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Diseases » Food allergies » Diagnosis
 

Diagnosis of Food allergies

Diagnostic Test list for Food allergies:

The list of medical tests mentioned in various sources as used in the diagnosis of Food allergies includes:

  • Diet diary
  • Elimination diet - remove the suspect food and see if the allergy is avoided.
  • Skin challenge tests
  • Diet changes - chaging the diet can test whether a particular food is the cause.
  • Double-blind food challenge
  • Cytotoxicity testing - a controversial test of dubious value.
  • Subcutaneous provocative challenge - a controversial test of dubious value.
  • Immune complex assay - a controversial test of dubious value.
  • IgG subclass assay - a controversial test of dubious value.

Food allergies Diagnosis: Book Excerpts

Tests and diagnosis discussion for Food allergies:

Food Allergy and Intolerances, NIAID Fact Sheet: NIAID (Excerpt)

To diagnose food allergy a doctor must first determine if the patient is having an adverse reaction to specific foods. This assessment is made with the help of a detailed patient history, the patient's diet diary, or an elimination diet.

The first of these techniques is the most valuable. The physician sits down with the person suspected of having a food allergy and takes a history to determine if the facts are consistent with a food allergy. The doctor asks such questions as:

  • What was the timing of the reaction? Did the reaction come on quickly, usually within an hour after eating the food?
  • Was allergy treatment successful? (Antihistamines should relieve hives, for example, if they stem from a food allergy.)
  • Is the reaction always associated with a certain food?
  • Did anyone else get sick? For example, if the person has eaten fish contaminated with histamine, everyone who ate the fish should be sick. In an allergic reaction, however, only the person allergic to the fish becomes ill.
  • How much did the patient eat before experiencing a reaction? The severity of the patient’s reaction is sometimes related to the amount of food the patient ate.
  • How was the food prepared? Some people will have a violent allergic reaction only to raw or undercooked fish. Complete cooking of the fish destroys those allergens in the fish to which they react. If the fish is cooked thoroughly, they can eat it with no allergic reaction.
  • Were other foods ingested at the same time of the allergic reaction? Some foods may delay digestion and thus delay the onset of the allergic reaction.
Sometimes a diagnosis cannot be made solely on the basis of history. In that case, the doctor may ask the patient to go back and keep a record of the contents of each meal and whether he or she had a reaction. This gives more detail from which the doctor and the patient can determine if there is consistency in the reactions.

The next step some doctors use is an elimination diet. Under the doctor's direction, the patient does not eat a food suspected of causing the allergy, like eggs, and substitutes another food, in this case, another source of protein. If the patient removes the food and the symptoms go away, the doctor can almost always make a diagnosis. If the patient then eats the food (under the doctor's direction) and the symptoms come back, then the diagnosis is confirmed. This technique cannot be used, however, if the reactions are severe (in which case the patient should not resume eating the food) or infrequent.

If the patient's history, diet diary, or elimination diet suggests a specific food allergy is likely, the doctor will then use tests that can more objectively measure an allergic response to food. One of these is a scratch skin test, during which a dilute extract of the food is placed on the skin of the forearm or back. This portion of the skin is then scratched with a needle and observed for swelling or redness that would indicate a local allergic reaction. If the scratch test is positive, the patient has IgE on the skin's mast cells that is specific to the food being tested.

Skin tests are rapid, simple, and relatively safe. But a patient can have a positive skin test to a food allergen without experiencing allergic reactions to that food. A doctor diagnoses a food allergy only when a patient has a positive skin test to a specific allergen and the history of these reactions suggests an allergy to the same food.

In some extremely allergic patients who have severe anaphylactic reactions, skin testing cannot be used because it could evoke a dangerous reaction. Skin testing also cannot be done on patients with extensive eczema.

For these patients a doctor may use blood tests such as the RAST and the ELISA. These tests measure the presence of food-specific IgE in the blood of patients. These tests may cost more than skin tests, and results are not available immediately. As with skin testing, positive tests do not necessarily make the diagnosis.

The final method used to objectively diagnose food allergy is double-blind food challenge. This testing has come to be the "gold standard" of allergy testing. Various foods, some of which are suspected of inducing an allergic reaction, are each placed in individual opaque capsules. The patient is asked to swallow a capsule and is then watched to see if a reaction occurs. This process is repeated until all the capsules have been swallowed. In a true double-blind test, the doctor is also "blinded" (the capsules having been made up by some other medical person) so that neither the patient nor the doctor knows which capsule contains the allergen.

The advantage of such a challenge is that if the patient has a reaction only to suspected foods and not to other foods tested, it confirms the diagnosis. Someone with a history of severe reactions, however, cannot be tested this way. In addition, this testing is expensive because it takes a lot of time to perform and multiple food allergies are difficult to evaluate with this procedure.

Consequently, double-blind food challenges are done infrequently. This type of testing is most commonly used when the doctor believes that the reaction a person is describing is not due to a specific food and the doctor wishes to obtain evidence to support this judgment so that additional efforts may be directed at finding the real cause of the reaction.

Exercise-Induced Food Allergy

At least one situation may require more than the simple ingestion of a food allergen to provoke a reaction: exercise-induced food allergy. People who experience this reaction eat a specific food before exercising. As they exercise and their body temperature goes up, they begin to itch, get light-headed, and soon have allergic reactions such as hives or even anaphylaxis. The cure for exercised-induced food allergy is simple—not eating for a couple of hours before exercising.

Treatment

Food allergy is treated by dietary avoidance. Once a patient and the patient's doctor have identified the food to which the patient is sensitive, the food must be removed from the patient's diet. To do this, patients must read lengthy, detailed ingredient lists on each food they are considering eating. Many allergy-producing foods such as peanuts, eggs, and milk, appear in foods one normally would not associate them with. Peanuts, for example, are often used as a protein source and eggs are used in some salad dressings. The FDA requires ingredients in a food to appear on its label. People can avoid most of the things to which they are sensitive if they read food labels carefully and avoid restaurant-prepared foods that might have ingredients to which they are allergic.

In highly allergic people even minuscule amounts of a food allergen (for example, 1/44,000 of a peanut kernel) can prompt an allergic reaction. Other less sensitive people may be able to tolerate small amounts of a food to which they are allergic.

Patients with severe food allergies must be prepared to treat an inadvertent exposure. Even people who know a lot about what they are sensitive to occasionally make a mistake. To protect themselves, people who have had anaphylactic reactions to a food should wear medical alert bracelets or necklaces stating that they have a food allergy and that they are subject to severe reactions. Such people should always carry a syringe of adrenaline (epinephrine), obtained by prescription from their doctors, and be prepared to self-administer it if they think they are getting a food allergic reaction. They should then immediately seek medical help by either calling the rescue squad or by having themselves transported to an emergency room. Anaphylactic allergic reactions can be fatal even when they start off with mild symptoms such as a tingling in the mouth and throat or gastrointestinal discomfort.

Special precautions are warranted with children. Parents and caregivers must know how to protect children from foods to which the children are allergic and how to manage the children if they consume a food to which they are allergic, including the administration of epinephrine. Schools must have plans in place to address any emergency.

There are several medications that a patient can take to relieve food allergy symptoms that are not part of an anaphylactic reaction. These include antihistamines to relieve gastrointestinal symptoms, hives, or sneezing and a runny nose. Bronchodilators can relieve asthma symptoms. These medications are taken after people have inadvertently ingested a food to which they are allergic but are not effective in preventing an allergic reaction when taken prior to eating the food. No medication in any form can be taken before eating a certain food that will reliably prevent an allergic reaction to that food.

There are a few non-approved treatments for food allergies. One involves injections containing small quantities of the food extracts to which the patient is allergic. These shots are given on a regular basis for a long period of time with the aim of "desensitizing" the patient to the food allergen. Researchers have not yet proven that allergy shots relieve food allergies.

Infants and Children

Milk and soy allergies are particularly common in infants and young children. These allergies sometimes do not involve hives and asthma, but rather lead to colic, and perhaps blood in the stool or poor growth. Infants and children are thought to be particularly susceptible to this allergic syndrome because of the immaturity of their immune and digestive systems. Milk or soy allergies in infants can develop within days to months of birth. Sometimes there is a family history of allergies or feeding problems. The clinical picture is one of a very unhappy colicky child who may not sleep well at night. The doctor diagnoses food allergy partly by changing the child's diet. Rarely, food challenge is used.

If the baby is on cow's milk, the doctor may suggest a change to soy formula or exclusive breast milk, if possible. If soy formula causes an allergic reaction, the baby may be placed on an elemental formula. These formulas are processed proteins (basically sugars and amino acids). There are few if any allergens within these materials. The doctor will sometimes prescribe corticosteroids to treat infants with severe food allergies. Fortunately, time usually heals this particular gastrointestinal disease. It tends to resolve within the first few years of life.

Exclusive breast feeding (excluding all other foods) of infants for the first 6 to 12 months of life is often suggested to avoid milk or soy allergies from developing within that time frame. Such breast feeding often allows parents to avoid infant-feeding problems, especially if the parents are allergic (and the infant therefore is likely to be allergic). There are some children who are so sensitive to a certain food, however, that if the food is eaten by the mother, sufficient quantities enter the breast milk to cause a food reaction in the child. Mothers sometimes must themselves avoid eating those foods to which the baby is allergic.

There is no conclusive evidence that breast feeding prevents the development of allergies later in life. It does, however, delay the onset of food allergies by delaying the infant's exposure to those foods that can prompt allergies, and it may avoid altogether those feeding problems seen in infants. By delaying the introduction of solid foods until the infant is 6 months old or older, parents can also prolong the child's allergy-free period.

Controversial Issues

There are several disorders thought by some to be caused by food allergies, but the evidence is currently insufficient or contrary to such claims. It is controversial, for example, whether migraine headaches can be caused by food allergies. There are studies showing that people who are prone to migraines can have their headaches brought on by histamines and other substances in foods. The more difficult issue is whether food allergies actually cause migraines in such people. There is virtually no evidence that most rheumatoid arthritis or osteoarthritis can be made worse by foods, despite claims to the contrary. There is also no evidence that food allergies can cause a disorder called the allergic tension fatigue syndrome, in which people are tired, nervous, and may have problems concentrating, or have headaches.

Cerebral allergy is a term that has been applied to people who have trouble concentrating and have headaches as well as other complaints. This is sometimes attributed to mast cells degranulating in the brain but no other place in the body. There is no evidence that such a scenario can happen, and most doctors do not currently recognize cerebral allergy as a disorder.

Another controversial topic is environmental illness. In a seemingly pristine environment, some people have many non-specific complaints such as problems concentrating or depression. Sometimes this is attributed to small amounts of allergens or toxins in the environment. There is no evidence that such problems are due to food allergies.

Some people believe hyperactivity in children is caused by food allergies. But researchers have found that this behavioral disorder in children is only occasionally associated with food additives, and then only when such additives are consumed in large amounts. There is no evidence that a true food allergy can affect a child's activity except for the proviso that if a child itches and sneezes and wheezes a lot, the child may be miserable and therefore more difficult to guide. Also, children who are on anti-allergy medicines that can cause drowsiness may get sleepy in school or at home.

Controversial Diagnostic Techniques

One controversial diagnostic technique is cytotoxicity testing, in which a food allergen is added to a patient's blood sample. A technician then examines the sample under the microscope to see if white cells in the blood "die." Scientists have evaluated this technique in several studies and have not been found it to effectively diagnose food allergy.

Another controversial approach is called sublingual or, if it is injected under the skin, subcutaneous provocative challenge. In this procedure, dilute food allergen is administered under the tongue of the person who may feel that his or her arthritis, for instance, is due to foods. The technician then asks the patient if the food allergen has aggravated the arthritis symptoms. In clinical studies, researchers have not shown that this procedure can effectively diagnose food allergies.

An immune complex assay is sometimes done on patients suspected of having food allergies to see if there are complexes of certain antibodies bound to the food allergen in the bloodstream. It is said that these immune complexes correlate with food allergies. But the formation of such immune complexes is a normal offshoot of food digestion, and everyone, if tested with a sensitive enough measurement, has them. To date, no one has conclusively shown that this test correlates with allergies to foods.

Another test is the IgG subclass assay, which looks specifically for certain kinds of IgG antibody. Again, there is no evidence that this diagnoses food allergy.

Controversial Treatments

Controversial treatments include putting a dilute solution of a particular food under the tongue about a half hour before the patient eats that food. This is an attempt to "neutralize" the subsequent exposure to the food that the patient believes is harmful. As the results of a carefully conducted clinical study show, this procedure is not effective in preventing an allergic reaction.

Summary

Food allergies are caused by immunologic reactions to foods. There actually are several discrete diseases under this category, and a number of foods that can cause these problems.

After one suspects a food allergy, a medical evaluation is the key to proper management. Treatment is basically avoiding the food(s) after it is identified. People with food allergies should become knowledgeable about allergies and how they are treated, and should work with their physicians.

Resources

HOTLINE:
National Jewish Medical and Research Center in Denver.
Nurses available to answer questions
1/800/222-LUNG
http://www.njc.org/

ALLERGY REFERRALS:
American Academy of Allergy, Asthma and Immunology
611 East Wells Street
Milwaukee, WI 53202
1/800/822-2762.
http://www.aaaai.org/scripts/find-a-doc/main.asp

EXTRACTS FOR ALLERGY TESTING:
U.S. Food and Drug Administration
Center for Biologics Evaluation and Research
1/800/835-4709
http://www.fda.gov/cber/index.html

ECZEMA:
National Arthritis, Musculoskeletal and Skin Diseases Information Clearinghouse
One AMS Circle
Bethesda, MD 20892-3675
301/495-4484
http://www.nih.gov/niams/

American Academy of Dermatology
930 N. Meacham Rd.
Schaumburg, IL 60173
1/888/462-DERM
http://www.aad.org/

Eczema Association
1221 S.W. Yamhill, Suite 303
Portland, OR 97205
503/228-4430

LACTOSE INTOLERANCE and CELIAC SPRUE:
National Digestive Diseases Information Clearinghouse
Box NDDIC
Bethesda, MD 20892
301/654-3810
http://www.niddk.nih.gov/health/digest/pubs/lactose/lactose.htm
http://www.niddk.nih.gov/health/digest/pubs/celiac/index.htm

FOOD CONTENTS:
U.S. Department of Agriculture
Food and Nutrition Information Center
301/436-7725
http://www.nalusda.gov/fnic/index.html

RECIPES:
American Dietetic Association
216 W. Jackson Boulevard
Chicago, IL 60606-6995
1/800/877-1600
http://www.eatright.org/

RESOURCES:
Food Allergy and Anaphylaxis Network
10400 Eaton Place, Suite 107
Fairfax, VA 22030
1/800/929-4040
http://www.foodallergy.org/

American College of Allergy, Asthma and Immunology
85 W. Algonquin Road, Suite 550
Arlington Heights, IL 60005
1/800/842-7777
http://allergy.mcg.edu/

Asthma and Allergy Foundation of America
1125 15th Street, N.W., Suite 502
Washington, DC 20036
1/800/7-ASTHMA
http://www.aafa.org/ (Source: excerpt from Food Allergy and Intolerances, NIAID Fact Sheet: NIAID)

Food Allergy and Intolerances, NIAID Fact Sheet: NIAID (Excerpt)

One controversial diagnostic technique is cytotoxicity testing, in which a food allergen is added to a patient's blood sample. A technician then examines the sample under the microscope to see if white cells in the blood "die." Scientists have evaluated this technique in several studies and have not been found it to effectively diagnose food allergy.

Another controversial approach is called sublingual or, if it is injected under the skin, subcutaneous provocative challenge. In this procedure, dilute food allergen is administered under the tongue of the person who may feel that his or her arthritis, for instance, is due to foods. The technician then asks the patient if the food allergen has aggravated the arthritis symptoms. In clinical studies, researchers have not shown that this procedure can effectively diagnose food allergies.

An immune complex assay is sometimes done on patients suspected of having food allergies to see if there are complexes of certain antibodies bound to the food allergen in the bloodstream. It is said that these immune complexes correlate with food allergies. But the formation of such immune complexes is a normal offshoot of food digestion, and everyone, if tested with a sensitive enough measurement, has them. To date, no one has conclusively shown that this test correlates with allergies to foods.

Another test is the IgG subclass assay, which looks specifically for certain kinds of IgG antibody. Again, there is no evidence that this diagnoses food allergy.

Controversial Treatments

Controversial treatments include putting a dilute solution of a particular food under the tongue about a half hour before the patient eats that food. This is an attempt to "neutralize" the subsequent exposure to the food that the patient believes is harmful. As the results of a carefully conducted clinical study show, this procedure is not effective in preventing an allergic reaction.

Summary

Food allergies are caused by immunologic reactions to foods. There actually are several discrete diseases under this category, and a number of foods that can cause these problems.

After one suspects a food allergy, a medical evaluation is the key to proper management. Treatment is basically avoiding the food(s) after it is identified. People with food allergies should become knowledgeable about allergies and how they are treated, and should work with their physicians.

Resources

HOTLINE:
National Jewish Medical and Research Center in Denver.
Nurses available to answer questions
1/800/222-LUNG
http://www.njc.org/

ALLERGY REFERRALS:
American Academy of Allergy, Asthma and Immunology
611 East Wells Street
Milwaukee, WI 53202
1/800/822-2762.
http://www.aaaai.org/scripts/find-a-doc/main.asp

EXTRACTS FOR ALLERGY TESTING:
U.S. Food and Drug Administration
Center for Biologics Evaluation and Research
1/800/835-4709
http://www.fda.gov/cber/index.html

ECZEMA:
National Arthritis, Musculoskeletal and Skin Diseases Information Clearinghouse
One AMS Circle
Bethesda, MD 20892-3675
301/495-4484
http://www.nih.gov/niams/

American Academy of Dermatology
930 N. Meacham Rd.
Schaumburg, IL 60173
1/888/462-DERM
http://www.aad.org/

Eczema Association
1221 S.W. Yamhill, Suite 303
Portland, OR 97205
503/228-4430

LACTOSE INTOLERANCE and CELIAC SPRUE:
National Digestive Diseases Information Clearinghouse
Box NDDIC
Bethesda, MD 20892
301/654-3810
http://www.niddk.nih.gov/health/digest/pubs/lactose/lactose.htm
http://www.niddk.nih.gov/health/digest/pubs/celiac/index.htm

FOOD CONTENTS:
U.S. Department of Agriculture
Food and Nutrition Information Center
301/436-7725
http://www.nalusda.gov/fnic/index.html

RECIPES:
American Dietetic Association
216 W. Jackson Boulevard
Chicago, IL 60606-6995
1/800/877-1600
http://www.eatright.org/

RESOURCES:
Food Allergy and Anaphylaxis Network
10400 Eaton Place, Suite 107
Fairfax, VA 22030
1/800/929-4040
http://www.foodallergy.org/

American College of Allergy, Asthma and Immunology
85 W. Algonquin Road, Suite 550
Arlington Heights, IL 60005
1/800/842-7777
http://allergy.mcg.edu/

Asthma and Allergy Foundation of America
1125 15th Street, N.W., Suite 502
Washington, DC 20036
1/800/7-ASTHMA
http://www.aafa.org/ (Source: excerpt from Food Allergy and Intolerances, NIAID Fact Sheet: NIAID)

Diagnosis of Food allergies: medical news summaries:

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

Diagnostic Tests for Food allergies: Online Medical Books

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


NAUSEA AND VOMITING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a history of alcohol or drug ingestion? Alcohol and many drugs such as digitalis, aspirin, nonsteroidal anti-inflammatory agents, antihypertensives, and antibiotics may cause gastric irritation or gastritis.
  2. Is there fever? Fever may point to a localized abdominal condition such as acute cholecystitis or acute appendicitis, as well as a systemic condition such as tuberculosis, brucellosis, yellow fever, and other febrile illnesses.
  3. Is there abdominal pain? Abdominal pain suggests the possibility of acute cholecystitis, acute appendicitis, pyelonephritis, pancreatitis, renal calculus, and peritonitis.
  4. Is there an abdominal mass? The presence of an abdominal mass suggests pyloric or intestinal obstruction, a pancreatic neoplasm, acute cholecystitis, Crohn's disease, perinephric abscess, diverticulitis, and other abscesses and neoplasms.
  5. Is there vertigo? The clinician should remember that inner ear diseases such as Ménière's disease and labyrinthitis may be associated with vomiting, and sometimes the patient does not mention vertigo.
  6. Is there headache? Migraine, concussion, cerebral tumors or other space-occupying lesions, meningitis, and subarachnoid hemorrhage are associated with headaches, nausea, and vomiting.

DIAGNOSTIC WORKUP

The basic workup includes a CBC, sedimentation rate, urinalysis, urine drug screen, chemistry panel and electrolytes, serum amylase, arterial blood gases, stools for occult blood, chest x-ray, EKG, and flat plate of the abdomen. Acute onset of nausea and vomiting with ataxia requires an immediate CT scan of the brain to rule out a cerebellar hemorrhage. A pregnancy test should be routine in women of child-bearing age. If there is fever, febrile agglutinins and a heterophile antibody titer should be done. If there is an abdominal mass, a gallbladder ultrasound and intravenous pyelogram may need to be done. Isotope scanning with iminodiacetic acid derivatives is extremely useful to detect acute cholecystitis. If there is chronic vomiting and abdominal pain, the diagnosis can often be made with an upper GI series, small bowel series, or barium enema.

When there is persistent vomiting with abdominal pain, an exploratory laparotomy may need to be considered. The presence of an abdominal mass or suspected pancreatic or biliary disease merits consideration of a CT scan. However, before ordering expensive diagnostic tests, a general surgeon or gastroenterologist ought to be consulted. Laparoscopy, gastroscopy, esophagoscopy, duodenoscopy, and colonoscopy all need to be considered in the workup. Gastroparesis and intestinal pseudo-obstruction can be ruled out by radioisotope studies and manometry of the stomach and small intestine. Angiography is useful to diagnose mesenteric artery ischemia.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Urticaria: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Idiopathic urticaria without angioedema
    –Most common diagnosis in patients with hives
    –Often related to food or drug allergies, bites, or stings
    –25% of patients with one episode will progress to chronic urticaria
  • Chronic urticaria
    –Idiopathic in 50% of cases
    –Chronic idiopathic urticaria spontaneously resolves within 2 years in 80% of patients
    –Criterion for chronic urticaria is duration of more than 6 weeks
  • Occult infection (e.g., sinusitis, oral infection, cholecystitis, vaginitis, prostatitis, hepatitis, HIV, tinea manus or pedis)
  • Malignancy
  • Thyroid disease
  • Drugs (e.g., radiocontrast media, penicillin, salicylates, benzoates, azo dyes)
    –May result in life-threatening episodes of urticaria and acute angioedema that can lead to anaphylaxis
  • Urticaria secondary to physical stimuli [e.g., exercise (cholinergic), vibratory pressure, sun exposure (solar urticaria), cold exposure]
    –Dermographism occurs in 5% of the population; manifests as a physical urticaria that arises in the distribution line of a scratch or rubbed skin area
  • Hereditary or acquired deficiency of complement factor C1
    –Generally appears as episodic angioedema in the absence of urticaria
    –Only in the absence of urticaria should hereditary or acquired complement deficiency be considered
  • Angioedema-urticaria-eosinophilia syndrome
    –Associated with elevated serum IgE, fever, and fluid retention during an acute attack
  • Urticarial vasculitis
    –Presents as urticaria that lasts longer than 12–24 hours
    –Associated with autoimmune disease (e.g., systemic lupus erythematosus)
  • Cutaneous mastocytosis/urticaria pigmentosa

Workup and Diagnosis

  • Complete history and physical examination
    –Family history of angioedema, anaphylaxis, etc.
    –Seasonal or activity-related (work/home) symptoms
    –Note whether urticaria occurs after ingestion of certain foods or with physical stimuli (e.g., exercise, pressure)
    –Physical exam should evaluate for underlying occult infections (e.g., UTI, vaginal yeast infection, tinea)
    –Firmly trace the blunt tip of a cotton applicator across the patient's back; patients with dermographism will develop a pruritic urticarial wheal within 5 minutes
  • Determine whether the patient has isolated urticaria, urticaria with angioedema, or isolated angioedema
  • Consider sinus X-rays, T4, TSH, and thyroid antibodies
  • In isolated angioedema without urticaria, check C2, C4, and/or C1 esterase inhibitor serum levels
  • IgE level measurement is indicated if angioedema-urticariaeosinophilia syndrome is suspected
  • If urticarial lesions last longer than 12–24 hours, a punch biopsy of the involved skin is indicated to confirm the presence of vasculitis
  • Perform age-appropriate malignancy screening
  • If a cause cannot be found, consider referral to a dermatologist to rule out an occult etiology, although many cases will ultimately be deemed idiopathic

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Nausea & Vomiting: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Central nausea/vomiting
    –Pregnancy (hyperemesis gravidarum)
    –Uremia
    –Hypercalcemia
    –Drugs (e.g., chemotherapy agents)
    –Carbon monoxide poisoning
  • Gastrointestinal disease
    –Infection (e.g., gastroenteritis, appendicitis, cholecystitis)
    –Obstruction (e.g., pyloric stenosis, small bowel obstruction, large bowel obstruction, gastroparesis, Ogilvie's syndrome)
    –Inflammation (e.g., pancreatitis, peptic ulcer disease)
    –Food poisoning
  • Toxic ingestions
    –Syrup of ipecac
    –Alcohol
    –Salicylates: Result in tachypnea, tinnitus,
  • and metabolic acidosis/respiratory alkalosis
    –Iron: Causes profound gastritis
    –Arsenic
  • Middle ear disease (e.g., Ménie're's disease, labyrinthitis, benign positional vertigo)
  • Post-tussive emesis (especially in children)
  • Motion sickness
  • CNS disease
    –Increased intracranial pressure due to brain tumor, CNS infection (e.g., meningitis, abscess), head trauma, hydrocephalus, subarachnoid hemorrhage, vestibular neuritis, or intracerebral hemorrhage
    –Migraine headache
  • Acute myocardial infarction (especially inferior MI)
  • Ovarian torsion
  • Testicular torsion
  • Malingering: Relatively common, but should be a diagnosis of exclusion until more serious causes are excluded
  • Intussusception: Classically causes colicky abdominal pain, vomiting, and currant jelly stools
  • Pyelonephritis or other abdominal process

Workup and Diagnosis

  • Complete history and physical examination is the most useful diagnostic aid
    –Neurologic examination looking for clues to CNS lesions
    –Ear examination to evaluate for middle ear disease
    –Ophthalmologic examination to evaluate for nystagmus in labyrinthitis or benign positional vertigo
    –Abdominal examination including stool guaiac to evaluate for GI pathology
  • Labs may include CBC, electrolytes, liver function tests, amylase, lipase, urinalysis, calcium, magnesium, salicylate level, hepatitis serologies, toxicology screen, and CSF analysis (for meningitis or bleeding)
  • ECG and cardiac enzymes may be indicated to evaluate for cardiac ischemia
  • Abdominal CT scan with oral and IV contrast if history and physical examination suggest abdominal pathology
  • Plain KUB X-rays may be indicated to evaluate for bowel obstruction or perforation
  • Abdomen/pelvic ultrasound is especially helpful in cases of lower abdominal pain in female patients or in suspected gallbladder disease
  • Endoscopy is indicated for suspected peptic ulcer disease
  • Head CT with and without contrast if CNS lesion is suspected

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

  • Urticaria
    –Epidemiology: Lifetime incidence 20%; most cases resolve within 48 hours; chronic >6 weeks
    –Pathophysiology: Hypersensitivity reaction: allergens (IgE-mediated, prior sensitization), complement, and other cytokines activate mast cells and basophils to release histamine (also kinins, prostaglandins, serotonin) with plasma extravasation; wheals/hives: dermis edema
    –Triggers: Most cases are idiopathic
    –IgE-mediated: Insects (bees, wasps, scorpions, spiders, jellyfish), foods (eggs, shellfish, tree nuts, peanuts, tomatoes), drugs (penicillins, cephalosporins, NSAIDs, barbiturates, amphetamines, insulin, blood products), pollen, danders, food additives
    –Non-IgE-mediated: Infections (strep, EBV; hepatitis A, B, and C; adenovirus, enterovirus; fleas, mites), drugs (opiates, acetylsalicylic acid, local anesthetics), physical (exercise, cold/heat, UV light, water, pressure), contrast dyes, latex
  • Chronic urticaria: Associated with collagen vascular diseases (SLE, cryoglobulinemia), inflammatory bowel disease, malignancy, thyroiditis, hyperthyroidism, Behçet disease, vasculitis
  • Angioedema: 50% of urticaria cases; subcutaneous and mucous membrane edema
  • Anaphylaxis (IgE-mediated)
    –Most potent foods: Peanuts, fish
    –Mortality: 100–500 deaths/year in U.S.
    –Associated shock has a poor prognosis
    • Hereditary angioedema
      –High mortality
      –Most cases are autosomal dominant
      –C1 esterase inhibitor deficiency
      –Recurrent episodes of edema (face, upper airway, extremities)
      –Triggers: Trauma, surgery
      –Unresponsive to epinephrine, antihistamines
  • Others: Erythema multiforme, mastocytosis, guttate psoriasis, flushing, cellulitis

Workup and Diagnosis

  • History: Exposure to triggers, associated symptoms, symptoms of hypo-/hyperthyroidism, “feeling of impending doom” (anaphylaxis), history of atopy, family history of systemic diseases
  • Physical exam
    –Wheals/hives: Transient, elevated, erythematous, severely pruritic plaques, sudden onset; each wheal lasts 30 minutes to 3 hours, reappearing in other areas
    –Papular uritcaria: 2–3 mm red papules surrounded by 10–20 mm wheals, most common in toddlers, due to fleas and mites (e.g., scabies)
    –Physical urticaria: 10–20 mm erythematous macules with central wheal
    –Angioedema: Edema of face, hands, feet, genitalia
    –Anaphylaxis: Irritability, wheals, broncho- or laryngospasm (wheezing/stridor), angioedema, hypotension (late finding in children), vomiting, bloody diarrhea, mental status change; develops over minutes to hours; may develop DIC
    –Hereditary angioedema: Nonpruritic edema
  • Labs/studies
    –Urticaria/anaphylaxis: IgE antibody skin test or radioallergosorbent test for IgE-mediated causes; culture, microscopy (ova and parasites)
    –Angioedema: C1 esterase inhibitor, C3, C4
    –Chronic urticaria: ANA, urinalysis, CBC, CRP, ESR, thyroid antibodies

» READ BOOK EXCERPT ONLINE »

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

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

  • Infections
    –Gastroenteritis is the most common cause among all pediatric age groups; may be viral, bacterial, or parasitic
    –Urinary tract infection/pyelonephritis
    –Sepsis
    –Meningitis
    –Viral hepatitis: e.g., Hepatitis A
    –Helicobacter pylori-related ulcer
  • Anatomic
    –Esophageal: Tracheoesophageal atresia, esophageal ring/web/stricture, achalasia
    –Gastric: Pyloric stenosis, volvulus
    –Small intestine: Duodenal atresia, malrotation, meconium ileus, duodenal hematoma, SMA syndrome, duplication, intussusception, hernia
    –Colon: Hirschprung, imperforate anus
  • Gastrointestinal
    –Gastroesophageal reflux disease
    –Allergy (e.g., celiac disease, milk protein)
    –Peptic ulcer disease
    –Appendicitis
    –Foreign body
    –Pancreatitis
    –Cholecystitis
    –Eosinophilic enteropathy
    –Pseudo-obstruction
  • Neurologic
    –Intracranial mass
    –Hydrocephalus
    –Pseudotumor cerebri
    –Migraines
  • Renal
    –Obstructive uropathy
    –Nephrolithiasis
    –Glomerulonephritis
    –Renal tubular acidosis
  • Toxins/drugs
    –Aspirin, theophylline, digoxin, lead
    –Chemotherapeutics
  • Pregnancy
  • Inborn errors of metabolism
  • Endocrine
    –Diabetic ketoacidosis
    –Adrenal insufficiency
    –Congenital adrenal hyperplasia
  • Respiratory
    –Pneumonia
    –Post-tussive

Workup and Diagnosis

  • History and physical crucial because of large differential
    • History
      –Duration, frequency, bilious material, abdominal pain, diarrhea, hematemesis, hematochezia, melena, headache, fever, dysuria, weight loss, urine output
      –Sick contacts, cough, rhinorrhea, neck stiffness
    • Birth history: Polyhydramnios, passage of meconium
    • Family history: Genetic disease, early childhood deaths
      • Physical exam
        –Vitals, weight, mucous membranes, nasal discharge, breath sounds, rashes, meningismus
        –Abdominal pain/distension, hepatosplenomegaly, abdominal masses, Murphy/obturator/psoas sign
        –Skin turgor, capillary refill
        –Neuro exam including funduscopy for papilledema
      • Labs: Initial screen based on physical exam
        –Consider electrolytes, LFTs, amylase, lipase
        –U/A and culture; lactate and pyruvate
        –Serum amino acids/urine organic acids, ammonia for metabolic diseases; blood gas for acidosis
        –CBC for infections, lumbar puncture
    • KUB or obstruction series as initial X-ray
    • Contrast study with upper GI series with or without small bowel follow-through or BE for anatomic problem
    • Abdominal ultrasound for pyloric stenosis
    • Head imaging including CT/MRI
    • Upper endoscopy and colonoscopy for mucosal inflammation

    » READ BOOK EXCERPT ONLINE »

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

    Vomiting – Projectile: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

  • Anatomic/obstructive
    –Pyloric stenosis: Classic description of progressive projectile vomiting; more common among first-born males and typically presents in weeks 4–8 of life; may see hypochloremic, hypokalemic metabolic alkalosis
    –Hiatal hernia
    –Pyloric atresia
    –Gastric volvulus
    –Gastric outlet obstruction due to chronic granulomatous disease, peptic ulceration near the pyloris, or gastric tumors
    –Duodenal web
    –Duodenal atresia
    –Duodenal stenosis
    –Superior mesenteric artery syndrome: Typically due to weight loss, postsurgical correction of scoliosis, or immobilization with body cast
    –Urinary tract obstruction: Ureteropelvic junction obstruction (abdominal pain and vomiting known as Dietl crisis); nephrolithiasis
    • Inflammatory
      –Gastroesophageal reflux disease
      –Peptic ulcer disease
      –Pyelonephritis
      –Meningitis
      –Encephalitis
      –Eosinophilic enteropathy
    • Central nervous system
      –Brain tumor
      –Trauma
      –Lead encephalopathy
      –Acute intracranial hemorrhage
      –Hydrocephalus
    • Metabolic/endocrine
      –Congenital adrenal hyperplasia
      –Hypercalcemia
      –Wolman disease
      –Phenylketonuria

    Workup and Diagnosis

    • Differentiating vomiting from projectile vomiting is often difficult when obtaining history
    • History: Age at presentation, frequency and amount of emesis, time after feeding until emesis, bilious or nonbilious, hematemesis, weight loss, fever, diarrhea, abdominal pain, melena, hematochezia, activity level, dysuria, menses, pica, recent trauma
    • Birth history: Meconium in nursery, oligohydramnios, polyhydramnios, newborn screen, birth weight
    • Family history: First born
    • Diet history: Formula intolerance
    • Surgical history: Previous abdominal surgeries
    • Social history: House built before 1965 (lead paint)
    • Physical exam: Weight, height, head cirumference, vital signs, mucous membranes, fontanelle, papilledema, equal breath sounds, abdominal distension, abdominal mass (palpable olive in pyloric stenosis), bowel sounds, skin turgor, capillary refill, reflexes, tone, strength
    • Chemistry panel with focus on chloride, CO2, potassium, calcium; CBC with differential for signs of infection, consider urine analysis and culture
    • Abdominal films for obstruction
    • Ultrasound a sensitive and specific method for pyloric stenosis; findings of elongation of pyloric channel and thickening of pyloric muscle; U/S for pelvic obstruction
    • Upper GI series for malrotation, atresia, superior mesenteric artery
    • CT scan for head or abdominal mass

    » READ BOOK EXCERPT ONLINE »

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

    NAUSEA AND VOMITING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

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

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

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

    Urticaria [Hives]: History
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products or detergents? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

    » READ BOOK EXCERPT ONLINE »

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

    Urticaria and angioedema: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    An accurate patient history can help determine the cause of urticaria. Such a history should include:

    ❑ drug history, including over-the-counter preparations (vitamins, aspirin, and antacids)

    ❑ frequently ingested foods (strawberries, milk products, fish)

    ❑ environmental influences (pets, carpet, clothing, soap, inhalants, cosmetics, hair dye, and insect bites and stings).

    Diagnosis also requires physical assessment to rule out similar conditions as well as a complete blood count, urinalysis, erythrocyte sedimentation rate, and a chest X-ray to rule out inflammatory infections. Skin testing, an elimination diet, and a food diary (recording time and amount of food eaten and circumstances) can pinpoint provoking allergens. The food diary may also suggest other allergies. For instance, a patient allergic to fish may also be allergic to iodine contrast materials.

    Recurrent angioedema without urticaria, along with a familial history, points to hereditary angioedema. (See Hereditary angioedema.) Decreased serum levels of complement 4 and complement 1 esterase inhibitors confirm this diagnosis.

    » READ BOOK EXCERPT ONLINE »

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

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

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started it? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel elimination patterns or the appearance of stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant and which contraceptive method she uses.

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with a CNS injury, quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

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

    Urticaria [Hives]: History
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is it related to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has he recently used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

    » READ BOOK EXCERPT ONLINE »

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

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

    A. Characteristics. Is the rash localized or systemic? Is it pruritic? What is the duration of symptoms? Does anything relieve the symptoms? Are there any specific triggers (2)?

    1. Food and drugs are common causes of urticaria.

    2. Certain systemic diseases can cause urticaria. Infections, connective tissue disorders, endocrine disorders, and neoplastic disorders are some examples.

    3. Insect stings and bites are another common cause of urticaria.

    B. Symptom chronology. When does it occur? How long does it last? Is it in association with physical trauma? Has the patient been on any medication that has helped relieve symptoms (e.g., antihistamines)?

    C. Family history. Are there any members of the family who suffer from a connective tissue disorder? Do any complement disorders occur in the family, such as hereditary angioedema, which can be associated with urticaria? Also, is there a family history of atopy?

    Physical examination

     A complete physical is required to rule out infection or other systemic diseases. An urticarial wheal is usually well demarcated. It begins as an erythematous area, which then develops a white center. The size of the wheal can vary from 2 mm to well over 30 cm. The rash is usually pruritic, especially when it occurs on the palms of the hand and the soles of the feet. Most often, the wheal will disappear within 3 to 4 hours of onset. The accompanying angioedema can last for a couple of days. The skin will return to normal once the wheal is gone.

    » READ BOOK EXCERPT ONLINE »

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

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

    As is usually the case in clinical practice, most diagnoses will be made by history and confirmed by physical examination and laboratory studies. Key points in the history include the following:

    A. Are the symptoms acute, chronic, or recurrent?

    B. If vomiting is the predominant feature, consider GI infection, reflux, gastritis, or ulcer.

    C. Nausea as the predominant feature often results from systemic problems.

    D. Is there a history of travel, drinking unsafe water, or eating unusual or uncooked food?

    E. Is there a history of fevers or chills (Chapter 2.6.)?

     F. Are general systemic symptoms or signs such as edema, discolored urine or jaundice, fatigue, weight loss or anorexia, headache, or blurred vision present?

     G. Are psychiatric symptoms present?

    H. Is the patient taking any medications?

    I. Is diarrhea present?

     J. Is there abdominal pain? The presence of abdominal pain raises some important and potentially serious possibilities:

    1. Common problems presenting with abdominal pain and vomiting include cholecystitis, appendicitis, gastritis or ulcer, hepatitis, small bowel obstruction, inferior myocardial infarction or ischemia, renal colic, peritonitis, pancreatitis, food poisoning, and complications of pregnancy.

     2. Uncommon problems presenting with abdominal pain and vomiting include diabetic ketoacidosis, drug withdrawal, uremia, and vasculitis or abdominal migraine.

     3. Rare problems presenting with abdominal pain and vomiting include porphyria, lead intoxication, adrenal insufficiency, hyperlipidemia, abdominal epilepsy, glaucoma, hypercalcemia, and acute hemolysis.

    Physical examination.

     A directed physical examination is dictated by the findings on history, but the following are areas of key importance:

    A. Vital signs. Focus on presence of fever, pulse, and blood pressure to assess hydration, and respiratory rate to look for acidosis-related hyperventilation.

     B. Skin, eyes, mucous membranes. Look for dehydration and signs of jaundice.

     C. Signs of systemic infection. Pay special attention to examining the lung and the costovertebral angle for tenderness.

     D. A detailed abdominal examination should include inspection, auscultation, palpation, percussion, areas of tenderness, rebound, guarding, hepatomegaly, Murphy’s sign, stool for occult blood, and bimanual pelvic examination.

    » READ BOOK EXCERPT ONLINE »

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

    Nausea/Vomiting: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Presenting Symptom

    ❑ Gastroesophageal reflux

    ❑ Pregnancy

    ❑ Psychogenic

    ❑ Bulimia

    ❑ Rumination

    ❑ Diabetic ketoacidosis

    ❑ Hepatitis

    ❑ Inferior myocardial infarction

    ❑ Uremia

    ❑ Adrenal insufficiency

    With Abdominal Pain

    ❑ Viral gastroenteritis

    ❑ Food poisoning

    ❑ Peptic ulcer disease

    ❑ Renal colic

    ❑ Pancreatitis

    ❑ Pyelonephritis

    ❑ Appendicitis

    ❑ Cholecystitis

    ❑ Small bowel obstruction

    ❑ Peritonitis

    With Neurologic Signs

    ❑ Migraine headache

    ❑ Vestibular disturbance

    ❑ Autonomic dysfunction

    ❑ Increased intracranial pressure

    ❑ Hypercalcemia

    ❑ Cerebellar hemorrhage

    Diagnostic Approach

    Neurological vomiting may be projectile (forceful emesis without prior nausea), positional, or associated with other neurological signs. Central vomiting (chemoreceptor trigger zone stimulation, usually caused by toxins) is alleviated by antidopaminergic medications, which do not work well when treating nausea due to mechanical causes such as obstruction.

    Early morning nausea suggests pregnancy or metabolic causes (e.g., uremia). Vomiting of a large amount of undigested food 4 to 6 hours after eating is consistent with gastric retention resulting from pyloric obstruction
    or gastroparesis or to esophageal disorders such as achalasia or Zencker diverticulum. Feculent vomiting suggests intestinal obstruction or gastrocolic fistula.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Urticaria/Angioedema: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Ingestants

    ❑ Drugs

    ❑ Inhalants

    ❑ Hymenoptera venom

    ❑ Latex sensitivity

    ❑ Dermatographism

    ❑ Pressure urticaria

    ❑ Cholinergic urticaria

    ❑ Cold urticaria

    ❑ Solar urticaria

    ❑ Infection

    ❑ Urticarial vasculitis

    ❑ Hereditary angioedema

    ❑ Mastocytosis

    Diagnostic Approach

    Urticaria appears as transient, mutable wheals with red raised serpiginous borders and clear centers, which often coalesce. Urticaria is experienced by 10% to 20% of the population at some time. Angioedema is well-demarcated localized edema.

    The appearance may be helpful. Gyrate hives (erythema gyratum) are associated with internal malignancy. Hives without pseudopods suggest allergy. Small lesions with erythematous flares suggest cholinergic urticaria. Urticarial lesions unchanged for 24 hours suggest vasculitis, especially if associated with scaling or purpura.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    anaphylaxis: Diagnosis
    (Handbook of Diseases)

    Anaphylaxis can be diagnosed by the rapid onset of severe respiratory or cardiovascular symptoms after ingestion or injection of a drug, vaccine, diagnostic agent, food, or food additive or after an insect sting. If these symptoms occur without a known allergic stimulus, rule out other possible causes of shock (such as acute myocardial infarction, status asthmaticus, and heart failure).

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Urticaria and angioedema: Diagnosis
    (Handbook of Diseases)

    An accurate patient history can help determine the cause of urticaria. Such a history should include:

    ❑  drug history, including over-the-counter preparations (vitamins, aspirin, and antacids)

    ❑  frequently ingested foods (strawberries, milk products, fish)

    ❑  environmental influences (pets, carpet, clothing, soap, inhalants, cosmetics, hair dye, and insect bites and stings).

    Diagnosis also requires physical assessment to rule out similar conditions, as well as a complete blood count, urinalysis, erythrocyte sedimentation rate, and a chest X-ray to rule out inflammatory infections. Skin testing, an elimination diet, and a food diary (recording time and amount of food eaten and circumstances) can pinpoint provoking allergens. The food diary may also suggest other allergies. For instance, a patient allergic to fish may also be allergic to iodine contrast materials.

    Recurrent angioedema without urticaria, along with a familial history, points to hereditary angioedema. Decreased serum levels of complement 4 and complement 1 esterase inhibitors confirm this diagnosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

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

    If the patient isn’t in distress, obtain his medical history. Does he have known allergies? Does urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note a history of chronic or parasitic infection, skin disease, or GI disorder.

    Physical examination

    Obtain the patient’s vital signs. Perform a complete cardiopulmonary assessment, noting signs and symptoms of shock or respiratory distress. Assess for urticaria in other areas because new crops may continue to appear.

    » READ BOOK EXCERPT ONLINE »

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

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

    Ask the patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    Physical examination

    Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure (ICP), a life-threatening emergency. If this occurs in a patient with a CNS injury, you should quickly check his vital signs. Stay alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

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

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

    If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

    » READ BOOK EXCERPT ONLINE »

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

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

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes, page 700.) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.

    » READ BOOK EXCERPT ONLINE »

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

    Regurgitation and Vomiting: Clinical Features and Diagnosis: Regurgitation
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Normal Variations

  • In infants,milk may flow from mouth during or after feeding with little effortor distress.
  • Common causes include overfeeding,air swallowed during feeding, crying, or coughing.
  • Physical exam is normal and weightgain is adequate. History and physical exam are diagnostic.

    • Gastroesophageal Reflux

  • Is the spontaneouspassage of stomach contents into esophagus.
  • Common finding in many infants. Maybegin by a few weeks of age and usually resolves by 8–12mos of age. Infant is otherwise asymptomatic and has normal weightgain. No testing is required in this clinical circumstance.
  • Gastroesophageal reflux disease refersto infants with regurgitation and vomiting associated with poorweight gain; respiratory symptoms (e.g., wheezing, hoarseness, orapnea); or esophagitis. Upper GI series is valuable to exclude anyanatomic abnormality. Esophageal pH probe study can quantitate frequencyand duration of acid reflux episodes. Endoscopy with biopsy shouldbe performed if esophagitis is suspected.

    • Esophageal Disorders

    Congenital Anomalies

    Esophageal Atresia with or without Tracheoesophageal Fistula

  • Esophagealatresia usually exists with distal tracheoesophageal fistula. Uppersegment of esophagus ends in blind pouch and lower segment communicateswith trachea.
  • Maternal history of polyhydramniosis common.
  • Drooling, choking, and regurgitationoccur with first feeding.
  • Opaque nasal catheter that fails topass into stomach and remains curled up in proximal esophagus establishesdiagnosis. Air in stomach on chest radiograph indicates presenceof tracheoesophageal fistula. If diagnosis is uncertain, injectionof small amount of contrast material into upper esophagus with fluoroscopyis confirmatory.

    • Esophageal Stenosis

  • Usuallyoccurs in middle third of esophagus.
  • Regurgitation and poor weight gainare prominent symptoms.
  • Contrast esophagram is diagnostic.

    • Esophageal Web

  • Mucosalmembrane that usually occurs in upper esophagus or at junction between middleand lower third of esophagus.
  • Obstruction may be complete and causeregurgitation soon after birth.
  • Diagnosis may be confirmed by esophagramor endoscopy.

    • Duplication

  • Duplicationsof esophagus are cystic or tubular structures that can compressesophagus, causing regurgitation. Some duplications contain gastricmucosa, which may produce GI bleeding.
  • Combination of tests, including chestradiography, upper GI radiographic series, and chest CT or MRI,is diagnostic.

    • Foreign Body

  • Esophagealforeign bodies usually cause obstruction at level of cricopharyngeusmuscle or just above lower esophageal sphincter.
  • Choking, coughing, dysphagia, regurgitation,and vomiting may occur. If foreign body is radiopaque, it may beseen on chest radiograph. Otherwise, filling defect is usually seenon esophagram.
  • Diagnosis may be confirmed by endoscopy.

    • Stricture

  • Usuallydue to long-standing reflux esophagitis but also may be due to causticingestion.
  • Usual manifestations are dysphagia,regurgitation, and vomiting.
  • Contrast esophagraphy or endoscopyis diagnostic.

    • Hiatal Hernia

  • Herniationof portion of stomach into thorax.
  • Usually is congenital and often isassociated with gastroesophageal reflux.
  • Although regurgitation, vomiting, andepigastric pain may occur, it can be asymptomatic.
  • Upper GI radiographic series is diagnostic.

    • Rumination

  • Regurgitationof already ingested food from stomach and esophagus into mouth, whereit is rechewed and swallowed or spit out.
  • Primarily occurs in 2 populations:developmentally impaired young children as self-stimulation behaviorand adolescents with significant psychological stress. Younger childrenhave minimal vomiting, whereas adolescents have significant vomiting.
  • pH probe shows resolution of esophagealacidification during sleep.

    • Diagnostic Approach: Regurgitation

  • In infantwith regurgitation who is otherwise well and gaining weight, mostlikely diagnosis is normal variation or mild gastroesophageal reflux.
  • Persistent regurgitation with poorweight gain, respiratory symptoms, or symptoms suggesting esophagitisrequires investigation.
  • Upper GI radiographic series excludesother causes of esophageal obstruction. Most reliable test for gastroesophagealreflux is esophageal pH monitoring. Endoscopy with biopsy can confirmdiagnosis of esophagitis.
  • Other investigations depend on history,physical exam, and results of the above studies.

    • » READ BOOK EXCERPT ONLINE »

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

    Vomiting: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and causes.) Explore associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.

    Obtain a medical history, noting GI, endocrine, and metabolic disorders; recent infections; and cancer, including chemotherapy or radiation therapy. Ask the patient about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant or which contraceptive method she's using.

    Inspect the patient's abdomen for distention and localized bulging, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess the patient's other body systems as appropriate.

    During the examination, keep in mind that projectile vomiting unaccompanied by nausea may be an indication of increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Urticaria [Hives]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient isn't in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products or detergents? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

    Next, assess respiratory status. Inspect the chest for sternal retractions and accessory muscle use. Auscultate and percuss the chest. Assess cardiac status. Obtain vital signs and pulse oximetry and begin cardiac monitoring. Assess all skin surfaces.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    NAUSEA AND VOMITING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs is essential in pinpointing the diagnosis of vomiting. For example, vomiting with tinnitus and vertigo suggests Ménière disease, whereas vomiting with hematemesis suggests gastritis, esophageal varices, and gastric ulcers. The laboratory workup should include a flat plate of the abdomen, upper GI series, esophagram, cholecystogram, gastric analysis, serum electrolytes, and amylase and lipase levels. Stools for occult blood, ova, and parasites are usually indicated. Gastroscopy and esophagoscopy are often indicated in the acute case, but an exploratory laparotomy should not be delayed if the patient’s condition is deteriorating and pancreatitis has been excluded.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Food allergies

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