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Diagnostic Tests for Generalized anxiety disorder

Contents
  1. Generalized anxiety disorder: Introduction
  2. Symptoms of Generalized anxiety disorder
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Alternative Diagnoses
  6. Misdiagnosis

Generalized anxiety disorder Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to 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 the diagnostic tests for Generalized anxiety disorder.

ANXIETY: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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

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

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

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).

Testing.

 Laboratory and other medical tests depend on clinical suspicion and the presenting physical symptoms. Hematocrit, thyroid stimulating hormone, and serum calcium are often all the laboratory testing that is necessary. Older patients who present with physical symptoms, especially chest pain, may need more extensive medical evaluation before assuming that the symptoms are caused by the anxiety disorder. For example, an anxious patient with atypical chest pain, aged more than 40 years or with cardiac risk factors, may need an exercise stress test before assuming the chest pain is not cardiac.

Diagnostic assessment.

 Once it has been determined that the patient has a primary anxiety disorder, the following specific disorders should be considered (4) (Table 3.1).

 A. Adjustment reaction with anxious features describes a condition in which the patient is experiencing clinically significant anxiety in reaction to a specific stressor, such as a major life event or interpersonal conflict. This diagnosis, which describes a more severe form of “normal” anxiety, responds to reassurance and short-term anxiolytics.

 B. Panic disorder is characterized by recurrent, spontaneous, and discrete episodes of intense anxiety associated with symptoms of autonomic arousal (panic attacks). Patients usually present with physical symptoms such as chest pain, dizziness, and shortness of breath. They may also develop anticipatory anxiety or agoraphobia, in which they avoid situations that may precipitate a panic attack (such as crowds). Panic disorder is usually very responsive to medication (antidepressants or benzodiazepines). Panic attacks can also be experienced in association with other anxiety disorders.

 C. Generalized anxiety disorder (GAD) is a chronic condition of at least 6 months duration, in which exists persistent, excessive worry or anxiety about several areas of life, often including physical health. These patients may be excessively worried about physical symptoms (i.e., hypochondriasis) and become high medical utilizers. Many patients on chronic benzodiazepines have generalized anxiety disorder. Often coexisting with other anxiety disorders, depression, or substance abuse, GAD is difficult to treat, but responds to medication and psychotherapy.

 D. Obsessive-compulsive disorder is characterized by recurrent, intrusive thoughts (obsessions) and compulsive behaviors or rituals. These symptoms must be specifically elicited, as these patients rarely present with these complaints. Handwashing is a common compulsion, and patients may present with severe hand dermatitis from repeated washings.

 E. Posttraumatic stress disorder (PTSD) causes persistent reexperiencing of traumatic or violent events through flashbacks or nightmares with associated autonomic arousal. Patients avoid any stimuli that may be associated with the trauma. It is often associated with irritability, hypervigilance, and sleep disturbance. It occurs most commonly in veterans, refugees, and victims of domestic violence and child abuse. Substance abuse, depression, and other anxiety disorders are often associated with PTSD. No reliable effective treatment exists for PTSD, although antidepressants seem to be helpful.

 F. Social phobias occur in patients who suffer severe anxiety in social settings, especially when they are exposed to unfamiliar people. These patients usually avoid any social situations. Social phobias respond well to cognitive-behavioral therapy and serotonin-selective reuptake inhibitors.

G. Specific or simple phobias are characterized by marked and persistent fears of specific situations or objects that interfere with the patient’s life. Common phobias include fear of heights, closed spaces, flying, and specific small animals (e.g., spiders, snakes). They often develop in childhood as a result of a traumatic event associated with the situation or object. They are treated by cognitive-behavioral therapy.


References

1. Barlow DH. Anxiety and its disorders. New York: Guilford Press, 1988.

2. Stern TA, Herman JB, Slavin PL. MGH guide to psychiatry in primary care. New York: McGraw-Hill, 1998.

3. Knesper DJ, Riba MB, Schwenk TL. Primary care psychiatry. Philadelphia: WB Saunders, 1997.

4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.

» READ BOOK EXCERPT ONLINE »

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

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

 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.

Testing.

 For typical mild major depressions, no tests are routinely indicated except as guided by the general medical history and physical examination. However, the following circumstances do warrant a laboratory workup: first onset of depression in later life; severely debilitating or treatment-refractory depression; or the presence of atypical features (e.g., onset despite the absence of past or family history or psychosocial stressors; severe cognitive complaints). Few empirical data guide the cost-effective use of screening laboratory tests in these cases, but most experienced clinicians would agree with performing most of the following: complete blood count; erythrocyte sedimentation rate; serum electrolytes, glucose, blood urea nitrogen, creatinine, hepatic transaminases, and serologic test for syphilis; and urinalysis. Older patients should also have an electrocardiogram and a chest x-ray study.

Diagnostic assessment

If the history and mental status examination reveal five depressive symptoms (including either depressed mood or decreased interests) present most of the day, nearly every day for a minimum of 2 consecutive weeks, then the patient has a major depressive syndrome. Such a syndrome can occur in the context of many conditions and not merely idiopathic major depression, so definitive diagnosis depends on the larger clinical picture. Depressive symptoms can occur in the context of delirium or dementia, either of which are evidenced by the presence of cognitive deficits (Chapters 4.3 and 4.4). Prior episodes of mania are indicative of bipolar disorder, whereas prior episodes of psychosis in the absence of mood syndrome indicate schizoaffective disorder. If the depression is caused by an identifiable physiologic factor (e.g., drugs or a general medical or neurologic disorder), it is a secondary depression (formerly known as “organic mood disorder”).

Clinically meaningful depressive symptoms that do not meet full criteria for a major depressive syndrome are even more common than full-fledged major depression in the primary care settings. Whereas some such patients are captured by diagnostic concepts such as dysthymic disorder or minor depression, many elude diagnostic categorization. Making the diagnostic distinction between major depression and other forms is important, because a large body of empirical evidence supports the efficacy of specific treatments for major depression and dysthymic disorder; however, the efficacy of treatments for other depressive conditions is largely unknown.

The following should lead to psychiatric referral sooner rather than later: prominent or imminent suicidality; psychotic symptoms; history of mania; psychiatric comorbidity such as alcohol dependence or a personality, anxiety, or eating disorder; and treatment intolerance or failure to respond to therapy.


References

1. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and diagnosis. Clinical Practice Guideline, Number 5. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; April 1993. AHCPR publication 93-0550.

2. Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study. JAMA 1994;
272:1749–1756.

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

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

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

Testing

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

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

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

Diagnostic assessment

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


References

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Anxiety: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Depression: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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)?”.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

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

Perform a complete physical examination. Check for signs of drug abuse, such as needle tracks and dilated pupils. Obtain baseline vital signs and neurologic status for future comparison.

» READ BOOK EXCERPT ONLINE »

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

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

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

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

Take vital signs and perform a cardiovascular assessment. Then proceed with the remainder of a complete physical assessment. Be sure to examine the pupils for dilation. Also, check for abdominal distention and increased muscle tension.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness. If you haven’t already done so, take the patient’s vital signs. Then complete your neurologic assessment.

» 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.

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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


 » Next page: Diagnosis of Generalized anxiety disorder

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