Diseases » Halitosis » Diagnosis

Diagnosis of Halitosis

Halitosis Diagnosis: Book Excerpts

• Ask the Following Questions - HALITOSIS
• Ask the Following Questions - ODOR
• Ask the following questions - ANOSMIA OR UNUSUAL ODORS
• Differential Diagnosis - Halitosis
• Differential Diagnosis - Breath Sounds (Decreased)
• Differential Diagnosis - Halitosis
• Approach to the Diagnosis - HALITOSIS AND OTHER BREATH ODORS
• Approach to the Diagnosis - DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING
• Approach to the Diagnosis - ANOSMIA OR UNUSUAL ODOR
• History and physical examination - Breath with fecal odor
• History and physical examination - Breath with fruity odor
• History and physical examination
  - Breath with ammonia odor [Uremic fetor]
• History and physical examination - Fetor hepaticus
• History and physical examination - Breath with fecal odor
• History and physical examination - Breath with fruity odor
• History and physical examination - Halitosis
• History and physical examination - Breath with ammonia odor [Uremic fetor]
• History and physical examination - Fetor hepaticus
• History - Halitosis
• History - Shortness of Breath
• Differential Overview - Patterned Breathing
• History - Breath odor, fecal
• History - Breath odor, fruity
• History - Breath with fecal odor
• History - Breath with fruity odor
• History - Halitosis
• History and physical examination - Breath with fecal odor
• History and physical examination - Breath with fruity odor
• History and physical examination - Breath with ammonia odor [Uremic fetor]
• History and physical examination - Fetor hepaticus
• Approach to the Diagnosis - DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING
• Approach to the Diagnosis - HALITOSIS AND OTHER BREATH ODORS
• Approach to the Diagnosis - ANOSMIA OR UNUSUAL ODOR

Diagnosis of Halitosis: medical news summaries:

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

• Dental authority highlights the link between oral health and smoking
• More news »

Diagnostic Tests for Halitosis: Online Medical Books

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

HALITOSIS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a history of ingestion or use of a foul substance? Such a history may suggest that the cause is onions, garlic, alcohol, tobacco, paraldehyde, mercury, or other substances.
2. Are there abnormalities of examination of the mouth, nose, and throat? Abnormalities that may be found on examination of the mouth, nose, and throat include gingivitis, carious teeth, pyorrhea, stomatitis, sinusitis, pharyngitis, and tonsillitis.
3. Is there a chronic productive cough? The presence of a chronic productive cough should suggest bronchiectasis, lung abscess, gangrene of the lungs, tuberculosis, and other lung infections.
4. Is there esophageal regurgitation? The history of esophageal regurgitation should suggest reflux esophagitis, peptic ulcer, partial intestinal obstruction, and esophageal diverticula. If there are none of these findings, one should look for uremia or cirrhosis.

DIAGNOSTIC WORKUP

Routine tests include a CBC and sedimentation rate to rule out chronic inflammation; a chemistry panel to rule out uremia and cirrhosis; and sputum, nose, and throat cultures to rule out chronic infections of the sinuses, nose, throat, and lungs. Cultures of any suspicious area of inflammation in the mouth, nose, and throat should be done. X-rays of the teeth, sinuses, and chest should also be done. An upper GI series and esophagogram will help diagnose reflux esophagitis, peptic ulcer, partial intestinal obstruction, and esophageal diverticula.

A 24-hr sputum collection may help differentiate bronchiectasis and lung abscesses. A tuberculin test and sputum for AFB smear, culture, and possible guinea pig inoculation may identify tuberculosis.

 

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ODOR: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there coma or disturbances of consciousness? The presence of coma or disturbances of consciousness should suggest alcoholism, diabetic acidosis, uremia, and hepatic coma.
2. Is the odor sweet? The presence of a sweet odor to the breath should suggest diabetic acidosis, alcoholism, and maple syrup urine disease.
3. Is the odor unpleasant or foul? The presence of an unpleasant or foul odor should suggest uremia, hepatic coma, anaerobic infections in the mouth or nasopharynx, and isovaleric aciduria.

DIAGNOSTIC WORKUP

Routine laboratory work includes a CBC, urinalysis, chemistry panel, blood alcohol level, and tests for serum acetone and serum amino acids. Urine for chromatography may help pick up certain keto acids. A culture of the mouth, gums, and nasopharynx may be necessary to diagnose anaerobic infections.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ANOSMIA OR UNUSUAL ODORS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it acute or chronic? Acute loss of smell would certainly suggest an acute upper respiratory infection (URI). It would also suggest recent exposure to toxic fumes or recent head injury. If the anosmia or unusual odor is intermittent, then one should consider psychomotor epilepsy.
2. Is there a history of trauma? A skull fracture, particularly if it involves the cribriform plate, may interrupt the olfactory nerves and cause anosmia.
3. Is there a history of drug use or overuse of nasal sprays? Captopril and penicillamine may cause anosmia. Overuse of alcohol or tobacco may also be the problem. Antirheumatic and antiproliferative drugs are also known to cause anosmia.
4. Is the anosmia unilateral or bilateral? If there is unilateral anosmia, one should consider an olfactory groove meningioma.
5. Are there other neurologic signs? Multifocal neurologic signs should suggest multiple sclerosis, and additional neurologic signs such as memory loss should suggest an olfactory groove meningioma or parietal lobe tumor.
6. Are there signs of a systemic disease? Many systemic diseases may cause anosmia, including hypothyroidism, diabetes, renal failure, hepatic failure, and pernicious anemia.

DIAGNOSTIC WORKUP

If the disorder is acute and associated with a URI, nothing need be done. However, if the condition has been of gradual onset, the nasopharyngeal examination is negative, and the history of drugs is negative, then a CT scan of the brain should be done. If this is negative, a workup for systemic disease should be done, and that should include a CBC and chemistry panel, thyroid profile, serum B ₁₂ and folic acid, glucose tolerance test, and liver profile. If the anosmia or unusual odors are intermittent, a wake-and-sleep EEG should be done.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

• Head and neck etiologies
  –Foods (e.g., onion, garlic)
  –Dental conditions (periodontal disease, gingivitis, denture odor, dental abscesses, food particles not cleaned from teeth)
  –Postnasal drip
  –Dry mouth (xerostomia): Mouth breathing, side effect of medications, salivary gland disease, dehydration
  –Nasal foreign body
  –Gastroesophageal reflux disease
  –Chronic sinusitis
  –Allergic rhinitis
  –Tonsillar disease (e.g., streptococcal pharyngitis)
  –Zenker's (pharyngoesophageal) diverticulum: Presents as dysphagia, regurgitation, cough, and extreme halitosis
  –Tobacco or alcohol use

• Systemic etiologies
  –Diabetes mellitus, especially with ketoacidosis
  –Uremia
  –Pulmonary disorders (e.g., bronchiectasis, pneumonia, neoplasms, tuberculosis)
  –Trimethylaminuria (fishy breath odor)
  –Liver failure (fetor hepaticus)
  –Menstruation may exacerbate halitosis

Workup and Diagnosis

• Careful dental and medical history, including dental hygiene habits and dietary history
  –Note associated symptoms that suggest systemic etiology (e.g., cough, nasal congestion)
  –Odor after sleeping, dieting, or exercising suggests xerostomia
  –Odor upon talking suggests postnasal drip
  –Bleeding gums suggests periodontal disease
• Dental examination to rule out treatable dental causes (e.g., periodontal disease)
• Physical examination should include careful oral, nasal, sinus, neck, pulmonary, and abdominal examinations
  –Assess odor from mouth and nose separately
  –Small malodorous whitish stones on tongue suggest tonsilloliths
  –Place dentures into plastic bag for several minutes and then smell to evaluate for denture odor
  –Spoon test involves scooping mucous/saliva from back of tongue and evaluating for malodor; if present, suggests postnasal drip
  –Nasolaryngoscopy if nasal cause is suspected but specific cause cannot be identified
• Zenker's diverticulum is diagnosed by contrast barium swallow

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Source: In a Page: Signs and Symptoms, 2004

Breath Sounds (Decreased): Differential Diagnosis
(In a Page: Signs and Symptoms)

Decreased airflow through respiratory tree

• Airway obstruction
  –Aspirated foreign body
  –Asthma
  –Bronchitis
  –Bronchiolitis
  –Croup
  –Epiglottitis
  –Neoplasm
  –Goiter
• Alveolar or interstitial processes
  –Pulmonary edema
  –Pneumonia
  –Pleurisy
  –Sarcoidosis
• Decreased lung expansion
  –Atelectasis
  –COPD or emphysema
  –Bronchiectasis
  –Kyphosis or scoliosis
  –Increased abdominal girth (e.g., ascites, obesity, pregnancy)
  –Pulmonary fibrosis
  –Diaphragmatic paralysis
  –Abdominal, chest wall, or pleuritic pain
  Obstructed transmission of sound
  • Obesity
  • Pleural effusion
  • Pneumothorax, hemothorax, or chylothorax
  • Pleural thickening
  • Large pulmonary embolus
  • Less common etiologies (“zebras”) include cystic fibrosis, alveolar hemorrhage, BOOP, now called COP, pneumonectomy (postsurgical), systemic lupus erythematosus, vocal cord paralysis, vocal cord dyskinesia, and psychogenic

  Workup and Diagnosis

  • History and physical examination
    –History should include associated symptoms (e.g., fever, dyspnea, wheezing, chest pain) and a detailed past medical, surgical, and exposure history
    –Physical examination should include vital signs; examination of oral cavity and neck for evidence of mass, foreign body, or tracheal deviation; inspection and palpation of the chest wall to assess for symmetric movement; percussion and auscultation of all chest fields for related abnormalities (e.g., rhonchi, wheezes, rales, rubs, egophony)
  • Initial labs may include CBC, pulse oximetry, arterial blood gas, and TSH
  • Chest X-ray is the initial imaging test
    –Associate the area of decreased breath sounds to hyperlucency or increased opacity on chest X-ray
    –Tracheal shift to a side with a density and decreased breath sounds likely signifies atelectasis or endobronchial obstruction
    –Tracheal shift away from a side with hyperlucency and decreased breath sounds may indicate tension pneumothorax
  • Lateral neck X-ray may be indicated to rule out epiglottitis (“thumb sign”)
  • If there is evidence of external airway compression, chest and neck CT scans may be needed for further evaluation
  • Pulmonary function testing

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Source: In a Page: Signs and Symptoms, 2004

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

• Upper respiratory
  –Stomatitis: Painful ulcerated lesions on oral mucosa and gingiva; coxsackie virus is commonly called hand-foot-and-mouth disease; herpangina refers to herpetic lesions on the soft palate and posterior pharynx; trench mouth refers to necrotizing gingivostomatitis with pseudomembrane caused by spirochetes or fusiform bacteria
  –Sinusitis: Acute or chronic; pathogens are Streptococcus pneumoniae, β-hemolytic strep, Haemophilus influenzae, and Moraxella catarrhalis; maxillary sinuses are most frequently involved
  –Pharyngitis/tonsillitis/tonsillar abscess: Group A strep

• Pulmonary disorders
  –Pulmonary abscess
  –Bronchiectasis
• Gastric disorders
  –GERD
  –Bezoar

• Dental etiologies
  –Poor oral hygiene: Bacterial accumulation on the teeth or tongue; gingival inflammation; food concretions within tonsillar crypts
  –Dental abscess: May be sequela of baby-bottle tooth decay, untreated dental caries, dental fracture, or poor hygiene
  –Orthodontic devices

• Chronic mouth breathing
  –Seen in children with nasal polyps, adenoid hypertrophy, allergic rhinitis, and chronic sinusitis
  –Rarely due to a nasopharyngeal tumor such as a hemangioma or fibromas
  –Resultant dryness causes alteration of the oral mucosa and resultant bad breath; taste and smell may be affected

• Nasal foreign body
  –Seen most often in the toddler/preschool age group
  –History of foreign body placement is not always forthcoming
  –Usually accompanied by unilateral nasal discharge

Workup and Diagnosis

• History
  –Onset, duration, severity of symptoms
  –Accompanying signs and symptoms, especially fever, nasal congestion, nasal discharge, sore throat, cough, tachypnea
  –History of recurrent pneumonia
  –History of GI upset, digestive problems
  –Dental history and frequency of dental care

• Physical exam
  –Examination of the oral cavity for dental hygiene, dental caries, gingival swelling, orthodontic devices that are poorly fitting or poorly maintained
  –HEENT examination including nasal cavity, oral lesions, tonsillar hypertrophy, asymmetry, exudate, or concretions
  –General medical evaluation including respiratory and GI systems

• Labs
  –Throat culture if streptococcal pharyngitis is suspected
• Radiology
  –X-ray or CT of sinuses for mucosal thickening or air-fluid levels
  –Lateral X-ray for adenoid hypertrophy
  –Chest X-ray if pulmonary lesion is suspected
• Studies
  –Endoscopy may be required for suspicion of GERD or bezoar

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

HALITOSIS AND OTHER BREATH ODORS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of bad breath involves a careful examination of the mouth and nasal passages. If this is negative, chest and sinus x-rays and upper GI series with barium swallow should be done. If the studies are still unrewarding, then endoscopy of the respiratory and upper GI tract would be indicated. Appropriate liver and renal function tests will be ordered when uremia or hepatic coma is suspected. If pyorrhea is suspected, refer the patient to a dentist.

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Source: Differential Diagnosis in Primary Care, 2007

DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Obviously, the association of other signs and symptoms will determine the workup in most cases. The most important things to do are to order a BUN level, electrolytes, FBS, and arterial blood gases, and a drug screen and to check for increased intracranial pressure by examining the eye grounds. If the history or physical findings suggest increased intracranial pressure, and other metabolic studies (e.g., BUN) are normal, a mannitol or urea drip is begun while awaiting the results of other investigations such as CT scan, EEG, and echoencephalogram. A neurosurgeon should be consulted immediately.

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Source: Differential Diagnosis in Primary Care, 2007

ANOSMIA OR UNUSUAL ODOR: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the disorder is the result of an acute infectious process, nothing needs be done. If it is associated with trauma or there has been a gradual onset, it is important to get a CT scan to rule out skull fracture or neoplasm. It is essential to rule out drug and alcohol use at the outset by a careful history and urine screen.

A good nasopharyngeal examination and nasopharyngoscopy must be done if local disease is suspected. These may need to be complemented by x-rays or CT scan of the sinuses. Systemic disease can be ruled out by a CBC, chemistry panel, thyroid profile, serum B12, glucose tolerance test, and liver profile. If epilepsy is suspected, a wake-and-sleep EEG needs to be done.

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Source: Differential Diagnosis in Primary Care, 2007

Breath with fecal odor: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient's condition permits, ask about previous abdominal surgery because adhesions can cause an obstruction. Also ask about loss of appetite. Is the patient experiencing abdominal pain? If so, have him describe its onset, duration, and location. Ask if the pain is intense, persistent, or spasmodic. Have the patient describe his normal bowel habits, especially noting constipation, diarrhea, or leakage of stool. Ask when the patient's last bowel movement occurred, and have him describe the stool's color and consistency.

Auscultate for bowel sounds — hyperactive, high-pitched sounds may indicate impending bowel obstruction, whereas hypoactive or absent sounds occur late in obstruction and paralytic ileus. Inspect the abdomen, noting its contour and any surgical scars. Measure abdominal girth to provide baseline data for subsequent assessment of distention. Palpate for tenderness, distention, and rigidity. Percuss for tympany, indicating a gas-filled bowel, and dullness, indicating fluid.

Rectal and pelvic examinations should be performed. All patients with a suspected bowel obstruction should have a flat and upright abdominal X-ray; some will also need a chest X-ray, sigmoidoscopy, and barium enema.

» READ BOOK EXCERPT ONLINE »

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

Breath with fruity odor: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn't in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and noncompliance with therapy — the most common causes of ketoacidosis in known diabetics. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.

» READ BOOK EXCERPT ONLINE »

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

Breath with ammonia odor [Uremic fetor]: History and physical examination

(Handbook of Signs & Symptoms (Third Edition))

When you detect ammonia breath odor, the diagnosis of chronic renal failure will probably be well established. Look for associated GI symptoms so that palliative care and support can be individualized.

Inspect the patient's oral cavity for bleeding, swollen gums or tongue, and ulceration with drainage. Ask the patient if he has experienced a metallic taste, loss of smell, increased thirst, heartburn, difficulty swallowing, loss of appetite at the sight of food, or early morning vomiting. Because GI bleeding is common in patients with chronic renal failure, ask about bowel habits, noting especially melanous stools or constipation.

Take the patient's vital signs. Watch for indications of hypertension (the patient with end-stage chronic renal failure is usually somewhat hypertensive) or hypotension. Be alert for other signs of shock (such as tachycardia, tachypnea, and cool, clammy skin) and altered mental status. Significant changes can indicate complications, such as massive GI bleeding or pericarditis with tamponade.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient is conscious, closely observe him for signs of impending coma. Evaluate deep tendon reflexes, and test for asterixis and Babinski’s sign. Be alert for signs of GI bleeding and shock, common complications of end-stage liver failure. Also, watch for increased anxiety, restlessness, tachycardia, tachypnea, hypotension, oliguria, hematemesis, melena, or cool, moist, pale skin. Place the patient in a supine position with the head of the bed at 30 degrees or greater. Administer oxygen if necessary, and determine the patient’s need for I.V. fluids or albumin replacement. Draw blood samples for liver function tests, serum electrolyte levels, hepatitis panel, blood alcohol content, a complete blood count, typing and crossmatching, a clotting profile, and ammonia level. Intubation, ventilation, or cardiopulmonary resuscitation may be necessary. Evaluate the degree of jaundice and abdominal distention and palpate the liver to assess the degree of enlargement.

Obtain a complete medical history, relying on information from the patient’s family if necessary. Focus on factors that may have precipitated hepatic disease or coma, such as a recent severe infection; overuse of sedatives, analgesics (especially) acetaminophen, alcohol, or diuretics; excessive protein intake; or recent blood transfusion, surgery, or GI bleeding.

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

Breath with fecal odor: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s condition permits, ask about previous abdominal surgery because adhesions can cause an obstruction. Also ask about loss of appetite. Is the patient experiencing abdominal pain? If so, have him describe its onset, duration, and location. Ask if the pain is intense, persistent, or spasmodic. Have the patient describe his normal bowel habits, especially noting constipation, diarrhea, or leakage of stool. Ask when the patient’s last bowel movement occurred, and have him describe the stool’s color and consistency.

Auscultate for bowel sounds; hyperactive, high-pitched sounds may indicate an impending bowel obstruction, whereas hypoactive or absent sounds occur late in obstruction and paralytic ileus. Inspect the abdomen, noting its contour and any surgical scars. Measure abdominal girth to provide baseline data for subsequent assessment of distention. Palpate the abdomen for tenderness, distention, and rigidity. Percuss it for tympany, indicating a gas-filled bowel, and dullness, indicating fluid.

Rectal and pelvic examinations should be performed. All patients with a suspected bowel obstruction should have a flat and upright abdominal X-ray; some will also need a chest X-ray, sigmoidoscopy, and a barium enema.

» READ BOOK EXCERPT ONLINE »

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

Breath with fruity odor: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Also ask about any changes in breathing pattern, increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and noncompliance with therapy—the most common causes of ketoacidosis in known diabetics. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.

» READ BOOK EXCERPT ONLINE »

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

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

If you detect halitosis, try to characterize the odor. Does it smell fruity, fecal, or musty? If the patient is aware of it, find out how long he has had it. Does he also have a bad taste in his mouth? Does he have difficulty swallowing or chewing? Does he have reflux or regurgitation? Does he have pain or tenderness? Ask the patient if he has a problem with flatus. Also ask him to describe the frequency of his bowel movements and the size and consistency of his stools.

Find out if the patient smokes or chews tobacco. Have him describe his diet and daily oral hygiene. Does he wear dentures? Complete the history by asking about chronic disorders and recent respiratory tract infection. If the patient reports a cough, find out if it’s productive.

Begin the physical examination by examining the patient’s mouth, throat, and nose. Look for lesions, bleeding, drainage, obstruction, and signs of infection, such as redness and swelling. Check for tenderness by percussing and palpating over the sinuses. Then auscultate the lungs for abnormal breath sounds. Auscultate the abdomen for bowel sounds, and percuss it, noting any tympany. Finally, take vital signs.

» READ BOOK EXCERPT ONLINE »

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

Breath with ammonia odor [Uremic fetor]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When you detect ammonia breath odor, the diagnosis of chronic renal failure will probably be well established. Look for associated GI symptoms so that palliative care and support can be individualized.

Inspect the patient’s oral cavity for bleeding, swollen gums or tongue, and ulceration with drainage. Ask the patient if he has experienced a metallic taste, loss of smell, increased thirst, heartburn, difficulty swallowing, loss of appetite at the sight of food, or early morning vomiting. Because GI bleeding is common in patients with chronic renal failure, ask about bowel habits, noting especially melena or constipation.

Take the patient’s vital signs. Watch for any indications of hypertension (the patient with end-stage chronic renal failure is usually somewhat hypertensive) or hypotension. Be alert for other signs of shock (such as tachycardia, tachypnea, and cool, clammy skin) and altered mental status. Any significant changes can indicate complications, such as massive GI bleeding or pericarditis with tamponade.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient is conscious, closely observe him for signs of impending coma. Evaluate deep tendon reflexes, and test for asterixis and Babinski’s reflex. Be alert for signs of GI bleeding and shock, common complications of end-stage liver failure. Also, watch for increased anxiety, restlessness, tachycardia, tachypnea, hypotension, oliguria, hematemesis, melena, or cool, moist, pale skin. Place the patient in a supine position with the head of the bed at 30 degrees. Administer oxygen if necessary, and determine the patient’s need for I.V. fluids for albumin replacement. Draw blood samples for liver function tests, serum electrolyte levels, hepatitis panel, blood alcohol count, a complete blood count, typing and crossmatching, a clotting profile, and ammonia level. Intubation, ventilation, or cardiopulmonary resuscitation may be necessary. Evaluate the degree of jaundice and abdominal distention, and palpate the liver to assess the degree of enlargement.

Obtain a complete medical history, relying on the patient’s family if necessary. Focus on any factors that may have precipitated liver disease or coma, such as a recent severe infection; overuse of sedatives, analgesics, (especially acetaminophen), alcohol, or diuretics; excessive protein intake; or recent blood transfusion, surgery, or GI bleeding.

» READ BOOK EXCERPT ONLINE »

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

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

A focus on the characteristics of the bad breath is critical, although the patient is often unable to self-diagnosis or describe accurately because of olfactory desensitization. Is the odor transient or constant? A constant odor suggests chronic systemic disease or serious disorders of the oral cavity. What are the precipitating, aggravating, or relieving factors? What are the patient’s smoking habits, medications, dietary preferences, and brushing and flossing routines?

Physical examination

A. Physical examination should be undertaken with an emphasis on the evaluation of the oral cavity, particularly looking for ulceration, dryness, trauma, postnasal drainage, infections, cryptic tonsils, or neoplasms.

B. Techniques for localizing the odor source (systemic versus oral cavity).

1. Seal lips and blow air through the nose. If fetid odor is noted, this is suggestive of a systemic source.

2. Pinch nose with lips closed. Hold respiration and exhale gently through the mouth. Odors detected in this fashion, generally are local in origin.

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

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

Are historical features helpful? Historical findings are neither sensitive nor specific; however, some symptoms are associated with specific diseases. Regardless of the cause, people associate shortness of breath with words that describe a sense of “work” or “effort” to breathe. Asthma is associated with words that denote a sense of “tightness.” Patients with interstitial lung disease choose terms emphasizing the sense of “rapid” breathing. Did the patient select terms indicating difficulty with both inhalation and exhalation? This is often reported by patients with CHF (Chapter 7.5). Patients who are deconditioned select rapid, breathing more, or heavy to describe their dyspnea. Patients suffering from neuromuscular disorders select terms denoting rapid breathing or difficulty with inhalation. Is the patient aged less than 40 years? Are the patient’s symptoms episodic? Reactive airway disease and hyperventilation are associated with these terms (2).

Physical examination

In the physical examination, focus on signs of respiratory or cardiac disease. For the respiratory system, this means a careful examination starting at the nose. Specifically, on head, eyes, ear, nose, and throat examination look for evidence of obstruction, infection, or postnasal drip. Exclude obstruction, subcutaneous emphysema, or tracheal deviation. On cardiac examination, look for evidence of cardiomegaly, S₃ gallop, or hepatojugular reflux (HJR). In this setting, HJR is very specific for CHF (1). Assess the lungs for abnormal breath sound intensity, rales, wheezing, rhonchi, or tachypnea. Examine the chest for abnormal movements or deformities. Exclude abdominal masses, ascites, pregnancy, or abdominal distention. Evaluate the extremities for edema, tenderness, or asymmetry. Do a complete neurologic examination, and screen for weakness atrophy, sensory loss, and fasciculations.

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

Patterned Breathing: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Tachypnea

❑ Paroxysmal nocturnal dyspnea

❑ Sleep apnea

❑ Cheyne-Stokes

❑ Kussmaul

❑ Biot

❑ Apneustic

❑ Ataxic

❑ Stertorous

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Source: Field Guide to Bedside Diagnosis, 2007

Breath odor, fecal: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Determine if the patient has had previous abdominal surgery because adhesions can develop and cause an obstruction. Ask if there has been a loss of appetite; abdominal pain with a description of its onset, duration, and intensity; and normal bowel habits, noting constipation, diarrhea, date of last bowel movement, color and consistency of stool, and leakage of stool.

Physical examination

Perform a full GI assessment. Auscultate for bowel sounds — hyperactive, high-pitched sounds may indicate impending bowel obstruction, whereas hypoactive or absent sounds occur late in obstruction and paralytic ileus. Inspect the abdomen, noting its contour and any surgical scars. Measure the patient’s abdominal girth to provide baseline data for subsequent assessment of distention. Percuss for tympany, indicating a gas-filled bowel, and dullness, indicating fluid. Palpate for tenderness, distention, and rigidity.

Rectal and pelvic examinations should be performed. All patients with a suspected bowel obstruction should have a flat and upright abdominal X-ray; some will also need a chest X-ray, sigmoidoscopy, and barium enema.

» READ BOOK EXCERPT ONLINE »

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

Breath odor, fruity: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and adherence to the treatment regimen. If you suspect that the patient has anorexia nervosa, obtain a dietary and weight history.

Physical examination

Perform a full neurologic examination, noting the patient’s LOC. Assess him for signs of dehydration and shock. Assess the patient’s GI system.

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

Breath with fecal odor: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s condition permits, ask about previous abdominal surgery because adhesions can cause an obstruction. Also ask about loss of appetite. Is the patient experiencing abdominal pain? If so, have him describe its onset, duration, and location. Ask if the pain is intense, persistent, or spasmodic. Have the patient describe his normal bowel habits, especially noting constipation, diarrhea, or leakage of stool. Ask when the patient’s last bowel movement occurred, and have him describe the stool’s color and consistency.

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

Breath with fruity odor: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient isn’t in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about any changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and noncompliance with therapy — the most common causes of ketoacidosis in a patient with diabetes. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.

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

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

If you detect halitosis, try to characterize the odor. Does it smell fruity, fecal, or musty? If the patient is aware of it, find out how long he has had it. Does he also have a bad taste in his mouth? Does he have difficulty swallowing or chewing? Does he have reflux or regurgitation? Does he have pain or tenderness? Ask the patient if he has a problem with flatus and about his pattern and description of bowel movements.

Find out if the patient smokes or chews tobacco. Have him describe his diet and daily oral hygiene. Does he wear dentures? Complete the history by asking about chronic disorders and recent respiratory tract infection. If the patient reports a cough, find out if it’s productive.

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

Breath with fecal odor: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's condition permits, ask about previous abdominal surgery because adhesions can cause an obstruction. Ask about loss of appetite. Is the patient experiencing abdominal pain? If so, have him describe its onset, duration, intensity, and location. Ask if the pain is intense, persistent, or spasmodic. Have the patient describe his normal bowel habits, especially noting constipation, diarrhea, or leakage of stool. Ask when the patient's last bowel movement occurred, and have him describe the stool's color and consistency.

Auscultate for bowel sounds—hyperactive, high-pitched sounds may indicate impending bowel obstruction, whereas hypoactive or absent sounds occur late in obstruction and paralytic ileus. Inspect the abdomen, noting its contour and any surgical scars. Measure abdominal girth to provide baseline data for subsequent assessment of distention. Palpate for tenderness, distention, and rigidity. Percuss for tympany, indicating a gas-filled bowel, and dullness, indicating fluid.

Rectal and pelvic examinations should be performed. All patients with a suspected bowel obstruction should have a flat and upright abdominal X-ray; some will also need a chest X-ray, sigmoidoscopy, and barium enema.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Breath with fruity odor: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and noncompliance with therapy—the most common causes of ketoacidosis in known diabetics. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Breath with ammonia odor [Uremic fetor]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When you detect ammonia breath odor, the diagnosis of chronic renal failure will probably be well established. Look for associated GI symptoms so that palliative care and support can be individualized.

Inspect the patient's oral cavity for bleeding, swollen gums or tongue, and ulceration with drainage. Ask the patient if he has experienced a metallic taste, loss of smell, increased thirst, heartburn, difficulty swallowing, loss of appetite at the sight of food, or early morning vomiting. Because GI bleeding is common in patients with chronic renal failure, ask about bowel habits, noting especially melanous stools or constipation.

Take the patient's vital signs. Watch for indications of hypertension (the patient with end-stage chronic renal failure is usually somewhat hypertensive) or hypotension. Be alert for other signs of shock (such as tachycardia, tachypnea, and cool, clammy skin) and altered mental status. Significant changes can indicate complications, such as massive GI bleeding or pericarditis with tamponade.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Fetor hepaticus: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient is conscious, closely observe him for signs of impending coma. Evaluate deep tendon reflexes, and test for asterixis and Babinski's sign. Be alert for signs of GI bleeding and shock, common complications of end-stage liver failure. Also, watch for increased anxiety, restlessness, tachycardia, tachypnea, hypotension, oliguria, hematemesis, melena, or cool, moist, pale skin. Place the patient in a supine position with the head of the bed at 30 degrees or greater. Administer oxygen if necessary, and determine the patient's need for I.V. fluids or albumin replacement. Draw blood samples for liver function tests, serum electrolyte levels, hepatitis panel, blood alcohol content, a complete blood count, typing and crossmatching, a clotting profile, and ammonia level. Intubation, ventilation, or cardiopulmonary resuscitation may be necessary. Evaluate the degree of jaundice and abdominal distention and palpate the liver to assess the degree of enlargement.

Obtain a complete medical history, relying on information from the patient's family if necessary. Focus on factors that may have precipitated hepatic disease or coma, such as a recent severe infection; overuse of sedatives, analgesics (especially acetaminophen), alcohol, or diuretics; excessive protein intake; or recent blood transfusion, surgery, or GI bleeding.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Obviously, the association of other signs and symptoms will determine the workup in most cases. The most important things to do are to order a blood urea nitrogen (BUN) level, electrolytes, fasting blood sugar (FBS), arterial blood gases, and a drug screen and to check for increased intracranial pressure by examining the eye grounds. If the history or physical findings suggest increased intracranial pressure, and other metabolic studies (e.g., BUN) are normal, a mannitol or urea drip is begun while awaiting the results of other investigations such as computed tomography (CT) scan, electroencephalogram (EEG), and echoencephalogram. A neurosurgeon should be consulted immediately.

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Source: Differential Diagnosis in Primary Care, 2007

HALITOSIS AND OTHER BREATH ODORS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of bad breath involves a careful examination of the mouth and nasal passages. If this is negative, chest and sinus x-rays and upper GI series with barium swallow should be done. If the studies are still unrewarding, then endoscopy of the respiratory and upper GI tract would be indicated. Appropriate liver and renal function tests will be ordered when uremia or hepatic coma is suspected. If pyorrhea is suspected, refer the patient to a dentist.

---

HAND AND FINGER PAIN

	V	I	N	D
	Vascular	Inflammatory	Neoplasm	Degenerative
				and Deficiency
Skin	Periarteritis nodosa Gangrene	Carbuncle Ulcers Folliculitis Herpes zoster	Carcinoma
Fascia, Ligaments, Tendon Sheaths, Subcutaneous Tissue		Felon Abscess Cellulitis Tendon sheath infection	Sarcoma
Arteries	Arteriosclerosis	Subacute bacterial endocarditis	Macroglobulinemia
Veins		Thrombophlebitis
Muscles		Myositis
Peripheral Nerves (Carpal Tunnel)		Multiple myeloma
Brachial Plexus	Ischemic neuritis Myocardial infarction	Bursitis Arthritis Pneumonia	Pancoast tumor
Spinal Cord and Cervical Roots		Tuberculosis	Primary or metastatic tumors of cord	Cervical spondylosis Syringomyelia
Bone		Gonococcal arthritis		Osteoarthritis

---

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Source: Differential Diagnosis in Primary Care, 2007

ANOSMIA OR UNUSUAL ODOR: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the disorder is the result of an acute infectious process, nothing needs be done. If it is associated with trauma or there has been a gradual onset, it is important to get a CT scan to rule out skull fracture or neoplasm. It is essential to rule out drug and alcohol use at the outset by a careful history and urine screen. A good nasopharyngeal examination and nasopharyngoscopy must be done if local disease is suspected. These may need to be complemented by x-rays or CT scan of the sinuses. Systemic disease can be ruled out by a CBC, chemistry panel, thyroid profile, serum B₁₂ test, glucose tolerance test, and liver profile. If epilepsy is suspected, a wake-and-sleep EEG needs to be done.

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Source: Differential Diagnosis in Primary Care, 2007

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