Diagnostic Tests for Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Benign Paroxysmal Positional Vertigo:
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Benign Paroxysmal Positional Vertigo Diagnosis: Book Excerpts
Diagnostic Tests for Benign Paroxysmal Positional Vertigo: Online Medical Books
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DIZZINESS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If there is true vertigo, an audiogram and a caloric test or electronystagmography should be done. Hallpike's maneuver should be done also. If these are abnormal, an x-ray of the mastoids, petrous bones, and internal auditory canals should be done. At this point a neurologist should be consulted. If an acoustic neuroma is strongly suspected, an MRI of the brain stem and auditory canals should be done. If the MRI of the brain is negative, a spinal fluid examination can be done to exclude such disorders as central nervous system lues and multiple sclerosis. An MRI of the brain needs to be done to distinguish multiple sclerosis. BSEPs, VEPs, and SSEPs will also be helpful in making the diagnosis of multiple sclerosis, along with the spinal fluid analysis mentioned above. A wake-and-sleep EEG needs to be done to exclude temporal lobe epilepsy. If migraine or migraine equivalents are suspected, perhaps a trial of beta-blockers would help make this diagnosis. If vertebral basilar artery ischemia is suspected, magnetic resonance angiography may be indicated.
If the dizziness is not true vertigo, a CBC and chemistry panel should be done at the outset. Additional studies in the form of 24-hr blood pressure monitoring, Holter monitoring, and echocardiography all have a valuable place in the diagnostic workup of dizziness without true vertigo. However, a referral to a cardiologist is wise before undertaking these expensive studies. If all studies are negative, perhaps a psychiatrist should be consulted.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ABDOMINAL PAIN, CHRONIC RECURRENT:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Dizziness:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask about a history of diabetes and cardiovascular disease. Is the patient taking drugs prescribed for high blood pressure? If so, when did he take his last dose?
If the patient's blood pressure is normal, obtain a more complete history. Ask about myocardial infarction, heart failure, kidney disease, or atherosclerosis, which may predispose the patient to cardiac arrhythmias, hypertension, and a transient ischemic attack. Does he have a history of anemia, chronic obstructive pulmonary disease, anxiety disorders, or head injury? Obtain a complete drug history.
Next, explore the patient's dizziness. How often does it occur? How long does each episode last? Does the dizziness abate spontaneously? Does it lead to loss of consciousness? Find out if dizziness is triggered by sitting or standing up suddenly or stooping over. Does being in a crowd make the patient feel dizzy? Ask about emotional stress. Has the patient been irritable or anxious lately? Does he have insomnia or difficulty concentrating? Look for fidgeting and eyelid twitching. Does the patient startle easily? Also, ask about palpitations, chest pain, diaphoresis, shortness of breath, and chronic cough.
Next, perform a physical examination. Begin with a quick neurologic assessment, checking the patient's level of consciousness (LOC), motor and sensory functions, and reflexes. Then inspect for poor skin turgor and dry mucous membranes, signs of dehydration. Auscultate heart rate and rhythm. Inspect for barrel chest, clubbing, cyanosis, and use of accessory muscles. Also auscultate breath sounds. Take the patient's blood pressure while he's lying down, sitting, and standing to check for orthostatic hypotension. Test capillary refill time in the extremities, and palpate for edema.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vertigo:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he’s ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note any evidence of alcohol abuse.
Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Decorticate posture:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Test the patient's motor and sensory functions. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask about headache, dizziness, nausea, changes in vision, and numbness or tingling. When did the patient first notice these symptoms? Is his family aware of behavioral changes? Also, ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Dizziness:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask about a history of diabetes and cardiovascular disease. Is the patient taking drugs prescribed for high blood pressure? If so, when did he take his last dose?
If the patient’s blood pressure is normal, obtain a more complete history. Ask if he’s had a myocardial infarction, heart failure, kidney disease, or atherosclerosis, which may predispose him to cardiac arrhythmias, hypertension, and a transient ischemic attack. Does he have a history of anemia, chronic obstructive pulmonary disease, anxiety disorders, or head injury? Obtain a complete drug history.
Next, explore the patient’s dizziness. How often does it occur? How long does each episode last? Does the dizziness abate spontaneously? Does it lead to loss of consciousness? Find out if dizziness is triggered by sitting or standing up suddenly or by stooping over. Does being in a crowd make the patient feel dizzy? Ask about emotional stress. Has the patient been irritable or anxious lately? Does he have insomnia or difficulty concentrating? Look for fidgeting and eyelid twitching. Does the patient startle easily? Also, ask about palpitations, chest pain, diaphoresis, shortness of breath, and chronic cough.
Next, perform a physical examination. Begin with a quick neurocheck, assessing the patient’s level of consciousness (LOC), motor and sensory function, and reflexes. Then inspect for poor skin turgor and dry mucous membranes, signs of dehydration. Auscultate heart rate and rhythm. Inspect for barrel chest, clubbing, cyanosis, and use of accessory muscles. Also auscultate breath sounds. Take the patient’s blood pressure while he’s lying, sitting, and standing to check for orthostatic hypotension. Test capillary refill time in the extremities, and palpate for edema.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vertigo:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he’s moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he’s ever fallen. Ask if he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note any evidence of alcohol abuse.
Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Decorticate posture [Decorticate rigidity, abnormal flexor response]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Test the patient’s motor and sensory function. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask family members if the patient experienced headache, dizziness, nausea, changes in vision, numbness, or tingling. When did the patient first notice these symptoms? Is his family aware of any behavioral changes? Also, ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dizziness:
Physical examination.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A focused physical examination usually confirms rather than makes the diagnosis. An otoscopic examination should be done looking for impacted cerumen or signs of infection. A focused neurologic examination should be done. The patient’s eyes should be observed for spontaneous, gaze-evoked or positional nystagmus. A Dix-Hallpike maneuver should be done when BPPV is suspected. The patient should be observed walking to assess cerebellar function and disequilibrium.
Testing
A screening audiogram can sometimes be helpful to detect slight asymmetrical hearing loss the patient may not have noted. To rule out cerebellar infarct or hemorrhage, an MRI—the study of choice—should be done if the diagnosis does not become clear after a period of watchful waiting. MRI is also warranted for a persistent, unilateral hearing loss to rule out acoustic neuroma. Other ancillary tests are usually not helpful unless targeted at specific symptoms (e.g., complete blood count if anemia is suspected).
Diagnostic assessment
Because dizziness can be a somatic presentation for many diagnoses, it is important to be methodical in the workup. First, attempt to classify the dizzy patient primarily in one of the four general categories noted above. A description of near-syncope allows one to pursue causes of cerebral hypoperfusion (e.g., heart disease, dehydration, anemia). Elderly patients who have noticed a gradual inability to maintain balance while walking or standing should be evaluated for treatable causes of disequilibrium, including peripheral neuropathies, vision problems, and medication side effects. Most patients, but especially the young patient who describes a vague “swimming” lightheadedness or symptoms of panic or anxiety (e.g., shortness of breath, chest pain, or numbness in arms or legs) should be primarily questioned about feelings of depression and abnormal stressors. Finally, if a patient presents with the whirling symptoms of vertigo, assess for risk of CNS ischemia or hemorrhage by taking into account the patient’s cardiovascular risks and presence of associated neurologic symptoms. Temporal factors and physical examination maneuvers can help differentiate between the primary causes of peripheral vestibular disease—BPPV, Ménière’s disease, and vestibular neuronitis.
References
1. Sloan PD. Dizziness in primary care: results from the National Ambulatory Medical Care Survey. J Fam Pract 1989;29:33–38.
2. McGee SR. Dizzy patients: diagnosis and treatment. West J Med 1995;162:37–42.
3. Baloh RW. Dizziness: neurological emergencies. Neurol Clin 1998;16(2):305–321.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Vertigo:
Physical examination (PE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
This will emphasize orthostatic vital signs, the eyes, ears, and neurologic and cardiovascular systems.
A. Detection of nystagmus is critical because it is the only objective sign of vertigo (5). Nystagmus can occur spontaneously or in response to changes in eye or body position. Peripheral vestibular disorders usually cause horizontal or rotatory nystagmus, whereas CNS pathology is reflected by vertical nystagmus—an ominous sign. In true vertigo caused by BPPV, DH maneuvers will often confirm the diagnosis (sensitivity 60% to 90%, specificity 90% to 95%) (2,3). The patient is moved rapidly from a sitting to a supine position with the head turned at a 30-degree angle, first to one side and then to the other. A positive DH test includes precipitation of vertigo, latency of onset by a few seconds, rotational nystagmus, resolution within a minute, and lessened symptoms and nystagmus with prolonged latency on repeated testing (i.e., fatiguability). Lack of latency and fatiguability characterize vertigo caused by serious central lesions.
B. Neurologic examination serves to detect brainstem or CNS pathology.
C. Otoscopy can detect otitis media or cholesteatoma. Nystagmus with vertigo following positive or negative pressure applied to the tympanic membrane (pneumatic otoscopy) suggests a perilymphatic fistula.
D. Other provocative tests (forced hyperventilation, vestibulo-ocular reflex testing, vigorous horizontal head shaking) are not routinely helpful.
Testing
A. Clinical laboratory tests. Most (80% to 90%) patients will need no laboratory testing (2,4,5). Audiometry is suggested if tinnitus or hearing loss is present. Blood tests are dictated by appropriate clinical indications only. Brainstem auditory-evoked responses can help elucidate multiple sclerosis. Holter monitoring is indicated if arrhythmias are suspected. Specialized testing—posturography, rotational chair testing, electronystagamography—is best ordered by a consultant.
B. Diagnostic imaging. Consider Doppler ultrasound for suspected transient ischemic attack and magnetic resonance imaging if CNS lesions are suspected.
Diagnostic assessment
A comprehensive history can categorize the patient’s problem as one of vertigo, presyncope, disequilibrium, or other (atypical). PE maneuvers (especially DH testing), detection of nystagmus, and assessment of neurologic function will further pinpoint the likely diagnosis. It is helpful to remember that true vertigo results most often from peripheral vestibular disorders, presyncope from cardiovascular dysfunction, disequilibrium from neurologic disorders, and other (atypical or vague) symptoms from psychological or psychiatric disease.
References
1. Sloane PD. Dizziness in primary care: results from the National Ambulatory Medical Care Survey. J Fam Pract 1989;29:33–38.
2. Derebery MJ. The diagnosis and treatment of dizziness. Med Clin North Am 1999;83:163–176.
3. Walker JS, Barnes SB. Dizziness—the difficult diagnosis. Emerg Med Clin North Am 1998;16:845–878.
4. Sloane PD. Evaluation and management of dizziness in the older patient. Clin Geriatr Med 1996;12:785–801.
5. Drachman DA. Clinical crossroads—a 69-year-old man with chronic dizziness. JAMA 1998;280:2111–2118. >
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Dizziness:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Differentiate between vertigo, disequilibrium, and lightheadedness. Each has its own non-overlapping differential:
• Vertigo is the illusory sensation of rotatory motion, either of the patient or the environment.
• Disequilibrium is a sensation of imbalance when standing and walking.
• Lightheadedness is a sensation of impending loss of consciousness.
Provide the patient with experiential examples to refine the history (e.g., vertigo after spinning around as a child).
Attempt to provoke dizziness with maneuvers to confirm a provisional diagnosis, such as observation of gait, ambulation, and turning; orthostatic vital signs; Dix–Hallpike maneuver; Romberg; and/or 3-minute hyperventilation. The Dix–Hallpike maneuver provokes vertigo and nystagmus by stimulation of the posterior semicircular canal with the head tilted toward the affected side at 30 degrees below the horizontal. Have the patient look straight ahead to observe nystagmus. The nystagmus will fatigue. These findings indicate posterior canalithiasis causing benign paroxysmal positional vertigo (BPPV). The Romberg maneuver is performed by observing the patient standing. Swaying with eyes closed suggests disordered proprioception and/or vestibular function. Swaying with eyes open or closed is cerebellar in origin.
Vertigo usually implies a vestibular lesion (rarely brainstem). Suspect a central lesion if symptoms are preceded by a headache and vomiting without tinnitus. Central dizziness is very sensitive to movement of the head and is usually constant. Other cranial nerve findings or long track signs are usually present. Tinnitus, pressure, or decreased hearing localizes the problem to the inner ear and indicates the involved side. Nystagmus may persist after vertigo clears. Spontaneous vertical nystagmus suggests a lesion at the vestibular nucleus or cerebellum. Nystagmus that reverses direction when the patient looks in the direction of the slow phase suggests a central lesion. Exertional lightheadedness occurs in severe anemia, aortic stenosis, pulmonary hypertension, pericardial disease, and hypertrophic cardiomyopathy.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Chronic/Recurrent Abdominal Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
Dizziness:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination with a quick check of the patient’s neurologic vital signs, including his level of consciousness (LOC), motor and sensory functions, and reflexes. Then inspect for poor skin turgor and dry mucous membranes, signs of dehydration. Auscultate heart rate and rhythm. Inspect for barrel chest, clubbing, cyanosis, and use of accessory muscles. Also auscultate breath sounds. Take the patient’s blood pressure while he’s lying, sitting, and standing to check for orthostatic hypotension. Test capillary refill time in the extremities, and palpate for edema.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vertigo:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient’s gait and posture for abnormalities.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Decorticate posture:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Test the patient’s motor and sensory functions. Evaluate pupil size, equality, and response to light. Test cranial nerve function and deep tendon reflexes. Then perform a neurologic examination.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vertigo:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Once presenceof vertigo has been established, next step is to determine whetherdisturbance is in peripheral or central vestibular system or whetherit is psychologic.Important information is age of child;whether vertigo is acute, recurrent, or chronic; presence of hearingloss, ear pain, or tinnitus; and any history of recent trauma ordrug ingestion.Complete physical exam should be performed,focusing on otologic and neurologic exams.Vertigo caused by disturbance of peripheralvestibular system often occurs suddenly, lasts short time, and isunassociated with loss of consciousness. Sudden change in head positionfrequently precipitates episode. Nausea, vomiting, tinnitus, hearingloss, and swaying or falling toward affected side are common findings.Nystagmus is inhibited by visual fixation and may change with headposition.Disturbance in central vestibular systemcan cause recurrent or chronic vertigo, which may be accompaniedby cranial nerve deficits, pyramidal signs, and cerebellar signs.If nystagmus occurs, it does not change with head position, noris it inhibited by visual fixation.The history and physical exam are diagnosticin many cases of vertigo. Audiologic testing or brainstem evokedresponses should be performed with suspected hearing loss.CT should be performed if there ishistory of acute head trauma. Otherwise, MRI is study of choiceif neuroimaging is indicated. Electroencephalography is useful ifseizures are suspected.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Syncope and Dizziness:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Neurocardiogenicsyncope, vascular syncope, breath-holding, hyperventilation, and psychologicdisturbances can usually be distinguished by history and physicalexam.If syncopal episode occurs on assumingupright posture, BP should be measured in supine and upright positions.Postural difference in systolic pressure of >15 mm Hg confirmsdiagnosis of orthostatic syncope.Individuals with recurrent syncope,family history of sudden death, or syncope occurring during intensiveexercise need further evaluation.If recurrent syncope occurs, tilt testingmay determine whether syncope is neurocardiogenic.Family history of syncope and suddendeath suggests hypertrophic cardiomyopathy or long QT interval syndrome.Syncope during intense exercise mayoccur with hypertrophic cardiomyopathy, severe aortic stenosis,anomalous left coronary artery from pulmonary artery, primary pulmonaryhypertension, or exercise-induced atrial fibrillation associatedwith WPW syndrome. Diagnosis of cardiac disorders canbe made from history, physical exam, chest radiograph, ECG, and2-D echocardiogram. Cardiac catheterization and angiography maybe necessary to make definitive diagnosis and to determine severityof lesion. Arrhythmia may be suspected from history, and routine ECGwith rhythm strip may be diagnostic. Otherwise, further testingmay be needed (e.g., Holter monitoring, maximal exercise testing,event recorder or implanted loop recorder monitoring, and electrophysiologictesting).With syncopal episode of unknown cause,ECG should be initially performed searching for WPW syndrome, longQT interval syndrome, or LV hypertrophy with T-wave changes indicativeof cardiomyopathy.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Recurrent Infection:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Recurrentviral URIs in otherwise normal child with normal growth and development occurbecause of recurrent exposure. Such infections rarely indicate underlyingimmune disorder with possible exception of selective IgA deficiency.Localized defect is usually the problemwhen recurrent infections occur at single anatomic site (otitismedia, urinary tract infection, pneumonia, or meningitis). Tests(e.g., CBC and differential counts; UA; urine, blood, and spinalfluid cultures) and chest radiography are often diagnostic.Primary or secondary immune deficiencyshould be suspected in children who have≥2 serious bacterial infections(pneumonia, meningitis, septicemia, osteomyelitis, septic arthritis)Infection with organisms of low virulenceChronic sinopulmonary infectionUnusual infecting agentsIncomplete clearing between episodesIncomplete response to treatment Frequent findings in children withimmunodeficiency are impaired growth; recurrent or chronic diarrhea,eczema, or thrush; hepatosplenomegaly; recurrent abscesses; recurrentosteomyelitis; small or absent tonsils; and no palpable lymph nodes.Neutropenia, aplastic anemia, hemolytic anemia, and thrombocytopeniaare other common findings.2 episodes of septicemia or meningitismay indicate asplenia or diminished splenic function, circulatingantibody deficiency, or complement deficiency. Recurrent meningococcalmeningitis or disseminated gonococcal infection may be due to deficiencyof C5, C6, C7, C8, or C9.≥2 serious pyogenic skin infections(furunculosis, subcutaneous abscesses, or cellulitis), without otherexplanation, that are associated with recurrent otitis media orpneumonia suggest possible neutropenia, defective chemotaxis, ordefective phagocytosis.Subcutaneous abscess or furunculosisassociated with lymph node, liver, or lung abscess suggests chronicgranulomatous disease.Protracted diarrhea and persistentoral thrush associated with recurrent otitis media, sinusitis, orpneumonia suggest IgA deficiency or defect in cell-mediated immunity.Single P. carinii pulmonary infection;L. monocytogenes infection occurring after newborn period; disseminatedor persistent herpes simplex, varicella, or cytomegalovirus infection;or chronic candidiasis of skin or mucous membranes may indicatedefective cell-mediated immunity.Unusual associated physical exam findingsare suggestive of certain immunologic disorders:Eczema andpetechiae (Wiskott-Aldrich syndrome)Partial albinism (Chediak-Higashi syndrome)Unusual facies with micrognathia, hypertelorism,malformed ears, and congenital heart defects (DiGeorge syndrome)Ataxia and telangiectasia (ataxia-telangiectasia)Fine hair with short extremities (cartilage-hairhypoplasia)Recurrent skin abscesses and eczema(hyper-IgE syndrome) The following diagnostic tests screenfor most primary immunologic defects. If any of these tests areabnormal, further investigations are necessary as outlined below.CBC and differentialAnalysis of blood smearQuantitative serum immunoglobulins(IgG, IgA, IgM, IgE)Functional antibody titers (polio,tetanus, diphtheria) for IgG function and isohemagglutinins (anti-Aand anti-B titers) for IgM functionSkin tests (Candida, tetanus toxoid)for delayed hypersensitivity and cell-mediated immunityCH50Chest radiograph (thymic shadow) Evaluation of Humoral Deficiency
Serum immunoglobulinlevels should be measured (IgA, IgG, IgM) and compared with age-relatednormal values. Even though total serum IgG may be normal, subclassdeficiency may still occur and quantitative measurements of individualsubclasses can be performed.Antibody function also should be assessed.Antibody responses to usual childhood immunizations (e.g., tetanusand diphtheria) can be determined. In children >18–24mos of age, antibody response to immunization with H. influenzaetype b capsular polysaccharide vaccine should be performed because somechildren respond normally to protein antigens but not to polysaccharideantigens.If immunoglobulin levels and antibodytiters are decreased, next step is enumeration of B cells in peripheralblood by flow cytometry. Beyond these tests, immunologic consultationshould be requested. Studies (e.g., in vitro mitogen or antigendriven B-cell proliferation and immunoglobulin secretion) may beneeded to delineate functional B-cell defects. Evaluation of Cell-Mediated Immunity
Should includeCBC, including absolute lymphocyte count, chest radiograph, anddelayed hypersensitivity skin tests. Presence of lymphopenia ishelpful because it occurs with T-cell disorders. Absence of thymussilhouette also may occur in some T-cell disorders, but thymus alsomay involute with stress.Best screening test for delayed-typehypersensitivity testing is Candida skin test or standardized panelof antigens prepared for this purpose. Presence of ≥1 positivedelayed-type skin tests generally indicates intact cell-mediatedimmunity. However, prior exposure of the antigen is a prerequisite. Positiveresponse to some antigens does not ensure normal cell-mediated immunityto all antigens, and depression of reactivity may occur with acuteviral infections. Frequently, children <1 yr of age areunresponsive to all antigens on the panel.Indirect assessment of T-cell functionmay be determined by enumeration of peripheral blood T-lymphocytesusing monoclonal antibodies to cell surface determinants. Otherspecialized tests measuring cell-mediated immunity include lymphocyteproliferation in vitro with mitogens, antigens, and allogenic cells. Evaluation of Phagocytic Function
Number andfunction of phagocytic cells must be ascertained.Number can be detected using WBC countand differential.Function of phagocytic cells–cellmotility (chemotaxis), ingestion (phagocytosis), and intracellularkilling (bactericidal activity) can be determined by different assays.An immunologist can help with selectionand interpretation of these tests. Evaluation of Complement Deficiency
Complementdeficiencies C1–C9 can be detected by CH50 assay.This assay depends on functional integrityof these complement components, and deficiency of any componentresults in marked decrease or absence of total hemolytic complementactivity.If the assay is low, individual complementcomponents can be measured to determine which component is deficient. >
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dizziness:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask about a history of diabetes and cardiovascular disease. Is the patient taking drugs prescribed for high blood pressure? If so, when did he take his last dose?
If the patient's blood pressure is normal, obtain a more complete history. Ask about myocardial infarction, heart failure, kidney disease, or atherosclerosis, which may predispose the patient to cardiac arrhythmias, hypertension, and a transient ischemic attack. Does he have a history of anemia, chronic obstructive pulmonary disease, anxiety disorders, or head injury? Obtain a complete drug history.
Next, explore the patient's dizziness. How often does it occur? How long does each episode last? Does the dizziness abate spontaneously? Does it lead to loss of consciousness? Find out if dizziness is triggered by sitting or standing up suddenly or stooping over. Does being in a crowd make the patient feel dizzy? Ask about emotional stress. Has the patient been irritable or anxious lately? Does he have insomnia or difficulty concentrating? Look for fidgeting and eyelid twitching. Does the patient startle easily? Also, ask about palpitations, chest pain, diaphoresis, shortness of breath, and chronic cough.
Next, perform a physical examination. Begin with a quick neurologic assessment, checking the patient's level of consciousness (LOC), motor and sensory functions, and reflexes. Then inspect for poor skin turgor and dry mucous membranes, signs of dehydration. Auscultate heart rate and rhythm. Inspect for barrel chest, clubbing, cyanosis, and use of accessory muscles. Also auscultate breath sounds. Take the patient's blood pressure while he's lying down, sitting, and standing to check for orthostatic hypotension. Test capillary refill time in the extremities, and palpate for edema.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Vertigo:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask your patient to describe the onset and duration of his vertigo, being careful to distinguish this symptom from dizziness. Does he feel that he's moving or that his surroundings are moving around him? How often do the attacks occur? Do they follow position changes, or are they unpredictable? Find out if the patient can walk during an attack, if he leans to one side, and if he has ever fallen. Ask whether he experiences motion sickness and if he prefers one position during an attack. Obtain a recent drug history, and note evidence of alcohol abuse.
Perform a neurologic assessment, focusing particularly on eighth cranial nerve function. Observe the patient's gait and posture for abnormalities.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Decorticate posture [Decorticate rigidity, abnormal flexor response]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Test the patient's motor and sensory functions. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask the patient about headache, dizziness, nausea, changes in vision, and numbness or tingling. When did the patient first notice these symptoms? Is his family aware of behavioral changes? Also ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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