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Diagnosis of Generalized anxiety disorder

Generalized anxiety disorder Diagnosis: Book Excerpts

Diagnostic Tests for Generalized anxiety disorder: Online Medical Books

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


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

  1. Is the anxiety intermittent or constant? Intermittent anxiety suggests the possibility of psychomotor epilepsy, a pheochromocytoma, or insulinoma. It is also possible that the patient is suffering from an intermittent cardiac arrhythmia such as paroxysmal supraventricular tachycardia or atrial fibrillation.
  2. What is the patient's age? The young or middle-aged patient is more likely to be suffering from a psychiatric disorder, whereas the older patient may be suffering from cerebral arteriosclerosis or some other type of dementia.
  3. If there is tachycardia, is it sustained during sleep? Tachycardia that is sustained during sleep would suggest hyperthyroidism, caffeine effects, or other drug effects.
  4. Is there associated weight loss? Sustained tachycardia with weight loss makes hyperthyroidism a very likely possibility.

DIAGNOSTIC WORKUP

Patients with intermittent anxiety with long periods of calmness in between should have a wake-and-sleep EEG and possibly a CT scan to rule out a cerebral tumor. A 24-hr urine collection for catecholamines should be done also to rule out a pheochromocytoma. Twenty-four-hr Holter monitoring may be necessary to rule out a paroxysmal cardiac arrhythmia. In difficult cases, a 24-hr EEG or an EEG with nasopharyngeal electrodes inserted may be necessary.

Patients with constant anxiety should have a thyroid profile, a drug screen, and an EKG. If these are not revealing, perhaps 24-hr Holter monitoring may be of some value. With a negative workup, a referral to a psychiatrist is in order. It may be even wiser to consult a psychiatrist before undertaking an expensive workup.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  1. Is there associated headache, papilledema, dementia, or focal neurologic signs? These findings would suggest a space-occupying lesion. This is something the clinician does not want to miss.
  2. Are there endocrine changes? A number of endocrinologic diseases may present with depression, including Cushing's disease, myxedema, hyperthyroidism, and menopause.
  3. Is there marked loss of appetite, weight, and libido? Endogenous depression, unipolar depression, and the depressive phase of manic-depressive psychosis may present with these findings. On the other hand, neurotic depressive reaction usually is not associated with significant loss of appetite, weight, or libido.

DIAGNOSTIC WORKUP

If the patient is suicidal, one should not hesitate to make a psychiatric referral or plan hospitalization immediately. To rule out organic causes, routine laboratory studies include a CBC, sedimentation rate, chemistry panel, VDRL test, and thyroid profile. If Cushing's syndrome is suspected, a serum cortisol and cortisol suppression test should be done. If menopause is suspected, order a serum FSH and estradiol level. A trial of estrogen therapy may be warranted. A CT scan of the brain should probably be done in all cases to exclude a brain tumor, especially if there is no response to treatment! Office tests to evaluate nonorganic depression include the Beck Depression Inventory and the Hamilton Depression Scale. A referral to a psychiatrist should also be considered early if the depression is severe or if there is suicidal ideation.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  • Generalized anxiety disorder
    –Excessive worry associated with at least three symptoms, including restlessness or edgy feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
    –The most common anxiety disorder in primary care
  • Panic disorder
    –Recurrent, unpredictable panic attacks with intense apprehension, fear or terror, and somatic symptoms (e.g., tachycardia)
    –May present with or without agoraphobia
  • Depression: Anxiety often presents in a mixed state with depression
  • Medications (e.g., bronchodilators, steroids, antidepressants, antihypertensives)
  • Substance use, including drugs (e.g., alcohol, caffeine, cocaine, cannabis)
  • Obsessive-compulsive disorder
    –Obsessions are persistent ideas, images, or impulses that generate anxiety
    –Compulsions are intentional repetitive behaviors or mental acts aimed at reducing the distress of obsessions
    • Anxiety disorder due to a general medical condition
      –Cardiovascular etiologies include MI, angina, arrhythmias, CAD, CHF, MVP
      –Respiratory etiologies include asthma, COPD, and pulmonary embolism
      –Endocrine etiologies include hyper- or hypothyroidism, hypoglycemia, and Cushing's syndrome
      –Neurological etiologies include Parkinson's disease and epilepsy
      –Cancer
    • Pheochromocytoma: Adrenal tumor that usually presents with hypertension and increased heart rate and sometimes with fright reaction of sweating, headache, and pale facial appearance
    • Parkinson's disease: Presents with tremor at rest, usually in one hand (as opposed to the more generalized essential tremor in anxiety)
    • Post-traumatic or acute stress disorder
    • Social anxiety disorder
    • Specific phobia
    • Bipolar disorder (especially manic stage)

    Workup and Diagnosis

    • Detailed history of onset, duration, and type of anxiety symptoms as well as specific events, stressors, or medical illnesses that produce anxiety
      –Complete drug and medication history, including caffeine, alcohol, over-the-counter preparations, herbals, illicit drugs, and prescription drugs
      –Physical exam should be directed toward ruling out organic medical diseases that may present with anxiety, including cardiovascular, pulmonary, endocrine, and neurologic disorders
      –A complete psychiatric examination is indicated for all patients (e.g., appearance, sleep evaluation, mini-mental status exam, affect)
    • DSM-IV criteria are used to determine the specific psychiatric disorders
    • No diagnostic tests are indicated except those that may determine underlying medical disorders (e.g., thyroid function tests, ECG, urine catecholamines)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs is all important. A triiodothyronine (T3) level, total thyroxine (T4) level, and free thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes, toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and 17-hydroxycorticosteroid level should be done on anyone suspected of having endogenous depression. (Possibly all depressed patients should get this screen.) Skull x-ray film, EEG, CT scan and even a spinal tap [to rule out multiple sclerosis (MS) and lues] may be worthwhile when other neurologic signs are present.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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

Obviously, it is tempting simply to do a lymph node biopsy, but certain other procedures should be done first. If the patient is febrile, febrile agglutinins, Monospot test, blood cultures, and cultures of any other suspicious body fluid should be made. An FTA-ABS test should be done as well as a chest x-ray and tuberculin test to rule out tuberculosis. A blood count usually shows leukemia, but a bone marrow may be necessary to diagnose leukemia, Hodgkin disease, and the reticuloendothelioses. Other x-rays, skin tests, and special diagnostic procedures may be necessary.

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Source: Differential Diagnosis in Primary Care, 2007

WEAKNESS AND FATIGUE, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs with generalized weakness and fatigue is very important in pinning down a diagnosis. Generalized lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or tuberculosis or other chronic infection such as AIDS. Weakness and weight loss and polyphagia with polyuria and polydypsia would suggest hyperthyroidism or diabetes mellitus. Generalized weakness with polyuria and no significant weight loss suggests hyperparathyroidism. Weakness with pallor suggests some type of anemia. Weakness and weight loss without polyuria or polyphagia suggest malignancy or malabsorption syndrome. Weakness with other significant neurologic signs and symptoms prompts the consideration of muscular dystrophy, amyotrophic lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use prompts the investigation of drug or alcohol abuse. Caffeine, especially in large quantities, can also cause significant weakness and chronic fatigue.

The initial workup of weakness and fatigue requires a CBC, sedimentation rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray and ECG. If muscular dystrophy or dermatomyositis is suspected, urine for creatinine, creatine and myoglobin can be done. Ultimately, a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum for acetylcholine receptor antibody may be done. If Addison disease is suspected, a serum cortisol may be done. A 24-hour urine aldosterone level may be done to exclude primary aldosteronism. Serum PTH may be done to exclude hyperparathyroidism.

It would be wise to consult an infectious disease specialist before ordering an expensive workup. It would also be wise to consult an oncologist when searching for a malignancy before ordering an expensive workup.

When all tests have negative findings, many clinicians have been tempted to make a diagnosis of chronic fatigue syndrome. It is questionable whether this is truly a disease or not.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RASH, GENERAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or the if symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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

Determine the severity of the patient’s agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and use of herbal medicine.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Ask the patient about prescribed or over-the-counter drug use, including supplements and herbal medicines. Check for signs of drug abuse, such as needle tracks and dilated pupils. Ask about alcohol intake. Obtain the patient’s baseline vital signs and neurologic status for future comparison.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake and alleviated by rest, tranquilizers, or exercise.

Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.

If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological basis. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.

» READ BOOK EXCERPT ONLINE »

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

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

During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what's bothering her. How does her current mood differ from her usual mood? Then ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (SeeSuicide: Caring for the high-risk patient.)

Ask the patient about her family — its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed, and whether anyone important to the patient has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she's feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.

Cultural cue  

Patients who don't speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.

» READ BOOK EXCERPT ONLINE »

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

Skin, clammy: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 564.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

» READ BOOK EXCERPT ONLINE »

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

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

Obtain a thorough patient history from a parent or caretaker, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant’s fluid intake and urine output over the past 24 hours, including the number of wet diapers during that time. Ask about the child’s preillness weight, and compare it to his current weight; weight loss in an infant reflects water loss.

» READ BOOK EXCERPT ONLINE »

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

Seizures, generalized tonic-clonic: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of a headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

» READ BOOK EXCERPT ONLINE »

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

Generalized anxiety disorder: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

For characteristic findings in patients with this condition, see Diagnosing generalized anxiety disorder.

Laboratory tests must exclude organic causes of the patient’s signs and symptoms, such as hyperthyroidism, pheochromocytoma, coronary artery disease, supraventricular tachycardia, and Ménière’s disease. For example, an electrocardiogram can rule out myocardial ischemia in a patient who complains of chest pain. Blood tests, including complete blood count, white blood cell count and differential, and serum lactate and calcium levels, can rule out hypocalcemia.

Because anxiety is the central feature of other mental disorders, psychiatric evaluation must rule out phobias, obsessive-compulsive disorder, depression, and acute schizophrenia.

Behaviors commonly associated with a diagnosis of anxiety may have cultural origins or acceptance. For example, Hispanics may experience “susto,” or a state of anxiety, insomnia, anorexia, and social withdrawal, following a frightening stimulus. Koreans may experience “Hwa-byung” — a state of anxiety and irritability, with various physiologic symptoms, such as headache and palpitations. African-Americans may experience “blockout,” involving collapse, dizziness, and reduced physical movement in time of stress.

» READ BOOK EXCERPT ONLINE »

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

Major depression: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

For characteristic findings in patients with this condition, see Diagnosing major depression.

The diagnosis is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms. A toxicology screening may suggest drug-induced depression.

» READ BOOK EXCERPT ONLINE »

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

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

Determine the severity of the patient’s agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and use of prescribed or over-the-counter drugs, including supplements and herbal medicines.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Check for signs of drug abuse, such as needle tracks and dilated pupils, and ask about alcohol intake. Obtain baseline vital signs and neurologic status for future comparison.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice any precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or excessive caffeine intake and alleviated by rest, tranquilizers, or exercise.

Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.

If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological cause. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.

» READ BOOK EXCERPT ONLINE »

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

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

During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what’s bothering her. How does her current mood differ from her usual mood? Then ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (See Suicide: Caring for the high-risk patient, page 234.)

Ask the patient about her family—its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed and whether anyone important to her has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she’s feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.

Cultural Cue: Patients who don’t speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.

» READ BOOK EXCERPT ONLINE »

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

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

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, examine the pupils for dilation. Check for abdominal distention and increased muscle tension.

» READ BOOK EXCERPT ONLINE »

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

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

Obtain a thorough patient history from a parent or caregiver, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant’s fluid intake and urine output over the last 24 hours, including the number of wet diapers during that time. Ask about the child’s pre-illness weight, and compare it with his current weight; weight loss in an infant reflects water loss.

» READ BOOK EXCERPT ONLINE »

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

Seizures, generalized tonic-clonic: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report any unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have any other seizures before recovering?

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

» READ BOOK EXCERPT ONLINE »

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

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

 The most common physical symptoms associated with anxiety disorders include palpitations, shortness of breath, dizziness, sweating, and abdominal and chest pain. Common psychological symptoms can include shakiness, nervousness, fear of dying or going crazy, derealization, or depersonalization. Some patients attribute their anxiety to their physical symptoms (“Of course, I was anxious. I thought I was having a heart attack”).

The assessment of anxiety disorders should include the nature, frequency, and duration of symptoms, precipitants, and impact of symptoms. A careful review of all medications (esp. stimulants, sympathomimetics, xanthines) and use of legal (e.g., caffeine) and illegal (e.g., cocaine) substances is essential. Comorbid medical and psychiatric illnesses should be assessed. The following symptoms should be specifically solicited: discrete episodes of severe anxiety (panic), intense fear of social settings, specific fears or phobias, obsessions or compulsions, and nightmares or flashbacks.

Physical examination.

The extent of the physical examination or medical workup depends on the age of the patient, severity of symptoms, and presence or suggestion of comorbid medical illnesses (3). Although many patients with chronic medical illnesses may suffer from anxiety, relatively few medical illnesses
directly cause anxiety. These include hyperthyroidism, hyperparathyroidism, tachyarrhythmias, and hypoxia from any cause (esp. chronic obstructive pulmonary disease).

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

Depression: History and mental status examination (MSE)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Symptoms and signs. The diagnosis of major depression depends on a systematic assessment of psychiatric symptoms and signs (i.e., the history and MSE). At least five symptoms from the following list must be present most of the day, nearly every day, for 2 consecutive weeks or more: depressed mood; decreased interests or pleasure; weight or appetite change; sleep disturbance; psychomotor agitation or retardation; anergia; worthlessness or guilt; trouble thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plan, or attempt. One of the symptoms must be depressed mood or decreased interests. Although somewhat arbitrary, the following grouping of symptoms may facilitate their recall.

 1. Mood—depressed mood: “How is your mood, your spirits?” “Sad,” “blue,” “down,” crying spells; the patient also may have irritability, anxiety, decreased mood reactivity, and decreased hedonic capacity.

 2. Ideational or psychological—decreased interests: thoughts of worthlessness, helplessness, hopelessness, suicide; decreased ability to concentrate; and ruminative thinking (thoughts dwelling on depressive themes). Given the risk of suicide, all patients with clinically significant depressive symptoms should be asked about their suicidal thoughts (“Many people who are depressed have thoughts about dying, wanting to be dead, or wanting to kill themselves. What thoughts like this have you had?”) (Chapter 3.4).

 3. Neurovegetative or somatic—change in appetite and weight: anorexia and weight loss are most common but hyperphagia and weight gain are possible; change in sleep (insomnia, especially early morning awakening is most common but hypersomnia is possible); decreased energy, decreased libido, psychomotor slowing or agitation; diurnal variation (in more severe cases, mornings are worse is the most common pattern).

 B. Other factors. In addition to the symptoms that define the condition, other factors should be assessed:

1. Function. How is the depression affecting performance at work? Interpersonal relations? Attention to grooming and other activities of daily living?

2. Psychosocial stressors. Both acute life events and ongoing stressors may be relevant.

3. Prior depressive episode. Detailed information about previous episodes and their treatments will guide both prognosis and current treatment.

4. Family history may reflect genetic vulnerability toward the condition, and also can shape the patient’s perceptions about the illness and recommended treatments.

5. General medical history. Careful review of past and current illnesses and drugs (including alcohol and other recreational drugs) is needed to identify potential physiologic causes or contributors.

 6. Other pertinent negatives. A past history of mania or psychosis suggests bipolar or schizoaffective disorder rather than major depression. Objective cognitive deficits (as opposed to merely subjective cognitive complaints) require further evaluation to determine the presence and cause of delirium or dementia, in which depressive symptoms are frequent.

Physical examination.

 Any patient with severe depression sufficient to warrant treatment should have both a general screening physical examination, paying particular attention to signs of anemia and endocrinopathies (e.g., hypothyroidism) and a careful screening neurologic examination.

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

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

 should focus on those common causes of generalized lymphadenopathy.

 A. History of present illness should focus on the duration, location, quality, and context of the lymphadenopathy. Note associated signs and symptoms such as rash, fever, sore throat, and cough (4) (Chapters 2.6, 8.1, and 13.6). The goal is to ascertain if the adenopathy is attributable to a specific cause.

 B. Past medical history should focus on known illness, medication usage, and allergies. Serum sickness from antibiotic use as well as diphenylhydantoin for seizure prevention can cause generalized lymphadenopathy. Common chronic illnesses (e.g., lupus erythematosus and rheumatoid arthritis) can also cause generalized lymphadenopathy.

 C. Social history should focus on the patient’s occupation, sexual history, and alcohol use. Hepatitis B, secondary syphilis, and early human immunodeficiency virus (HIV) can all present with generalized lymphadenopathy. Patients with Hodgkin’s disease can develop painful adenopathy with alcohol use.

D. Family history. Inquire about family illness with a genetic predisposition as well as any exposures to household contacts with infectious diseases (e.g., tuberculosis, infectious mononucleosis, or hepatitis B).

 E. Review of systems should focus on constitutional symptoms such as weight loss, fatigue, night sweats, malaise, arthralgias, nausea, and vomiting (1).

Physical examination

 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.

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

Anxiety: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Situational/characterologic

❑ Post-traumatic stress disorder

❑ Drugs/withdrawal

❑ Generalized anxiety disorder

❑ Panic disorder

❑ Phobia

❑ Agitated depression

❑ Hypoglycemia

❑ Hyperthyroidism

Diagnostic Approach

Anxiety ranges from a vague sense of uneasiness to one of imminent danger and dread. Thoughts race and concentration is difficult. There is a heightened self-awareness and startle response. Restlessness, bitten fingernails, tremor, tic, and excessive sweating are often noticeable. Sympathetic nervous system activation may cause palpitations, flushing, sweating, or diarrhea. Hyperventilation may occur, with lightheadedness, and circumoral numbness.

Heightened perception and negative interpretation of normal bodily sensations is a common stimulus to visit the physician. Anxiety is frequently somatized to symptoms of chest pain, palpitations, or shortness of breath. Anxiety-related air swallowing (aerophagia) produces belching.

Repression is a defense mechanism, leading to dissociation from awareness and conversion to hysterical symptoms such as paralysis, anesthesia, aphonia, or amnesia. Blocking of one side of a conflict (a common defense mechanism) distorts the perception of reality, causing decision-making to become difficult.

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Source: Field Guide to Bedside Diagnosis, 2007

Depression: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Dysthymia

❑ Major depression

❑ Adjustment disorder with depressed mood

❑ Seasonal affective disorder

❑ Bipolar disorder

❑ Drug-induced

❑ Grief

❑ Thyroid disease

❑ Dementia

❑ Stroke

❑ Paraneoplastic

Diagnostic Approach

Depression often presents in primary care settings masked in the form of somatic symptoms, such as anorexia, weight loss, fatigue, insomnia (especially early morning awakening), or difficulty concentrating. It is also common for the perception of symptoms produced by another organic cause to be heightened by depression. Depression becomes pathologic when it interferes with normal function.

Once depression is identified, it is critical to assess suicide risk. The best way to do this is to straightforwardly ask patient, if they have thought of harming themselves and if so, do they have a plan. Risk factors for suicide include living alone, prior suicide attempt, family history of suicide attempt or substance abuse, general medical illness, extreme hopelessness, psychosis, and substance abuse.

The SQ is a one-question screen: “Have you felt depressed or sad much of the time in the past year?”. The CAGE questionnaire is designed to identify drinkers who are alcohol-dependent or heavy drinkers (>8 drinks/day):
1) “Have you ever felt you should Cut down your drinking?” 2) “Have people Annoyed you by criticizing your drinking?” 3) “Have you ever felt bad or Guilty about your drinking?” 4) “Have you ever taken a drink first thing in the morning (Eye-opener)?”.

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Source: Field Guide to Bedside Diagnosis, 2007

Anxiety disorder, generalized: Diagnosis
(Handbook of Diseases)

For characteristic findings in patients with this condition, see Diagnosing generalized anxiety disorder.

In addition, laboratory tests must exclude organic causes of the patient’s signs and symptoms, such as hyperthyroidism, pheochromocytoma, coronary artery disease, supraventricular tachycardia, and Ménière’s disease. For example, an electrocardiogram can rule out myocardial ischemia in a patient who complains of chest pain. Blood tests — including a complete blood count, white blood cell count and differential, and serum lactate and calcium levels  —  can rule out hypocalcemia.

Because anxiety is the central feature of other mental disorders, psychiatric evaluation must rule out phobias, obsessive-compulsive disorders, depression, and acute schizophrenia.

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Source: Handbook of Diseases, 2003

Depression, major: Diagnosis
(Handbook of Diseases)

The DSM-IV-TR describes specific characteristics of patients with this condition. (See Diagnosing major depression.)

The diagnosis of major depression is supported by psychological tests, such as the Beck Depression Inventory, which may help determine the onset, severity, duration, and progression of depressive symptoms. A toxicology screening may suggest drug-induced depression.

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Source: Handbook of Diseases, 2003

Skin, clammy: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition permits, obtain his medical history. Does he have type 1 diabetes mellitus or a cardiac disorder? Is he taking medication? If so, determine whether he takes an antiarrhythmic. Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination? 

Physical examination

Check the patient’s vital signs. Perform a complete cardiovascular assessment, followed by a physical assessment. Check the patient’s blood glucose level. Next, examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

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

Seizures, generalized tonic-clonic: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain the patient’s medical history. Has he had generalized or focal seizures before? If so, how frequently? Do other family members have seizures? Is the patient receiving drug therapy? Is he compliant? Ask about sleep deprivation and emotional or physical stress at the time the seizure occurred. Ask about the use of alcohol or illicit drugs.

If you didn’t witness the seizure, obtain a description from the patient’s family. Ask when it started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body immediately? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering? Does he complain of headache and muscle soreness?

Physical examination

If the patient may have sustained a head injury, perform a complete neurologic examination, observing closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Assess his vital signs. Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

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

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

Determine the severity of the patient’s agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet and known allergies.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Ask the patient about prescribed or over-the-counter drug use, including supplements and herbal medicines. Ask about alcohol intake.

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

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

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice any precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or excessive caffeine intake and alleviated by rest, tranquilizers, or exercise. Obtain a complete medical history, especially noting drug use.

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

Skin, clammy: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is the patient taking any medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

» READ BOOK EXCERPT ONLINE »

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

Seizures, generalized tonic-clonic: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report any unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have any other seizures before recovering? Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals?

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

» READ BOOK EXCERPT ONLINE »

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

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

Determine the severity of the patient's agitation by examining the number and quality of agitation-induced behaviors, such as emotional lability, confusion, memory loss, hyperactivity, and hostility. Obtain a history from the patient or a family member, including diet, known allergies, and all medications, including the use of herbal medicine. Also ask the patient about substance abuse.

Ask if the patient is being treated for any illnesses. Has he had any recent infections, trauma, stress, or changes in sleep patterns? Observe the patient for signs of substance abuse, such as needle tracks, dilated pupils, jaundiced skin, or abdominal ascites. Ask him about alcohol intake. Obtain the patient's baseline vital signs and neurologic status for future comparison.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient's anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake or alleviated by rest, tranquilizers, or exercise.

Obtain a complete medical history, especially noting drug use including over-the-counter drugs and herbal supplements. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.

If the patient's anxiety isn't accompanied by significant physical signs, suspect a psychological basis. Determine the patient's level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin, clammy: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If you detect clammy skin, remember that rapid evaluation and intervention are paramount. (See Clammy skin: A key finding, page 562.) Ask the patient if he has a history of type 1 diabetes mellitus or a cardiac disorder. Is he taking medications, especially an antiarrhythmic? Is he experiencing pain, chest pressure, nausea, or epigastric distress? Does he feel weak? Does he have a dry mouth? Does he have diarrhea or increased urination?

Next, take the patient's vital signs and pulse oximetry. Examine the pupils for dilation and check his level of consciousness. Note respiratory rate. Assess for respiratory distress. Auscultate the heart and lungs. Place the patient on a cardiac monitor and assess heart rhythm. Also, check for abdominal distention and increased muscle tension.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Fontanel depression: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Obtain a thorough patient history from a parent or caretaker, focusing on recent fever, vomiting, diarrhea, and behavioral changes. Monitor the infant's fluid intake and urine output over the past 24 hours, including the number of wet diapers during that time. Ask about the child's preillness weight, and compare it with his current weight; weight loss in an infant reflects water loss. Then perform a complete physical examination.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, generalized tonic-clonic: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If you didn't witness the patient's seizure, obtain a description from his companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

Next, assess the patient's level of consciousness (LOC) and proceed with a complete neurologic examination.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs is all important. A triiodothyronine (T3) level, total thyroxine (T4) level, and free thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes, toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and 17-hydroxycorticosteroid level should be done on anyone suspected of having endogenous depression. (Possibly all depressed patients should get this screen.) Skull x-ray film, EEG, CT scan, and even a spinal tap (to rule out multiple sclerosis [MS] and lues) may be worthwhile when other neurologic signs are present. case presentation #14 A 62-year-old white woman is brought to your office because the family has noticed that she is depressed. The patient has insomnia, frequent nightmares, and weight loss over the past 6 months despite the fact that she has a good appetite.

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Source: Differential Diagnosis in Primary Care, 2007

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

Obviously, it is tempting simply to do a lymph node biopsy, but certain other procedures should be done first. If the patient is febrile, febrile agglutinins, monospot test, blood cultures, and cultures of any other suspicious body fluid should be made. A fluorescent treponemal antibody absorption test (FTA-ABS) test should be done as well as a chest x-ray and tuberculin test to rule out tuberculosis. A blood count usually shows leukemia, but a bone marrow biopsy may be necessary to diagnose leukemia, Hodgkin lymphoma, and the reticuloendothelioses. Other x-rays, skin tests, and special diagnostic procedures may be necessary.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

WEAKNESS AND FATIGUE, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The association of other symptoms and signs with generalized weakness and fatigue is very important in pinning down a diagnosis. Generalized lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or tuberculosis or other chronic infection such as acquired immunodeficiency syndrome (AIDS). Weakness, weight loss, and polyphagia with polyuria and polydipsia would suggest hyperthyroidism or diabetes mellitus. Generalized weakness with polyuria and no significant weight loss suggests hyperparathyroidism. Weakness with pallor suggests some type of anemia. Weakness and weight loss without polyuria or polyphagia suggest malignancy or malabsorption syndrome. Weakness with other significant neurologic signs and symptoms prompts the consideration of muscular dystrophy, amyotrophic lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use prompts the investigation of drug or alcohol abuse. Caffeine, especially in large quantities, can also cause significant weakness and chronic fatigue. The initial workup of weakness and fatigue requires a CBC, sedimentation rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray, and echocardiogram (ECG). If muscular dystrophy or dermatomyositis is suspected, urine tests for creatinine, creatine, and myoglobin can be done. Ultimately, a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum for acetylcholine receptor antibody may be done. If Addison disease is suspected, a serum cortisol test may be done. A 24-hour urine aldosterone level may be done to exclude primary aldosteronism. Serum parathyroid hormone (PTH) may be done to exclude hyperparathyroidism. It would be wise to consult an infectious disease specialist before ordering an expensive workup. It would also be wise to consult an oncologist when searching for a malignancy before ordering an expensive workup. When all tests have negative findings, many clinicians have been tempted to make a diagnosis of chronic fatigue syndrome. It is questionable whether this is truly a disease or not.

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Source: Differential Diagnosis in Primary Care, 2007

RASH, GENERAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or if the symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

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Source: Differential Diagnosis in Primary Care, 2007


 » Next page: Signs of Generalized anxiety disorder

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