the most common etiology
  • Cholecystitis
  • Diverticulitis
  • Gastroenteritis
  • Pancreatitis
  • Perforated duodenal ulcer
  • Gastritis
  • Biliary or renal colic
  • Mesenteric ischemia
  • Ruptured abdominal aortic aneurysm
  • Bowel obstruction
  • Bacterial peritonitis
  • Intra-abdominal or pelvic abscess
  • Colitis
  • Urinary tract infection or pyelonephritis
  • Perforated viscus
  • Sickle cell crisis
  • Gynecologic etiologies
    –Pelvic inflammatory disease
    –Tubo-ovarian abscess
    –Ruptured ectopic pregnancy
    –Ovarian cyst rupture or torsion
  • Intussusception
  • Nonabdominal causes of pain that mimic an acute abdomen are numerous and may include myocardial infarction, atypical angina, pericarditis, pneumonia, pulmonary embolus, and pelvic pathology (e.g., pelvic inflammatory disease, ovarian torsion)

Workup and Diagnosis

  • Distinguish etiologies requiring emergent or urgent surgical intervention (e.g., ruptured aortic aneurysm, perforated viscus, appendicitis, intestinal obstruction, ischemic bowel, ruptured ectopic pregnancy) from non-emergent causes
  • History and physical examination
    –Nature of pain, location, onset, duration, intensity, similarity to past episodes, aggravating and alleviating factors, guarding, bowel sounds, distension, presence of a mass, blood on rectal exam, and cervical or adnexal tenderness
    –In general, patients who present with extremely severe pain of immediate onset require surgical intervention
    –Crampy, colicky pain that occurs in waves implies distension of a hollow viscus (e.g., renal colic, intestinal obstruction)
    –Constant, localized pain implies inflammation (e.g., appendicitis, diverticulitis, cholecystitis)
    –Hypotension and shock may be present
  • Initial tests include CBC, electrolytes, BUN/creatinine, LFTs, amylase/lipase, urinalysis, and pregnancy test
  • Plain abdominal X-rays may reveal obstruction, perforation (free air), or other pathology
  • Ultrasound is a quick, inexpensive test for biliary tract disease, AAA, ectopic pregnancy, or peritoneal fluid
  • Abdominal CT will often establish the diagnosis for appendicitis, aortic aneurysm, and diverticulitis
  • Diagnostic peritoneal lavage may be indicated in cases of suspected trauma, bowel perforation, or peritonitis

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Source: In a Page: Signs and Symptoms, 2004

Breast Pain & Discharge: Differential Diagnosis
(In a Page: Signs and Symptoms)

Breast pain

  • Fibrocystic change
    –Most common benign breast condition
    –Clinically present in 50% and histologically in 90% of women
  • Mastitis
    –Associated with lactation
  • Extramammary causes of pain (e.g., cervical radiculitis, costochondritis, herpes zoster, angina)
  • Breast cancer
    –Occurs in 1/9 women (lifetime risk)
  • Cyst
  • Breast abscess
  • Unilateral or bilateral gynecomastia
  • Phylloides tumor
  • Intraductal papilloma
  • Fat necrosis
  • Trauma
  • Fibroadenoma
  • Lipoma
  • Pregnancy
    Breast discharge
  • Duct ectasia
  • Galactorrhea
  • Mondor's disease
  • Chronic nipple stimulation
  • Pregnancy
  • Hypothyroidism
  • Sarcoidosis
  • Systemic lupus erythematosus
  • Cirrhosis or other hepatic disease
  • Breast cancer
    –Occurs in 1/9 women (lifetime risk)
  • Intraductal papilloma
  • Fibrocystic change
  • Medications (e.g., phenothiazines, metoclopramide, tricyclic antidepressants, reserpine, opiates, cimetidine, androgens)
  • Hypothalamic and pituitary abnormalities (e.g., prolactinoma, acromegaly, empty sella syndrome)
  • Pseudocyesis

Workup and Diagnosis

  • History includes past medical history, duration and pattern of pain and/or discharge, family history of breast or gynecologic cancer, and menstrual/pregnancy history
  • Breast exam 7–9 days after menstrual flow
    –Fibrocystic areas: Slightly irregular, mobile, bilateral, upper outer quadrant; compression causes tenderness
    –Breast cancer: Solitary, irregular, or stellate; hard, nontender, fixed; not clearly delineated from surrounding tissue, ± lymphadenopathy
    –Mastitis: Inflamed, edematous, erythematous, indurated, tender areas, axillary lymphadenopathy
    –Nipple discharge: Bloody or serosanguinous discharge is suspicious for cancer; oral contraceptives, estrogens, or elevated prolactin levels may result in clear, serous, or milky discharge
  • Diagnostic mammogram is indicated in patients >30 years old who present with solitary or dominant mass or asymmetric thickening
    –Compare with prior mammograms if possible
  • Ultrasound is used to distinguish solid versus cystic
  • Fine-needle aspiration, breast biopsy, cytologic exam of discharge, ductogram and/or galactogram may be indicated
  • Endocrine evaluation may include prolactin levels, TSH, FSH, and LH

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Source: In a Page: Signs and Symptoms, 2004

Flank Pain/CVA Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Degenerative disk disease and/or disk herniation is the most frequent cause of pain
  • Muscle spasm or cramping
  • Trauma
  • Nephrolithiasis/urolithiasis (renal or ureteral calculi or stones) is the most common urinary tract etiology
  • Pyelonephritis (acute or chronic)
    –E. coli is the most common cause of upper and lower urinary infections, followed by Staphylococcus saprophyticus
    –Acute pyelonephritis is usually a complication of a lower UTI
    –Chronic pyelonephritis is usually associated with obstruction
    • Perirenal (kidney) abscess
    • Acute pancreatitis
    • Glomerulonephritis
    • Herpes zoster
    • Bacterial cystitis
    • Polycystic kidney disease
    • Renal infarction or trauma
    • Papillary necrosis
    • Duodenal ulcer
    • Cholecystitis or biliary colic
    • Pneumonia
    • Appendicitis
    • Obstructive uropathy
    • Ectopic pregnancy
    • Cervicitis
    • Renal or bladder cancer
    • Leaking or ruptured abdominal aortic aneurysm

    Workup and Diagnosis

    • History should include onset, duration, quality, intensity, and location of pain; radiation; associated symptoms (e.g., nausea/vomiting, fever, dysuria, hematuria, rash); history of recent trauma or illness; and family history of renal disease or cancer
    • Exam should include complete cardiovascular, pulmonary, abdominal, and genitourinary exam, and pelvic exam if suspect cervicitis or ectopic pregnancy
      –Turner's sign (bluish discoloration at flank) and/or Cullen's sign (bluish discoloration at the umbilicus) indicate retroperitoneal hemorrhage and may be present in cases of pancreatitis or ruptured AAA
      –Initial labs may include CBC, ESR, electrolytes, BUN/creatinine, calcium, amylase/lipase, liver function tests, pregnancy test, blood cultures, urinalysis, and urine culture
    • Urine cytology, cystoscopy, and biopsy may be indicated if renal or bladder cancer is suspected
    • Renal or abdominal ultrasound or abdominal CT scan
    • Spiral CT scan without contrast is the gold standard to diagnose stones and urinary tract obstruction
    • Intravenous pyelography has high sensitivity/specificity for stones, urinary tract obstruction, and renal cysts
    • Voiding cystourethrography
    • Lumbosacral X-ray may be indicated to evaluate for degenerative joint disease
    • Lumbosacral MRI may be indicated to evaluate for disk disease

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Source: In a Page: Signs and Symptoms, 2004

Neck Stiffness/Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Trauma
    –Paraspinal neck stiffness: Commonly due to motor vehicle collisions (“whiplash”) or abnormal sleep posture
    –Cervical spine fracture with spasm of neck muscles
    –Subarachnoid hemorrhage: Most commonly due to ruptured cerebral aneurysm
    –Epidural hematoma
    –SCIWORCA: Spinal Cord Injury Without Radiographic Abnormality occurs in pediatric patients with ligamentous laxity and hypermobility of the cervical spine
    –Rotary atlantoaxial subluxation: Subluxation of the cervical spine at C1-C2 level, resulting in sternocleidomastoid spasm with tilting of the head toward the affected side and chin pointed toward the ipsilateral side
  • Infection
    –Meningitis: Often bacterial (e.g., Neisseria meningitidis, Streptococcus pneumoniae) or viral (e.g., HIV, Epstein-Barr virus, enterovirus, herpes simplex virus)
    –Cervical lymphadenitis
    –Tonsillopharyngitis
    –Epiglottitis
    –Retropharyngeal abscess
    –Epidural abscess
    –Discitis
  • Torticollis: Idiopathic sternocleidomastoid spasm, resulting in tilting of the head toward the affected side with the chin pointed to the contralateral side
  • Inflammatory
    –Rheumatoid arthritis
    –Ankylosing spondylitis
    –Degenerative joint disease
  • Tumors (especially leptomeningeal metastases)
  • Dystonic reaction: Idiosyncratic drug reaction, often to psychiatric medications (e.g., haloperidol, prochlorperazine)

Workup and Diagnosis

  • History and physical examination focusing on evidence of trauma and infection
    –All patients with possible traumatic injury should be maintained in a cervical collar and backboard until diagnostic workup is complete
  • Initial labs may include CBC, electrolytes, BUN/creatinine, calcium, glucose, and ESR
  • Blood cultures are indicated if infectious etiologies are suspected
  • Lumbar puncture with CSF analysis is useful in cases of suspected infection or subarachnoid hemorrhage
  • Cervical spine radiographs are indicated in trauma or neck infection (may reveal prevertebral soft-tissue swelling)
  • Head CT scan without contrast may show bleeding in cases of subarachnoid hemorrhage (fails to reveal subarachnoid blood in 10% of cases)
  • Neck CT scan may be indicated in suspected soft tissue disease (e.g., retropharyngeal abscess) or occult vertebral fracture if not adequately visualized on plain films
  • MRI of the spine may be indicated in suspected epidural abscess or epidural hematoma

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Source: In a Page: Signs and Symptoms, 2004

Pelvic Pain - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute pain (<6 months)

  • Pregnancy-related
    –Ectopic pregnancy
    –Threatened abortion
    –Incomplete abortion
    –Septic abortion
    –Ruptured corpus luteal cyst
  • Gynecologic (noncyclic)
    –Ovarian cyst
    –Pelvic inflammatory disease
    –Tubo-ovarian abscess
    –Vaginitis/cervicitis
    –Ovarian torsion
    –Uterine fibroids
    –Pelvic (ovarian, uterine, urinary) neoplasm
    –Pelvic floor prolapse (cystocele/rectocele)
  • Gynecologic (cyclic pain)
    –Primary dysmenorrhea
    –Endometriosis
    –IUD
    –Mittelschmerz (midcycle ovulation)
  • Nongynecologic
    –Irritable bowel syndrome
    –UTI/pyelonephritis
    –Nephrolithiasis
    –Appendicitis
    –Diverticulitis
    –Sexual abuse/trauma
    –Abdominal aortic aneurysm
    –Mesenteric ischemia/infarction

  • Chronic pain (>6 months)
  • Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
    –Pelvic adhesions
    –Interstitial cystitis
    –Inflammatory bowel disease
    –Adenomyosis
    –Leiomyoma (fibroids)
    –Hernia (femoral or inguinal)
    –Depression
    –Irritable bowel syndrome
    –Diverticulosis or diverticular abscess
    –Lymphoma
  • Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria

Workup and Diagnosis

  • History and physical examination
    –Note the nature, severity, onset, radiation, duration of pain; relation to menstrual cycle, intercourse, or other activities; chronic versus acute; chance of pregnancy
    –Note associated symptoms: Fever, nausea, vomiting, dysuria, frequency, vaginal bleeding/discharge, abdominal or back pain
    –Screen for domestic violence and sexual abuse
    –Full abdominal and pelvic exams, including speculum, bimanual, and rectal exam
  • Laboratory studies may include urine pregnancy test, urinalysis, urine Gram stain and culture, cervical cultures for Chlamydia and gonorrhea, and wet mount of vaginal smear
  • Consider ultrasound if ovarian cyst, torsion, or mass is suspected, or to evaluate for intrauterine versus ectopic pregnancy
  • Diagnostic laparoscopy for acute abdomen or endometriosis
'>

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Source: In a Page: Signs and Symptoms, 2004

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

  • Cardiovascular etiologies
    –Myocardial infarction
    –Angina
    –Acute coronary syndrome
    –Pulmonary embolus
    –Pericarditis
    –Arrhythmias
    –Mitral valve prolapse
    –Aortic stenosis
    –Aortic dissection
    –Cardiac tamponade
  • Pulmonary etiologies
    –Pneumonia
    –COPD
    –Asthma
    –Pneumothorax
    –Tension pneumothorax
    –Hemothorax
    –Empyema
    –Pneumomediastinum
    –Lung cancer
  • Gastrointestinal etiologies
    –Esophagitis/GERD
    –Gastritis
    –Peptic ulcer disease
    –Perforated ulcer
    –Esophageal spasm
    –Pancreatitis
    –Esophageal rupture
    –Pneumoperitoneum
  • Musculoskeletal etiologies
    –Muscle strain or spasm
    –Intercostal muscle spasm
    –Costochondritis
    –Trauma (e.g., rib fracture)
  • Zoster
  • Cancer (e.g., lymphoma)
  • Panic disorder
  • Less common etiologies include Tietze's syndrome, Pott's disease (tuberculosis of the spine), xyphodenia, cholecystitis, peritonitis, liver cancer, and hepatitis

Workup and Diagnosis

  • History and physical examination
    –Assess onset, duration, location, radiation, type of pain, and exacerbating and alleviating factors
    –Cardiovascular evaluation includes assessment of heart sounds, murmurs, gallops or rubs, and carotid bruit
    –All patients require a rectal exam (e.g., to assess for occult bleeding due to GI etiologies, to assess for occult bleeding before initiating anticoagulation)
    –Risk factors for coronary artery disease include smoking, hyperlipidemia, diabetes, and a personal or family history of coronary artery disease
  • Initial evaluation may include pulse oximetry, CBC, electrolytes, BUN/creatinine, calcium, glucose, PT/INR/PTT, ECG, chest X-ray, and cardiac enzymes
  • Patients with suspected coronary artery disease may require stress testing, echocardiogram, and/or cardiac catheterization
  • Further studies to consider include arterial blood gas, liver function tests, amylase and lipase, CT of chest and abdomen, VQ scan, peak flow testing and pulmonary function tests, arteriogram, bronchoscopy, EGD, and/or esophagram
  • Transesophageal echocardiogram and/or CT scan or MRI of the chest may be required to rule out aortic dissection (if widened mediastinum is present on X-ray)

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Source: In a Page: Signs and Symptoms, 2004

Ear Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Otitis media
    –Most cases are of viral origin
    –Red tympanic membrane with decreased mobility
    –Male > female; peak incidence 6–18 months
    –Risk factors include day care, supine bottle feeding, smoking in household, siblings with otitis media, anatomic abnormalities (e.g., Down's syndrome)
  • Eustachian tube dysfunction
    –Common in young children
  • Otitis externa
    –Pain upon movement of tragus
  • Malignant (necrotizing) otitis externa
    –Usually due to Pseudomonas –Mostly seen in diabetics
  • Referred pain
    –TMJ: May result in ear pain, jaw pain, neck pain, and/or headache
    –Dental infection, trauma, or orthodontic intervention (e.g., tightening of braces)
    –Pharyngitis or tonsillitis
    –Post-tonsillectomy/adenoidectomy
    –Retropharyngeal abscess and other ENT deep-space infections
    –Cervical adenitis
    –Sinusitis/rhinitis
    –Laryngitis
    –Trigeminal neuralgia
    –Esophagitis
    –Cervical spine arthritis
    –Parotiditis/sialoadenitis (including mumps)
    –Angina/acute coronary syndrome
  • Foreign body in ear canal (including impacted cerumen)
  • Reaction to topical agents
  • Trauma: Laceration, abrasion, barotrauma (e.g., deep sea diving, airplane)
  • Cellulitis
  • Tympanostomy tube obstruction
  • Myringitis bullosa
  • Furunculosis (localized abscess)
  • Varicella or herpes simplex/zoster infection in the ear canal
  • Mastoiditis
    –Ear protrudes anteriorly
  • Tumor
  • Eczema/psoriasis
  • Mumps

Workup and Diagnosis

  • History and physical examination, including otoscopic exam with pneumatic otoscopy and complete head and neck examination
    –Pain upon traction of pinna suggests otitis externa (hyperemic external canal)
    –Bulging, red, immobile tympanic membrane is consistent with acute otitis media (with or without otorrhea secondary to perforation)
    –Retracted, immobile tympanic membrane may be seen in serous otitis media
    –Mass lesion behind tympanic membrane suggests cholesteotoma or tumor
    –Tonsillar asymmetry or uvular deviation suggests peritonsillar abscess or mass
  • Tympanometry may reveal otitis media with effusion, eustachian tube dysfunction, or tympanostomy tube obstruction
  • Audiometry to evaluate for hearing loss
  • Consider culture of otorrhea if perforation (not canal) or complicated (e.g., recurrent infection, spread of infection such as meningitis or mastoiditis)
  • Lateral neck X-ray will diagnose retropharyngeal mass or abscess
  • Head CT is indicated if intracranial lesion or basilar skull fracture is suspected
  • Consider CBC and ESR if suspect malignant necrotizing otitis media
  • Check glucose in recurrent severe otitis externa

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Rectal Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Anal fissure
    –Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
    –Chronic fissure presents with long-standing itching and mild pain, with or without bleeding
  • Perianal abscess (with or without associated fistula formation
  • Thrombosed hemorrhoid
  • Levator ani syndrome
  • Proctalgia fugax (rectal muscle spasm)
  • Coccyodynia/coccygodynia
  • Fecal impaction
  • Neoplasm (rectal, pelvic, or cauda equina)
  • Idiopathic
  • Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
    • Solitary rectal ulcer syndrome
      –Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
      –Neoplasm is a concern
    • Pruritus ani
    • Trauma
    • Anal sex
    • Constipation
    • Diarrhea
    • Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves

Workup and Diagnosis

  • A careful history and physical exam are crucial and often diagnostic for many conditions
    –Acute anal fissure presents as an anal tear (typically posterior) with a tender perineum; no further workup is necessary if the classic history and exam are found
    –Chronic anal fissure presents as an open ulcer with drainage and sentinel pile
    –Levator ani symptoms can be elicited by digital rectal examination
    –Proctalgia fugax symptoms cannot be elicited by exam
    –Coccyodynia: Palpation of coccyx reproduces symptoms
  • In cases of perianal abscess, must rule out the presence of an anal fistula and inflammatory bowel disease
  • Anoscopy may be indicated to rule out inflammatory bowel disease
  • If an underlying disease process is suspected, consider stool cultures, viral titers, serologies, and/or biopsy

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Testicular Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Epididymitis
    –Insidious onset of symptoms seen in adolescent (postpuberty) boys
    –Bacterial (e.g., Chlamydia, Enterobacter) versus viral (mumps, mononucleosis, adenovirus)
  • Testicular torsion
    –Twisting of the spermatic cord results in testicular ischemia
    –Acute onset of severe pain, diffuse tenderness
    –Negative urinalysis; absent cremasteric reflex
    –Testes on affected side are tender, shortened, and lie transversely
    –Duration of ischemia (time until detorsion is completed) determines the viability of the affected testicle
  • Hydrocele
    –A collection of fluid between the layers of the tunica vaginalis; usually nontender
  • Varicocele
    –Palpated as a “bag of worms” above testes
    –Dull ache exacerbated by strenuous exercise; left >right
  • Epididymal or testicular appendage torsion
    –Subacute onset seen in prepubertal boys
    –Localized to the upper pole of testicle
    –Negative U/A; normal cremasteric reflex
  • Ruptured abdominal aortic aneurysm
  • Peritonitis
  • Referred pain due to an incarcerated hernia, constipation, or kidney stone
    • Scrotal trauma
      –Results from a direct blow or saddle injury
      –May result in traumatic epididymitis, hematocele, or laceration of the tunica albuginae (testicular rupture)
    • Fournier's gangrene
      –Necrotizing fasciitis of the perineum
      –Seen primarily in older men
    • Henoch-Schönlein purpura
      –Systemic vasculitis resulting in scrotal pain, abdominal pain, arthralgias, nonthrombocytopenic purpura, and renal disease
      –Occurs in prepubertal boys
    • Tumor
      –Painless scrotal mass is a testicular neoplasm until proven otherwise

    Workup and Diagnosis

    • History and physical examination including abdomen, back, genitalia, and digital rectal examination
      –Note character of onset (sudden or subacute), duration (minutes, hours, or days), location (generalized or localized), quality (sharp or dull, moderate or severe, constant or intermittent), and previous episodes
      –Palpate testicle and spermatic cord to assess for tenderness, effusion, subcutaneous emphysema, size, and lie of testicle, and assess for hernias
      –Transilluminate for presence of fluid
      –“Blue dot sign”: Bluish discoloration along upper pole seen in about 20% of cases of torsion of the testicular appendix and due to infarction and necrosis
      –“Prehn's sign”: Relief of pain with elevation of the testis in testicular torsion
    • If testicular torsion is suspected, emergent detorsion is necessary, generally by a urologic specialist
    • Culture for Neisseria gonorrhoeae and Chlamydia trachomatis in sexually active males before urinalysis
    • Urinalysis in all patients: Elevated WBC or RBC levels suggest infection (e.g., epididymitis)
    • Ultrasound of the testicles using color Doppler measures blood flow and evaluates for masses
    • Radionucleotide scintigraphy may also be used to assess blood flow
    • Recent studies have advocated the use of MRI

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

  • Lumbosacral muscle strain
    –Most common etiology of low back pain
    –Most common cause of disability in adults <45 years old
    –Aggravated by movement, better with rest
  • Lumbar disc herniation
    –Especially of L4-L5 and L5-S1
    –Usually with unilateral radiation down the leg in a dermatomal pattern
    –Increased pain with sitting
    • Spinal stenosis
      –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
      –Increased pain with standing
    • Sacral-iliac joint dysfunction
      –Especially in young, thin women or in pregnancy
      –Unilateral upper buttock pain, relieved with movement
    • Vertebral fracture
      –Often associated with trauma or osteoporosis
    • Spondylolisthesis
      –Especially in young athletes
    • Secondary gain (e.g., drug seeking, disability or liability issue)
    • Extraspinal causes (e.g., radiation from kidney stones)
    • Systemic causes (<1%)
      –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
      –Infection: Osteomyelitis, abscess
      –Abdominal aortic aneurysm
      –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
      –Cauda equina syndrome
      –Paget's disease

    Workup and Diagnosis

    • History and physical are the most important diagnostic tools
      –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
    • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
    • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
      –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
      –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
      –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
    • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study
    '>>'>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

  • Trauma
    • 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
  • Osteoarthritis
  • Rheumatoid arthritis
  • Gouty arthritis
  • Infection
  • Distal biceps tendon rupture
    • Pronator syndrome
      –Median nerve entrapment distal to elbow
      from racquet or throwing sports
      –Anterior pain and distal paresthesias
      –Pain with resisted pronation
    • Radial tunnel syndrome
      –Compression of the radial nerve as it crosses the head of the radius
  • Loose body (e.g., bone fragment)

    • Workup and Diagnosis

    • History and physical examination
      –Include careful exam of the hand, wrist, elbow, and shoulder of the affected side
      –Evaluate for pain, paresthesias, bony point tenderness, crepitus on palpation, swelling and ecchymosis, limited range of motion, and neurovascular compromise (e.g., coolness, pallor, loss of distal pulses)
  • Standard X-rays include A/P, lateral, and oblique views
  • Aspiration may be diagnostic as well as therapeutic for bursitis; send for cultures and crystals
  • Occasionally, nerve conduction tests are indicated to evaluate nerve entrapment and/or carpal tunnel syndrome
  • Rarely, an MRI is indicated; may be considered if the treatment is not progressing as planned

    • » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

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

  • Dental or periodontal pathology
    –Associated with temperature sensitivity and pain upon biting
    • 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)

    Workup and Diagnosis

    • History and physical examination, with focus on the head and neck
      –Review onset, character, and pattern of pain; past medical and surgical history; associated symptoms (e.g., weight loss, sinus pain, skin complaints); and complete review of systems, including screening for local and systemic pathology and a cervical evaluation for muscle, neural, or skeletal referred pain
      –Perform a thorough oral exam of the buccal mucosa, lips, hard palate, soft palate, posterior pharynx, floor of mouth, and the top, sides, and undersurface of the tongue
      –Perform a head, neck, ear, nose, cardiac, pulmonary, and lymphatic exam
      –Suspect dental pathology until proven otherwise
    • Initial workup is aimed at assessing the mouth and jaw for dental, periodontal, or TMJ disorders
    • Appropriate laboratory studies are based upon the suspected diagnosis (e.g., CBC and ESR for temporal arteritis)
    • Imaging studies may include Panorex films, sinus X-ray, CT scan, and/or MRI
    • Therapeutic trial of medications (e.g., NSAIDs)
    • Temporal artery biopsy is indicated if ESR elevated
    • Biopsy any suspicious lesion
    • Referral to a dental or medical specialist may be necessary
    '>

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    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

    Workup and Diagnosis

    • History and physical examination are often diagnostic
      –Inspect the patient's gait for limitations of motion or other abnormalities
      –Visually assess symmetry between the knees: Note swelling, deformity, erythema, and muscle atrophy
      –Palpate: Note tenderness, warmth, and crepitus
      –“Milk the joint” to elicit an effusion
      –Test for range of motion (active and passive)
      –Perform McMurray circumduction test and ligament testing (e.g., Lachman test, anterior/posterior drawer tests, thumb sign, varus/valgus stress tests)
    • X-rays are often indicated
      –AP, lateral, and merchant or sunrise films of both knees
      –When possible, also obtain weight-bearing A/P films
      –Merchant and sunrise X-rays of the patella are used to evaluate alignment and injury to the patella
      –On occasion, tunnel views of the knee are useful (e.g., for OCD)
    • Joint aspiration should be performed in patients with joint effusions; fluid analysis includes cell count with differential, crystals, Gram stain, and culture
    • MRI may not be necessary during initial evaluation, but may help with confirmation of specific injuries and surgical planning (e.g., PCL tear, meniscus tear, OCD)
    • Bone scan may be used to evaluate malignancy or infection
    • In some cases, blood work may include CBC, ESR, C-reactive protein, alkaline phosphatase, and uric acid

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    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

    Workup and Diagnosis

    • History
      –Acute or chronic
      –Mechanical (pain worsens with activities, improves with rest, and usually involves weight-bearing joints)
      –Inflammatory (waxing and waning, symptoms unrelated to use, morning stiffness)
      –History of trauma
      –Night-time symptoms
      –Attempted treatments
      –Systemic symptoms: Fever, rash, pain, fatigue
      –Past medical history: Birth history, existing medical conditions, surgeries, broken bones, growth and development, medications
      –Unusual exposures such as tick bites
      • Physical exam
        –Vital signs, including growth parameters
        –Musculoskeletal exam for swelling, tenderness, warmth, redness, range of motion, asymmetry
        –Muscle strength and neurologic exam (tone, sensory and reflexes)
        –Lympadenopathy, organomegaly, rash, systemic symptoms
    • Radiologic evaluation may include X-ray, US, MRI, and bone scan to evaluate for fracture, infection, tenosynovitis, or internal derangements
    • Lab investigation may include CBC, ESR, CRP, examination of synovial fluid, viral titers (parvovirus), Lyme titers, RF, and ANA

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

    Workup and Diagnosis

    • History
      –Acute or chronic; persistent or intermittent; degree of pain, night-time symptoms
      –Systemic symptoms such as fever, weight loss, rash, and fatigue
      –Mouth and/or genital ulcers, abdominal pain, vomiting, diarrhea, bloody stools
      –Past medical history: Birth history, existing medical conditions, surgeries, broken bones, growth and development, any recent URI, genital infection or strep infection, unusual exposures such as tick bites
    • Physical exam
      –Vital signs including growth parameters
      –Musculoskeletal exam for swelling, tenderness, warmth, redness over the joints, range of motion of the joints; asymmetry, muscle strength
      –Lympadenopathy, organomegaly, rash, dysmorphic features, presence of bone pain and neurologic exam (tone, sensory, and reflexes)
    • Labs: CBC, ESR or CRP, RF and ANA; Lyme titers, lupus panel, complement (C3, C4) levels; viral titers (HCV, EBV, parvovirus), LDH, U/A, LFTs
    • Radiology: CXR, X-ray of involved joints, US, MRI, and bone scan to rule out infection, malignancy, and to confirm effusion and tenosynovitis
    • Studies: ECG, echocardiogram, angiogram, UGI/SBF, endoscopy when clinically indicated

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

    Workup and Diagnosis

      • History
        –Onset, duration, and specific quality of pain
        –Ability to localize (may distinguish otologic from nonotologic)
        –Associated otologic symptoms: Otorrhea, hearing loss, imbalance, prior ear surgery, antecedent events
        –Pain associated with mastication, swallowing, voice change, purulent rhinorrhea
      • Otologic exam
        –Inspection and palpation of pinna, tragus, and preauricular area, and mastoid bone
        –Direct otoscopy for signs of external- or middle-ear infection or inflammation
        –Obstructing cerumen or foreign bodies must be removed to evaluate deeper structures
      • Complete head and neck exam
        –Nose and nasal cavities, oral cavity, and pharynx (particularly teeth and tonsils), TMJ
        –Examination of nasopharynx and larynx may require fiberoptic endoscopy
    • Tympanometry, if middle ear status (fluid, retraction, perforation) is not evident from otoscopy
    • CT or MRI
      –Useful to delineate extent of cholesteatoma, mastoiditis, petrous apicitis, tumor
      –May be necessary to evaluate either otologic disease or an ill child with nonotologic source (rule out abscess or tumor)

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

    Workup and Diagnosis

      • History
        –Type of pain, location, radiation, duration
        –Relieving and worsening factors including foods
        –Awakens from sleep, activity level, emesis, diarrhea
        –Nausea, hematochezia, melena, fever, dysuria, hematuria
        –Sexual activity, anorexia, headache, cough, rashes
        –Stool frequency, joint complaints
    • Surgical history: Previous abdominal surgery
    • Social history: Stressors, changes in school or family
    • Physical exam
      –Height, weight, temperature, pulse
      –General appearance, hydration status
      –Pharyngeal erythema/exudates, abdominal tenderness
      –Psoas sign, obturator sign, palpable masses
      –Rectal exam including hemoccult
      –Rashes, joint swelling, vaginal exam
    • Labs: Geared toward history and physical findings
      –Consider CBC with differential, urinalysis, and culture
      –stool for culture and O&P
      –Amylase and lipase, LFTs, H. pylori antibody (IgG)
      –Hydrogen breath test for sugar intolerance
      –Pregnancy test, vaginal cultures
      –Throat culture
    • Consider KUB or obstruction series
    • Abdominal CT scan with contrast versus ultrasound
    • Pelvic ultrasound for torsion, ectopic pregnancy, abscess, hydrometrocolpos

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

      Workup and Diagnosis

        • History
          –Onset, duration, location of symptoms
          –History of trauma, heavy lifting, overuse, athletics
          –Systemic symptoms such as fever, irritability
          –Menstrual and sexual history
          –Past medical history of similar complaints, orthopedic conditions, general medical conditions
          –Family history of scoliosis, rheumatic disease
        • Physical exam
          –General appearance, fever, irritability
          –Spinal contour, symmetry
          –Gait, posture
          –Range of motion limitations
          –Point tenderness, SI tenderness
          –Associated neurologic findings (sensation, strength, DTRs)
      • Labs
        –If rheumatologic condition is suspected, consider CBC, ESR, ANA, RF, HLA typing
        –If infectious process is suspected, obtain CBC, ESR
        –Urine microscopy and culture
      • Studies
        –Plain films can reveal fractures such as spinal compression fractures, disk space abnormalities, and sacroiliac abnormalities associated with spondyloarthrosis
        –MRI may be required to discover disk herniation, disk space infection, tumors

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

      • Workup and Diagnosis

      • History
        –Activity at onset, (chest pain with exercise is a red flag!), precipitating/relieving factors, quality of pain (sharp vs dull)
        –Associated symptoms (shortness of breath, diaphoresis, cough/wheeze, nausea/vomiting), recent illness, response to eating, sleeping, different foods (caffeine, chocolate, spicy, or high-fat foods)
        –Personal/family history of asthma, allergies, eczema
        –Recent diagnosis of heart disease or death in a family member often generates fear in the patient or parent, prompting the evaluation of chest pain
        –Social history: Recent life stressors (school problems, family discord, etc.); drug use, especially cocaine
        • Physical exam
          –Reproducible with palpation likely musculoskeletal
          –Chest exam: Wheezing, rales, crepitus
          –Cardiac exam: Usually normal, even with cardiac causes; pericarditis is associated with rub
      • Chest X-ray for infiltrates, pneumonia, pneumothorax
      • ECG and cardiac enzymes are rarely required but relatively inexpensive and readily available, and can rule out MI and provide reassurance for families
      • Cardiac stress test
        –Continuous ECG monitoring while the patient exercises to evaluate for coronary insufficiency
        –Used for patients with exercise-induced chest pain and/or coronary abnormalities

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

    Workup and Diagnosis

      • Despite urgency of surgical emergencies, a thorough history is essential
        –Onset and duration of symptoms, location, and character of pain
        –Previous trauma, preceding illness, or associated symptoms
        –Past medical history/family history: Bone, hematologic, and metabolic disorders
    • Labs
      –CBC with differential, platelets, PT/INR, ESR, CRP
    • Radiographic evaluation
      –Plain X-ray: AP pelvis and frog-leg lateral of the pelvis, full length femur, and knee films
      –CT scan: Helps define bony anatomy especially with 3D reconstruction images
      –MRI may demonstate joint effusion in synovitis and infection, marrow edema in osteomyelitis, physeal widening in SCFE, or occult fracture such as femoral neck stress fracture
      –Ultrasound for newborn DDH
      • Nuclear medicine
        –Triple-phase bone scan may be helpful when the diagnosis is questionable, or if differentiating between bone and joint infections
      • Interventional radiology
        –Joint aspiration to evaluate for septic arthritis

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

    Workup and Diagnosis

      • History
        –Specific location, duration, onset, aggravating or alleviating factors, and pain characteristics
        –Previous trauma, preceding illness, or associated symptoms
        –Past medical history and family history including bone, hematologic, or metabolic disorders
      • Physical exam
        –Bilateral hip, knee, and ankle exam
        –Redness, warmth, effusion, active and passive ROM
        –Palpate joint line, patella, tibial tubercle, pes anserine, and medial/lateral ligaments
        –Patella tracking or apprehension, varus/valgus stress, Lachman, and anterior posterior drawer tests
        –Crepitus along the flexion arc and McMurray test
      • Labs
        –Often not needed unless concerned about infection
        –CBC with differential, platelets, PT/INR, ESR, CRP
        –Knee aspirate for cell count and differential with Gram stain, culture, and crystals
      • Radiography
        –Plain X-ray: Screening knee films include AP, lateral, Merchant views
        –AP pelvis and frog-leg lateral of the pelvis or femur films if indicated by exam findings
    • MRI to show soft tissues such as meniscus and ligaments
      –May demonstate joint effusion in synovitis/infection, marrow edema in osteomyelitis, ligament rupture

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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

      Workup and Diagnosis

      • History
        –History of trauma, viral symptoms, rash
        –Sexual history and history of STDs
        –Past medical history of similar episodes
      • Physical exam
        –With testicular torsion, the absence of the cremasteric reflex is one of the most characteristic features; the affected testis is also often higher and more horizontal than the contralateral testis
        –In epididymitis and orchitis, elevation of the testis improves the pain, and the cremasteric reflex is usually preserved
        –In torsion of the appendix testis, a bluish dot may be seen in the superior portion of the affected testis
        –A hernia often can be felt extending from the inguinal area into the scrotum
        –A varicocele is described as feeling like a “bag of worms,” and is best examined with the patient standing
      • Urinalysis
        –Normal in patients with torsion
        –Pyuria is a feature of epididymitis
      • Doppler ultrasound is indicated for patients in whom the physical exam is not diagnostic; it may be bypassed by the surgeon in the interest of time when the exam is very specific for testicular torsion

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    Source: In A Page: Pediatric Signs and Symptoms, 2007

    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)

    Workup and Diagnosis

    • History
      –Onset, duration of symptoms
      –Unilateral or bilateral
      –Associated systemic symptoms
    • Physical exam
      –General state of health, including growth parameters and weight loss
      –Unilateral or bilateral lesions
      –Reducibility of scrotal mass or enlargement
      –Palpation of testes: Tenseness, nodules
      –Hydroceles can sometimes be transilluminated
      –Patent defects can usually be palpated when there is a hernia, particularly if the patient performs a Valsalva maneuver (“turn your head and cough”)
      –Varicocele is usually left sided and feels like “a bag of worms”
        • Labs
          –CBC and differential, LDH, ESR if malignancy is suspected
        • Radiology
          –Ultrasound may be helpful confirming hernia, hydrocele, or varicocele
          –PET scans are used to detect malignant metastasis or relapse
      • Studies
        –A testicular nodule usually must be biopsied to rule out malignancy

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    FOOT, HEEL, AND TOE PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Special considerations in the approach to the diagnosis of foot pain include examining the shoes for abnormal areas of wear and tear, measuring the arches, palpating the joints for maximal tenderness, and ordering laboratory tests for joint disease (page 341). Nerve blocks and lidocaine injections in the plantar fascia and other areas of maximum tenderness will assist in diagnosis. Abnormal weight distribution is diagnosed by quantitative scintigraphs. A therapeutic trial of proper-fitting shoes and arches may be indicated. Weight control is essential in the obese. Referral to a podiatrist or orthopedic surgeon is often necessary.

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    Source: Differential Diagnosis in Primary Care, 2007

    ABDOMINAL PAIN, GENERALIZED: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. On the other hand, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel.

    It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it.

    If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed with an exploratory laparotomy immediately. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

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    Source: Differential Diagnosis in Primary Care, 2007

    LOW BACK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic exam should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive.

    If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

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    Source: Differential Diagnosis in Primary Care, 2007

    ARM PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs found on a good history and physical examination is most important in pinpointing the diagnosis. Thus, arm pain with tenderness and limitation of motion at the elbow suggests tennis elbow, gout, or rheumatoid arthritis. Arm pain with loss of sensation in the distribution of the median nerve suggests carpal tunnel syndrome. Injection of lidocaine into bursa or trigger points may be diagnostic.

    The laboratory workup should include x-rays of the involved area and of the cervical spine, especially if there is a radicular distribution of the pain. If there are focal neurologic signs, a neurologist should be consulted before ordering an MRI: A cervical rib will not be missed in this way. An ECG and myocardial enzymes may be necessary to exclude a myocardial infarct, and an exercise tolerance test will help exclude coronary insufficiency. Arteriogram, phlebogram, lymphangiogram, electromyogram (EMG) with nerve conduction studies, myelogram, and nerve blocks will be necessary in specific cases.

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    Source: Differential Diagnosis in Primary Care, 2007

    BREAST PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of a painful breast is usually made by taking a careful history. What drugs are the patient taking? Associated symptoms and signs (see sections on bloody discharge, page 90 and swelling, page 92) are also important. A culture of the discharge, mammography, and serum, estrogen, and prolactin levels may be important, but referral to an endocrinologist is wise when the history does not provide a simple solution, especially when the pain is bilateral. Biopsy (frozen section) is necessary when tumor is suspected and mammography is equivocal, because faith in mammography has declined somewhat in recent years.

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    Source: Differential Diagnosis in Primary Care, 2007

    CHEST PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there are significant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often be necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done to rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

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    Source: Differential Diagnosis in Primary Care, 2007

    ELBOW PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In the approach to the diagnosis, the traumatic conditions and arthritic disorders will probably stand out. A diagnostic dilemma occurs when the elbow looks normal and has good movement. Nevertheless, most of these cases are caused by tennis elbow, myositis, and fasciitis. Thus, a simple injection at the trigger point will assist the diagnosis and give the patient immediate and sometimes lasting relief. If this is unsuccessful, referral to an orthopedic surgeon is wise.

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    Source: Differential Diagnosis in Primary Care, 2007

    EPIGASTRIC PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of midepigastric pain is identical to that for generalized abdominal pain (see page 22).

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    Source: Differential Diagnosis in Primary Care, 2007

    EYE PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tenometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.

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    Source: Differential Diagnosis in Primary Care, 2007

    FACIAL PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of face pain includes a careful history and physical with a good neurologic examination. The sinuses are transilluminated and x-rays may be performed. The teeth and occlusion are examined carefully and possibly x-rayed. A histamine test may be indicated. The busy physician may want to refer the patient to a neurologist immediately, but this will obviously take away the challenge.

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    Source: Differential Diagnosis in Primary Care, 2007

    FLANK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of flank pain usually involves careful examination of the urine and a urine culture, an IVP, and plain films of the abdomen and spine. If these are negative, bone scans, arteriogram, and other tests listed below may be required. CT has eliminated the need for exploratory laparotomy in many cases.

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    Source: Differential Diagnosis in Primary Care, 2007

    GROIN PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In the approach to the diagnosis of groin pain, a mass or tender structure is usually present in the groin. If the mass is a lymph node, careful examination of the genitalia and lower extremities will often show the cause, but a urethral or vaginal smear and culture may be necessary to show gonorrhea. Investigation of the genitourinary (GU) tract and the GI tract for causes of referred pain is then undertaken, if the mass is reducible a hernia is likely and referral to a surgeon is in order. Incarcerated hernias, of course, demand immediate referral.

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    Source: Differential Diagnosis in Primary Care, 2007

    HAND AND FINGER PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

    1. Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
    2. Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
    3. Causalgia by stellate ganglion block to see if pain is relieved
    4. Cervical spine disease by a roentgenogram, possibly a myelogram or MRI, and nerve blocks of the various roots. Referral to a neurologist is often necessary. In early rheumatoid arthritis, the joints may be normal on inspection but pain and stiffness of the hands and fingers in the morning is an excellent clue.

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    Source: Differential Diagnosis in Primary Care, 2007

    HIP PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The history and physical examination will allow differentiation of many of the conditions listed above. For example, the history of trauma suggests sprain, fracture, or contusion. Remember fractures of the hip can occur in the elderly without a history of trauma. A positive straight leg raising (SLR) test suggests a herniated disc or other cauda equina pathology. X-ray of hip and lumbosacral spine will help rule out fracture or osteoarthritis but CT scan, bone scan, or an MRI may be necessary. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic.

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    Source: Differential Diagnosis in Primary Care, 2007

    LEFT LOWER QUADRANT PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    There is no doubt about the value of a good history and physical examination, including both the rectal and pelvic areas. After this, the signs and symptoms should be summarized and grouped together; in many cases, this will pinpoint the diagnosis.

    The laboratory workup can now proceed. In acute cases, the physician should order a flat plate of the abdomen, CBC, urinalysis (and examine it him- or herself), and serum amylase level before exploratory surgery. A pregnancy test is ordered in women of childbearing age. In chronic cases, sigmoidoscopy, barium enema, upper GI series, small-bowel follow-through, and stool for blood, ova, and parasites need to be done before culdoscopy, peritoneoscopy, or colonoscopy is contemplated. An exploratory laparotomy remains a useful diagnostic tool even in chronic cases of LLQ pain.

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    Source: Differential Diagnosis in Primary Care, 2007

    Breast pain [Mastalgia]: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it's intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a nursing mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced flulike symptoms or sustained injury to the breast? Has she noticed a change in breast shape or contour?

    Ask the patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

    Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?

    Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient's arms raised above her head and then with her hands pressed against her hips.

    Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Common causes and associated findings.)

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

    Abdominal pain: History and physical examination

    (Handbook of Signs & Symptoms (Third Edition))

    If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.

    If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

    Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

    Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last period, changes in her menstrual pattern, or dyspareunia.

    Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

    Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

    Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Common causes and associated findings, pages 14 to 17.)

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

    Arm pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

    If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Also ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

    Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

    If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

    If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

    Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Common causes and associated findings.)

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

    Back pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs.

    Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜" (1 cm) in muscle size, especially in the calf.

    To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

    Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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

    Chest pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

    Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.

    Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Common causes and associated findings, pages 136 and 137.)

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

    Eye pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

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

    Flank pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

    Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

    During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

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

    Jaw pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin the patient history by asking him to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

    Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, a headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders such as chest pain in a patient with an MI.)

    Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛" (3 cm) or more than 2⅜"  (6 cm) between the upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

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

    Leg pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

    Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he’s taking and whether they have helped to relieve his leg pain.

    Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient’s range of motion (ROM) in the hip and knee. Also, check reflexes with the patient’s leg straightened and raised, noting action that causes pain. Then compare both legs for symmetry, movement, and active ROM. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit associated pain.

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

    Neck pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

    Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Common causes and associated findings, pages 432 and 433.)

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

    Rectal pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient reports rectal pain, inspect the area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.

    After the examination, proceed with your evaluation by taking the patient’s history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

    Make sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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

    Throat pain: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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

    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.)

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

    Osteoarthritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    A thorough physical examination confirms typical symptoms, and absence of systemic symptoms rules out an inflammatory joint disorder. X-rays of the affected joint help confirm diagnosis of osteoarthritis but may be normal in the early stages. X-rays may require many views and typically show:

    ❑ narrowing of joint space or margin

    ❑ cystlike bony deposits in joint space and margins and sclerosis of the subchondral space

    ❑ joint deformity due to degeneration or articular damage

    ❑ bony growths at weight-bearing areas

    ❑ fusion of joints. (See Digital joint deformities, page 591.)

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Septic arthritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    CONFIRMING DIAGNOSIS Identifying the causative organism in a Gram stain or culture of synovial fluid or a biopsy of synovial membrane confirms septic arthritis. When synovial fluid culture is negative, positive blood culture may confirm the diagnosis.

    Joint fluid analysis shows gross pus or watery, cloudy fluid of decreased viscosity, usually with 50,000/µl or more white cells, primarily neutrophils. Synovial fluid glucose is usually more than 40 mg/dl. (See Other types of arthritis, page 584.)

    Other diagnostic measures include the following:

    ❑ X-rays can show typical changes as early as 1 week after initial infection — distention of joint capsules, for example, followed by narrowing of joint space (indicating cartilage damage) and erosions of bone (joint destruction).

    ❑ White blood cell count may be elevated, with many polymorphonuclear cells; erythrocyte sedimentation rate is increased.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Neurogenic arthropathy: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Patient history of painless joint deformity and underlying primary disease suggests neurogenic arthropathy. Physical examination may reveal bone fragmentation in advanced disease. X-rays confirm diagnosis and assess severity of joint damage. In the early stage of the disease, soft-tissue swelling or effusion may be the only overt effect; in the advanced stage, articular fracture, subluxation, erosion of articular cartilage, periosteal new bone formation, and excessive growth of marginal loose bodies (osteophytosis) or resorption may be seen. Computed tomography scan helps define the extent of disease.

    Other diagnostic measures include:

    ❑ vertebral examination: narrowing of disk spaces, deterioration of vertebrae, and osteophyte formation, leading to ankylosis and deforming kyphoscoliosis

    ❑ synovial biopsy: bony fragments and bits of calcified cartilage.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Juvenile rheumatoid arthritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Persistent joint pain and the rash and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA. Disease activity and response to therapy can also be monitored through laboratory results.

    ❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.

    ❑ Erythrocyte sedimentation rate and C-reactive protein, haptoglobin, immunoglobulin, and C3 complement levels may be elevated.

    ❑ ANA test may be positive in patients who have pauciarticular JRA with chronic iridocyclitis.

    ❑ RF is present in 15% of JRA cases, compared with 85% of rheumatoid arthritis cases.

    ❑ Positive HLA-B27 antigens may forecast later development of ankylosing spondylitis.

    ❑ X-rays in early stages reveal changes, including soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Psoriatic arthritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis.

    CONFIRMING DIAGNOSIS X-rays confirm joint involvement and show:

    ❑ erosion of terminal phalangeal tufts

    ❑ “whittling” of the distal end of the terminal phalanges

    ❑ “pencil-in-cup” deformity of the distal interphalangeal joints

    ❑ relative absence of osteoporosis

    ❑ sacroiliitis

    ❑ atypical spondylitis with syndesmophyte formation. Hyperostosis and paravertebral ossification result, which may lead to vertebral fusion.

    Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Rheumatoid arthritis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Typical clinical features suggest this disorder, but a definitive diagnosis is based on laboratory and other test results:

    ❑ X-rays — in early stages, show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; finally, cartilage and bone destruction and erosion, subluxations, and deformities

    ❑ rheumatoid factor test — positive in 75% to 80% of patients as indicated by a titer of 1:160 or higher

    ❑ synovial fluid analysis — reveals increased volume and turbidity but decreased viscosity and complement (C3 and C4) levels; white blood cell count usually exceeds 10,000/µl

    ❑ erythrocyte sedimentation rate — elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation commonly parallels disease activity)

    ❑ complete blood count — usually reveals moderate anemia and slight leukocytosis.

    A C-reactive protein test can help monitor response to therapy.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Complex regional pain syndrome: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    There’s no laboratory test for CRPS, so the diagnosis is based on the patient’s history and clinical findings. A history of injury to an extremity may point to CRPS. Bone X-rays may aid in ruling out other conditions, such as osteomyelitis and stress fractures, which cause similar signs and symptoms. Additional tests may include bone scans, nerve conduction studies, and thermography (a test to show temperature changes and lack of blood supply in the painful area of the affected limb). With early diagnosis, prognosis improves.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Pain disorder: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    For characteristic findings in patients with this condition, see Diagnosing pain disorder, page 476.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Breast pain [Mastalgia]: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it’s intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a breast-feeding mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced any flulike symptoms or sustained an injury to the breast? Has she noticed any change in breast shape or contour?

    Ask your patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

    Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?

    Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient’s arms raised above her head and then with her hands pressed against her hips.

    Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Causes and associated findings, page 134.)

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

    Eye pain [Ophthalmalgia]: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient’s eye pain doesn’t result from a chemical burn or from acute angle-closure glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of severe pain that developed suddenly. Does he have headaches? If so, find out how often and at what time of day they occur.

    During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the eyelids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 322.)

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

    Abdominal pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.

    If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

    Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

    Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.

    Also ask about appetite changes and the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

    Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

    Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Causes and associated findings, pages 16 to 21.)

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

    Arm pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

    If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right-upper-quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts any movements. Also ask if heat, rest, or drugs relieve it. Finally, ask about any preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

    Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

    If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

    If the patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

    Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Causes and associate findings.)

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

    Back pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient’s expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescription and over-the-counter drugs.

    Next, perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient’s posture if pain doesn’t prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜” (1 cm) in muscle size, especially in the calf.

    To reproduce leg and back pain, place the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

    Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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

    Chest pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

    Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.

    Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated findings, pages 164 to 167.)

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

    Facial pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by characterizing the patient’s facial pain. Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or worsens it? Ask the patient to point to the painful area. If facial pain is recurrent, have him describe a typical episode. Review his medical and dental history, noting especially previous head trauma, dental disease, and infection.

    Carefully examine the face and head. Inspect the ear for vesicles and changes in the tympanic membrane to rule out referred ear pain. Inspect the nose for deformity or asymmetry. Evaluate the condition of the mucous membranes and septum as well as the size and shape of the turbinates. Characterize any secretions. Palpate the frontal, ethmoid, and maxillary sinuses for tenderness and swelling.

    Evaluate oral hygiene by inspecting the teeth for caries, percussing any diseased teeth for pain, and asking the patient about any sensitivity to hot, cold, or sweet liquids or foods. Have him open and close his mouth as you palpate the temporomandibular joint for tenderness, spasm, locking, and crepitus.

    Examine the function of cranial nerves V and VII. To evaluate cranial nerve V, instruct the patient to clench his teeth. Then palpate the temporal and masseter muscles and evaluate muscle contraction. Test pain and sensation on his forehead, cheeks, and jaw. Next, test the corneal reflex by lightly touching the cornea with a piece of cotton.

    To evaluate cranial nerve VII, inspect the face for symmetry and then have the patient perform facial movements that demonstrate facial muscle strength—raising his eyebrows, frowning, showing his teeth, closing his eyes tightly, and wrinkling his nose. (See Major nerve pathways of the face.)

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

    Flank pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

    Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

    During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

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

    Jaw pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

    Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)

    Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛” (3 cm) or more than 2⅜” (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

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

    Leg Pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

    Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask what medications he’s taking and whether they have helped to relieve his leg pain.

    Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient’s range of motion in the hip and knee. Also, check reflexes with the patient’s leg straightened and raised, noting any action that causes pain. Then compare both legs for symmetry, movement, and active range of motion. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit any associated pain.

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

    Neck pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

    Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there is not a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings, pages 548 to 551.)

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

    Rectal pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If your patient reports rectal pain, inspect the area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Check for inflammation and other lesions. A rectal examination may be necessary.

    After examination, proceed with your evaluation by taking the patient’s history. Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

    Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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

    Throat pain: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate; if exudate is present, obtain a specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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    Source: Professional Guide to Signs & Symptoms (Fifth 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.)

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

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

    After ruling out pregnancy or the use of phenytoin or similar prescription drugs as the cause of gum swelling, take a history. Have the patient fully describe the swelling. Has he had it before? Is it localized or generalized? Find out when the swelling began, and ask about any aggravating or alleviating factors. Is the swelling painful? Then explore the patient’s medical history, focusing on major illnesses, bleeding disorders, and pregnancies. Also check his dental history. Does he wear dentures? If so, are they new? Ask about use of alcohol and tobacco, which are gum irritants. Then have the patient describe his diet to evaluate nutritional status. Ask about his intake of citrus fruits and vegetables.

    Next, inspect the patient’s mouth in a good light. If he wears dentures, ask him to remove them before you begin. As you examine the gums, characterize their color and texture, and note any ulcers, lesions, masses, lumps, or debris-filled pockets around the teeth. Then inspect the teeth for discoloration, obvious decay, and looseness.

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

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

     A. Demographics. The patient’s age is sometimes helpful in determining the cause of arthralgia. Systemic lupus erythematosus (SLE) commonly presents between the second and fourth decades of life. Rheumatoid arthritis (RA) is more common between the fourth and sixth decades; osteoarthritis (OA) peaks in the seventh and eighth decades. Infectious causes, as well as trauma, have no particular age association. Younger, female patients are more likely to have RA or SLE, whereas postmenopausal women are affected by gout and OA of the knee and hand. Male patients more likely have gout, ankylosing spondylitis, and OA of the hip. Race is helpful in some disorders: SLE is more common in African-Americans.

     B. Affected joints. The new onset of monarticular symptoms can be seen in trauma, infection, crystal-induced disease, periarticular problems, and degenerative and inflammatory arthritic processes. Early OA can present in one joint, most commonly the knee, or in any joint damaged by antecedent trauma. Recurrent pain in one joint can indicate OA flare, gout or pseudogout attack, SLE, sarcoidosis, or a periarticular problem. Gout presents in the first metatarsal phalangeal joint in 50% of cases (Chapter 12.6).

    Multiple joint involvement, especially with other associated symptoms, is characteristic of a systemic process. Symmetric involvement of the metacarpal-phalangeal, proximal interphalangeal joints (PIPs), wrist, and feet is more common in RA; involvement of the knees or hips is unusual (1). OA favors the PIPs, distal interphalangeal, carpal-metacarpal joint of the thumb, hips, knees, ankles, feet, and spinal column (1), but involvement is not necessarily symmetric. Erosive OA can affect multiple joints of the hands. SLE often affects the hand and wrists.

     C. Pain characteristics. Additional history includes the exact location of the pain (around vs. inside the joint), the time course (episodic or intermittent vs. constant pain), and the presence and onset of joint swelling or warmth. Joints that are stiff in the morning and hurt at rest are seen in RA. RA pain waxes and wanes throughout the day and night, and is unrelated to activity. OA pain is associated with use and improves with rest.

    D. Family history. RA, SLE, gout, ankylosing spondylitis, and OA of the fingers all have a familial component. SLE is also found in families with other autoimmune diseases.

     E. Lifestyle factors. Dietary history is important in gout, as a diet high in purine foods (liver, sweetbreads, kidneys, red meat, sardines, and anchovies) can precipitate an attack in susceptible individuals. Certain underlying diseases, sexual practices, alcoholism, and intravenous drug use are risk factors for septic arthritis.

     F. Associated symptoms. Other complaints are often helpful in narrowing the differential diagnosis. Fatigue that does not improve with rest can be seen in RA, SLE, and infectious arthralgia. Rash can be seen in arthralgia resulting from a variety of infectious and inflammatory causes. Urticaria is common in the acute serum sickness syndrome. A history of a tick bite or targetlike rash may indicate arthritis from Lyme disease. Vaginal discharge, pelvic pain, or urethritis symptoms or discharge should raise the possibility of an infectious cause or Reiter’s disease. Fever is likely with infectious, and some inflammatory, causes of arthralgia.

     G. Past medical history. Other known medical illnesses are also important as they may be associated with inflammatory or degenerative causes of arthralgia (Table 12.1). Childhood joint disease predisposes to early onset degenerative disease.

    New medications, including diuretics, chemotherapeutic agents, antituberculosis drugs, and low-dose aspirin, can precipitate gout. Other medications and vaccination reactions can cause polyarticular arthralgias.

    Physical examination

    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).

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

    Chest Pain, Atypical: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Characteristics of the chest pain. Important questions to ask: What is the quality of pain? Where is it located? What is its duration and intensity? What symptoms accompany the pain? Does anything trigger the chest pain or make the pain better or worse? Is there any relationship between exertion and the pain?

     B. Determining the likelihood of ischemic heart disease. Four major features in the initial history and physical examination can be used to determine the likelihood of IHD. They are in order of importance:

     1. Angina description (definite angina, probable angina, probably not angina, and not angina).

     2. Prior myocardial infarction [by history, or electrocardiographic (EKG) findings].

    3. Age (risk of IHD increases with age).

    4. Number of risk factors (e.g., diabetes, smoking, hypercholesterolemia, and hypertension).

     C. Features suggesting nonanginal pain. Features suggesting nonanginal pain include pleuritic pain (sharp or knifelike pain brought on by respiratory movements or cough), pain localized with one finger, pain reproduced by movement or palpation of the chest wall or arms, constant pain lasting for days, and very brief episodes of pain lasting a few seconds (1).

     D. Other key considerations. Key considerations in the history include the following:

    1. All presentations of chest pain should be taken seriously until proven to be benign.

    2. The description of pain can be greatly influenced by socioeconomic status, education, culture, and personality.

    3. A review of cardiac risk factors is appropriate for all patients who present with chest pain.

    4. Red flags suggesting a noncardiac, life-threatening condition include tachypnea, dyspnea, and hypoxemia.

    5. Sharp, stabbing, or pleuritic qualities do not completely exclude an ischemic cause (Chapter 8.5). In the Multicenter Chest Pain Study, IHD was diagnosed in 22% of patients coming to the emergency room with a sharp quality pain (2).

    Physical examination

    No reliable physical signs can be used to determine whether a patient with atypical chest pain has ischemic heart disease. The main purpose of the examination is to assess the patient for evidence of complications from atherosclerotic disease (e.g., peripheral vascular disease, cerebrovascular disease, and congestive heart failure). Pay attention to findings on the vascular examination (e.g., peripheral artery bruits, retinal arteriolar changes, the presence of a cardiac gallop) and for signs of the consequences of diminished myocardial contractility (e.g., lower extremity edema or pulmonary crackles) (Chapter 7.5).

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

    Chest Pain, Substernal: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Characteristics of pain in stable angina

     1. Quality. The pain of angina pectoris is often not described as a pain at all. Instead, it is frequently referred to as a squeezing, heaviness, or pressure sensation lasting 5 to 10 minutes. Diaphoresis, dyspnea, nausea, and vomiting often accompany the discomfort. Pain that is sharp, stabbing (especially if exacerbated by deep inspiration), pain reproducible with chest wall palpation, and pain lasting seconds or days to weeks is less likely to be from CAD.

     2. Location. Generally, angina is poorly localized in the retrosternal area, anterior chest, or epigastrium and typically radiates to the left arm, neck, or jaw.

     3. Precipitating and alleviating factors. Angina is often precipitated by conditions that increase myocardial oxygen demand, most commonly physical exertion, emotional stress, or cold weather. It is relieved promptly with rest or sublingual nitroglycerin.

     B. Characteristics of pain in unstable angina. According to the clinical practice guidelines recently developed by the Agency for Health Care Policy (1), unstable angina is defined as:

    1. Angina at rest lasting greater than 20 minutes.

     2. New onset angina (< 2 months) precipitated by walking one to two blocks or by climbing one flight of stairs at a normal pace.

     3. Angina that is more frequent, longer in duration, or occurring at a lower threshold.

    C. Risk factors. The Framingham Heart Study along with numerous other large epidemiologic studies has established the following risk factors for   CAD (2):

    1. Sex and age: men aged 45 years or older; women aged 55 years or older; women with premature menopause without hormone replacement.

    2. Family history: MI or sudden death occurring in a first-degree male relative aged 55 years or younger or in a first-degree female relative aged 65 years or younger.

    3. Smoking: in men who smoke one pack per day, a three- to fivefold risk for CAD compared with nonsmokers. Those who quit smoking can reach the same risk level of nonsmokers within 2 years of stopping.

    4. Hypertension: blood pressure greater or equal to 140/90 (Chapter 7.8).

    5. Cholesterol: total cholesterol greater than 200; low-density lipoprotein (LDL) greater than 130; high-density lipoprotein (HDL) less than 35. An HDL level above 60 is protective.

    6. Diabetes mellitus: a twofold increase in CAD, compared with nondiabetics (Chapter 14.1).

    Physical examination

     A. Focused physical examination. This should include vital signs (notably blood pressure). During a symptomatic episode, the finding of a mitral regurgitation murmur, S3 or S4 gallop, bruits or precordial lift all suggest a high likelihood of CAD. Findings of xanthelasma, tendinous xanthomata, tobacco-stained teeth and fingernails, and decreased or asymmetrical peripheral pulses indicate the likely presence of cardiac risk factors. >

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

    Low Back Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

     The history should include evaluation for “red flag” conditions.

    A. Pain characteristics. Assess the nature of the pain, along with the onset and duration of the symptom. Is there any radiating pain, leg weakness, or paresthesia? Pseudoclaudication is suggestive of spinal stenosis. Pain radiating below the knee is more likely to be a true radiculopathy (1). Nerve root compression is highly unlikely without sciatic pain (1). Was the onset after a traumatic event? A seemingly insignificant episode (e.g., a minor fall) may be a “red flag” for fracture in an elderly patient. Are there alleviating or exacerbating factors? Does the pain limit the patient physically or socially? Is there a history of previous back problems or back surgery?

    B. Review of systems. Look for associated symptoms that can indicate a “red flag” condition or an underlying medical cause. Gastrointestinal and genitourinary symptoms are particularly important, especially incontinence (Chapter 10.10).

     C. Psychosocial information. Has the patient initiated any new activities? If work-related, assess typical job tasks. Investigate whether the back pain could have any relationship, sexual, or mood implications. Sexual activity can be severely affected simply because of pain, but sexual dysfunction can also result from neurologic abnormalities associated with the cause of the back pain. Back pain is associated with depression and poor sleep patterns. Drug-seeking behavior may be exhibited along with a complaint of back pain. Addiction may have resulted from former or on-going treatment of the pain. Legal issues can complicate the diagnosis and treatment of back pain. Ask the patient whether litigation involving the back pain is under consideration.

    Physical examination

    Evaluation should be both general and specific. It is prudent to leave the potentially most painful parts of the examination to the end.

     A. General. Examination includes auscultation of the heart and assessment of peripheral pulses and blood pressure. Abdominal examination should focus on possible causes of back pain (Table 12.5). Assess gait.

     B. Neurologic. The lower extremity examination includes motor strength, deep tendon reflexes, sensation, proprioception, and certain functional maneuvers (Table 12.6). Romberg and Babinski reflexes should also be assessed. Rectal examination should assess sphincter tone, which can be compromised in sacral root dysfunction. In the primary care setting, most clinically significant disc herniations will be detected by the following limited examination: dorsiflexion of the great toe and ankle, Achilles reflex, light touch sensation of the medial (L 4), dorsal (L5), and lateral (S1) aspect of the foot, and the straight leg raise (SLR) test (1).

     C. Musculoskeletal. Assess range of motion of the spine and lower extremities. Perform the SLR test passively with the patient supine. Note the angle of leg elevation precipitating pain. A positive test for sciatica is buttock pain radiating to the posterior thigh, and perhaps to the lower leg and foot. Sciatica, with pain and resistance on internal rotation of the hip, can indicate piriformis muscle spasm or strain. The SLR test is usually negative in spinal stenosis (2). Percussion of the spine and upper pelvis helps to identify areas of localized tenderness, as in fracture, metastatic disease, and some rheumatologic conditions. Palpate standard trigger points looking for fibromyalgia. Check for paraspinal muscle spasm. Measure thigh and calf circumferences to look for muscular atrophy.

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

    Abdominal Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. History of present illness. Medication use, alcohol and tobacco history, and menstrual history in women are vital. When did the pain begin and what are the characteristics of the pain? Use the “OPQRST” approach outlined below to question the patient about pain characteristics.

     1. O: Onset of pain. Pain of sudden onset or that awakens a patient from sleep can represent appendicitis, leaking abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, or perforating ulcer. Gradual onset of pain can represent cholecystitis, diverticulitis, inflammatory bowel disorders, or pancreatitis. Longstanding pain without debility that is worsened by emotional stress is suggestive of irritable bowel syndrome.

     2. P: Palliative or Provocative factors (diet, exercise, sleep, bowel movement, and so on).

    3. Q: Quality of pain—pain descriptors are often associated with specific causes:

    a. “Burning” pain—ulcer

    b. “Agony”—pancreatitis

    c. “Shearing” or “tearing”—abdominal aortic aneurysm

    d. “Colicky” or “cramping”—cholecystitis, bowel obstruction, urolithiasis, irritable bowel syndrome

    e. “Constant ache”—appendicitis, peritonitis, herpes zoster

    4. R: Radiation or Referred—pain from appendicitis, simple colic, and bowel obstruction from strangulation or volvulus is often first felt in the epigastrium. Abdominal causes may result in referred or radiating pain to extraabdominal sites:

    a. Abdominal aortic aneurysm—to the midback

    b. Biliary colic—to the right scapula

    c. Renal colic—to the costovertebral angles, testicle, or thigh

    d. Hernias—to the genitalia

    5. Extraabdominal pathology can cause referred pain to the abdomen.

    a. Cardiac ischemia—to the epigastrium

    b. Scrotal pathology—to the abdomen

    6. S: Severity—level of intensity (some use a 1–10 scale)

     7. T: Time or Temporal relationships—with meals, after bowel movement, menses, and so on

     B. Past medical history. Is there a history of previous abdominal or pelvic surgery? Prior abdominal surgery increases the risk for bowel incarceration, obstruction, and strangulation. Fallopian tube surgery and prior pelvic inflammatory disease (PID) increase a woman’s risk for ectopic pregnancy (Chapter 11.3).

    C. Review of systems. Are there associated symptoms that point to a specific etiology? Chills and fever suggest infectious causes (UTI, PID, prostatitis, and pneumonia). Emesis occurring before the onset of pain is associated with appendicitis; with the onset of pain, cholecystitis or urolithiasis; after onset of pain, gastroenteritis. Late onset or feculent emesis suggests bowel obstruction; bilious emesis occurs in cholecystitis. Postprandial right upper quadrant pain is common in cholecystitis. Diarrhea with a recent travel history suggests dysentery or parasitic infections. Genitourinary complaints (dysuria, frequency, hematuria, vaginal discharge, and dypareunia) should prompt evaluation for UTI, sexually transmitted disease, and PID.

    Physical examination

    A thorough, targeted physical examination, directed by a complete history, leads to a correct diagnosis in most cases (2).

    Complete vital signs are essential. Tachycardia or hypotension can indicate hypovolemia and the need for urgent intervention (Chapter 7.12). Rapid, shallow breaths occur with peritoneal irritation. Inspect the abdomen for distention (obstruction), pulsations (AAA), or scars from past surgery. High-pitched hyperactive bowel sounds occur with bowel obstruction. Palpation and percussion help localize tenderness, organomegaly, and masses. Pain with movement, rebound tenderness, or rigidity are indicative of peritonitis and should prompt surgical consultation.

    Cardiovascular, pulmonary, and digital rectal and genitourinary examinations should be included in all evaluations of significant abdominal pain. The pelvic examination must be done to exclude ectopic pregnancy and PID. Among patients in whom pregnancy is a possibility, the presence of peritoneal signs, cervical motion tenderness, or lateral (or bilateral) abdominal or pelvic tenderness should raise concern about possible ectopic pregnancy (3).

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

    Calf Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Pain characteristics. What is the pattern of onset, quality, location, duration, and intensity of the pain? What, if anything, helps relieve the pain? A report of a sensation of being “clubbed in the back of the leg” or “shot in the calf,” along with an audible pop or snap sound, suggests an acute Achilles tendon rupture (ATR) (1). Cramping calf pain may indicate a metabolic disturbance or a denervating disease. Numbness and burning pain or an electric-shock sensation, may indicate a neurological process. A “creeping and crawling” sensation deep within the muscles of the legs and thighs that is somewhat relieved with movement of the extremity is suggestive of restless leg syndrome (RLS).

     B. Preceding events. Was the pain preceded by any specific activity or trauma? Any recent prolonged inactivity? Unilateral calf pain after a period of immobility, especially in the presence of risk factors (e.g., lower extremity venous disease, oral contraceptive use), is DVT until proved otherwise. If the patient presents with a history of direct trauma to the calf, a compartment syndrome or intramuscular hematoma should be suspected. Pain occurring at night and disrupting sleep is suggestive of RLS or arterial disease.

     C. Associated symptoms. Coexisting symptoms can help to differentiate the cause of the pain. Any fever or back or knee pain should be noted. Ask about leg swelling, bruising, weakness, tingling, or other changes in sensation.

    D. Pertinent medical history. Does the patient smoke? Is there a history of any form of arthritis, or a Baker’s cyst? Any recent hip, knee, gynecologic, or lower abdominal surgery? Is the patient pregnant or postpartum? Pertinent medical illnesses include peripheral vascular disease, varicosities, malignancy, hematologic disorders, and diabetes. Acquired immune deficiency syndrome has been associated with a syndrome of calf pain, swelling, and tenderness along with cutaneous hyperesthesia to light touch. The syndrome is believed to be caused by hyperalgesic thrombophlebitis (2).

    E. Family history. A family history of DVT or inherited causes of hypercoagulability increase the risk for DVT (3).

    Physical examination (PE)

     A. Initial PE. Is the patient febrile? Inspect the patient’s back and check the curvature of the spine. Examine both legs from the groin and buttocks down for size, symmetry, skin color, pigmentation, hair distribution, and venous pattern. Note any skin lesions. Palpate lower extremity pulses and check for edema. Assess capillary refill. Note the temperature of the leg, especially over the area of pain. Palpate the calf for localized tenderness or a cord, which can indicate a superficial or deep thrombophlebitis. Feel for any increased firmness of the calf muscles. Palpate for masses, swelling, or tenderness in the lower back and entire leg. Check the mobility and flexibility of the spine and note if movement provokes any distal pain or weakness. Examine the knee and ankle joints on the affected side. Assess joint range of motion (ROM) and muscle strength. Check lower extremity reflexes and perform a good peripheral sensory examination.

     B. Additional PE. If evaluation suggests arterial insufficiency, assess for postural color changes by elevating the patient’s leg 60°. If ATR is suspected, perform a Thompson test. With the patient prone, squeeze the calf muscle just distal to its maximal girth. Plantar flexion of the foot is the normal result, indicating an intact Achilles tendon. A positive Homan or Lowenberg sign is suggestive of DVT. However, these signs are neither sensitive or specific for the diagnosis (4,5).

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

    Chronic Pelvic Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

     As with any pain, the onset, duration, and pattern of the pain must be assessed. The location, intensity, character, and radiation are important historical elements. Aggravating or relieving factors are important, especially as they relate to the urinary, musculoskeletal, or gastrointestinal systems as well as the relationship of pain to sexual activity or menstruation. Systemic symptoms such as fatigue and anorexia are often present. A medication history (e.g., use of birth control pills or over-the-counter medications) should be obtained. The past obstetric, gynecologic, and general surgical histories are extremely important.

    It should be noted that women with a history of pelvic inflammatory disease are four times more likely to develop chronic pelvic pain. The list of possibilities for the condition is substantial. A person with intestinal, sexual, urinary, musculoskeletal, and systemic symptoms may be suffering from a psychiatric disorder (e.g., depression) and an acknowledged or remote history of sexual abuse. Often this information is possible to obtain only when the provider creates an atmosphere of mutual respect and trust.

    Dyspareunia is often present. Cyclic pain that is related to menstruation usually points to a gynecologic problem. Pain referred to the anterior thigh, pain associated with irregular uterine bleeding, or new onset dysmenorrhea may have a uterine or ovarian cause. Urethral tenderness, dysuria, or bladder pain suggests interstial cystitis or a urethral problem (Chapter 10.1). Pain on defecation, melana, bloody stools, or abdominal pain with alternating diarrhea and constipation can point toward pelvic floor problems, irritable bowel syndrome, or inflammatory bowel diseases.

    Physical examination

     A. The general condition of the patient should be noted. Does the patient look chronically ill, which may suggest a pelvic lesion or an inflammatory bowel disorder? Does the patient appear anxious, stressed, or inappropriate?

     1. Can the patient point to the pain with one finger? If so, this can indicate that the pain may have a discrete source.

    2. An examination of the lower back, sacral area, and coccyx, including a neuologic examination of the lower extremities, is necessary. Herniated disc, exaggerated lumbar lordosis, and spondylolisthesis can all cause pelvic pain.

     3. Examine the abdomen, looking for surgical scars, distension, and palpable tenderness, particularly in the epigastrium, flank, back, or bladder.

     B. A thorough pelvic examination is the most important part of the evaluation.

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

    Hip Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Pain characteristics. What is the exact location of the pain? Pain arising from the lumbar spine is perceived in the buttock and, less commonly, in the groin and anterior thigh. This must be differentiated from radicular pain arising from the spine. True hip pain more often localizes to the anterior midgroin or midthigh area. Lateral hip or thigh pain most likely represents trochanteric bursitis (1). How is the pain described? A “snapping” type discomfort is most commonly caused by iliotibial band syndrome. Constant pain can indicate infection or cancer.

    B. Involved joints. Hip osteoarthritis (OA) can have a monarticular onset, or other joints may be involved. Of hip OA patients, 20% will develop bilateral involvement.

    C. Precipitating factors. Has there been a recent fall or other trauma? In an elderly or an osteoporotic patient, hip fracture can occur after a very minor incident. A contusion over the greater trochanter can lead to persistent bursitis; a contusion over the iliac crest, to a tear of the muscle aponeurosis. Has there been any preceding athletic or overuse activity that could cause muscle strain? Ischial bursitis usually develops after prolonged sitting.

    D. Other symptoms. Bacterial involvement of the hip joint can be accompanied by fever and shaking chills (2). Other symptoms may be present in cancer, pelvic, intraabdominal, or retroperitoneal pathology. Sciatica commonly accompanies trochanteric bursitis.

     E. Past medical history. Any prior hip problems or hip surgery? A patient with a hip replacement may develop loosening of prosthetic components, which can be a source of pain, or can seed the joint during a recent infection or invasive procedure. Aseptic necrosis of the femoral head is more likely in patients with sickle cell disease. Previous occult hip fracture or delayed treatment, can also lead to aseptic necrosis. Patients receiving long-term steroids may manifest constant hip pain. Congenital or developmental defects are found in 80% of patients with hip OA.

    Physical examination

     A. General. If referred pain is suspected, evaluate the appropriate organ system. Palpate the groin and thigh for hernias, lymph nodes, and vascular cords. Assess gait. An unwillingness to bear weight suggests fracture, even with a negative preliminary x-ray finding. Check the neurovascular status of the distal extremity after any traumatic episode.

     B. Musculoskeletal. Observe the involved extremity. In femoral neck fractures, the involved leg may appear slightly shortened and externally rotated. Intertrochanteric fractures can cause the involved leg to be internally rotated and shortened. Evaluate the spine, including the straight leg raise test, if spinal pathology is being considered. Compression of the patient’s pelvis with the patient side lying may localize pain to the sacroiliac joint. Check for leg length discrepancy by measuring each extremity from the anterior superior iliac spine (ASIS) to the medial malleolus; for hip joint shortening, measure from the ASIS to the greater trochanter.

    Palpate the greater trochanter, ischial tuberosity, and surrounding muscle groups for tenderness. The hip joint is not easily palpated; palpable warmth is produced only when intensely inflamed. Document joint range of motion. Nondisplaced or impacted fractures may not be painful, except at extremes of motion. Pain in all directions suggests intraarticular disease. Pain arising from the hip is typically elicited at the extreme ranges of motion, as well as with motion against resistance. With the patient supine, bend the uninvolved leg at the knee and hip and bring it toward the chest. Watch the opposite hip for flexion (Thomas test), indicating a flexion contracture of that hip. Loss of internal rotation occurs early in OA, followed by the loss of extension, adduction, and flexion. Pain and an inability to fully abduct or extend the hip can also be seen in rheumatoid arthritis (RA). Trochanteric bursitis may present with pain on external rotation only. Muscle strain (e.g., a “groin pull”) will produce pain on passive stretch or resisted contraction of the involved muscles only. In iliotibial band syndrome, the “snapping” of the band may be audible and palpable as the hip is flexed and extended. Document any muscle weakness or muscle atrophy.

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

    Knee Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Age and etiology. The patient’s age is an important factor in determining the likelihood of certain knee problems. Because of stronger ligaments, avulsion fracture (anterior intercondylar eminence of the tibia, tibia tubercle) is more common in younger age groups, whereas ligamentous rupture occurs in older persons. Patellar dislocations and apophysitis are more likely in growing adolescents.

     B. Trauma. Understanding the mechanism of injury and estimating the acceleration or deceleration and torsional forces across the knee joint, predict the likelihood of occult fractures and internal derangement. Patients describing a popping sensation during a rotational or twisting injury, followed by an immediate swelling, usually have internal derangement of either meniscal or ligamentous components, or both. Locking of the knee suggests a “bucklehandle” meniscal tear obstructing normal hingejoint activity of the femoraltibial joint.

     C. Alleviating or exacerbating factors. Patellofemoral syndrome (PFS) or chrondromalacia patella is associated with anterior knee pain that worsens going up or down stairs or with prolonged sitting. Morning stiffness that improves with mild activity, but worsens as the day progresses, is typical of degenerative arthritis (osteoarthritis). The stiffness of rheumatoid arthritis (RA) generally does not improve with activity. Patients with multiple joint pains should be questioned about fever or skin rash to rule out infectious or inflammatory joint disease.

    Physical examination

    Both knees, as well as the hip, ankle, and foot on the affected side, should be examined. The knees are inspected for symmetry, signs of quadriceps or calf wasting, and any obvious swellings, discoloration, or pallor. Thigh, knee, calf circumference, and leg length are measured to document any asymmetry. Measurement of the quadriceps or Q angle (normal <15°) is important to evaluate anterior knee pain. Inability to perform full knee flexion and extension will highlight any effusion. Neurovascular supply should also be evaluated.

    In nonacute circumstances, the suprapatellar bursa is milked to determine if effusion is present. The patellar apprehension test may detect patellar dislocation; the patellar grind test is used to detect PFS. Evaluation of patellofemoral tracking within the femoral groove also helps make the latter diagnosis as the patella will track laterally in PFS, leading to the characteristic “jockey cap” patella. The knee should be carefully palpated for tenderness of the patellotibial insertion (Osgood-Schlatter’s disease), the body of the infrapatellar tendon (tendinitis), the insertion of the tendon on the patella (Sinding-Larsen-Johannson disease), medial and lateral joint line (potential meniscal pathology), pes anserine bursa (bursitis), or iliotibial band insertion. Plica, a painful, thickened band of exuberant synovium, can also be diagnosed by palpitation of the medial and lateral joint lines.

    Ligamentous testing is done next. Test the posterior cruciate ligament through the posterior drawer sign. Use the Lachman test for the anterior cruciate ligament, or, in obese patients, the anterior drawer sign. The medial collateral ligament is tested in zero and 15° of flexion by applying a valgus stress to the knee. The lateral collateral ligament is tested similarly using a varus stress. McMurray’s test may detect a meniscal tear. A duck walk test can also be used to look for a posterior meniscal tear. The patient’s gait is observed, specifically looking for forefoot varus and heel valgus, Morton’s foot deformity, and femoral anteversion, all of which can accentuate valgus stress on the knee and lead to a painful overuse syndrome. >

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

    Neck Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. General. Patient age and occupation are important. An individual’s job can involve awkward or prolonged body positioning (1). Some of the conditions listed in Table 12.8 can present with fever or with constitutional or other musculoskeletal symptoms. More diagnosis-specific symptoms may be present (e.g., chest pain with a myocardial infarction).

    B. Pain characteristics. What is the character, location, frequency, and duration of pain? Tumors of the cervical spine can present with unremitting neck pain that is worse at night. Referred neck pain from intrathoracic pathology is more often located anteriorly.

    C. Precipitating factors. Any prior history of neck problems? Has there been any preceding neck trauma or change in work or avocational activities? A history of collision trauma may warrant consideration of concurrent head injury. Is there any relationship of the pain to a particular neck position or movement? Careful questioning may be needed to uncover this latter information, but it is crucial to determining the mechanism of pain production. Have there been any emotional stressors?

    D. Associated symptoms. Is headache present? Any paresthesia, dyskinesia, or weakness of the trunk or upper or lower extremities? Bladder dysfunction can occur with a central spinal cord injury. What is the distribution of any radicular pain? An increase in radicular symptoms with coughing or sneezing suggests nerve root impingement (2).

    Physical examination

     A. General. After any cervical spine injury, order an x-ray study first to rule out an unstable injury. Assess gait, which can be impaired with a cervical myelopathy. Notice neck posture (3). Torticollis can occur secondary to trauma, muscle strain, vertebral subluxation, viral infection or from a psychogenic cause. Examine other head and neck structures (e.g., lymph nodes) and the temporomandibular joints (1). Look for meningeal signs, if appropriate.

     B. Musculoskeletal examination. Palpate for muscle tenderness or spasm in the neck and head. Tender trigger points may be found in fibromyalgia. Assess active and passive range of motion (ROM) of the neck and shoulders. ROM is not affected with referred sources of pain. Decreased passive ROM may be seen in rheumatoid arthritis (RA), ankylosing spondylitis (AS), disseminated idiopathic skeletal hyperostosis (DISH), compression fractures, and cervical spondylosis. Active contraction or stretching of strained muscles or ligaments will precipitate pain.

     C. Neurologic examination. Include the examination of cranial nerves, motor function, tone, and reflexes of the upper and lower extremities. Look for muscle atrophy. Check pinprick and light touch sensation in the upper extremities, looking for a dermatomal pattern of loss. Evaluate cerebellar, vibration, and position sense in the legs. The exact level of nerve root involvement cannot be precisely known from the physical examination because of overlapping innervation (2) (Table 12.9). A Spurling’s test (extension and rotation of the head and neck while applying downward pressure to the top of the head) that precipitates radicular symptoms is very suggestive of nerve root pathology (1).

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

    Pleuritic Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Characteristics of the pleuritic pain. What is the acuity of the pain, its location, and exacerbating features?

     1. Acute onset suggests sudden development as viral or idiopathic pleurisy, PE, pneumonia, or pneumothorax.

    Insidious onset suggests a slower inflammatory or irritative process usually resulting in a pleural effusion with the pain generally diminishing as fluid accumulates (Chapter 8.4).

    2. Pleuritic chest pain localizes above the underlying pleural pathology through intercostal innervation.

     3. Through phrenic innervation, shoulder pain can indicate ipsilateral diaphragmatic involvement, usually by abdominal pathology (Table 8.1).

     4. Substernal pain improved by leaning forward suggests pericarditis (Chapter 7.1).

    5. Provocation of pain by shoulder movement indicates a musculoskeletal cause.

    B. Focused review of systems. What symptoms or history accompany the pain that might suggest a respiratory infection, PE, or malignancy? A nonproductive cough is nonspecific, and a productive cough suggests infection. Hemoptysis suggests malignancy, tuberculosis, or pulmonary embolism. A fever suggests infection but can occur with PE. Recent surgery or lower extremity trauma or swelling increase the risk for PE. Unexplained weight loss suggests malignancy or tuberculosis (TB).

    C. Past medical history. Past history can provide clues to the cause including malignancy, recent myocardial infarction, uremia, lupus, and rheumatoid arthritis.

    D. Other history. Inquire about oral contraceptives (PE risk), TB, or asbestos exposure.

    Physical examination

     A. Focused physical examination. This should include vital signs with attention to temperature and respiratory rate and examination of the chest. Tenderness to palpation indicates a musculoskeletal cause. Dullness to percussion suggests pleural effusion or parenchymal pathology and hyperresonant percussion indicates pneumothorax. On auscultation, a pleural friction rub is the only sign of pleurisy; crackles suggest pneumonia; and decreased breath sounds indicate pneumothorax or effusion. The examination result is frequently normal.

     B. Additional physical examination. Abdominal tenderness can suggest a subdiaphragmatic process (Table 8.2, Abdominal). Lower extremity edema, tenderness, or Homans’ sign can imply deep vein thrombosis (DVT) and PE. Lymphadenopathy can represent lymphoma or metastatic disease.

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

    Shoulder Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

    A. Characteristics of the pain. What is the onset, location, radiation, severity, and duration of the pain? Is there any instability, weakness, stiffness, or locking? Are there exacerbating or alleviating maneuvers? Has there been any associated trauma? What was the mechanism of injury? Any associated neurologic or systemic symptoms? Is there a history of prior shoulder problems? Are other joints involved?

    Physical examination

    Observe the shoulder for symmetry, motion, and signs of injury. Palpate all bony structures [including the acromioclavicular (AC) joint and bicipital groove]; check cervical spine range of motion (ROM) and the neurovascular status of the affected arm. If fracture is suspected, obtain an x-ray study. If finding on the x-ray is negative, proceed with passive and active ROM testing of the shoulder. Assess muscle strength and perform provocative tests for specific suspected pathology (Table 12.12) (1).

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

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

    A. Timing of the pain. What is the onset and duration of the pain? Was there a specific inciting incident or trauma? When does the pain occur? Pain wakening the patient from sleep may suggest a malignancy. Is pain present at rest? Does movement or weightbearing exacerbate the symptom? Any associated joint stiffness?

    B. Location of the pain. Localization to the joint is typical in osteoarthritis (OA). Exceptions are hip OA, where pain can localize to the groin or thigh, and OA of the spine, where pain can localize to the buttocks. Radiation of the pain may suggest periarticular or neuropathic problems.

    C. Associated symptoms. Fever, night sweats, or weight loss may suggest an infectious cause or an underlying systemic illness. Rash can occur with infectious or inflammatory arthritides.

     D. Medical history. Many medical problems can be associated with an inflammatory or a degenerative arthritis (Table 12.7). Knowledge of prior joint surgery or prosthesis placement is important. A history of childhood joint disease (e.g., slipped capital epiphysis) or bone disease (e.g., osteochondritis dissecans) can predispose to early onset degenerative joint disease.

     E. Social history. The patient’s support system is especially important if severe functional impairment is present. The employment or recreational history may indicate a risk of repetitive joint trauma. Sexual risk factors and a history of alcohol or intravenous (IV) drug abuse are important.

    F. Medications. What medication or treatment has been used and what was the response? A history of systemic steroid use can lead to osteonecrosis of the femoral head.

    Physical examination

    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.

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

    Scrotal Pain: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

     A. Trauma rarely causes significant damage to the testicle. Traumatic damage is extremely rare in prepubertal patients (4). Unless the testicle is ruptured or a secondary torsion occurs, pain from trauma usually resolves in less than 1 hour (4). Severe pain or evidence of testicular rupture associated with minor trauma is suggestive of occult tumor (1,4).

     B. Symptoms and disease course

    1. Testicular torsion is the most common cause of scrotal pain in first year of life (3). It is frequently misdiagnosed as colic, or an intraabdominal disorder. The highest incidence occurs between the ages of 12 to 18 years (5). Testicular torsion causes acute pain with testicular swelling and scrotal erythema, and nausea and vomiting are common.

    2. Torsion of testicular appendage. Torsion is common between the ages of 10 to 15 years; however, it is rare in neonates and adults (5). Pain can last several days with malaise and may not localize to the scrotum initially, but presents as lower abdominal pain.

     3. Epididymitis is the most common cause of acute scrotal pain in adults (1). It is rare in prepubertal children (5). In infants or young children, suspect urogenital anomaly or dysfunction (3). The onset can be abrupt or insidious. Fever, voiding symptoms, or both are common (4). Scrotal edema and erythema can occur, but less commonly than that seen with torsion (5).

     4. Orchitis is usually caused by extension of epididymitis inflammation to the testis (4). Mumps orchitis, which is seen only after puberty in 20% of mumps cases, is usually unilateral (70%). It is declining in the United States because of immunization (5).

     C. Sexual activity is an important factor in all age groups. In prepubertal children, rule out abuse or self-experimentation. In adolescents and adults, infection and trauma can occur from sexual practices. A good history is especially important.

    D. Recurrent pain. A history of previous ipsilateral pain is associated with a 44% incidence of testicular torsion (1). Consider multiple causes. Is previous pain similar or different from the current episode?

     E. Infection. Look for a history of urinary tract infection (UTI), dribbling, urgency, dysuria, and incomplete emptying (Chapter 10.1). Consider reflux, obstruction, chronic prostatitis, and unusual sexual practices.

     F. Concurrent illness. Possibilities include Henoch–Schönlein purpura, mononucleosis, Buerger’s disease, coxsackie B virus, and polyarteritis nodosa (1,4). Also consider incarcerated hernia or thrombosed varicocele (1).

    Physical examination

     A. Observation. Especially in the very young, it is important to quietly observe the patient before initiating an examination (4). Is he quiet or active? Playing or fussing? Is there guarding?

     B. Referred pain. The neonate or young child with abdominal pain always deserves an examination of the scrotum (2,4).

    C. Scrotum. Edema and redness are found in torsion and epididymitis. They occur early in testicular torsion. If pain is present longer than 24 hours and no scrotal changes are noted, torsion is unlikely (4). Discoloration suggests trauma but it can also be seen with delayed diagnosis of torsion and epididymitis. Check for the cremasteric reflex, which rules out testicular torsion if present on the painful side (2,4). Its presence must be demonstrated on the nonpainful side to be reliable indicator. Unilateral swelling without skin changes suggests hernia or hydrocele (4). In torsion, pain increases when the scrotum is elevated; it decreases with epididymitis (Prehn’s sign) (5) (Chapter 10.7).

    D. Penis. Look for discharge, redness, and trauma. Partial hypospadius suggests possible other genitourinary anomalies. A higher incidence of UTI is seen in the uncircumcised neonate.

     E. Testes. Are they present or absent? Examine the inguinal canal. Evaluate for high versus low, transverse versus vertical lie. High, transverse testicle suggests torsion (4). Evaluate size, shape, and tenderness. The testicle with torsion will become swollen early in the process, however, the appendage with torsion does not cause a difference is testicular size (2). Feel and look for a palpable mass on the margin of the testis. Transilluminate for the “blue dot sign” to diagnosis torsion in the appendage (4,5). Does tenderness involve the entire testicle or is it asymmetric (4)?

     F. Other. Rule out other causes, examine skin for petechiae, and look for adenopathy. Examine the abdomen and flank for a source of referred pain or signs of trauma. Fever is not usually present with a testicular torsion (unless delayed), but can be found in epididymitis (4).

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

    Acute Monoarticular Arthritis: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Injury

    ❑ Gout

    ❑ Osteoarthritis

    ❑ Lyme disease

    ❑ Gonococcal arthritis

    ❑ Seronegative spondyloarthropathy

    ❑ Septic arthritis

    ❑ Pseudogout

    ❑ Septic bursitis

    ❑ Avascular necrosis

    Diagnostic Approach

    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.

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    Source: Field Guide to Bedside Diagnosis, 2007

    Polyarticular Arthritis: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Osteoarthritis

    ❑ Rheumatoid arthritis

    ❑ Lyme arthritis

    ❑ Systemic lupus erythematosus

    ❑ Psoriatic arthritis

    ❑ Polyarticular gout

    ❑ Viral arthritis

    ❑ Scleroderma

    ❑ Reiter syndrome

    ❑ Inflammatory bowel disease

    ❑ Gonococcal arthritis

    ❑ Ankylosing spondylitis

    ❑ Systemic vasculitis

    ❑ Sarcoidosis

    ❑ Pseudogout (CPPD)

    ❑ Acute rheumatic fever

    ❑ Still disease

    Diagnostic Approach

    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

    Arthritis/Dermatitis: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑Lyme disease

    ❑Erythema nodosum

    ❑Rheumatoid arthritis

    ❑Systemic lupus erythematosus

    ❑Psoriatic arthritis

    ❑Disseminated gonococcemia

    ❑Sarcoidosis

    ❑Scleroderma

    ❑Dermatomyositis

    ❑Reiter syndrome

    ❑Rheumatic fever

    ❑Behçet syndrome

    ❑Still disease

    ❑Hypersensitivity vasculitis

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Chronic/Recurrent Abdominal Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Irritable bowel syndrome

    ❑ Peptic ulcer disease

    ❑ Cholecystitis

    ❑ Chronic pancreatitis

    ❑ Inflammatory bowel disease

    ❑ Intermittent mesenteric ischemia

    ❑ Pancreatic cancer

    ❑ Gastric cancer

    ❑ Endometriosis

    ❑ Recurrent intestinal obstruction

    ❑ Sickle cell anemia

    ❑ Radiculopathy

    ❑ Adrenal insufficiency

    ❑ Lead poisoning

    ❑ Porphyria

    Diagnostic Approach

    Examining a patient during an episode of pain is important for diagnosis. A significant proportion of patients with chronic abdominal pain will remain undiagnosed despite extensive testing. For these patients, repeated history and examination, during which one looks for new symptoms or any change in the pattern of symptoms, may eventually yield a formulation.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Pleuritic Chest Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Costochondritis

    ❑ Pneumonia

    ❑ Rib fracture

    ❑ Pulmonary embolism

    ❑ Pleurisy

    ❑ Pneumothorax

    ❑ Pericarditis

    ❑ Lung cancer

    ❑ Pneumomediastinum

    ❑ Splenic infarction

    Diagnostic Approach

    Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Cardiac pain is almost never pleuritic (LR 0.2), sharp or stabbing (LR 0.3), positional (LR 0.3) or reproduced by palpation (LR 0.3).

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Acute Nonpleuritic Chest Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Chest wall pain

    ❑ Angina

    ❑ Unstable angina

    ❑ Myocardial infarction

    ❑ Gastroesophageal reflux

    ❑ Herpes zoster

    ❑ Thoracic root compression

    ❑ Panic disorder

    ❑ Aortic stenosis

    ❑ Aortic dissection

    ❑ Mediastinal mass

    ❑ Biliary disease

    Diagnostic Approach

    It is essential to maintain a high index of suspicion (low threshold for investigation) for critical problems; however, most chest pain has a benign cause. The patient with myocardial ischemia often is reluctant to label the symptom as “pain.” Instead descriptors are used such as squeezing, pressure, tightness, fullness, a heavy weight on the chest, burning (attributed to indigestion),
    or a toothache (when jaw radiation is present). A closed fist held to the sternum is commonly employed to explain the symptoms. Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Recurrent episodic pain or persistent pain lasting days is unlikely to represent a critical problem. Pain lasting a few seconds or pain that is sharp or stabbing in quality is almost never ischemic, especially if reproducible by palpation
    or movement.

    Syncope with chest pain should raise suspicion of aortic dissection,
    ruptured aortic aneurysm, pulmonary embolism, or critical aortic stenosis. “Angor anomie,” a sense of impending doom, is found in serious conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and to a lesser extent, panic disorder. Sternal pain may be caused by xiphoidalgia, myelomatosis, ankylosing spondylitis, osteomyelitis, or traumatic fracture.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Ear Pain/Discharge: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Ear Pain

    ❑ Acute otitis media

    ❑ Acute otitis externa

    ❑ Eustachian dysfunction

    ❑ Temporomandibular joint arthritis

    ❑ Traumatic tympanic membrane rupture

    ❑ Foreign body, external auditory canal

    ❑ Erysipelas

    ❑ Herpes zoster oticus

    ❑ Dental abscess

    ❑ Frostbite

    ❑ Relapsing polychondritis

    ❑ Malignant otitis externa

    ❑ Acute mastoiditis

    ❑ Nasopharyngeal cancer

    Ear Discharge

    ❑ Otitis externa

    ❑ Eczematoid dermatitis

    ❑ Low-viscosity cerumen

    ❑ Otitis media with perforation

    ❑ Foreign body

    ❑ Psoriasis

    ❑ Herpes zoster oticus

    Diagnostic Approach

    If ear pain is present without ear findings, consider referred pain from the tonsils, teeth, trachea, or temporomandibular joint. Ear pain may be an early sign of nasopharyngeal carcinoma. Lesions of the anterior portion of the tongue refer pain in front of the ear whereas the posterior one-third of the tongue refers pain to within the ear.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Facial / Dental / Temporomandibular Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Maxillary sinusitis

    ❑ Dental infection

    ❑ Temporomandibular joint dysfunction

    ❑ Myofascial masseter pain

    ❑ Migraine

    ❑ Trigeminal neuralgia

    ❑ Frontal sinusitis

    ❑ Ethmoid sinusitis

    ❑ Sphenoid sinusitis

    ❑ Parotitis

    ❑ Parotid calculus

    ❑ Orbital fracture

    ❑ Mandibular fracture

    ❑ Maxillary fracture

    ❑ Myocardial infarction

    ❑ Connective tissue disease

    ❑ Temporal arteritis

    ❑ Cavernous sinus thrombosis

    ❑ Glossopharyngeal neuralgia

    Diagnostic Approach

    The V1 ophthalmic branch of the trigeminal innervates the forehead, cornea (corneal reflex), dorsum of the nose, and anterior cranial dura. The V2 maxillary branch innervates the upper lip, lateral nose, upper cheek, anterior temple, upper jaw and teeth, roof of the mouth, and middle cranial dura. The V3 mandibular branch innervates the lower lip, chin, posterior cheek, external ear, mucosa of the lower mouth, anterior two-thirds of the tongue, and parts of the anterior and middle cranial dura.

    Pain provoked by hot, cold, or sweet foods is usually dental in origin. Neuralgia may produce a similar pain, but the pain will have a refractory period after an initial response. Pain increased by chewing suggests trigeminal neuralgia, temporomandibular joint pain, or jaw claudication. Pain increased by swallowing and taste is consistent with glossopharyngeal neuralgia. Objective sensory loss persisting after the pain is an important clue to organic disease.

    Epidemiologic studies reveal that temporomandibular joint tenderness is common, occurring in 35% of asymptomatic people, clicking in 25%, crepitus in 8%, and jaw deviation in 15%.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Low Back Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Musculoligamentous strain

    ❑ Lumbar disc herniation

    ❑ Osteoarthritis

    ❑ Compression fracture

    ❑ Pyelonephritis

    ❑ Secondary gain

    ❑ Scoliosis

    ❑ Spondylolisthesis

    ❑ Metastatic cancer

    ❑ Spinal stenosis

    ❑ Transverse process fracture

    ❑ Pancreatic cancer

    ❑ Ankylosing spondylitis

    ❑ Sacroiliitis

    ❑ Aortic dissection

    ❑ Cauda equina syndrome

    ❑ Vertebral osteomyelitis

    ❑ Epidural abscess

    Diagnostic Approach

    Radicular pain has such a high sensitivity for nerve root compression that its absence makes important disc herniation unlikely. Not all radicular pain is due to a herniated disc however. Other causes include spinal stenosis, ligamentous hypertrophy, deep lumbar muscle spasm, and deep trochanteric bursitis.

    Back pain at rest or unassociated with posture/movement should increase the suspicion of tumor, fracture, infection, or referred visceral pain. Spinal tenderness is a sensitive but not specific indicator. Clues to metastatic cancer include a history of cancer, unexplained weight loss, and signs of cord compression, such as motor weakness of the legs, urinary or fecal incontinence, and absent anal reflex. Recent bacterial infection, injection drug use, or immune suppression (from steroids, chemotherapy, or HIV) should raise suspicion for infection. Fever occurs in osteomyelitis (50%), epidural abscess (83%), and tuberculosis (27%).

    A red flag for fracture in a young adult is major trauma, such as a fall from a height or a motor vehicle accident. In older adults, minor trauma or strenuous lifting can cause a compression fracture.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Acute Abdominal Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Generalized/Periumbilical

    ❑ Gastroenteritis

    ❑ Obstipation

    ❑ Small bowel obstruction

    ❑ Large bowel obstruction

    ❑ Mesenteric ischemia

    ❑ Peritonitis

    ❑ Abdominal aortic dissection

    ❑ Sickle cell crisis

    Right Upper Quadrant/Epigastrium

    ❑ Hepatitis

    ❑ Biliary colic

    ❑ Peptic ulcer disease

    ❑ Pyelonephritis

    ❑ Acute cholecystitis

    Right Lower Quadrant

    ❑ Appendicitis

    ❑ Inflammatory bowel disease

    ❑ Salpingitis

    ❑ Rectus abdominus muscle strain

    ❑ Ureteral calculus

    ❑ Ruptured corpus luteum cyst

    ❑ Ruptured ectopic pregnancy

    ❑ Ovarian torsion

    Left Upper Quadrant

    ❑ Pancreatitis

    ❑ Splenic infarction

    ❑ Pyelonephritis

    ❑ Myocardial infarction

    Left Lower Quadrant

    ❑ Inflammatory bowel disease

    ❑ Diverticulitis

    ❑ Salpingitis

    ❑ Rectus abdominus muscle strain

    ❑ Ureteral calculus

    ❑ Ovarian torsion

    ❑ Ruptured corpus luteum cyst

    ❑ Ruptured ectopic pregnancy

    ❑ Sigmoid volvulus

    Diagnostic Approach

    Acute abdominal pain is a classic symptom that can herald conditions ranging from the trivial to the life-threatening. The accurate diagnosis and timely management of abdominal pain requires an understanding of the mechanisms of pain, recognition of typical patterns of clinical presentation, a broad differential of common causes, and an index of suspicion for variant presentations and unusual causes. The ultimate disposition decision may require a repeated history and physical examination over several hours. Narcotic analgesics should be withheld until a diagnosis is established because they can mask the expression of diagnostic characteristics of the disease. History indicates the diagnosis in 85% to 90% of cases. Consider organs located in the region of maximal pain and the time-course of onset. An intrathoracic source must always be considered with upper abdominal pain. Physical examination can demonstrate peritoneal inflammation and rebound tenderness by eliciting pain with gentle percussion of the abdomen as opposed to sharp release of the depressed hand. Muscular rigidity or “guarding” is an early sign of peritoneal inflammation. Auscultation may reveal silence, consistent with ileus or advanced peritonitis, hyperactive high-pitched sounds with early bowel obstruction, or a friction rub with splenic infarct or hepatic metastases. Pelvic and rectal examinations are mandatory in every patient who has abdominal pain.

    Parietal pain, caused by inflammation of the parietal peritoneum, is
    a sharp, steady, aching pain, well-localized over the inflamed area, and
    accentuated by pressure. Tonic reflex spasm of the abdominal musculature is present. Visceral pain, caused by obstruction of a hollow viscera, is classically intermittent and cramping, but distension may produce dull, steady pain. The patient with visceral pain will writhe incessantly, while the patient with parietal pain lies still in bed. Referred pain is aching and perceived to be near the surface, accompanied by skin hyperalgesia and increased tone of the abdominal wall. Vascular occlusion can be recognized by severe pain out of proportion to physical findings in a patient with vascular disease or atrial fibrillation. Visceral pain is perceived at the level the nerves enter the spinal cord. An example is gallbladder pain which may be first perceived at the scapula, then later in the right upper quadrant when the somatically innervated overlying parietal peritoneum is inflamed.

    If the patient is well one moment, then has excruciating pain, which is maximal at onset, consider a ruptured hollow viscera or a vascular event, such as myocardial infarction or ruptured aortic aneurysm.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Acute Knee Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Osteoarthritis

    ❑ Patellofemoral pain

    ❑ Collateral ligament sprain

    ❑ Meniscal tear

    ❑ Anterior cruciate tear

    ❑ Infrapatellar quadriceps tendinitis

    ❑ Acute monoarticular arthritis

    ❑ Prepatellar bursitis

    ❑ Anserine bursitis

    ❑ Hamstring injury

    ❑ Baker cyst

    ❑ Septic joint

    ❑ Iliotibial band syndrome

    ❑ Hemarthrosis

    ❑ Patellar fracture

    ❑ Patellar dislocation

    ❑ Osteochondritis desiccans

    ❑ Osteonecrosis

    Diagnostic Approach

    Careful questioning about the mechanism of injury is most important. Overuse injury or undue stress caused by unbalanced walking is a common source. A sensation of “giving away” on stepping down is a symptom of posterior horn meniscus or anterior cruciate tear. Joint line pain is seen in osteoarthritis, high-grade collateral ligament injury, meniscal tear, and tibial plateau fracture. Pain located medially several centimeters below this is due to anserine bursitis or low-grade medial collateral ligament injury. Anterior knee pain is found in injury to the quadriceps mechanism or large joint effusions. Popliteal pain is usually due to a large knee effusion.

    Systematically stress the knee in each direction, looking for pain and/or laxity, comparing with the contralateral side. The range of motion may be limited by effusion, by a meniscal tear, or by a loose body. True locking, with ability to flex but not extend fully, occurs 10 degrees short of full extension. A McMurray maneuver is performed by rotating the tibia on the femur medially with the knee flexed at 90 degrees and then extending the knee, then repeating the process with lateral rotation. A painful “clunk” with medial rotation indicates a lateral meniscus tear, and the same finding with lateral rotation suggests a medial meniscus tear. An anterior drawer sign is elicited as pain and a laxity when the tibia is pulled forward with the knee at 90 degrees, indicating anterior cruciate injury. A Lachman manuver, performed at 15 degrees flexion, is more sensitive. With effusion the hollows of the knee are filled, and a transmitted fluid wave can be elicited.

    In acute knee injury, the Ottawa Knee Rule minimizes the number of x-rays without missing a significant fracture. Obtain an x-ray if: (a) age is >54, (b) there is tenderness at the head of the fibula, (c) there is isolated patellar tenderness, (d) there is an inability to flex the knee to 90 degrees, or (e) there is an inability to bear weight immediately and take four steps in the E.R.

    Palpable clicks are not necessarily pathologic; they may be caused by the semitendinosus tendon slipping over the medial condyle or the iliotibial band slipping over the lateral condyle.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Ankle/Foot Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Ankle Pain

    ❑ Ankle sprain

    ❑ Fibular fracture

    ❑ Achilles tendinitis

    ❑ Acute gout

    Foot Pain

    ❑ Plantar fasciitis

    ❑ Acute gout

    ❑ Hallux valgus (bunion)

    ❑ Sciatica

    ❑ Metatarsalgia

    ❑ Metatarsal stress fracture

    ❑ Tibialis anterior tendinitis

    ❑ Pes planus

    ❑ Calcaneal fracture

    ❑ Interdigital neuroma

    ❑ Posterior tibial nerve entrapment

    ❑ Compartment syndrome

    Diagnostic Approach

    In acute ankle injury, ability to bear weight for four steps and absence of bone tenderness at the posterior edge or the tip of either malleolus rule out a significant fracture (Ottawa ankle rule).

    In acute foot injury, ability to bear weight for four steps and absence of bone tenderness at the navicular or the base of the fifth metatarsal rule out a significant midfoot fracture (Ottawa foot rule).

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Elbow Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑Lateral epicondylitis

    ❑Olecranon bursitis

    ❑Medial epicondylitis

    ❑Bicipitoradialis tendinitis

    ❑Cubital tunnel syndrome

    ❑Radial head fracture

    ❑Septic arthritis

    ❑Gout

    ❑Osteoarthritis

    ❑Elbow dislocation

    ❑Ruptured distal biceps tendon

    ❑Epitrochlear lymphadenitis

    ❑Cervical radiculopathy

    Diagnostic Approach

    Pain arising from within the elbow joint is poorly localized between the lateral epicondyle and the olecranon, and there is inability to straighten the elbow. Referred pain to the elbow is vague, not affected by elbow movement, but increased by movement of the neck or shoulder.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Eye Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Conjunctivitis

    ❑ Corneal abrasion

    ❑ Foreign body

    ❑ Sinusitis

    ❑ Migraine

    ❑ Acute glaucoma

    ❑ Orbital cellulitis

    ❑ Zoster prodrome

    ❑ Orbital fracture

    ❑ Keratitis

    ❑ Scleritis

    ❑ Iritis

    ❑ Optic neuritis

    ❑ Temporal arteritis

    Diagnostic Approach

    A foreign body sensation occurs with a foreign body, corneal abrasion, or keratoconjunctivitis sicca. Itching is associated with allergic and vernal conjunctivitis. Photophobia occurs with iritis and herpes simplex keratitis. Deep pain suggests acute glaucoma or posterior scleritis. Pain on eye movement is found with optic neuritis, sinusitis, and influenza.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Flank Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Ureteral calculus

    ❑ Acute pyelonephritis

    ❑ Latissimus strain

    ❑ Perinephric abscess

    ❑ Renal infarction

    ❑ Renal trauma

    ❑ Renal cancer

    ❑ Mononeuritis

    ❑ Papillary necrosis

    Diagnostic Approach

    Renal pain occurs with stretching of the capsule and distension of the collecting system. The pain is usually severe and aching, with nausea, vomiting, and ileus. There may be hyperesthesia in the T 9 to 10 dermatome.

    Ureteral pain begins in the costovertebral angle and radiates to the lower abdomen, upper thigh, testis, or labia. The pain is excruciating, with crescendo waves of colic. The patient writhes but is unable to obtain relief. Hyperesthesia over the T 12 dermatome often occurs along with tenderness over the kidney or ureter.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Osteoarthritis: Diagnosis
    (Handbook of Diseases)

    A thorough physical examination confirms typical symptoms, and the absence of systemic symptoms rules out an inflammatory joint disorder. X-rays of the affected joint help confirm diagnosis of osteoarthritis but may be normal in the early stages. X-rays may require many views and typically show:

    ❑  narrowing of joint space or margin

    ❑  cystlike bony deposits in joint space and margins

    ❑  sclerosis of the subchondral space

    ❑  joint deformity due to degeneration or articular damage

    ❑ bony growths at weight-bearing areas

    ❑  fusion of joints.

    No laboratory test is specific for osteoarthritis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Neurogenic arthropathy: Diagnosis
    (Handbook of Diseases)

    A patient history of painless joint deformity and underlying primary disease suggests neurogenic arthropathy. The physical examination may reveal bone fragmentation in advanced disease. X-rays help confirm the diagnosis and help assess the severity of joint damage.

    In the early stage of the disease, soft-tissue swelling or effusion may be the only overt effect; in the advanced stage, articular fracture, subluxation, erosion of articular cartilage, periosteal new bone formation, and excessive growth of marginal loose bodies (osteophytosis) or resorption may be seen.

    Other diagnostic measures include:

    ❑ vertebral examination:narrowing of disk spaces, deterioration of vertebrae, and osteophyte formation, leading to ankylosis and deforming kyphoscoliosis

    ❑ synovial biopsy: bony fragments and bits of calcified cartilage.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Juvenile rheumatoid arthritis: Diagnosis
    (Handbook of Diseases)

    Persistent joint pain, rash, and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA and for monitoring disease activity and response to therapy.

    ❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.

    ❑ Erythrocyte sedimentation rate, complement (C)-reactive protein, haptoglobin, immunoglobulin, and C3 levels may be elevated.

    ❑ Test results may be positive for ANAs in patients who have pauciarticular JRA with chronic iridocyclitis.

    ❑ RF is present in 15% of patients with JRA, as compared with 85% of patients with RA.

    ❑ Positive HLA-B27 test may forecast later development of ankylosing spondylitis.

    ❑ Early X-ray changes include soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Psoriatic arthritis: Diagnosis
    (Handbook of Diseases)

    Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis. X-rays confirm joint involvement and show:

    ❑ marginal erosion at interphalangeal joints with areas of thin, “fluffy” new bone formation

    ❑ “whittling” of the distal end of the terminal phalanges

    ❑ “pencil-in-cup” deformity of the distal interphalangeal joints

    ❑ relative absence of osteoporosis

    ❑ sacroiliitis

    ❑ atypical spondylitis with syndesmophyte formation, resulting in hyperostosis and paravertebral ossification, which may lead to vertebral fusion.

    Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Rheumatoid arthritis: Diagnosis
    (Handbook of Diseases)

    Typical signs and symptoms suggest RA, with a firm diagnosis supported by laboratory and other test results:

    ❑ X-raysin early stages show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.

    ❑ RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.

    ❑ Synovial fluid analysisshows increased volume and turbidity but decreased viscosity and elevated white blood cell counts (often greater than 10,000/µl).

    ❑ Serum protein electrophoresis may show elevated serum globulin levels.

    ❑ Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation typically parallels disease activity).

    ❑ Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Complex regional pain syndrome: Diagnostic tests
    (Handbook of Diseases)

    There is no laboratory test for CRPS, so the diagnosis is based on the patient’s history and clinical findings. A history of injury to an extremity may point to CRPS. Bone X-rays may aid in ruling out other conditions, such as osteomyelitis and stress fractures, which cause similar signs and symptoms. With early diagnosis, prognosis improves.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Abdominal pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient’s condition permits, obtain his history. Ask whether he has had this type of pain before. Because some patients report abdominal pain as indigestion or gas pain, it’s important to ask the patient to describe his pain in detail. For example, is it dull, sharp, stabbing, or burning? Ask him where the pain is located and whether it radiates to other areas. If a language barrier exists between you and the patient, use a pain rating scale with visual cues such as faces.

    Ask the patient about factors that relieve the pain or make it worse. For example, do movement, coughing, exertion, vomiting, eating, elimination, or walking relieve the pain or worsen it? Ask him when the pain began and whether it’s intermittent or constant. If pain is intermittent, ask about the duration of a typical episode.

    Intermittent, cramping abdominal pain suggests obstruction of a hollow organ. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity.

    Ask the patient about substance abuse and a history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

    Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Has he experienced increased flatulence, constipation, diarrhea, or changes in stool consistency? When was the patient’s last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

    Physical examination

    Obtain the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

    Auscultate for bowel sounds in all four quadrants for at least 10 to 15 seconds and characterize their motility. Listen for systolic bruits in such locations as the abdominal aorta, renal artery, or iliac artery. (See Auscultating for vascular sounds.)

    Percuss all quadrants, noting the percussion sounds.

    ALERT: Abdominal percussion or palpation is contraindicated in patients with suspected abdominal aortic aneurysm, those who have received abdominal organ transplants, and children with suspected Wilms’tumor. If performing abdominal percussion or palpation in patients with suspected appendicitis, use extreme caution to avoid precipitating a rupture.

    Palpate the entire abdomen for masses, rigidity, and tenderness. Involuntary rigidity is generally asymmetrical, evident on inspiration and expiration, unaffected by relaxation techniques, and painful when the patient sits up using his abdominal muscles alone. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. Peritonitis and appendicitis can cause rebound tenderness. Because appendicitis may be accompanied by increased abdominal wall resistance and guarding, perform the maneuver for rebound tenderness only once — repeating the maneuver can rupture an inflamed appendix. (See Eliciting rebound tenderness, page 4.)

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Back pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Ask the patient where the pain is located; back pain in some areas can signal the presence of a life-threatening condition.

    Act Now: If the patient reports acute, severe back pain, quickly obtain his vital signs and perform a rapid evaluation to rule out life-threatening causes. If he describes deep lumbar pain unaffected by activity, observe for a pulsating epigastric mass. Presence of this sign may indicate a dissecting abdominal aortic aneurysm. Withhold food and fluids because the patient may require emergency surgery. Prepare for I.V. fluid replacement and oxygen administration.

    If he reports severe epigastric pain that radiates through the abdomen to the back, assess for absent bowel sounds and abdominal rigidity and tenderness. These symptoms may indicate a perforated ulcer or acute pancreatitis. Start an I.V. line for fluids and medications, administer oxygen, insert a nasogastric tube, and withhold food.

    If the patient complains of scapular area back pain, especially if accompanied by shortness of breath or diaphoresis, give oxygen via a nasal cannula or mask and obtain a 12-lead electrocardiogram to rule out myocardial infarction.

    After you have ruled out potential life-threatening causes of back pain, continue to obtain the patient’s history. Observe him for expressions of pain while gathering information. Ask about previous injuries and illnesses, dietary habits, alcohol intake, and cigarette smoking. Inquire about medications, including past and present prescriptions, use of over-the-counter drugs, and disease processes or pain control regimens.

    Ask the patient about the onset of his back pain. Were there precipitating factors? Ask the patient to rate the pain on a standardized pain scale. Ask him for details about the pain — is it burning, stabbing, throbbing, or aching? Constant or intermittent? If it’s intermittent, does it occur at a specific time of day? Does the pain radiate? Is there associated weakness? Does he experience repetitive pain or different types of pain? What, if anything, lessens the pain? What aggravates it? The patient’s answers will help identify the cause of his back pain. For example, visceral referred back pain is indicated if the patient states that the pain isn’t affected by activity and rest. In contrast, spondylogenic-referred back pain is likely if the pain increases with activity and decreases with rest. Pain of neoplastic origin is indicated if the patient reports that he can obtain relief by walking and that the pain increases at night.

    Physical examination

    Perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask the patient about unusual sensations in the legs, such as numbness and tingling. If pain doesn’t prevent standing, observe the patient’s posture — does he stand erect or lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes (stand close by during these tests so that you can assist the patient if he falls). Weakness may reflect a muscular disorder or spinal nerve root irritation.

    Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. (See How to elicit Babinski’s reflex.) Evaluate the strength of the extensor hallucis longus by asking the patient to keep his great toe firmly in place against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜"(1 cm) in muscle size, especially in the calf.

    To reproduce leg and back pain, assist the patient into a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica.

    Note the range of motion of the hip and knee. Palpate the flanks and percuss with your fingertips or fist to reveal the presence of costovertebral angle (CVA) tenderness.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Chest pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Ask the patient to rate the pain using a standardized pain rating scale. Is the pain a dull, aching, pressurelike sensation, or sharp, stabbing, and knifelike? Is it constant or intermittent? If it’s intermittent, ask how long an episode lasts. Ask him about precipitating, aggravating, or alleviating factors. Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Ask about medications he’s taking, if any, including recent dosage or schedule changes.

    ALERT: Chest pain in perimenopausal women may be difficult to diagnose because it may present atypically. Fatigue, nausea, dyspnea, and shoulder or neck pain are symptoms more likely to signal an MI in women than in men.

    Physical examination

    Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Check for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Eye pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

    Physical examination

    During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Flank pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

    Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

    Physical examination

    During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Jaw pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

    Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)

    Physical examination

    Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth ? Less than 1⅛" (3 cm) or more than 2⅜" (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Neck pain: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient hasn’t sustained trauma, inquire about the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there a particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

    Physical examination

    Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion (ROM) in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings.)

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Scrotal swelling: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient isn’t in distress, obtain his medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is he 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 the patient have a history of prostate surgery or prolonged catheterization? Is the swelling affected by changing his body position or level of activity?

    Physical examination

    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 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: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Abdominal pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have obstruction of a hollow organ.

    If the pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

    Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

    Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

    Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is his urine cloudy or pink?

    » READ BOOK EXCERPT ONLINE »

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

    Arm pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

    If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right-upper-quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts any movements. Also ask if heat, rest, or drugs relieve it. Finally, ask about any preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

    » READ BOOK EXCERPT ONLINE »

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

    Back pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If life-threatening causes of back pain are ruled out, continue with a complete history. Be aware of the patient’s expressions of pain as you do so.

    CULTURAL CUE:A patient’s cultural background may impact his response to pain. For example, a patient of Irish descent may have a stoic response. A Jewish patient or one of Italian descent may be more vocal. The Navajo patient may view pain as a way of life. A patient of Filipino descent may regard pain as a chance to atone for past transgressions.

    Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs as well as herbal remedies.

    » READ BOOK EXCERPT ONLINE »

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

    Breast pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it’s intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a nursing mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced any flulike symptoms or sustained any injury to the breast? Has she noticed any change in breast shape or contour?

    Ask your patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

    » READ BOOK EXCERPT ONLINE »

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

    Chest pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

    Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.

    » READ BOOK EXCERPT ONLINE »

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

    Eye pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

    » READ BOOK EXCERPT ONLINE »

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

    Facial pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin by characterizing the patient’s facial pain. Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or worsens it? Ask the patient to point to the painful area. If facial pain is recurrent, have the patient describe a typical episode. Review the patient’s medical and dental history, noting especially previous head trauma, dental disease, and infection.

    » READ BOOK EXCERPT ONLINE »

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

    Flank pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

    Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

    » READ BOOK EXCERPT ONLINE »

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

    Jaw pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Did it arise suddenly or gradually? Where on the jaw does he feel pain? Does the pain radiate to other areas?

    Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints.

    Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. Also ask about aggravating or alleviating factors.

    » READ BOOK EXCERPT ONLINE »

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

    Leg pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

    Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he’s taking and whether they have helped to relieve his leg pain.

    » READ BOOK EXCERPT ONLINE »

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

    Neck pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

    » READ BOOK EXCERPT ONLINE »

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

    Rectal pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

    Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

    » READ BOOK EXCERPT ONLINE »

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

    Throat pain: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

    » READ BOOK EXCERPT ONLINE »

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

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

    If the patient isn’t in distress, proceed with the medical 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?

    CULTURAL CUE:Patients of certain cultural backgrounds, such as Mexican-Americans, may need to establish a trusting relationship before discussing matters of a personal nature.

    » READ BOOK EXCERPT ONLINE »

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

    Abdominal Pain: Clinical Features and Diagnosis: Acute Abdominal Pain
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Neonates

    Colic

    Historically thought of as cause of abdominalpain but now conceptualized more broadly. See Chap. 11, Crying and Irritability.

    Necrotizing Enterocolitis

  • Infantsappear ill and usually have abdominal distension and often evidenceof GI bleeding.
  • Progression of illness commonly resultsin bowel infarction and often perforation.
  • See Chap.22, Gastrointestinal Bleeding).

    • Gastrointestinal Obstruction or Perforation of Any Viscus

  • Reasonableassumption is that neonates with GI tract obstruction or perforationof viscus have abdominal pain, which may be expressed by persistentcrying and irritability.
  • Vomiting and abdominal distension areprominent findings.
  • Common causes of obstruction in neonatesare pyloric stenosis, intestinal atresia, volvulus with malrotation,meconium ileus, and congenital aganglionic megacolon.
  • See Chap.55, Regurgitation and Vomiting.

    • Infants

    Gastroenteritis

  • Usual presentingfeatures are vomiting, diarrhea, abdominal pain, and fever.
  • Rotavirus is most common pathogen.Frequent bacterial pathogens include Salmonella, Shigella, and Campylobacterspecies.
  • Detection of rotavirus antigen in stoolby enzyme immunoassay is diagnostic. Positive stool culture is diagnosticof bacterial infection.
  • See Chap.14, Diarrhea.

    • Viral Illness

  • Many virusescan produce illnesses that may be accompanied by mild nonspecificabdominal pain. Some viruses produce disease in respiratory tractand include rhinoviruses, respiratory syncytial virus, parainfluenzaviruses, influenza viruses, and adenoviruses.
  • Illness is usually mild and self-limitedand resolves in 3–7 days.
  • Clinical findings include fever, rhinorrhea,cough, headache, anorexia, vomiting, mild sore throat, and myalgia.
  • Diagnosis is usually clinical; however,viral culture or polymerase chain reaction of nasal secretions canoften identify specific virus.

    • Incarcerated Inguinal Hernia

  • Common causeof intestinal obstruction.
  • Painful, tender mass is palpable ininguinal area with extension at times into scrotum.
  • Persistent vomiting, abdominal distension,and inability to reduce hernia suggest intestinal obstruction.
  • Surgery should be performed immediatelyif hernia cannot be reduced and bowel obstruction is suspected.If hernia can be reduced, surgery is usually planned in severaldays, after edema has diminished.

    • Intussusception

  • Clinicalfindings are intermittent abdominal pain, vomiting, abdominal mass,and currant jelly stools.
  • Not only is air-contrast enema diagnostic,but in many cases it also may be therapeutic.

    • Trauma, Including Child Abuse

  • Many abdominalinjuries are mild and cause only abdominal wall musculoskeletal pain.
  • More serious abdominal injuries includecontusion, laceration, or rupture of spleen, liver, kidney, or intestine.Pancreatic and major vessel injuries are less common.
  • Splenic injury causes tenderness andoccasionally splenic enlargement secondary to hematoma formation.CT is best method for diagnosing contusion, laceration, or ruptureof spleen.
  • With significant liver injury, serumaminotransferase levels are usually >3–5 timesnormal level. CT is the best method to determine type and degreeof liver injury.
  • Hematuria and flank pain may occurwith kidney injury. With history of mild trauma and possibilityof isolated renal injury, excretory urography may be performed.
  • If more serious injury has occurredwith possible involvement of other abdominal organs, CT is radiologicprocedure of choice. Elevated serum amylase level suggests pancreaticinjury, which can be delineated by CT.
  • Pelvic trauma may injure pelvis, bladder,urethra, or rectum.

  • Rectal exam should be performed to determinewhether rectal laceration has occurred.
  • Pelvic tenderness or pain may indicatepelvic fracture, which can be confirmed by plain radiography.
  • Bladder and urethral injuries may causesuprapubic pain and hematuria.
  • If blood is seen at meatus, prostateis higher than normal position, or there is evidence of scrotaltrauma, urethrography should be performed.
  • Child abuse should be suspected wheneverany unexplained injuries, burns, or fractures occur. Typical skinlesions include bruises in varying stages of healing, especiallyon face, back, chest and abdomen, and different types of scars indicativeof burns or trauma with various implements.
  • Stabilization of patient with significantabdominal trauma is first priority.
  • After history and physical exam, thefollowing tests should be performed:

  • CBC with differential
  • Analysis of serum electrolytes, glucose,creatinine, amylase, aspartate and alanine aminotransferases, andblood urea nitrogen
  • Radiography of chest and abdomen
  • Cervical spine and pelvic radiographyshould be performed if indicated. In serious cases, abdominal CTshould be considered because it is most efficient and effectivemethod to investigate significant abdominal trauma.

    • Other

    Less common causes of abdominal pain in infantsinclude appendicitis, cow milk protein sensitivity, lactose intolerance,GI obstruction, sickle cell pain episodes, lead poisoning, and neoplasms.

    Preschool Children

    Constipation

  • Definedas difficult and painful passage of hard stools.
  • Abdominal pain is usually intermittent,crampy, and generalized.
  • Stool may be palpable on abdominalor rectal exam.
  • After bowel movement, pain and palpablestool masses disappear.
  • See Chap.9, Constipation.

    • Urinary Tract Infection

  • Lower abdominal,suprapubic, or flank pain associated with dysuria suggests presenceof urinary tract infection.
  • Fever and vomiting are common findings.
  • Pyuria suggests diagnosis, which isconfirmed by positive urine culture.
  • See Chap.15, Dysuria.

    • Pneumonia

  • May producereferred epigastric or periumbilical abdominal pain, especiallyif inflammation occurs in lower lobes of lung.
  • Fever, cough, tachypnea, and pleuriticpain suggest its presence.
  • Chest radiography is usually confirmatory.
  • See Chap.10, Cough.

    • Lactose Intolerance

  • Common inpreschool and school-aged children, especially African-Americanand Hispanic children.
  • Clinical manifestations include diarrheaand recurrent abdominal pain in those individuals who have low lactaseactivity and who ingest large amounts of lactose-containing products.
  • See Chap.14, Diarrhea.

    • Sickle Cell Pain Episodes

  • Vasoocclusiveepisode may cause mild-to-severe abdominal pain. Chest, back, and extremitypain also may occur.
  • Diagnosis can be confirmed by Hgb electrophoresis.

    • Food Poisoning

  • Resultsfrom ingestion of food contaminated with bacteria.
  • Crampy abdominal pain, diarrhea, andvomiting are typical features.
  • Recovery usually occurs in 1–2days.
  • History and physical exam suggest diagnosis.Positive stool culture or culture of suspected contaminated foodconfirms diagnosis.
  • See Chap.14, Diarrhea.

    • Diabetic Ketoacidosis

  • Can be initialpresentation of insulin-dependent diabetes mellitus.
  • Omission of insulin, acute illness,and emotional stress can be predisposing factors to diabetic ketoacidosis.
  • History of polyphagia, polydipsia,and polyuria of <1 mo's duration is usually found.Mild nonspecific abdominal pain and vomiting also may occur.
  • Kussmaul respirations are compensatoryphenomena of severe metabolic acidosis.
  • Severe illness may produce alterationin mental status that ranges from drowsiness to coma.
  • Presence of glucosuria, ketonuria,hyperglycemia, and metabolic acidosis confirm diagnosis.

    • Gastrointestinal Obstruction

  • Should besuspected with presence of persistent bilious vomiting and abdominal pain.
  • In this age group, common causes includeincarcerated inguinal hernia and surgical adhesions.

    • Henoch-Schönlein Purpura

  • Common causeof vasculitis in childhood.
  • Characterized by purpuric rash on buttocksand lower legs, abdominal pain, GI bleeding, transient migratoryarthritis of large joints, and hematuria.
  • Diagnosis is usually clinical.
  • See Chap.28, Hematuria.

    • Neoplasm

  • Wilms tumor,neuroblastoma, and lymphoma usually present with abdominal masses, butabdominal pain also may occur, especially with Wilms tumor.
  • See Chap.1, Abdominal Masses.

    • Drugs and Toxins

  • Acute ingestionof significant amounts of alcohol, iron, lead, or aspirin may produce abdominalpain.
  • History and measurement of toxic agentin blood are diagnostic.

    • School-Aged Children and Adolescents

  • Common causesof abdominal pain in this age group are gastroenteritis, viral illness, constipation,urinary tract infection, pneumonia, trauma, and sickle cell disease,as discussed previously.
  • Functional abdominal pain, which isusually chronic, is discussed below.

    • Acute Appendicitis

  • Occurs mostcommonly between 5 and 15 yrs of age but can occur in children <2 yrs.
  • First clinical manifestation is usuallycrampy periumbilical pain with shift in pain to right lower quadrantduring next few hours and is due to irritation of parietal peritoneumby small amount of fluid from inflamed appendix.
  • Location of appendix determines locationof pain.
  • Retrocecal appendix may irritate psoasmuscle; retrocolic appendix may cause pain in right flank.
  • Pelvic appendix may produce mild abdominalpain yet distinct tenderness on rectal exam.
  • Irritation of rectosigmoid colon byinflammatory fluid may cause mild diarrhea; irritation of uretermay cause dysuria.
  • Low-grade fever usually occurs withnonperforated appendix, whereas perforation usually produces sickerchild with higher fever, more vomiting, and more severe abdominalpain because of peritonitis or a localized abscess. Abdomen is distendedand tender, and signs of septic shock may be present. Children <2yrs are more likely to present with peritonitis and septic shock.
  • Abdominal findings depend on when childis seen during course of illness. Early in illness, right lowerquadrant tenderness may be found. With progression of illness, involuntaryspasm and rebound tenderness occur.
  • Child favors right side of abdomenand walks bent over. Climbing up on exam table, coughing, or jumpingup and down aggravate pain and indicate peritoneal inflammation.
  • Leukocytosis is common.
  • Results of UA either are normal orshow pyuria because of inflammation of ureter.
  • Abdominal radiography may occasionallyshow fecalith, edema of lateral abdominal wall, concave lumbar scoliosis,dilated cecum with air-fluid level, or localized ileus in rightlower quadrant.
  • Diagnosis is usually clinical. Otherstudies are unnecessary if findings are characteristic
  • In equivocal cases, abdominal U/Sor CT may be helpful.
  • With suspected appendicitis, surgeryshould be performed, as it is only definitive way to confirm diagnosis.
  • Appendiceal colic can cause recurrentepisodes of acute right lower quadrant pain. Drinking fluids oreating usually exacerbate the pain within 5–15 mins. Findingof maximum tenderness at McBurney point is evidence for this disorder.No lab tests are diagnostic.
  • Resolution of pain after removal ofappendix is confirmatory.

    • Peptic Ulcer Disease

  • May occurin stomach or duodenum.
  • Ulcer development is related to gastritiscaused by Helicobacter pylori.
  • Secondary ulcers usually occur in stomachand may be due to septicemia, burns, head injury, or NSAIDs.
  • Abdominal pain typically occurs inepigastric area and can awaken individual from sleep.
  • In many cases, food or antacids relievepain.
  • Vomiting and GI bleeding (heme-positivestools, hematemesis, melena) also may occur.
  • Physical exam can be normal or revealepigastric tenderness.
  • Method of choice to identify ulceris endoscopy.

    • Biliary Tract Disease

    Acute Cholecystitis

  • Usuallyrelated to presence of gallstones.
  • Clinical findings include right upperquadrant pain, vomiting, and low-grade fever. Enlarged gallbladdermay be palpable in right upper quadrant.
  • Abdominal U/S usually showsgallstones and thickened gallbladder wall.
  • Cholescintigraphy may be performedif individual is obese or has gas-filled loops of bowel.

    • Biliary Colic

  • Resultsfrom acute obstruction of cystic or common bile duct, usually by stone.
  • Pain is in right upper quadrant orepigastric region.
  • Associated symptoms often include nausea,vomiting, and jaundice.
  • Plain abdominal radiograph may showstones in some cases; otherwise, abdominal U/S is usuallydiagnostic.

    • Pancreatitis

  • Common causesinclude viral infection, blunt trauma, cystic fibrosis, and idiopathic etiologies.
  • Abdominal pain is usually epigastricand can range from mild to severe. Eating usually aggravates thepain.
  • Other clinical findings include fever,anorexia, nausea, and vomiting. Epigastric tenderness may be foundon exam. Serum amylase and lipase concentrations are usually increased.
  • Abdominal U/S and CT are usefulin demonstrating any abnormalities of pancreas.

    • Obstructive Uropathy

  • Any typeof obstructive uropathy may produce abdominal pain.
  • Most common type is ureteropelvic junctionobstruction, which may present with abdominal pain or recurringattacks of flank pain along with nausea and vomiting.
  • Various tests may be used to evaluateurinary tract obstruction including renal U/S, voiding cystourethrography,intravenous urography, and diuretic renography.

    • Urolithiasis

  • Characterizedby acute flank pain and hematuria.
  • At time of presentation, excretoryurography is useful for diagnosis of radiolucent stones and demonstrationof level of obstruction.
  • See Chap.28, Hematuria.

    • Intraabdominal Abscess

  • May occurwith localization of inflammatory process within abdominal cavity.
  • Common causes in pediatric populationare appendiceal abscesses.
  • Tender mass may be palpable on rectalexam with pelvic abscess. Leakage of abscess usually produces seriousillness with associated gram-negative septicemia.
  • Abdominal U/S or CT is usuallydiagnostic.

    • Primary Bacterial Peritonitis

  • May be associatedwith infection of preexisting ascites, which may be associated with nephroticsyndrome or chronic liver disease.
  • May occur spontaneously without anyprior underlying disease process.
  • S. pneumoniae, S. pyogenes, and gram-negativeenteric bacteria (e.g., E. coli) are common pathogens.
  • Usual clinical findings are fever,abdominal pain, and tenderness, especially with movement (coughing,jumping up and down). Vomiting and abdominal distension also mayoccur.
  • Paracentesis with Gram stain and cultureof fluid may reveal pathogen.

    • Other

  • For inflammatorybowel disease, see Chap. 14,Diarrhea.
  • For hepatitis, see Chap. 36, Jaundice.

    • Adolescent Girls

    Primary Dysmenorrhea

  • Common problemin adolescence.
  • Crampy lower abdominal pain usuallybegins 1–3 yrs after onset of menarche.
  • Occurs with menses or 1–2days before menses and may last a few hours or several days. Nausea,vomiting, headache, lower backache, thigh pain, nervousness, anddizziness also may occur.
  • Usually diagnosis of exclusion.

    • Mittelschmerz

  • Definedas lower abdominal pain that occurs at menstrual mid-cycle and lastsminutes, several hours, or (rarely) 2–3 days.
  • Pain may be due to spillage of fluidfrom follicular cyst during ovulation, which irritates peritoneum.
  • Timing of pain provides most importantdiagnostic clue.

    • Pelvic Inflammatory Disease

  • N. gonorrhoeaeand C. trachomatis are most common pathogens.
  • Clinical manifestations include vaginaldischarge, lower abdominal pain, cervical motion tenderness, adnexaltenderness, and fever. Occasionally, mass (abscess) may be palpablein adnexa or cul-de-sac.
  • Positive cervical culture is diagnostic.Laparoscopy may be necessary to confirm chronic disease.

    • Ovarian Disorders

  • Bleedinginto ovarian cyst or rupture of cyst may cause acute lower quadrantpain and tenderness.
  • Pain usually disappears within a dayafter rupture of physiologic cyst, whereas pain, nausea, vomiting,and fever may persist with other cysts.
  • Abdominal U/S may be diagnostic;otherwise, diagnosis may be confirmed by laparoscopy or at timeof surgery.
  • Torsion of ovarian cyst or fallopiantube (less common) may produce unilateral lower abdominal pain andpalpable mass.
  • In older children and adolescents,torsion is more likely with ovarian tumor. Other findings includenausea, vomiting, and fever.
  • Abdominal U/S usually demonstratescyst or tumor.

    • Endometriosis

  • Definedas presence of endometrial glands and stroma outside normal locationof uterine lining.
  • Usual presenting feature is pelvicpain, which may be cyclic or acyclic.
  • Pelvic exam in adolescents usuallyreveals mild-to-moderate tenderness rather than nodules or massesoften found in adult women.
  • If trial of NSAIDs followed by cyclicoral contraceptives fails to relieve pain, laparoscopy with biopsyshould be performed to confirm diagnosis.

    • Genital Malformations with Obstruction

  • Uterineand vaginal malformations that cause obstruction of genital tractmay produce pelvic pain, which is often chronic.
  • Lesions include imperforate hymen,transverse vaginal septum, vaginal or cervical atresia, and noncommunicatinguterine horn.
  • Pelvic U/S and MRI are usefulin defining anatomy of these lesions.

    • Complications of Pregnancy

  • Crampy abdominalpain and mild uterine bleeding are common findings with threatenedabortion. History usually includes ≥1 missed menstrual cycles.Internal os is closed, and no tissue has been expelled.
  • With incomplete abortion, uterine bleeding,painful uterine contractions, and passage of tissue fragments areusual findings. Presence of fever and pelvic pain during any stageof spontaneous or induced abortion suggests a septic abortion.
  • Any female with delayed menstrual period,lower abdominal pain, and abnormal vaginal bleeding should be suspectedof having ectopic pregnancy. There may be no history of missed menstrual periodor abnormal bleeding. Results of hCG urine pregnancy test are usuallypositive.
  • Pelvic U/S may be helpfulin demonstrating presence of ectopic pregnancy.
  • Positive culdocentesis with nonclottingblood also suggests ectopic pregnancy.
  • Laparoscopy or laparotomy confirmsdiagnosis.

    • Diagnostic Approach: Acute Abdominal Pain

  • Completehistory and reliable physical exam are far more valuable than anylab test or radiograph in diagnosis.
  • Ability of physician to make diagnosislargely depends on consideration of all possibilities, knowledgeof how they present, and planned orderly approach.
  • Age, type of onset, character and locationof pain, and associated findings are useful in diagnosis.
  • Abdominal pain of sudden onset is mostlikely to occur with intussusception, perforation of viscus, ortorsion of fallopian tube or ovary. Pain of gradual onset usuallyoccurs with appendicitis, pancreatitis, and cholecystitis. Severeintermittent pain may occur with gastrointestinal, genitourinary,or biliary tract obstruction.
  • Pain of peritonitis is diffuse, constant,and exacerbated by movement.
  • More recurrent or chronic pain usuallyoccurs with constipation, sickle cell pain episodes, and inflammatorybowel disease.
  • Lesions of stomach, duodenum, pancreas,and biliary tract commonly cause epigastric pain. Small bowel andproximal colon lesions usually produce umbilical pain. Distal colonlesions may cause hypogastric pain, whereas rectal lesions may producesacral pain.
  • Irritation of diaphragm may cause shoulderpain, and gallbladder disease may produce pain at right scapula.
  • Lesions involving ureter or femalegenital tract may produce lower abdominal and pelvic pain.
  • Most important diagnostic goal is todistinguish abdominal pain that may be life threatening.

  • 2 clinicalcircumstances represent potentially serious disease and requireimmediate investigation: (a) abdominal pain associated with biliousvomiting, persistent vomiting, or abdominal distension, and (b)abdominal pain associated with either localized or diffuse reboundtenderness. Very few clinical problems require such urgent operativeintervention that orderly approach needs to be abandoned. Only exceptionis massive exsanguinating hemorrhage.
  • Children in whom the diagnosis is uncertainshould be admitted to hospital and observed.

  • Period of active observation is extremeimportance and is safe.
  • Most causes can be diagnosed at thebedside by careful and often repeated clinical observations.
  • Initial lab tests are CBC with differential,UA, urine culture, analysis of stool for blood, ESR, chest and abdominalradiography, and abdominal U/S.
    • '>'>>

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Back Pain: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Congenital

  • Congenitalspine anomalies, including absence of lumbar pedicle, spinal fusion,or spinal stenosis, are unusual causes of back pain.
  • Plain radiographs are useful for diagnosis.In some cases, MRI is necessary for diagnosis.

    • Developmental

    Scoliosis

    Idiopathic scoliosis may be associated withmild back pain, particularly after long activity. When scoliosisis associated with more severe back pain, other underlying disordersshould be considered (e.g., infection, herniated disc, spondylolysis,spondylolisthesis, and tumor).

    Scheuermann Disease

  • Disorderof unknown cause that usually occurs in older children and adolescentsinvolved in athletics.
  • Most common site is thoracolumbar area,although thoracic or lumbar spine may be affected alone. Pain isusually worse with forward flexion and relieved by rest.
  • Spine radiographs show increased kyphosiswith anterior wedging of ≥1 vertebrae, irregular vertebral endplates, and disc herniation upward or downward into adjacent vertebra(Schmorl node).

    • Trauma

    Musculoskeletal

  • Muscle strainis common cause of back pain and is usually result of improper conditioning,heavy lifting, overuse in sport-related activity, or contusion.
  • History of trauma followed by spasmof paraspinous muscles and limited range of motion of spine suggestdiagnosis. Tenderness over vertebrae may indicate fracture.
  • Although spine radiographs are usuallydiagnostic, some fractures may not be visible, and technetium bonescan can be useful in localization of occult fracture.

    • Herniated Disc

  • Most commonin individuals who participate in vigorous athletic activities.
  • Trauma is often predisposing factor.
  • Most commonly involved discs are thosebetween L4 and L5 and L5 and S1.
  • Intermittent or constant lower backor buttock pain with radiation down the leg is most common presentation.Limp and disturbed gait are frequent findings.
  • Sneezing, coughing, or laughing mayaggravate pain.
  • There is limitation of movement oflumbosacral spine and often spasm of paraspinous muscles.
  • Straight leg raising test is usuallyabnormal.
  • Decreased sensation in L4–S1dermatome and motor weakness are variable findings.
  • MRI confirms diagnosis.

    • Spondylolysis

  • Definedas fracture of pars interarticularis of vertebral arch, which occursprimarily in older children and adolescents, especially in thoseparticipating in gymnastics, dance, or weight lifting.
  • Usual location is lumbar spine, andless commonly thoracic spine.
  • Pain is especially aggravated by extensionmovements of leg. There is localized tenderness and limited rangeof motion of spine.
  • Plain radiographs usually demonstratedefect.

    • Spondylolisthesis

  • Involvessame defect as spondylolysis, but there is also forward slippageof 1 vertebra on the other, usually L5 on S1.
  • Plain radiographs are usually diagnostic.

    • Slipped Vertebral Epiphysis

  • Posteriorrim of inferior epiphysis, usually L4, and adjacent disc are displacedinto spinal canal.
  • Pain usually occurs after heavy lifting.
  • Diagnosis may be confirmed by plainradiographs or CT.

    • Spinal Epidural Hematoma

  • May occurafter a fall, another injury, or spontaneously in children withbleeding disorders.
  • Pain is usually followed by signs ofspinal cord compression.
  • CT or MRI is diagnostic.

    • Infection/Inflammation

    Discitis

  • Thoughtto result from bacterial or low-grade viral infection and usuallyoccurs in preschool or school-age children.
  • Most common sites of infection aredisc spaces in lumbar region.
  • Affected children may have low back,hip, or lower abdominal pain; limp or reluctance to walk; and sometimesfever. Localized tenderness over involved disc space, spasm of adjacentmuscles, and pain with straight leg raising are usually found.
  • Early in course of illness, plain radiographsare normal; later, they show narrowing of disc space with irregularerosions and sclerosis of vertebral end plates. Nuclear scintigraphyshows increased uptake in vertebral bodies on each side of involveddisc space. CT or MRI may be useful in atypical or questionablecases by confirming presence of disc space narrowing and vertebralend-plate destruction.
  • Although controversy exists about whetherdisc space aspirate should be performed, in some cases S. aureuscan be cultured from disc space aspirate or blood.

    • Disc Space Calcification

  • Rare lesionin pediatric population. Although pathogenesis is uncertain, itmay follow nonspecific inflammatory reaction of disc space. Mostcommonly involved area is cervical spine.
  • There is cervical or thoracic pain,localized tenderness over disc space, muscle spasm, and occasionalfever.
  • Plain radiographs show calcification.

    • Osteomyelitis

  • Most commonpathogen causing osteomyelitis of spine is S. aureus. Other pathogens includeS. pneumoniae, group A Streptococcus, E. coli, P. aeruginosa, andSalmonella species.
  • Localized back pain, tenderness overinvolved vertebrae, restriction of spine motion, and fever are commonfindings. There is usually leukocytosis and increased sedimentationrate.
  • Plain radiographs may be normal earlyin course of illness, but after about 10 days, radiologic findingsinclude disc space narrowing, decreased height of vertebra, andsclerotic/lytic lesions of vertebral body, pedicles, orneural arches. Extension into soft tissues can produce paravertebralmass. Nuclear scintigraphy usually shows increased uptake earlyin illness.
  • Bone aspirate or biopsy may revealpathogen, and blood cultures also may be positive.

    • Tuberculosis of Spine

  • Much lesscommon than pyogenic infection.
  • Thoracic spine is most common siteof involvement, with pain radiating to intercostal areas. Involvementof cervical spine may produce neck pain and torticollis, whereaslumbar spine involvement may produce lower back pain and limp. Feveralso may occur.
  • Plain radiographs show destructionand collapse of vertebrae with narrowing of disc spaces.
  • Involvement of spinal cord at any levelmay produce extremity weakness.
  • Diagnosis should be considered in childrenwho have history of exposure or who live in endemic area and whohave persistent back or neck pain.
  • CBC, sedimentation rate, chest radiograph,Mantoux test, early morning gastric aspirates, and bone biopsy foracid-fast bacilli and culture should be performed.

    • Iliac Osteomyelitis

  • Uncommoninfection.
  • Clinical manifestations include lowback pain, fever, and tenderness over ilium.
  • Nuclear scintigraphy shows increaseduptake. Bone aspirate or biopsy is diagnostic.

    • Sacroiliac Joint Infection

  • Most commonpathogen is S. aureus. Prior pelvic fracture is risk factor.
  • Usually presents with pain in lowerback, hip, or buttock; limp; and fever. Flexion, abduction, andexternal rotation of leg cause sacroiliac pain if joint is involved.
  • Plain radiographs may be normal earlyin illness, but within 10 days, lytic and sclerotic changes of bonemargins and widening of joint space are usually seen. Nuclear scintigraphyshows increased uptake in affected bone.
  • Aspiration or open biopsy is usuallyrequired to establish specific diagnosis. Blood culture also mayreveal pathogen.

    • Juvenile Rheumatoid Arthritis

  • Can affectthe spine at any level and cause persistent back pain and decreasedrange of motion. Most commonly involved area is cervical spine.
  • Plain radiographs of cervical spinemay show atlantoaxial displacement, ankylosis of apophyseal joints,and narrowing of disc spaces.
  • See Chap.37, Limp

    • Ankylosing Spondylitis

  • Disorderof unknown cause that primarily affects boys >8 yrs.
  • Most common feature is arthritis oflower extremity joints, which may include hips, knees, ankles, andfeet. Back pain and limitation of motion of lumbosacral spine orsacroiliac joints also can occur.
  • Diagnostic clue is presence of enthesitis,especially involving heel.
  • Plain radiographs of lumbosacral spineand sacroiliac joints may show changes consistent with sacroiliitis.
  • Slit-lamp exam should be performedbecause uveitis can occur.
  • HLA-B27 antigen is positive in about90% of cases. Antinuclear antibody and rheumatoid factorare usually negative.

    • Spinal Epidural Abscess

  • Rare infectionin childhood that can be acute or chronic.
  • Most common pathogen is S. aureus.Predisposing factors include local wound infection, decubitus ulcer,or spine surgery.
  • Back pain, localized spine tenderness,tender spinal mass, and fever are common findings. Lumbosacral involvementmay produce buttock and leg pain with leg weakness, impaired sensation,decreased deep tendon reflexes, and impaired bowel and bladder function.
  • Radiographs of spine are usually normalbut sometimes show evidence of osteomyelitis. CT or MRI may be diagnostic.
  • Diagnosis is confirmed at surgery.

    • Sickle Cell Disease

  • Back painmay occur in sickle cell vasoocclusive episode and is usually musculoskeletalin origin. Infarction of posterior ribs or vertebrae may cause backpain and bone tenderness.
  • Can usually be demonstrated by bonescintigraphy.

    • Neoplasm

  • Tumors ofthe spine or spinal cord are uncommon in pediatric population.
  • Clinical features include persistentpain sometimes waking child during night, sciatic pain, painfulscoliosis, localized tenderness, palpable mass, lower extremityweakness, sensory changes, and bowel or bladder disturbances.
  • Histologic diagnosis is necessary exceptfor perhaps osteoid osteoma.

    • Vertebral Tumors

  • Most commonbenign tumor of spine is osteoid osteoma.

  • Pain often awakens child from sleep.
  • Localized tenderness and scoliosisalso may occur.
  • Spine radiograph shows small radiolucentarea surrounded by sclerosis.
  • Osteoblastoma has same histology asosteoid osteoma but is larger.
  • Aneurysmal bone cyst may affect posteriorelements of spine, vertebral bodies, or ribs, causing pain and sometimespalpable mass.

  • Commonlyoccurs in adolescence.
  • Spine radiograph shows cyst with finetrabeculae and thin cortex.
  • MRI shows extent of tumor and any neuralcompression.
  • Eosinophilic granuloma commonly presentswith persistent thoracic back pain in adolescence. Radiographs showcircumscribed area of osteolysis and any vertebral collapse.
  • Most common primary malignant bonetumors affecting spine are osteogenic sarcoma and Ewing sarcoma.Common metastatic lesions include neuroblastoma, Wilms tumor, leukemia,and lymphoma. Usual findings are persistent pain, bone tenderness,fever, and weight loss. Spine radiographs, nuclear scintigraphy,CT, and MRI are useful in locating and defining the extent of thetumor.

    • Intraspinal Tumors

  • May arisewithin spinal cord (astrocytoma, ependymoma), within dura but outside spinalcord (neurofibroma, lipoma, dermoid), and outside dura (commonly,extension of paravertebral neuroblastoma).
  • May present with spinal pain with radiationto specific dermatome, leg or arm weakness, limp or difficulty walking,and bowel or bladder disturbance. Clinical findings include weaknessor spasticity of extremities, decreased sensation, pathologic reflexes,relaxation of anal sphincter, and scoliosis.
  • Spine radiographs are useful, but CTand MRI help locate and define extent of lesion.

    • Referred Pain

  • Infection/inflammationor mass in abdominal, thoracic, retroperitoneal, or pelvic regionscan cause referred back pain. Examples are pneumonia, pyelonephritis,pancreatitis, appendicitis, cholecystitis, and hydronephrosis.
  • History and physical exam suggest thesediagnoses, which are discussed in other chapters.

    • Psychogenic

  • Back paincan be due to anxiety, depression, hypochondriasis, or conversionreaction.
  • Pain is nonspecific and nonlocalizing.
  • Physical and neurologic exams, CBC,sedimentation rate, and spine radiographs are normal.
  • Psychosocial history provides cluesto diagnosis.

    • Diagnostic Approach

  • History,physical exam, and spine radiographs are usually diagnostic of congenital spineanomalies, fractures, Scheuermann disease, spondylolysis, and spondylolisthesis.
  • MRI is procedure of choice to confirmdiagnosis of herniated disc.
  • Fever usually occurs with inflammatorydisorder or infection affecting spine. When fever accompanies backpain, CBC and erythrocyte sedimentation rate should be performed.
  • Nuclear scintigraphy is useful, especiallywith suspected osteomyelitis, discitis, or sacroiliac joint infection.
  • Aspirate or biopsy of lesion shouldbe strongly considered with suspected osteomyelitis. Blood culturemay reveal organism, but yield is often low.
  • Spine radiographs are useful in diagnosisof vertebral spine and intraspinal masses.
  • CT and MRI are valuable in diagnosingtumors as well as spinal epidural abscess.
  • For all tumors except possibly osteoidosteoma, histologic exam is necessary for diagnosis.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Chest Pain: Clinical Features and Diagnosis
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Musculoskeletal Disorders

    Muscle

    Trauma

  • Normal activitycan strain chest wall musculature.
  • Participation in athletics or overexertionalso may injure specific muscle groups of chest wall.
  • Blunt trauma from accidents, athleticinjuries, or physical abuse can cause chest wall contusions.

    • Stitch

  • Definedas sharp pain occurring in upper quadrants of abdomen under costalmargin during strenuous activity.
  • Resolves when exercise is over.
  • Stress on peritoneal ligaments is thoughtto be the cause.

    • Precordial Catch

  • Also calledTexidor twinge and defined as benign self-limited disorder of unknown cause.
  • Characterized by acute onset of sharppain, usually localized over cardiac apex and occurring at restor with mild activity.
  • Usually lasts up to 1 min but may befollowed by dull ache.
  • Deep inspiration may aggravate pain.

    • Sickle Cell Pain Episodes

    Chest pain can occur during vasoocclusiveepisode and usually involves muscle ache.

    Bone/Cartilage

    Trauma

  • Accidentalor nonaccidental trauma may produce rib fractures.
  • Localized bone tenderness suggestsrib contusion or fracture.
  • Chest radiography should be performed.

    • Costochondritis

  • Common causeof chest pain in adolescence.
  • Localized pain and tenderness occurover the affected costochondral junction. Left fourth and fifthjunctions are most commonly involved.

    • Sickle Cell Disease (Thoracic Bone Infarction)

  • Chest painmay occur as result of thoracic bone infarction that may affectribs, sternum, or vertebrae.
  • Nuclear scintigraphy can demonstrateinfarction.

    • Slipping-Rib Syndrome

  • Pain isthought to arise from eighth, ninth, or tenth ribs overriding theone above.
  • Diagnosis may be confirmed by graspingcostal margin and pulling anteriorly to reproduce pain (hookingmaneuver). Same maneuver may produce palpable click as cartilagesslip over one another.

    • Tietze Syndrome

  • Syndromeof unknown cause characterized by swelling at right sternoclavicularor second sternochondral junction.
  • Pain may last for weeks with frequentremissions and exacerbations.

    • Osteomyelitis

  • Localizedpain and tenderness along with fever characterize osteomyelitisof sternum or rib.
  • S. aureus is most common pathogen.
  • Nonspecific lab findings are leukocytosisand increased erythrocyte sedimentation rate.
  • Although chest radiograph may be normalearly in illness, nuclear scintigraphy reveals localized uptakeof radionuclide.
  • In 10–14 days, chest radiographyshows periosteal bone formation and destructive lesions.
  • Bone aspiration or biopsy is usuallydiagnostic.

    • Neoplasm

  • Bone tumorsof chest wall are rare; however, neoplastic disease may cause localized ribor sternal pain.
  • Acute lymphoblastic leukemia may involvesternum or ribs. Chest pain is not infrequent during course of thisillness but is rarely presenting symptom. Metastatic neuroblastomaalso may cause bone pain.
  • See Chap.1, Abdominal Masses and Chap. 38, Lymphadenopathy.

    • Trachea and Proximal Bronchi Disorders

  • Tracheobronchialpain usually occurs in neck or chest where inflammation is.
  • See Chap.10, Cough.

    • Parietal Pleura Disorders

    Intercostal nerves conduct pain impulsesfrom parietal pleura to spinal cord.

    Pneumonia

  • Most commoncause of pleuritic chest pain is pneumonia.
  • Pain is localized, sharp, stabbing,and knifelike and usually occurs with inspiration. Shallow breathsminimize pain, whereas laughing and coughing aggravate it. Pleuralfriction rub indicates pleural involvement.
  • Chest radiograph shows infiltrate andsometimes pleural effusion.
  • See Chap.10, Cough).

    • Pleurodynia

  • Self-limitedillness usually caused by enteroviral infection.
  • Fever and paroxysms of sharp chestpain without evidence of pneumonia are usual presenting clinicalfeatures. Pain usually subsides within 1 wk.
  • Positive pharyngeal viral culture or4-fold increase in antibody titer is diagnostic.

    • Empyema

  • Definedas presence of pus in pleural space and usually occurs from extensionof bacterial pneumonia.
  • Most common pathogen in pediatric populationis S. pneumoniae.
  • High spiking fever, respiratory distress,and occasional chest pain characterize empyema. Usually no breathsounds are heard over affected area.
  • Chest radiograph shows effusion, butthoracentesis must be performed for specific diagnosis. Analysisof fluid should include white cell and differential counts; Gramand acid-fast stains; protein; glucose; and aerobic, anaerobic,fungal, and acid-fast cultures.

    • Pneumothorax

  • Definedas accumulation of air in pleural space.
  • Common causes include penetrating woundsof chest, rib fracture, positive pressure ventilation, pneumonia,cystic fibrosis, and idiopathic.
  • Although chest pain is acute, unilateral,and severe, degree of respiratory distress depends on how largepneumothorax is. Large pneumothorax results in hyperresonance topercussion on involved side.
  • Chest radiography is diagnostic.

    • Hemothorax

  • Definedas collection of blood in pleural space.
  • Most common cause is trauma, surgicalor nonsurgical.
  • Degree of respiratory distress dependson size of hemothorax. Decreased breath sounds and dullness to percussionover affected side of chest usually occur.
  • Chest radiograph that shows collapseof lung surrounded by opacification suggests presence of hemothorax.
  • Diagnosis is confirmed by thoracentesis.

    • Pneumomediastinum

  • Definedas presence of air or gas in mediastinum that can cause acute, severechest pain that may be referred to back, shoulders, and neck.
  • Palpation of subcutaneous air in softtissues of chest wall or neck signifies presence of mediastinalemphysema.
  • Common causes include pneumothoraxwith dissection of air into mediastinum, asthma, cystic fibrosis,and chest trauma with disruption of tracheobronchial tree.
  • Chest radiography is diagnostic.

    • Postpericardiotomy Syndrome

  • Thoughtto be immunologic reaction associated with introduction or reactivationof virus at time of intrapericardial surgery.
  • Usually occurs 1–3 wks aftersurgery in children >2 yrs.
  • Clinical manifestations include fever,chest pain, pericardial and pleural effusions, and sometimes pulmonaryparenchymal disease. Sharp or dull pain is precordial in locationand worsens with inspiration and lying down. Pleural and pericardialfriction rubs may be heard, unless there are significant effusions.
  • Pericardial effusions can be life threateningif they are large.
  • Serum may be positive for antiheartantibody.
  • Average duration of illness is 2–3wks, but recurrences sometimes occur months or years later.

    • Pulmonary Embolism

  • Definedas thrombus or any foreign material (e.g., air or fat) in pulmonaryarteries that causes obstruction of pulmonary blood flow.
  • Risk factors in pediatric populationinclude deep venous thrombosis, central venous catheter, prolongedimmobilization, ventriculoatrial shunt, right-sided endocarditis,intravenous drug use, septicemia, and severe dehydration.
  • Chest pain associated with pulmonaryembolism is acute and can be pleuritic or nonpleuritic. Usuallyassociated with dyspnea. Other findings include sweating, nausea,vomiting, palpitations, syncope, and anxiety.
  • Physical exam commonly reveals tachycardia,dyspnea or tachypnea, and fever. Other findings include crackles,wheezes, pleural friction rub, prominent RV impulse, accentuatedpulmonary closure sound, S4 gallop, systolic ejection murmur alongsternal border, hepatomegaly, and edema.
  • Chest radiograph is normal or showsconsolidation, atelectasis, or pleural effusion.
  • ECG findings include ST-segment orT-wave changes in right precordial leads and RV hypertrophy.
  • Pulmonary isotope lung perfusion scanthat shows bilateral segmental defects strongly suggests presenceof pulmonary emboli, whereas normal scan effectively excludes pulmonaryemboli. If scan is abnormal, ventilation (xenon) scan should beperformed. With pulmonary emboli, perfusion scan should be abnormaland ventilation scan normal.
  • MRI also may be useful in diagnosisof pulmonary embolism. If diagnosis is still uncertain, pulmonaryangiogram is best way to establish presence of pulmonary embolism.

    • Neoplasm

  • Primarychest neoplasms are rare in children.
  • Chest pain is usually secondary topleural metastases, which can occur with Wilms tumor, osteogenicsarcoma, neuroblastoma, or rhabdomyosarcoma.
  • Chest radiography may show mass ormetastases.
  • Chest CT locates and defines extentof mass or metastases.
  • Histologic diagnosis is definitive.

    • Cardiac Disorders

  • Cardiacdisorders that cause chest pain usually produce myocardial ischemiaor inflammation of parietal pericardium.
  • Middle and inferior cardiac nervesconduct myocardial pain impulses to upper thoracic rami, sympatheticchain, and spinal cord. Pain impulses from upper parietal pericardiumtravel along intercostal nerves, and those from lower pericardiumtravel along phrenic nerves and then to spinal cord.

    • Myocardial Ischemia Including Infarction

  • Myocardialischemia causes angina, which has been described as gripping, crushing, sharp,knifelike pain in retrosternal or left chest areas that usuallyfollows exercise or exertion and is relieved by rest. Pain may betransmitted to neck, shoulder, arm, or back. In some cases, myocardialinfarction may occur. Tachypnea, tachycardia, gallop rhythm, sweating,nausea, and vomiting are common findings.
  • Causes of myocardial ischemia includesevere aortic stenosis, coronary artery anomalies (including anomalouscoronary artery from pulmonary artery), myocarditis, cardiomyopathy,Kawasaki disease, familial dysproteinemias, and cocaine use.
  • ECG changes may indicate myocardialischemia or injury. ECG leads overlying subepicardial or transmuralischemic area show inverted T waves. Symmetric tall peaked T wavesare seen in leads overlying subendocardial ischemic area. Leadsoverlying subendocardial injury show ST depression with concaveor flat contour, whereas those overlying subepicardial injury showST elevation with upwardly convex or concave contour. Within hoursto days of myocardial infarction, Q waves and inverted T waves appearin leads overlying infarction.
  • 2-D echocardiogram may show local orgeneralized myocardial dysfunction.
  • Elevation of creatine kinase MB fractionor troponin T is usually found with destruction of myocardial tissue.
  • Nuclear scintigraphy of myocardiummay show decreased local uptake.
  • Cardiac catheterization and angiographyare necessary in some cases for definitive diagnosis.

    • Pericarditis

  • Most commoncauses in children are viral infection, acute rheumatic fever, andpostpericardiotomy syndrome. Less common are purulent pericarditis,uremia, systemic lupus erythematosus, juvenile rheumatoid arthritis,and radiation therapy.
  • Triad of fever, chest pain, and pericardialfriction rub signify pericarditis.
  • Chest pain is usually acute and substernalwith radiation to neck, shoulders, and arms. Sitting up and leaningforward eases pain, whereas deep breathing, coughing, and lyingdown aggravate it.
  • ECG shows elevated ST segments in nearlyall leads that progress to T-wave flattening and inversion in someof the leads, which may persist for months after acute lesion hasresolved.
  • 2-D echocardiography commonly revealspericardial effusion.

    • Mitral Valve Prolapse

  • Associationof chest pain and mitral valve prolapse has been seriously questioned, bothin adults and children. Mechanism of pain, which is ill definedand usually nonexertional, is uncertain. Other causes of chest painshould be considered in children with chest pain and mitral valveprolapse.
  • Midsystolic click or late systolicmurmur (mitral incompetence) or both are heard at apex.
  • M-mode or 2-D echocardiography confirmsdiagnosis of mitral valve prolapse.

    • Arrhythmias

  • Supraventriculartachycardia may cause some chest discomfort as well as cardiac failure.
  • Sinus tachycardia or premature ventricularcontractions have been associated with palpitations.
  • Important to differentiate by historywhether child is having chest pain or different sensation causedby palpitations.
  • ECG rhythm strip confirms diagnosisof arrhythmia. If cardiac rhythm is normal, Holter monitoring maybe useful.
  • With intermittent chest pain and suspectedarrhythmia, event recorder is another useful diagnostic technique.

    • Diaphragm Disorders

  • Intercostalnerves conduct impulses from peripheral diaphragm to spinal cord. Phrenicnerves (C3–C5) conduct pain impulses from central diaphragmto spinal cord.
  • With diaphragmatic irritation, painmay radiate to lower chest or shoulder, depending on extent of involvement.
  • Possible causes include subphrenicor hepatic abscess and perihepatitis (Fitz-Hugh-Curtis syndrome).

    • Gastrointestinal Disorders

    Esophagus

    Gastroesophageal Reflux

  • Common causeof transient chest pain is reflux of gastric contents from stomachinto esophagus. Severe reflux may lead to esophagitis with persistentchest pain.
  • Monitoring for 24 hrs with esophagealpH probe can determine presence and severity of reflux. Endoscopywith biopsy can diagnose esophagitis.
  • See Chap.55, Regurgitation and Vomiting).

    • Caustic Ingestion

  • Ingestionof caustic substances may cause sharp or burning pain in midsternaland lower chest.
  • Esophagoscopy is diagnostic.

    • Foreign Body

  • Foreignbody lodged in esophagus commonly causes choking, drooling, anddifficulty swallowing. Associated dull ache also may occur.
  • Chronically impacted foreign body maycause esophagitis.
  • If foreign body is radiopaque, maybe seen on chest radiograph. Otherwise, filling defect may be seenon esophagram.
  • Esophagoscopy is diagnostic for chronicallyimpacted foreign body.

    • Hiatal Hernia

  • Definedas sliding hernia with gastroesophageal junction lying above diaphragm.
  • Symptoms of hiatal hernia are thoseof gastroesophageal reflux with epigastric and lower chest paincommonly occurring after meals.
  • Sometimes large hiatal hernia may beseen on plain radiograph with retrocardiac mass extending to rightlateral chest wall.
  • Upper GI series is diagnostic.

    • Spasm

  • May causechoking episodes during feeding, difficulty in swallowing, and substernal chestache.
  • May be related to stress, rapid eating,and drinking cold liquids.
  • Upper GI series with video playbackcapability is diagnostic.

    • Tear

  • Persistentsevere vomiting may produce acute esophageal tear, which causeschest pain along with hematemesis.
  • Esophagoscopy is diagnostic.

    • Referred Pain

  • Gastritis,peptic ulcer disease, cholecystitis, and pancreatitis may causereferred chest pain.
  • See Chap.2, Abdominal Pain.

    • Neurologic Disorders

    Intercostal Nerve

    Trauma

    Injury to intercostal nerve may produce painin dermatome supplied by nerve.

    Herpes Zoster Neuritis

  • Herpes zostercan cause painful, vesicular lesions along ≥1 dermatomes correspondingto intercostal nerves.
  • Positive viral culture of lesion isconfirmatory.

    • Dorsal Root

  • Trauma (fractures)or spinal disease (tumor, osteomyelitis, epidural abscess) can involvecervical or upper thoracic dorsal roots and cause chest pain.
  • Pain often occurs with body motionor after coughing, sneezing, or laughing. Hypesthesia to pin prickor light touch may be found in affected dermatomes.
  • Useful diagnostic tests include cervicaland thoracic spine radiographs, nuclear scintigraphy, CT, and MRI.

    • Psychologic Disorders

  • Anxietywith or without hyperventilation, depression, school phobia, hypochondriasis,and conversion reactions are common causes of chest pain, especiallyin adolescence.
  • Pain has no particular characteristicsand usually diminishes once patients can talk about problem andreceive reassurance that they are not seriously ill.
  • Hyperventilation attacks are most commonin girls and may produce air hunger, dizziness, syncope, palpitations,and paresthesias.
  • Generally, specific stressful situationthat is related to onset of chest pain can be identified.
  • Family history of chest pain and occurrenceof recurrent somatic complaints (e.g., headache and abdominal pain)are also common.
  • To make diagnosis of psychogenic chestpain, positive clinical psychologic evidence must exist.
  • Onset of pain in association with stressfulemotional situation suggests that pain is manifestation of psychologicproblem.
  • In general, psychologic symptoms donot occur in isolation but are accompanied by other signs of unhappinessand anxiety.
  • Psychosocial history is most usefulclinical tool in making diagnosis of psychogenic chest pain.

    • Idiopathic Chest Pain

  • Most commoncause of chest pain in childhood and adolescence is idiopathic.Such pain is nonspecific but may be recurrent or chronic.
  • This is diagnosis of exclusion.

    • Diagnostic Approach

  • Most commoncauses of chest pain in pediatric population are idiopathic, musculoskeletal,and psychologic.
  • If complaint has been present for >6mos, organic cause is less likely.
  • History and physical exam are diagnosticin many cases.
  • Chest radiography should be performedwith localized rib or bone pain, any respiratory distress, or suspectedpulmonary disorder.
  • With suspected heart disease, ECG shouldbe performed.
  • 2-D echocardiography may be necessary,depending on suspected diagnosis.
  • Psychologic causes must be substantiatedby clinical psychologic evidence.
  • Children in whom no definite causecan be found are more likely to complain recurrently, presumablyfor secondary gain.
  • In adolescence, chest pain is frequentcomplaint, but it is usually benign. Knowledge about recent lifeevents and individual's beliefs about the symptom are importantin managing this problem.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Breast pain [Mastalgia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it's intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient breast-feeding? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced flulike symptoms or sustained injury to the breast? Has she noticed a change in breast shape or contour?

    Ask the patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

    Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?

    Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient's arms raised above her head and then with her hands pressed against her hips.

    Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Eye pain [Ophthalmalgia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does the patient wear contact lenses? How often are they removed or replaced if they're disposable? Does he have headaches? If so, find out how often and at what time of day they occur.

    During the physical examination, don'tmanipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Abdominal pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain in his own words. Ask him if the pain is dull, sharp, stabbing, or burning and to rate his pain on a scale, such as the visual analog scale, FACES pain scale, or verbal numeric scale for intensity of pain. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.

    If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient to point where the pain is located and if it radiates to other areas.

    Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

    Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menstrual cycle, changes in her menstrual pattern, or dyspareunia.

    Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

    Perform a physical examination. Take the patient's vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

    Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Arm pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Quickly assess him for severe injuries requiring immediate treatment. If you've ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

    If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

    Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It's important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

    If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

    If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

    Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Back pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries, surgeries, and illnesses, and a family history. Ask about diet and alcohol intake. Take a drug history, including past and present prescriptions, over-the-counter drugs, and herbal medicines. Ask the patient to rate the pain according to a pain scale and describe the type and location of his pain.

    Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than 3⁄89 (1 cm) in muscle size, especially in the calf.

    To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Note the range of motion of the hip and knee.

    Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Chest pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Ask when the pain began and if the patient ever experienced this type of pain in the past. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Ask him to rate the pain on a pain scale. Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

    Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.

    Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Place the patient on a cardiac monitor and evaluate his heart rhythm. Also, look for jugular vein distention and peripheral edema. Note the feel of his skin. Is it cool and clammy or warm and diaphoretic? Auscultate his chest for extra heart sounds. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Flank pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's condition isn't critical, take a thorough history. Ask about the onset of his pain and apparent precipitating events. Have him describe the pain's location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

    Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

    During the physical examination, palpate the patient's flank area and percuss the CVA to determine the extent of pain.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Jaw pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin the patient history by asking him to describe the pain's character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

    Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, a headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders such as chest pain in a patient with an MI.)

    Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 1⁄89 (3 cm) or more than 23⁄89 (6 cm) between the upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Leg pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn't prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

    Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he's taking and whether they've helped to relieve his leg pain.

    Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient's range of motion (ROM) in the hip and knee. Also, check reflexes with the patient's leg straightened and raised, noting action that causes pain. Then compare both legs for symmetry, movement, and active ROM. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit associated pain.

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Neck pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient hasn't sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Does any particular event precipitate the pain? Also, ask about other symptoms, such as headaches or back pain. Next, focus on the patient's current and past illnesses and injuries, diet, drug history, and family health history.

    Thoroughly inspect the patient's neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion (ROM) in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski's and Kernig's signs if there isn't a history of neck trauma, and palpate the cervical lymph nodes for enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Rectal pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by taking the patient's history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

    Be sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stools, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he's experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary and drug history.

    Then inspect the rectal area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Throat pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? How was it treated? Is it accompanied by fever, ear pain, or dysphagia? Review the patient's medical history for throat problems, allergies, and systemic disorders.

    Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx and the nasopharynx. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose. Also, check the patient's ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 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.)

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    Source: Nursing: Interpreting Signs and Symptoms, 2007

    FOOT, HEEL, AND TOE PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Special considerations in the approach to the diagnosis of foot pain include examining the shoes for abnormal areas of wear and tear, measuring the arches, palpating the joints for maximal tenderness, and ordering laboratory tests for joint disease (page 286). Nerve blocks and lidocaine injections in the plantar fascia and other areas of maximum tenderness will assist in diagnosis. Abnormal weight distribution is diagnosed by quantitative scintigraphs. A therapeutic trial of proper-fitting shoes and arches may be indicated. Weight control is essential in the obese. Referral to a podiatrist or orthopedic surgeon is often necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Abdominal Pain, Generalized: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. In contrast, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel. It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it. If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed immediately with an exploratory laparotomy. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    LOW BACK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic examination should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive. If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow-up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

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    Source: Differential Diagnosis in Primary Care, 2007

    ARM PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs found on a good history and physical examination is most important in pinpointing the diagnosis. Thus, arm pain with tenderness and limitation of motion at the elbow suggests tennis elbow, gout, or rheumatoid arthritis. Arm pain with loss of sensation in the distribution of the median nerve suggests carpal tunnel syndrome. Injection of lidocaine into bursa or trigger points may be diagnostic. The laboratory workup should include x-rays of the involved area and of the cervical spine, especially if there is a radicular distribution of the pain. If there are focal neurologic signs, a neurologist should be consulted before ordering an MRI: A cervical rib will not be missed in this way. An ECG and myocardial enzymes may be necessary to exclude a myocardial infarct, and an exercise tolerance test will help to exclude coronary insufficiency. Arteriogram, phlebogram, lymphangiogram, electromyogram with nerve conduction studies, myelogram, and nerve blocks will be necessary in specific cases.

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    Source: Differential Diagnosis in Primary Care, 2007

    Breast Pain: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of a painful breast is usually made by taking a careful history. What drugs is the patient taking? Associated symptoms and signs (see sections on bloody discharge, page 306 and swelling, page 74) are also important. A culture of the discharge, mammography, and determination of serum, estrogen, and prolactin levels may be important, but referral to an endocrinologist is wise when the history does not provide a simple solution, especially when the pain is bilateral. Biopsy (frozen section) is necessary when tumor is suspected and mammography is equivocal, because faith in mammography has declined somewhat in recent years.

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    Source: Differential Diagnosis in Primary Care, 2007

    CHEST PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A possible myocardial infarction must be the first consideration in all adults with acute chest pain, especially if there are significant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often be necessary. After this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done to rule out coronary insufficiency or myocardial infarction. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

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    Source: Differential Diagnosis in Primary Care, 2007

    ELBOW PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In the approach to the diagnosis, the traumatic conditions and arthritic disorders will probably stand out. A diagnostic dilemma occurs when the elbow looks normal and has good movement. Nevertheless, most of these cases are caused by tennis elbow, myositis, and fasciitis. Thus, a simple injection at the trigger point will assist the diagnosis and give the patient immediate and sometimes lasting relief. If this is unsuccessful, referral to an orthopedic surgeon is wise.

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    Source: Differential Diagnosis in Primary Care, 2007

    Epigastric Pain: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of midepigastric pain is identical to that for generalized abdominal pain .

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    EYE PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tonometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    FACIAL PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis of face pain includes a careful history and physical with a good neurologic examination. The sinuses are transilluminated, and x-rays may be performed. The teeth and occlusion are examined carefully and possibly x-rayed. A histamine test may be indicated. The busy physician may want to refer the patient to a neurologist immediately, but this will obviously take away the challenge.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    FLANK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis of flank pain usually involves careful examination of the urine and a urine culture, an IVP, and plain films of the abdomen and spine. If these are negative, bone scans, arteriogram, and other tests listed below may be required. CT has eliminated the need for exploratory laparotomy in many cases.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    GROIN PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In the approach to the diagnosis of groin pain, a mass or tender structure is usually present in the groin. If the mass is a lymph node, careful examination of the genitalia and lower extremities will often show the cause, but a urethral or vaginal smear and culture may be necessary to show gonorrhea. Investigation of the genitourinary (GU) tract and the GI tract for causes of referred pain is then undertaken. If the mass is reducible, a hernia is likely and referral to a surgeon is in order. Incarcerated hernias, of course, demand immediate referral.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    HAND AND FINGER PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

    1. Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
    2. Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
    3. Causalgia by stellate ganglion block to see if pain is relieved
    4. Cervical spine disease by a roentgenogram, possibly a myelogram or magnetic resonance imaging (MRI), and nerve blocks of the various roots. Referral to a neurologist is often necessary. In early RA, the joints may be normal on inspection, but pain and stiffness of the hands and fingers in the morning is an excellent clue.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    HIP PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The history and physical examination will allow differentiation of many of the conditions listed above. For example, the history of trauma suggests sprain, fracture, or contusion. Remember that fractures of the hip can occur in elderly persons without a history of trauma. A positive straight-leg-raise (SLR) test suggests a herniated disc or other cauda equina pathology. X-ray of hip and lumbosacral spine will help rule out fracture or osteoarthritis, but CT scan, bone scan, or MRI may be necessary. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Left Lower Quadrant Pain: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    There is no doubt about the value of a good history and physical examination, including both the rectal and pelvic areas. After this, the signs and symptoms should be summarized and grouped together; in many cases, this technique will pinpoint the diagnosis. The laboratory workup can now proceed. In acute cases, the physician should order a flat plate of the abdomen, CBC, urinalysis (and examine it him or herself), and serum amylase level before exploratory surgery. A pregnancy test is ordered in women of childbearing age. In chronic cases, sigmoidoscopy, barium enema, upper GI series, small-bowel follow-through, and stool examination for blood, ova, and parasites should be done before culdoscopy, peritoneoscopy, or colonoscopy is contemplated. An exploratory laparotomy remains a useful diagnostic tool even in chronic cases of LLQ pain.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Back, Joint, and Extremity Pain - Case 5-1: 2-Year-Old Boy: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 2-year-old boy presented to the emergency department for evaluation of back pain. Three days before admission, he began to complain of abdominal pain, refused to eat lunch that day, and spent most of the afternoon watching television rather than playing outside with his siblings. At that time, he was taken to a nearby hospital for evaluation. On examination, he had mild, diffuse abdominal tenderness but no rebound tenderness or involuntary guarding. Abdominal radiographs showed significant stool in the rectum and distal colon. He was diagnosed with constipation, was given a glycerin suppository, and was discharged home after producing a moderate amount of stool.
    On the day of admission, he returned to the hospital with persistent abdominal pain and new complaints of low back pain. His oral intake had been poor over the past few days. There had been minimal response to a glycerin suppository earlier that day. He also seemed particularly uncomfortable while his diaper was being changed. There was no fever, cough, hematemesis, hematochezia, dysuria, or urinary frequency. There were no ill contacts and no known trauma. The only pet was an elderly dog that had been euthanized earlier in the week.

    II. Past Medical History

    Tympanostomy tubes had been placed at 15 months of age for recurrent otitis media. He had only one episode of otitis media after the tubes were placed. He did not have a previous history of constipation. He does not take any medications. The family history was remarkable for a paternal uncle who had a myocardial infarction at 55 years of age.

    III. Physical Examination

    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: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 2-year-old boy presented with a 2-week history of difficulty walking. The parents had noticed that he would no longer run while playing with his siblings. Over the past week, he had begun walking with a limp and refusing to climb stairs. His pediatrician detected splenomegaly and tenderness over the right hip. There was no fever, cough, rhinorrhea, throat pain, diarrhea, or trauma. There had been no ill contacts. A pet dog was acquired 1 week earlier. Hip radiographs and several laboratory studies were obtained, after which the patient was immediately referred to the emergency department.

    II. Past Medical History

    The patient was born at term without complications. He had been hospitalized with wheezing at 4 months of age and required oral antibiotics at 12 months of age for outpatient treatment of pneumonia. He was not receiving any medications and had no allergies. Family history was remarkable for a maternal aunt with rheumatic heart disease.

    III. Physical Examination

    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: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 14-year-old boy presented to the emergency department complaining of left knee pain. Three days before this visit, he noted left knee pain after playing basketball and began to limp. This knee pain improved over the next few days. While walking across a wooden floor on the evening of his emergency department presentation, he slipped and fell. As soon as he stood up, he noted pain in his left knee again that occasionally radiated to the left hip. He did not strike his head. There was no other bone pain. There was no headache, blurry vision, or loss of consciousness. There was no fever, weight loss, myalgias, or malaise.

    II. Past Medical History

    The patient had required hospitalization at 8 years of age for disorientation after a car accident; his symptoms resolved, and he was discharged the next day. At 10 years of age, he developed poststreptococcal glomerulonephritis. He had been treated with a short course of corticosteroids but had not required specific therapy since that time. He did not report taking any medications. There was no family history of endocrine or autoimmune disorders.

    III. Physical Examination

    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: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 16-year-old girl was admitted with joint pain and a 35-pound weight loss over the preceding 7 months. After completion of her gymnastics season 7 months before admission, she had noticed decreased energy and stiff, slightly swollen peripheral joints bilaterally, including elbows, wrists, knees, and ankles. She was diagnosed with juvenile rheumatoid arthritis and treated with naproxen, a nonsteroidal antiinflammatory drug (NSAID). Her pain improved slightly. Shortly after starting naproxen, she began having daily episodes of epistaxis that required four to five facial tissues to control the bleeding. Five months before admission, she changed from naproxen to ibuprofen without significant change in the degree of joint pain.
    Three months before admission, she noticed a change in her bowel habits, from two to three stools per week to daily stools that were frequently mixed with blood. One month before admission, she developed intermittent cramping abdominal pain. She continued to have episodes of epistaxis and was treated with fluticasone nasal spray and an oral antihistamine for presumed allergic rhinosinusitis. Her weight decreased from 148 pounds to 113 pounds. She complained of decreased appetite and decreased activity level over the preceding few months. There were no fevers, flank tenderness, dysuria, urgency, or frequency. There was no change in mood or intentional weight loss. There was no change in her menstrual cycle. She had not traveled recently.

    II. Past Medical History

    She had not previously required hospitalization. Menarche occurred at 11 years of age. Her periods were regular. There were no other medical problems. Her only medications were ibuprofen, fluticasone nasal spray, and oral antihistamines as previously mentioned. There was a family history of hypertension in older relatives.

    III. Physical Examination

    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: I. History of Present Illness
    (Pediatric Complaints and Diagnostic Dilemmas)

    A 13-year-old African-American boy without significant past medical history presented to the emergency department with a 2-day history of worsening back pain. The pain was located in his upper and lower back, and, although he was uncomfortable in any position, standing upright made his back pain significantly worse. His pain was not relieved with cyclobenzaprine, a muscle relaxant. The patient had no history of trauma and denied weakness, sensory loss, and bowel or bladder dysfunction as well as recent fevers, upper respiratory symptoms, cough, nausea, vomiting, weight loss, and night sweats.

    II. Past Medical History

    His past medical history was remarkable for one previous episode of back pain 2 years earlier that required use of a wheelchair for 2 weeks. He had received iron supplements for treatment of anemia at that time. Additional details of that episode were not available. He had never been hospitalized and had no surgical problems. He was not sexually active and had no history of cigarette or drug use. Family history was significant for a sister with sickle cell trait.

    III. Physical Examination

    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: II. Past Medical History
    (Pediatric Complaints and Diagnostic Dilemmas)

    The patient had received all required immunizations, and, aside from a broken nose sustained from a batted softball 3 years earlier, he had no significant past medical history. He did not require any regularly scheduled medications. He had no known medication allergies.
    His family history was significant for a mother and maternal grandmother with migraine headaches and trisomy 21 in his youngest brother. There is no family history of arthritis or malignancy. His recent travel had consisted of 2 weeks at the New Jersey shore over the summer and 1 month of “sleep-away” camp in northeastern Pennsylvania.

    III. Physical Examination

    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: Signs of Arthritis

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