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Diseases » Hypotension » Diagnosis
 

Diagnosis of Hypotension

Hypotension Diagnosis: Book Excerpts

Diagnosis of Hypotension: medical news summaries:

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

Diagnostic Tests for Hypotension: Online Medical Books

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


HYPOTENSION, CHRONIC: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is the hypotension found only on standing? The finding of hypotension on standing suggests orthostatic hypotension, which may be due to several causes, including hypopituitarism, diabetic neuropathy, anemia, and various cardiovascular disorders.
  2. Is there a history of drug ingestion? Many drugs induce hypotension, including nitroglycerin and its analogues, vasodilators, quinidine, and tricyclic drugs.
  3. Is there cardiomegaly or a heart murmur? These findings suggest mitral valvular disease, aortic stenosis, and congestive heart failure.
  4. Is there pallor? The finding of pallor suggests anemia.
  5. Is there hyperpigmentation? The presence of hyperpigmentation suggests Addison's disease.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, chemistry panel, urinalysis, thyroid panel, EKG, and chest x-ray. Blood volume and arterial blood gas studies may be useful. If there is cardiomegaly or a murmur, echocardiography and venous pressure and circulation time should be done. A cardiologist should also be consulted.

If there is hyperpigmentation, a serum cortisol and ACTH stimulation test should be done. A skull x-ray can be done to rule out pituitary tumors. A visual field examination by a qualified ophthalmologist may be helpful in this regard also. Twenty-four-hr blood pressure monitoring may be useful in the workup also.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  • Orthostatic hypotension
    –Most common in elderly
    –May result in syncope or near-syncope upon standing
    –Decrease of more than 20 mmHg in systolic blood pressure, or a decrease of 10 mmHg in diastolic blood pressure within 2–5 minutes of standing
  • Hypotension secondary to medications is common in elderly patients (e.g., antihypertensives; vasodilators, including nitrates, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers; hypoglycemic agents; antidepressants; opiates; alcohol)
    • Volume depletion
      –Often due to hyperglycemia, dehydration, hemorrhage, occult bleeding, vomiting, diarrhea, or diuretic use
    • Autonomic failure
      –Absence of reflex-induced increase in heart rate as blood pressure is decreased
      –Often due to Parkinson's disease, cerebellar disorders, neuropathies, or Shy-Drager syndrome
    • Postprandial hypotension (within 75 minutes of eating)
      –Very common in elderly
    • Adrenal insufficiency
      –ACTH stimulation test shows inadequate increase in serum cortisol from baseline
  • Diabetic autonomic neuropathy
  • Shock
    –Cardiogenic shock
    –Septic shock
    –Neurogenic shock
    –Hemorrhagic shock
  • Anaphylaxis
  • Splenic rupture
  • Ectopic pregnancy
  • Hepatitis

Workup and Diagnosis

  • History and physical examination
    –Compare blood pressure to patient's usual values
    –The absence of reflex-induced increase in heart rate as blood pressure falls indicates autonomic failure, which may require a workup for suspected underlying neurologic or pharmacologic conditions
    –Cardiogenic shock is often accompanied by cool, clammy extremities
  • Laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, calcium, urinalysis, and ECG
  • Additional studies (e.g., blood cultures, echocardiogram, blood type and cross) may be indicated based on the underlying disorder
  • Swan-Ganz catheterization (right heart catheterization) may be indicated to establish the etiology (e.g., cardiogenic versus noncardiogenic) and determine patient management
  • For diagnosis of adrenal insufficiency, obtain baseline cortisol level and then administer 250 µ g of ACTH (Cortrosyn); obtain serum cortisol levels 30 and 60 minutes after ACTH administration; if cortisol level increases by <7, then adrenal insufficiency is highly likely
>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Low Back Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Lumbosacral muscle strain
    –Most common etiology of low back pain
    –Most common cause of disability in adults <45 years old
    –Aggravated by movement, better with rest
  • Lumbar disc herniation
    –Especially of L4-L5 and L5-S1
    –Usually with unilateral radiation down the leg in a dermatomal pattern
    –Increased pain with sitting
    • Spinal stenosis
      –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
      –Increased pain with standing
    • Sacral-iliac joint dysfunction
      –Especially in young, thin women or in pregnancy
      –Unilateral upper buttock pain, relieved with movement
    • Vertebral fracture
      –Often associated with trauma or osteoporosis
    • Spondylolisthesis
      –Especially in young athletes
    • Secondary gain (e.g., drug seeking, disability or liability issue)
    • Extraspinal causes (e.g., radiation from kidney stones)
    • Systemic causes (<1%)
      –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
      –Infection: Osteomyelitis, abscess
      –Abdominal aortic aneurysm
      –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
      –Cauda equina syndrome
      –Paget's disease

    Workup and Diagnosis

    • History and physical are the most important diagnostic tools
      –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
    • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
    • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
      –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
      –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
      –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
    • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study
    '>>'>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

HYPOTENSION AND SHOCK: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of shock must be vigorous with emergency CBC, blood cultures, blood gases, ECG, electrolytes, blood urea nitrogen (BUN), and type and cross-match of blood at the same time vigorous antishock measures are applied. Checking the GI tract for blood loss with a rectal and nasogastric tube can be both diagnostic and therapeutic. To work up chronic hypotension, one should not forget venous pressure and circulation times (to diagnose decreased cardiac output and CHF), serial electrolytes and cortisol levels (to rule out adrenal insufficiency), and sedimentation rate and cultures of various body fluids to exclude a chronic infectious disease (e.g., tuberculosis).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

LOW BACK PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic exam should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive.

If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Pulse pressure, narrowed: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Also check for changes in skin temperature or color, the strength of peripheral pulses, and the patient’s level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope.

» READ BOOK EXCERPT ONLINE »

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

Pulse, absent or weak: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you detect an absent or a weak pulse, quickly palpate the remaining arterial
pulses to distinguish between localized or generalized loss or weakness. Then quickly check the patient’s other vital signs, evaluate his cardiopulmonary status, and obtain a brief history. Based on your findings, proceed with emergency interventions. (See Managing an absent or a weak pulse, pages 506 and 507.)

» READ BOOK EXCERPT ONLINE »

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

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

If the patient doesn’t have cardiac tamponade, find out if he has a history of chronic cardiac or pulmonary disease. Ask about the development of associated signs and symptoms, such as a cough or chest pain. Then auscultate for abnormal breath sounds.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headaches, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

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

Blood pressure decrease [Hypotension]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Is his gait unsteady? Does he have palpitations? Does he have chest or abdominal pain or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient's blood pressure while he's lying down, sitting, and then standing; compare readings. (See Ensuring accurate blood pressure measurement.) A drop in systolic or diastolic pressure of 10 to 20 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension.

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note paradoxical pulse — an accentuated fall in systolic pressure during inspiration — which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding and palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Also, carefully assess the patient for possible sources of infection such as open wounds.

» READ BOOK EXCERPT ONLINE »

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

Low birth weight: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 382 and 383.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

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

Pulse pressure, narrowed: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Check for changes in skin temperature or color, strength of peripheral pulses, and level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope.

» READ BOOK EXCERPT ONLINE »

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

Pulse, absent or weak: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you detect an absent or weak pulse, quickly palpate the remaining arterial pulses to distinguish between localized or generalized loss or weakness. Then quickly check other vital signs, evaluate cardiopulmonary status, and obtain a brief history. Based on your findings, proceed with emergency interventions. (See Managing an absent or weak pulse, pages 638 and 639.)

» READ BOOK EXCERPT ONLINE »

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

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

If the patient doesn’t have cardiac tamponade, find out if he has a history of chronic cardiac or pulmonary disease. Ask about the development of associated signs and symptoms, such as a cough or chest pain. Auscultate for abnormal breath sounds.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

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

Blood pressure decrease [Hypotension]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Gait unsteady? Does he have palpitations, chest or abdominal pain, or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient’s blood pressure while he’s lying down, sitting, and then standing and compare readings. A drop in systolic or diastolic pressure of 10 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension. (See Ensuring accurate blood pressure measurement, page 104.)

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note a paradoxical pulse—an accentuated fall in systolic pressure during inspiration—which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding, palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Also, carefully assess the patient for possible sources of infection such as open wounds.

» READ BOOK EXCERPT ONLINE »

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

Low birth weight: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 488 and 489.) Follow with a routine neonatal examination.

» READ BOOK EXCERPT ONLINE »

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

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

 The history should include evaluation for “red flag” conditions.

A. Pain characteristics. Assess the nature of the pain, along with the onset and duration of the symptom. Is there any radiating pain, leg weakness, or paresthesia? Pseudoclaudication is suggestive of spinal stenosis. Pain radiating below the knee is more likely to be a true radiculopathy (1). Nerve root compression is highly unlikely without sciatic pain (1). Was the onset after a traumatic event? A seemingly insignificant episode (e.g., a minor fall) may be a “red flag” for fracture in an elderly patient. Are there alleviating or exacerbating factors? Does the pain limit the patient physically or socially? Is there a history of previous back problems or back surgery?

B. Review of systems. Look for associated symptoms that can indicate a “red flag” condition or an underlying medical cause. Gastrointestinal and genitourinary symptoms are particularly important, especially incontinence (Chapter 10.10).

 C. Psychosocial information. Has the patient initiated any new activities? If work-related, assess typical job tasks. Investigate whether the back pain could have any relationship, sexual, or mood implications. Sexual activity can be severely affected simply because of pain, but sexual dysfunction can also result from neurologic abnormalities associated with the cause of the back pain. Back pain is associated with depression and poor sleep patterns. Drug-seeking behavior may be exhibited along with a complaint of back pain. Addiction may have resulted from former or on-going treatment of the pain. Legal issues can complicate the diagnosis and treatment of back pain. Ask the patient whether litigation involving the back pain is under consideration.

Physical examination

Evaluation should be both general and specific. It is prudent to leave the potentially most painful parts of the examination to the end.

 A. General. Examination includes auscultation of the heart and assessment of peripheral pulses and blood pressure. Abdominal examination should focus on possible causes of back pain (Table 12.5). Assess gait.

 B. Neurologic. The lower extremity examination includes motor strength, deep tendon reflexes, sensation, proprioception, and certain functional maneuvers (Table 12.6). Romberg and Babinski reflexes should also be assessed. Rectal examination should assess sphincter tone, which can be compromised in sacral root dysfunction. In the primary care setting, most clinically significant disc herniations will be detected by the following limited examination: dorsiflexion of the great toe and ankle, Achilles reflex, light touch sensation of the medial (L 4), dorsal (L5), and lateral (S1) aspect of the foot, and the straight leg raise (SLR) test (1).

 C. Musculoskeletal. Assess range of motion of the spine and lower extremities. Perform the SLR test passively with the patient supine. Note the angle of leg elevation precipitating pain. A positive test for sciatica is buttock pain radiating to the posterior thigh, and perhaps to the lower leg and foot. Sciatica, with pain and resistance on internal rotation of the hip, can indicate piriformis muscle spasm or strain. The SLR test is usually negative in spinal stenosis (2). Percussion of the spine and upper pelvis helps to identify areas of localized tenderness, as in fracture, metastatic disease, and some rheumatologic conditions. Palpate standard trigger points looking for fibromyalgia. Check for paraspinal muscle spasm. Measure thigh and calf circumferences to look for muscular atrophy.

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

Orthostatic Hypotension: Differential Overview
(Field Guide to Bedside Diagnosis)

Dysautonomia

❑ Diabetes

❑ Drugs

❑ Pernicious anemia

❑ Amyloidosis

❑ Guillain-Barré syndrome

❑ Wernicke syndrome

Other

❑ Dehydration

❑ Prolonged standing

❑ Hemorrhage

❑ Thermodilation

❑ Vasovagal response

❑ Pregnancy

❑ Addison disease

Diagnostic Approach

Dysautonomia is characterized by orthostatic hypotension (postural lightheadedness, fainting, dim vision, weakness, unsteady gait), urinary dysfunction (frequency, urgency, stress incontinence), sexual dysfunction (impotence, retrograde ejaculation), bowel dysfunction (nocturnal diarrhea, incontinence), and/or decreased sweating. It is most easily recognized by the presence of orthostatic hypotension without reflex tachycardia. Within 2 to 5 minutes of quiet standing there will be a 20 mm Hg drop in systolic pressue, a 10 mm Hg drop in diastolic pressure, or symptoms of cerebral hypoperfusion.

With gastrointestinal hemorrhage, an orthostatic blood pressure change of 10 mm Hg suggests a loss of at least 20% of intravascular volume.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Low Back Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Musculoligamentous strain

❑ Lumbar disc herniation

❑ Osteoarthritis

❑ Compression fracture

❑ Pyelonephritis

❑ Secondary gain

❑ Scoliosis

❑ Spondylolisthesis

❑ Metastatic cancer

❑ Spinal stenosis

❑ Transverse process fracture

❑ Pancreatic cancer

❑ Ankylosing spondylitis

❑ Sacroiliitis

❑ Aortic dissection

❑ Cauda equina syndrome

❑ Vertebral osteomyelitis

❑ Epidural abscess

Diagnostic Approach

Radicular pain has such a high sensitivity for nerve root compression that its absence makes important disc herniation unlikely. Not all radicular pain is due to a herniated disc however. Other causes include spinal stenosis, ligamentous hypertrophy, deep lumbar muscle spasm, and deep trochanteric bursitis.

Back pain at rest or unassociated with posture/movement should increase the suspicion of tumor, fracture, infection, or referred visceral pain. Spinal tenderness is a sensitive but not specific indicator. Clues to metastatic cancer include a history of cancer, unexplained weight loss, and signs of cord compression, such as motor weakness of the legs, urinary or fecal incontinence, and absent anal reflex. Recent bacterial infection, injection drug use, or immune suppression (from steroids, chemotherapy, or HIV) should raise suspicion for infection. Fever occurs in osteomyelitis (50%), epidural abscess (83%), and tuberculosis (27%).

A red flag for fracture in a young adult is major trauma, such as a fall from a height or a motor vehicle accident. In older adults, minor trauma or strenuous lifting can cause a compression fracture.

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Source: Field Guide to Bedside Diagnosis, 2007

Pulse pressure, widened: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain the patient’s history, including a family medical history. Obtain a drug history. Has he experienced chest pain, shortness of breath, weakness, fatigue, or syncope? Ask the patient whether he recently had a fever. Ask about prolonged exposure to hot weather, excessive exercise, anxiety, or anemia.

Physical examination

Assess the patient for signs and symptoms of heart failure, such as crackles, dyspnea, and jugular vein distention. Check for changes in skin temperature and color and strength of peripheral pulses. Evaluate the patient’s LOC. Auscultate the heart for the presence of a murmur, and check for peripheral edema.

» READ BOOK EXCERPT ONLINE »

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

Hypotension, orthostatic: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition is stable, obtain his history. Ask whether he frequently experiences dizziness, weakness, or fainting when he stands. Ask whether he experienced associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Obtain a complete medication history, including his use of prescription, over-the-counter, herbal preparations, and other supplements. Also ask about his use of illicit drugs.

Physical examination

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

ALERT: Assess the patient for signs and symptoms of hemorrhage and hypovolemic shock. Observe his skin color and check peripheral circulation and capillary refill time. Inspect the skin and mucous membranes for signs of bleeding.

» READ BOOK EXCERPT ONLINE »

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

Pulsus paradoxus [Paradoxical pulse]: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If you’ve ruled out cardiac tamponade, obtain the patient’s history. Does he have a history of chronic cardiac or pulmonary disease? Ask about the development of associated signs and symptoms, such as cough or chest pain.

Physical examination

Auscultate for abnormal breath sounds and assess the patient’s respiratory status, oxygenation, and effort. Assess the patient’s vital signs and cardiovascular system, and monitor his cardiac rhythm.

» READ BOOK EXCERPT ONLINE »

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

Pulse pressure, narrowed: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient about specific cardiac symptoms, such as chest pain, dizziness, or syncope. Obtain his past medical history, and assess his risk factors for heart disease.

» READ BOOK EXCERPT ONLINE »

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

Pulse pressure, widened: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Obtain the patient’s medical, family, and drug histories. If you don’t suspect increased ICP, ask about such associated symptoms as chest pain, shortness of breath, weakness, fatigue, or syncope.

» READ BOOK EXCERPT ONLINE »

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

Pulse, absent or weak: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

After you detect an absent or weak pulse, review the patient’s history of heart disease. Ask him what medications he’s taking and whether he has any other illnesses. Also, question him about associated signs and symptoms, such as chest pain or dyspnea.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient doesn’t have cardiac tamponade, find out if he has a history of chronic cardiac or pulmonary disease. Ask about the development of associated signs and symptoms, such as a cough or chest pain.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

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

Pulse pressure, narrowed: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

After you detect a narrowed pulse pressure, check for other signs of heart failure, such as hypotension, tachycardia, dyspnea, jugular vein distention, pulmonary crackles, and decreased urine output. Also check for changes in skin temperature or color, the strength of peripheral pulses, and the patient's level of consciousness (LOC). Auscultate the heart for murmurs. Ask about a history of chest pain, dizziness, or syncope. Obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulse, absent or weak: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If you detect an absent or a weak pulse, quickly palpate the remaining arterial pulses to distinguish between localized or generalized loss or weakness. If localized, ask whether the patient has experienced or is presently experiencing pain in that area. Assess the limb for color and temperature. Then quickly check the patient's other vital signs, evaluate his cardiopulmonary status, and obtain a brief history. Based on your findings, proceed with emergency interventions. (See Managing an absent or a weak pulse, pages 498 and 499.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulsus paradoxus: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient doesn't have signs of cardiac tamponade, find out if he has a history of chronic cardiac or pulmonary disease. Ask about the development of associated signs and symptoms, such as a cough or chest pain. Then auscultate for abnormal breath sounds.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headaches, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient's skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient's gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Blood pressure, decreased [Hypotension]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Is his gait unsteady? Does he have palpitations? Does he have chest or abdominal pain or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient's blood pressure while he's lying down, sitting, and then standing; compare readings. (See Ensuring accurate blood pressure measurement.)

A drop in systolic or diastolic pressure of 10 to 20 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension.

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note paradoxical pulse—an accentuated fall in systolic pressure during inspiration—which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding and palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Carefully assess the patient for possible sources of infection such as open wounds.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Low birth weight: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

As soon as possible, evaluate the neonate's neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age.) Follow with a routine neonatal examination.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

LOW BACK PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic examination should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive. If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow-up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

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Source: Differential Diagnosis in Primary Care, 2007

HYPOTENSION AND SHOCK: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of shock must be vigorous with emergency CBC, blood cultures, blood gases, ECG, electrolytes, blood urea nitrogen (BUN), and type- and cross-match of blood at the same time that vigorous antishock measures are applied. Checking the GI tract for blood loss with a rectal and nasogastric tube can be both diagnostic and therapeutic. To work up chronic hypotension, one should not forget venous pressure and circulation times (to diagnose decreased cardiac output and CHF), serial electrolytes and cortisol levels (to rule out adrenal insufficiency), and sedimentation rate and cultures of various body fluids (to exclude a chronic infectious disease [e.g., TB]).

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Source: Differential Diagnosis in Primary Care, 2007


 » Next page: Signs of Hypotension

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