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Diseases » Edema » Tests
 

Diagnostic Tests for Edema

Contents
  1. Edema: Introduction
  2. Symptoms of Edema
  3. Diagnosis
  4. Failure to Diagnose
  5. Alternative Diagnoses
  6. Misdiagnosis
  7. Complications

Edema Tests: Book Excerpts

Edema Diagnosis: Book Excerpts

Diagnosis of Edema: medical news summaries:

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

Diagnostic Tests for Edema: Online Medical Books

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

EDEMA, GENERALIZED: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

A CBC should be done to rule out significant anemia that may be the cause of the edema. If there is anemia, we need to determine its source. Liver function tests are done to rule out liver disease, and serum protein electrophoresis and tests for BUN and creatinine should be done to exclude renal disease. The urinalysis is very important both for the routine studies and also to examine the urinary sediment for diseases such as chronic glomerulonephritis and collagen disease. If there is significant loss of protein in the urine, one should be considering nephrosis. An EKG, chest x-ray, and venous pressure and circulation time will be extremely helpful in diagnosing congestive heart failure, but pulmonary function tests can be done as the vital capacity is significantly reduced in this disease. When there is a strong suspicion of congestive heart failure, echocardiography or radionuclide-gated blood pool scintigraphy should be done to determine the left ventricular ejection fraction (LVEF). A value of less than 45% is considered abnormal. A thyroid profile should be done to diagnose myxedema. A CT scan of the chest will help diagnose constrictive pericarditis. Occasionally, the edema is due to an abdominal tumor. A CT scan of the abdomen and pelvis will be helpful in those cases. Contrast lymphangiography may be necessary to diagnose lymphedema.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EDEMA, LOCALIZED: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

A venous ultrasound study, impedance plethysmography, and contrast venography are very useful in the diagnosis of deep vein thrombophlebitis. d -dimer testing is also a sensitive indicator of active deep vein thrombophlebitis and the need for anticoagulants. Patients with suspected cellulitis or osteomyelitis should have a CBC, sedimentation rate, and cultures of the blood or any fluid that is available from the site of the lesion, either direct or by aspiration. X-rays and CT scans of the involved area are useful as well. Bone scans are often of value in diagnosing osteomyelitis and fractures. Lymphangiography will be helpful in the diagnosis of carcinomatosis or lymphedema from other causes. A CT scan of the abdomen or pelvis may also demonstrate the malignant lymph nodes. A thyroid profile will diagnose cases of pretibial myxedema due to thyrotoxicosis. Patients with upper extremity edema should have a chest x-ray and CT scan of the mediastinum to determine the causes of superior vena cava syndrome.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PERIORBITAL EDEMA: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, chest x-ray, VDRL test, and x-ray of the sinuses and orbits. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. A CT scan of the brain and sinuses probably ought to be done in these cases, but why not get an ear, nose, and throat or neurologic consultation first?

If there is generalized edema, the workup should proceed as outlined on page 138 .

Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. Superior vena cava syndrome may be diagnosed by a chest x-ray in many cases, but a CT scan of the mediastinum may be necessary.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEMORAL MASS OR SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Surgical consultation may be wise at the outset. A reducible mass would suggest a femoral hernia, but an upper GI series with a small bowel follow-through would confirm this diagnosis. Of course, if it is felt that the femoral hernia is irreducible, this study would not be done, and exploratory surgery would be indicated. If the mass is suspected to be a lymph node, a biopsy should be done. If the mass is suspected to be an abscess, an incision and drainage should be done. If tuberculosis is suspected, a tuberculin test as well as an AFB smear and culture should be done. If the mass is suspected to be a saphenous varix, venography will confirm the diagnosis. Exploratory surgery of the groin will clarify the diagnosis in confusing cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

A CBC, sedimentation rate, urinalysis, chemistry panel, and VDRL test should be done routinely. If a tumor of the testicle is suspected, 24-hr urine gonadotrophins and alpha-fetoprotein levels may be ordered. If there is a urethral discharge, a smear and culture should be done. If a hernia is strongly suspected, a general surgeon should be consulted. Testicular scans with technetium-99m will help distinguish torsion of the testicle from orchitis or epididymitis. Scrotal ultrasound may be useful in differentiating a hematoma, abscess, or rupture from orchitis. It may also be helpful in evaluating testicular tumors. CT scan of the abdomen and pelvis may be necessary to rule out metastasis.

The expense of some or all of these tests may be avoided by consulting a urologist early in the diagnostic workup.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

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

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Edema, generalized: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the
day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

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

Edema of the arm: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema Pitting or nonpitting? page 240.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

» READ BOOK EXCERPT ONLINE »

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

Edema of the leg: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 240.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans' sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Edema, generalized: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

» READ BOOK EXCERPT ONLINE »

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

Edema of the arm: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema’s severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting? page 292.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare the radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

» READ BOOK EXCERPT ONLINE »

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

Edema of the face: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 292.) Next, take vital signs and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.

» READ BOOK EXCERPT ONLINE »

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

Edema of the leg: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or any recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 292.) Because leg edema may compromise arterial blood flow, palpate or use a handheld Doppler device to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.

» READ BOOK EXCERPT ONLINE »

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.)

» READ BOOK EXCERPT ONLINE »

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

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

 A. Generalized edema manifests in the most dependent area (e.g., pedal edema in ambulatory patients, presacral edema in bedbound patients).

B. Peripheral edema (3)

1. Sparing of the feet suggests lipedema.

2. Pitting edema present for more than 3 months usually indicates a low serum protein level. Chronic edema can have fibrosis as well.

3. Assessment of color

a. Redness suggests infection or phlebitis.

b. A red-blue color suggests DVT.

c. A slightly cyanotic color bilaterally suggests CHF (Chapter 7.5).

d. The presence of ecchymosis suggests trauma.

Testing

Routine studies can include complete blood count (CBC), urinalysis, chest films, electrocardiogram (ECG), and biochemical screening to include albumin, total protein, total cholesterol, liver function tests, and thyroid function tests (4). Specific tests or imaging studies are indicated in clinical situations listed below.

Diagnostic assessment

A. Edema affecting the arms only

1. Edema exclusively of the upper extremities, caused by increased venous pressure, points to superior vena cava syndrome. A venogram will be useful.

2. If venous obstruction is suspected, obtain a venogram and Doppler or ultrasound studies.

3. If a thoracic outlet syndrome is suggested, computed tomography (CT), magnetic resonance imaging (MRI), or plain films may be helpful.

B. Edema of the arms and legs

1. Cardiac causes include CHF and constrictive pericarditis (Chapter 7.5). Diagnostic studies include a chest x-ray (CXR) study and ECG.

2. A leading hepatic cause is cirrhosis. Liver function tests are indicated.

3. Renal causes

a. Nephrotic syndrome: order 24-hour urine protein and lipids.

b. Glomerulonephritis or acute tubular necrosis: obtain urinalysis with sediment evaluation.

c. Preeclampsia: laboratory tests include urine protein, urate, blood urea nitrogen (BUN), creatinine, and serum bilirubin (5).

4. Other causes of generalized edema and tests that may be useful include hypothyroidism [thyroid-stimulating hormone, (TSH)], aldosteronism (serum potassium), Cushing’s disease (cortisol or dexamethasone test), malnutrition (prealbumin), beriberi (thiamine), malabsorption (total protein), angioedema, inflammatory bowel disease (sigmoidoscopy), serum sickness, malignancies (CT or MRI), and idiopathic edema (6).

C. Unilateral edema of the legs only points to a local peripheral cause such as trauma, venous obstruction, mass, or inflammation.

D. Bilateral chronic edema of the legs only

1. If tenderness is present, consider lipedema if no foot involvement, or varicose veins if the foot is involved.

2. Consider the possibility of a medication-related cause: see above.

3. An elevated TSH may point to a diagnosis of hypothyroidism or Grave’s disease.

4. Unilateral left-sided edema could be caused by iliac compression or pelvic mass obstructing venous outflow. A venogram, CT, or MRI may be helpful.


References

1. Braunwald E. Edema. In: Fauci AS, ed. Harrison’s principles of internal medicine, 14th ed. New York: McGraw Hill, 1998:210–214.

2. Powel AA, Armstrong MA. Peripheral edema. Am Fam Physician 1997;55:1721–1726.

3. Weber R. Leg edema. In: Rakel RE, ed. Saunders manual of medical practice. Philadelphia: WB Saunders, 1996:207–209.

4. Friedman HH. Edema. In: Friedman HH, ed. Problem oriented medical diagnosis, 6th ed. Boston: Little, Brown and Company, 1996:1–4.

5. Taylor RB. Manual of family practice. Boston: Little, Brown and Company, 1997:
497–499.

6. MacGregor GA, deWardner HE. Idiopathic edema. In: Schrier RW, Gottschalk CW, eds. Diseases of the kidney, 5th ed. Boston: Little, Brown and Company, 1993:
2493–2501.>

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

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

 A. General. A comprehensive physical examination should be performed on all patients with generalized lymphadenopathy. Focus on those findings consistent with the most frequent causes of generalized lymphadenopathy. Note the patient’s temperature and weight, because fever and weight loss are frequent findings. Examine the skin, mucous membranes, abdominal organs, and joints; specifically, the presence of rash, mucocutaneous ulceration, organomegaly, and arthritis can be a guide to possible causes of the adenopathy. The presence of splenomegaly in a patient with adenopathy implies a systemic illness (e.g., infectious mononucleosis, lymphoma, leukemia, lupus, sarcoidosis, toxoplasmosis, or cat scratch disease) (Chapter 15.4). Additionally, search for other abnormal lymph nodes. Studies have shown that clinicians identified only 17% of those cases of generalized lymphadenopathy when it was present (1).

 B. Nodal examination. The abnormal lymph node groups should be specifically examined.

1. Size. Lymph nodes enlarged up to 1 cm in diameter can be considered normal in size. These have a low malignancy risk and can usually be observed. Lymph nodes greater than 1.5 cm × 1.5 cm in area have been shown to have a 38% risk of cancer involvement and merit further workup (2).

 2. Location. Anterior cervical, submandibular, and inguinal nodes are normally palpable. The presence of supraclavicular adenopathy is always abnormal and carries a 90% cancer risk in those aged more than 40 years. Postocciptal nodes are associated with infectious mononucleosis, scalp lesions, toxoplasmosis, and non-Hodgkin’s lymphoma. Axillary nodes are associated with upper extremity infections, breast cancer, cat scratch disease, and lymphomas. Epitrochlear nodes are associated with pyogenic infections, sarcoidosis, tularemia, and syphilis. Inguinal nodes are associated with lower extremity infections and sexually transmitted diseases.

 3. Pain. The presence or absence of pain is not a reliable indicator of the cause of adenopathy. Capsular swelling from acute infections can cause pain as can necrotic hemorrhage from a malignant lymph node.

 4. Consistency. Rock hard nodes are consistent with metastatic disease (2). Firm rubbery nodes are found with lymphomas. Soft nodes tend to occur with infectious causes; however, this should not be considered diagnostic.

Testing

 A. Primary laboratory test. Initial laboratory testing should include a complete blood count (CBC) and a slide test for infectious mononucleosis (IM) (1). Atypical lymphocytes are suggestive of IM, cytomegalovirus, or toxoplasmosis. Neutropenia is found with viral illness, lupus, brucellosis, and bone marrow replacement. Severe anemia can be seen with malignancy and autoimmune processes. If the initial mononucleosis spot is negative, the test should be repeated at intervals of 1, 2, and 3 weeks, if atypical lymphocytes are present in the CBC.

 B. Secondary testing. If the initial laboratory results are nondiagnostic, order a purified protein derivative (PPD), antinuclear antibody, hepatitis B surface antigen, HIV, rapid plasma reagin, cytomegalovirus serology, and chest X-ray (CXR) study. Although the CXR is seldom positive, it can be helpful in finding tuberculosis (TB), histoplasmosis, lymphoma, or sarcoidosis. Although a PPD will not be diagnostic of TB, it can be helpful in differentiating sarcoid from TB on a node biopsy (2).

 C. Lymph node biopsy. If the aforementioned laboratory testing is nondiagnostic, then lymph node biopsy may be indicated. The largest and most pathologic node should be removed. Axillary and inguinal nodes should be avoided as they often reveal only reactive hyperplasia. Biopsy should be avoided in cases of suspected IM and drug reaction because the histologic picture is easily confused with malignant lymphoma (2). Experienced hematologists or hematopathologists should handle all specimens. The value of fine needle aspiration is controversial, with reasonable arguments both for and against (4).

Diagnostic assessment

Generalized lymphadenopathy merits evaluation beyond mere observation, as a specific systemic illness will be the likely cause. The history and examination should focus on infectious, autoimmune, granulomatous, and malignant causes. If a specific entity is suspected based on the history and physical examination, then that entity should be specifically evaluated. In the event the cause is unclear, first order a CBC and mononucleosis spot. If these are negative, then serologic testing and a CXR are warranted. Consider lymph node biopsy in those cases where the node is rock hard or larger than 1.5 cm × 1.5 cm in size (1). Biopsy should be avoided in those cases where viral causes are clinically suggested.


References

1. Ferrer R. Lymphadenopathy: differential diagnosis and evaluation. Am Fam Physician 1998;58:1313–1320.

2. Pangalis GA, Vassilalopoulos TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol 1993;20:570–582.

3. Williamson HA. Lymphadenopathy in a family practice. J Fam Pract 1985;20:
449–452.

4. Henry P, Longo D. Enlargement of lymph nodes and spleen. Harrison’s on line 1999;61. www.harrisonsonline.com/

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

Edema: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

The degree of edema is influenced by membrane permeability, hydrostatic pressure, and/or oncotic pressure. Edema implies an increase in interstitial volume of several liters. Low protein fluids (hypoalbuminemia, cardiac, and venous edema) pit easily and recover quickly on release. High protein fluids (cellulitis, lymphedema) resist pitting and recover slowly.

The distribution of the edema combined with an estimation of the jugular venous pressure (JVP) can help differentiate heart failure, cirrhosis, renal sodium retention and nephrotic syndrome. Anasarca suggests cardiac, renal, or hepatic disease. Splenomegaly is found more often in patients with cirrhosis than those with congestive heart failure.

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Source: Field Guide to Bedside Diagnosis, 2007

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

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

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

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

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Source: Field Guide to Bedside Diagnosis, 2007

Edema, generalized: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

» READ BOOK EXCERPT ONLINE »

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

Edema of the arm: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Determine the edema’s severity by comparing the size and symmetry of the arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Differentiating between pitting and nonpitting edema, page 245.) Next, examine and compare the color and temperature of the arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility.

» READ BOOK EXCERPT ONLINE »

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

Edema of the face: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Differentiating between pitting and nonpitting edema, page 245.) Next, take the patient’s vital signs, and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.

» READ BOOK EXCERPT ONLINE »

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

Edema of the leg: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Begin the physical examination by examining each leg for pitting edema. (See Differentiating between pitting and nonpitting edema, page 245.) Because leg edema may compromise arterial blood flow, palpate or use Doppler ultrasonography to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Edema: Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Age of onset is important in determiningcause of edema. Other distinguishing features are presence of hypoalbuminemia ± proteinuria.

Fetal and Neonatal Onset

  • Hydropsfetalis should be suspected in either second or third trimesterof pregnancy, when discrepancy exists between size of fetus andpresumed gestational age.
  • Polyhydramnios occurs in ≥50% ofcases, and this can be confirmed by U/S.
  • First step in diagnosis of fetal hydropsis to perform prenatal antibody screen to exclude any kind of isoimmunization.
  • Other tests include CBC and RBC indicesin both parents to screen for alpha-thalassemia; hemoglobin electrophoresis;Kleihauer-Betke test for fetomaternal transfusion; and maternalrapid plasma reagin, appropriate serology, and cultures for congenitalinfection.
  • U/S can detect multiple pregnancies(twin-twin transfusion), chondrodysplasias (limb length measurements),and many congenital anomalies.
  • Fetal movement studies also can bedone using real-time U/S.
  • Fetal echocardiography may detect cardiacstructural defects and fetal arrhythmias.
  • If these tests fail to reveal causeof fetal hydrops, amniocentesis can be performed. Several testsare commonly performed on amniotic fluid: fetal karyotype, culturesand polymerase chain reaction for infection, specific metabolictests for storage diseases, and alpha-fetoprotein (congenital nephrosis).
  • Fetal blood can be obtained by cordocentesisfor other tests: CBC, blood type, hemoglobin electrophoresis, serumalbumin, cultures and polymerase chain reaction, karyotype, andspecific tests for metabolic disorders.
  • After infant's birth, physicalexam as well as exam of umbilical cord and placenta narrow diagnosticpossibilities and suggest most appropriate investigations.

  • Several testsshould be considered depending on clinical circumstances: infant's bloodgroup and Rh type; CBC; hemoglobin electrophoresis; UA; chest, longbone, abdominal, and spine radiography; ECG; 2-D echocardiography;maternal and infant rapid plasma reagin; urine culture for cytomegalovirus;serology for toxoplasmosis; serum electrolytes, creatinine, glucose,and liver function tests; blood urea nitrogen; analysis of fluidfrom effusion or ascites for chyle, protein, or culture; chromosomalkaryotype; metabolic studies; and exam of placenta including histology.
  • Other investigations depend on resultsof these tests and suspected diagnosis.

    • Postneonatal Onset

  • UA screensfor proteinuria and renal disease.
  • In absence of significant proteinuriaor cardiac failure, serum albumin should be measured. Fluid overloadand allergic reactions are common causes of edema with normal serumalbumin. Decreased serum albumin without proteinuria suggests liverdisease, protein-losing enteropathy, or protein-caloric malnutrition.
  • Jaundice, hepatomegaly, and abnormalliver function tests are manifestations of liver disease.
  • Elevated fecal alpha1-antitrypsinlevel indicates increased protein loss in stool and is seen withvarious causes of protein-losing enteropathy.
  • Protein-calorie malnutrition can beassessed by plotting weight and height on growth charts developedby CDC (2001).
  • U/S or MRI may help diagnosecauses of lymphedema.

    • » READ BOOK EXCERPT ONLINE »

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

    Edema, generalized: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

    Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

    Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Edema of the arm: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

    Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting?page 226.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Edema of the face: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient isn't in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

    Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting?page 226.) Next, take the patient's vital signs, and assess his neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Edema of the leg: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

    Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting?page 226.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans'sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Edema

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