Diagnosis of Insomnia
Diagnostic Test list for Insomnia:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Insomnia
includes:
- Sleep diary
- Sleep studies
Insomnia Diagnosis: Book Excerpts
Tests and diagnosis discussion for Insomnia:
Patients with insomnia are evaluated with the help of a medical history
and a sleep history. The sleep history may be obtained from a sleep diary
filled out by the patient or by an interview with the patient's bed
partner concerning the quantity and quality of the patient's sleep.
Specialized sleep studies may be recommended, but only if there is
suspicion that the patient may have a primary sleep disorder such as sleep
apnea or narcolepsy. (Source: excerpt from Insomnia: NWHIC)
Diagnosis of Insomnia: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Insomnia:
Diagnostic Tests for Insomnia: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Insomnia.
INSOMNIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there dyspnea? If there is a history of dyspnea, heart disease or lung disease should be suspected.
- Is there a history of drug or alcohol ingestion? There are many drugs that may cause insomnia, including the amphetamines, theophylline, caffeine, anticonvulsants, nicotine, thyroid hormones, and the sympathomimetics. Alcohol may induce sleep, but patients complain of early morning wakening.
- Is there a history of a painful condition? Abscessed teeth, arthritis, sciatica, bone metastasis, hiatal hernia, and esophagitis are just a few of the conditions that may keep a patient awake because of pain.
- Are there other psychiatric symptoms? Anxiety, loss of libido, loss of appetite, and depression may be associated with hyperthyroidism, general paresis, organic brain syndrome, chronic anxiety, and endogenous depression.
DIAGNOSTIC WORKUP
Routine studies include a CBC, sedimentation rate, urinalysis and drug screen, chemistry panel, thyroid profile, VDRL test, EKG, and chest x-ray. Arterial blood gases and pulmonary function testing should be done to rule out pulmonary disease. A venous pressure and circulation time will help rule out early congestive heart failure. Blood pressure monitoring can be used to rule out paroxysmal hypertension. If an organic brain syndrome is suspected, a CT scan or MRI of the brain should be done. If psychiatric symptoms are present, the patient should be referred to a psychiatrist. Alternatively, a therapeutic trial of psychotherapeutic agents may be initiated if the patient is not suicidal. When all of the above diagnostic tests are negative, a sleep study must be done. However, home monitors for apnea and oxygen desaturation are available and may be an inexpensive alternative to rule out obstructive sleep apnea.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
SLEEP APNEA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there excessive snoring? Excessive snoring would indicate obstructive sleep apnea from large tonsils, deviated nasal septum, cleft palate, other abnormalities, and obesity.
- Is there obesity? More than 60% of patients with sleep apnea have obesity, and pickwickian syndrome should be considered in these patients, as well as idiopathic obesity.
- Are there abnormalities of the neurologic examination? The presence of neurologic abnormalities should make one think of poliomyelitis, Shy-Drager syndrome, brain stem tumors, and other neurologic disorders.
DIAGNOSTIC WORKUP
The most important diagnostic test is an all-night polygraphic recording (polysomnography). This will differentiate between obstructive and nonobstructive sleep apnea. If obstructive sleep apnea is suspected, a referral should be made to an ear, nose, and throat specialist. If there are abnormalities on the neurologic examination, a neurologic consultation should be sought. If idiopathic nonobstructive sleep apnea is suspected, the patient should be referred to a pulmonologist. A therapeutic trial of continuous positive airway pressure may be done. Some cases should have evaluation for a pituitary tumor, a thyroid profile, and a trial of tricyclic drugs and progesterone.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
GAIT DISTURBANCES:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there abnormalities on neurologic examination? An abnormal neurologic examination should make one think of multiple sclerosis, peripheral neuropathy, muscular dystrophy, Parkinson's disease, Huntington's chorea, and a host of degenerative neurologic conditions.
- Is there a painful limp? The findings of a painful limp should make one suspect hip, knee, or ankle joint pathology. A herniated lumbar disk may also cause a characteristic antalgic gait.
- Is the gait characteristic of a particular type? Characteristic gaits include the short-stepped shuffling gait of Parkinson's disease, the ataxic gait of multiple sclerosis and cerebellar disorders, the reeling, clownish gait of Huntington's chorea, the pelvic tilt of muscular dystrophy, and the steppage gait of peripheral neuropathy.
- Could the gait disturbance be due to malingering or hysteria? The gait of conversion hysteria is quite remarkable. The patient has a normal neurologic examination and has no difficulty maintaining balance while sitting down, but there is total inability to walk or stand without reeling about.
DIAGNOSTIC WORKUP
Routine orders would include a CBC, sedimentation rate, chemistry panel, VDRL test, and urinalysis. If there is a painful limp, x-rays of the hip, knee, or ankle on the affected side should be performed. An x-ray of the lumbar spine will not usually be of great assistance, however. If plain x-rays are negative, a CT scan or MRI of the lumbar spine, hip, knee, or ankle may be of assistance in the diagnosis. A bone scan may pick up obscure fractures and other pathology.
If there are abnormalities on the neurologic examination, MRI or CT scan of the appropriate level of suspected pathology will be done. A spastic gait with abnormal cranial nerve findings would suggest a cerebral tumor or other brain disease, and a CT scan or MRI of the brain should be done. Keep in mind that the MRI is almost double the cost of a CT scan, and the diagnostic yield is not that much greater in many cases.
A spastic gait without cranial nerve signs or papilledema would suggest a spinal cord disorder, and an MRI or CT scan of the appropriate level of the spinal cord should be done. A CT scan of the cervical spine, however, is not very useful and MRI is preferred.
If multiple sclerosis is suspected, a spinal tap for myelin basic protein or gamma globulin levels should be done. A VEP study, a BSEP study, or a SSEP study will also be useful in diagnosing multiple sclerosis.
If there is an ataxic gait, cerebellar disorder should be suspected, and a CT scan of the brain may be done. However, an ataxic gait may also suggest multiple sclerosis, pernicious anemia, and tabes dorsalis. If the VDRL test is negative, a FTA-ABS test should be done. Blood levels for vitamin B
12
and folic acid will help diagnose pernicious anemia. A Schilling test, however, is sometimes necessary to facilitate this diagnosis. If muscular dystrophy is suspected, electromyographic examination and muscle biopsy will help confirm the diagnosis. If the patient has a steppage gait, the workup of peripheral neuropathy should be done, as noted on
page 350
.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Insomnia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Unnecessary concern about deviation from “normal” sleeping patterns
-
Acute, transient insomnia (<4 weeks)
–Situational stress (most common)
–Acute illness or injury
–Medications or drugs (e.g., cocaine)
–Change in sleep environment or hours - Chronic insomnia (>4 weeks)
–Difficulty falling asleep: May be due to poor sleep hygiene, conditioned insomnia (initial acute insomnia progresses to chronic due to maladaptive distorted sleep cognitions), medications (e.g., sedatives, decongestants, oral contraceptive use, antidepressants, bronchodilators), drugs (including over-the-counter and herbal preparations, alcohol, nicotine, illicit drugs), and caffeine (e.g., coffee, soda, medications)
–Difficulty staying asleep: May be due to sleep apnea, medications and drugs (e.g., alcohol), depression, anxiety, dementia, psychosis, mania, post-traumatic stress disorder, and various medical conditions (e.g., COPD, asthma, CHF, angina, GERD, peptic ulcer disease, IBD, BPH, UTI, pregnancy, uremia, diabetes mellitus, hyperthyroidism, menopause, pain, pruritus, seizures)
-
RLS
–“Creepy-crawly” unpleasant sensations in
the legs and/or feet
–Temporarily relieved by moving limbs
-
Periodic limb movement disorder
–Arms and/or legs jerk during sleep
–May be a primary disorder or secondary to uremia, neuropathy, or iron deficiency
–Often in the elderly
–Often occurs with restless legs syndrome
Narcolepsy
REM-behavior disorder
–Rare, mostly in elderly
–Thrashing or seemingly purposeful
behaviors during sleep
Prion fatal familial insomnia
Workup and Diagnosis
-
Sleep and medication/drug history, including bed partner history
-
Sleep diary is the most effective specific assessment tool
–Should be recorded each morning
–Include time in bed, time asleep, awakenings, estimate of
sleep quality, associated symptoms (e.g., pain, dyspnea, urinary frequency)
-
A focused physical examination to evaluate cardiovascular, pulmonary, and neurologic systems and mental status will improve diagnostic accuracy
-
Polysomnography (sleep study) is useful to evaluate sleep apnea, restless legs syndrome, periodic limb movement disorder, and REM-behavior disorder
-
“Insomnia” is a self-reported condition; labs or other testing is often unnecessary unless underlying medical conditions are suspected
–ECG, chest X-ray, echocardiogram, pulmonary function
tests if suspect undiagnosed cardiac or pulmonary disease
–EEG if suspect undiagnosed seizure disorder
–TSH and free T4 if suspect thyroid disease
–Iron studies and BUN/creatinine if suspect restless legs
syndrome or periodic limb movement disorder (iron deficiency and renal failure are risk factors for both)
–Consider blood alcohol level, CBC and MCV, LFTs, and toxicology screen if suspect alcohol or illicit drug abuse
>
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
INSOMNIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the approach to the diagnosis, every physician should take the time to talk to the patient about possible reasons for fear or hostility. A nagging wife or mother-in-law, financial worries, a strict boss, or fear of losing a job are just a few examples of problems that can be handled with some sympathetic professional help. A good physical and neurologic examination may reveal an organic cause. The laboratory evaluation will be based on suspicion of one or more of the diseases mentioned above and using the list of tests that follows this discussion. A skull x-ray, EEG, CT scan, and possibly a spinal tap are indicated if a neurologic disorder is strongly suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
SLEEP APNEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A thorough examination of the upper respiratory system is essential: It may be wise to get an otolaryngologist to do this. A CBC to rule out anemia and arterial blood gases to rule out anoxia and hypercarbia may be helpful. Spirometry, chest x-ray, ECG, and arm-to-tongue circulation time will help rule out pulmonary and cardiovascular disorders. Ultimately, overnight polysomnography will be required to secure the diagnosis. A pulmonologist or otolaryngologist ought to be consulted before ordering this expensive test.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
GAIT DISTURBANCES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup depends on the presence or absence of other neurologic signs. If a peripheral nerve lesion is suspected, a workup for diabetes and a careful history for alcoholism and porphyria are expected. A suspected spinal cord lesion requires x-rays of the spinal column, spinal tap, Schilling test, and possibly a myelogram or MRI. When the lesion is believed to be in the brain or brainstem, an MRI or CT scan are almost axiomatic before a spinal tap or other radiocontrast studies are considered. A neurologist or neurosurgeon can best decide how the workup should be conducted.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Insomnia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Take a thorough sleep and health history. Find out when the patient’s insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, phenylpropanolamine, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?
Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder, or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he commonly finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient’s spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.
Assess the patient’s emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations, and note behavior that may indicate alcohol withdrawal. After reviewing complaints that suggest an undiagnosed disorder, perform a physical examination.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Insomnia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Take a thorough sleep and health history. Find out when the patient’s insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, phenylpropanolamine, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?
Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder, or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he often finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient’s spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.
Assess the patient’s emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations, and note behavior that may indicate alcohol withdrawal. After reviewing any complaints that suggest an undiagnosed disorder, perform a physical examination. (See Differential diagnosis: Insomnia, pages 450 and 451.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Insomnia:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of insomnia. Insomnia cannot be diagnosed by the amount of time a person sleeps. Rather, it is distinguished by the daytime consequences of unsatisfactory sleep (4). A pertinent history for insomnia would include:
1. A history of restlessness, irritability, daytime somnolence, and impaired work or social functioning, which can lead to situational stress. This may be a transient problem, but it can lead to difficulties with initiation of sleep and early awakenings.
2. Use of caffeine or other stimulants, especially over-the-counter medications (e.g., decongestants) that may contain ephedrine or phenylpropanolamine. Late evening exercise can also be a stimulant. Alcohol may help induce sleep, but it interferes with REM sleep and leads to nonrestorative sleep and early awakenings.
3. Affect changes, sadness, hopelessness, and vegetative signs such as weight loss should suggest depression, the most common psychiatric disorder associated with insomnia (Chapter 3.3). This is especially true if the insomnia persists for weeks. Anxiety disorders cause difficulty with getting to sleep, whereas patients with depression may fall asleep more readily but have early awakening.
4. Medical problems such as peptic ulcer disease and heart failure have been implicated in insomnia (Chapters 7.5 and 9.6). A history of frequent nocturnal urinations can also disrupt sleep and may indicate benign prostate hyperplasia or other prostate problems. Hyperthyroidism can cause irritability and insomnia, as can thyroid replacement therapy for hypothyroidism. Other problems such as asthma, angina, back pain, and sinusitis can also cause sleep disorders.
5. Loud snoring, daytime somnolence, forgetfulness, difficulty concentrating, and a history from the bed partner of periods of discontinuation of breathing during sleep of 10 seconds or more should suggest a more thorough evaluation for obstructive sleep apnea. Daytime napping, associated findings of gastrointestinal reflux disease, and hypertension are also suggestive associations for sleep apnea.
6. The bed partner is also a good person to ask about leg movements during sleep. This could be suggestive of a periodic limb movement disorder. A similar syndrome, restless legs, is associated with a history of unpleasant sensations in the legs and a persistent desire to move them. Both conditions cause a delay in sleep onset and nocturnal awakenings.
7. Sleep phase disturbances caused by jet lag or shift work can be characterized by early awakening or by awakening later in the day.
Physical examination.
The physical examination for insomnia is more a search for other underlying disease states than for any specific signs for insomnia, although hypertension, obesity, and thick neck suggest consideration of sleep apnea.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Visual Disturbance:
Differential Overview
(Field Guide to Bedside Diagnosis)
Acute Loss/Scotoma
❑ Ophthalmic migraine
❑ Amaurosis fugax
❑ Retinal detachment
❑ Acute angle closure glaucoma
❑ Optic neuritis
❑ Papilledema
❑ Retinal artery occlusion
❑ Giant cell arteritis
❑ Trauma
❑ Toxic
❑ Occipital stroke
❑ Ischemic optic neuropathy
❑ Retinal hemorrhage
❑ Vitreous hemorrhage
❑ Central retinal vein occlusion
Gradual Loss
❑ Refractive error
❑ Intraocular hypertension
❑ Cataract
❑ Diabetic retinopathy
❑ Macular degeneration
❑ Cytomegalovirus retinitis
❑ Drugs
❑ Keratoconjunctivitis sicca
❑ Optic nerve compression
❑ Pituitary adenoma
❑ Choroidal melanoma
❑ Retinitis pigmentosa
Diagnostic Approach
Homonymous hemianopsia may be perceived as blurring or as trouble finding the start of a line of print. On closer inspection, visual loss in corresponding fields in both eyes will be detected. This usually results from a lesion in the suprageniculate pathway. The macula is usually spared in cortical lesions. Bitemporal hemianopsia is due to a chiasmal lesion such as a pituitary adenoma, anterior communicating artery aneurysm, cerebellar tumor with third ventricle hydrocephalus, or meningitis. Thiamine deficiency, methanol toxicity, or optic neuritis at the chiasm can cause true acute bilateral visual loss
An afferent pupillary defect (Marcus Gunn pupil) is diagnostic for a prechiasmal optic nerve lesion. Have the patient fixate on a far object, and then shine a bright light into his or her eyes. The initial (abnormal) response is dilation instead of brisk contraction.
Tunnel vision causes a patient to turn his or her head to avoid bumping into objects, and it can be outlined by visual field confrontation. Causes include glaucoma, retinitis pigmentosa, and quinine toxicity.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Sleep Disorders:
Differential Overview
(Field Guide to Bedside Diagnosis)
Insomnia
❑ Stress
❑ Drugs
❑ Medical disorders
❑ Phase shift
❑ Sleep apnea
❑ Conditioned insomnia
❑ Depression
❑ Restless leg syndrome
❑ Nocturnal myoclonus
❑ Nightmares
Hypersomnia
❑ Drugs
❑ Medical disorders
❑ Adolescence
❑ Narcolepsy
Diagnostic Approach
Insomnia may occur as difficulty falling asleep, multiple awakenings from sleep, or awakening early and being unable to fall back to sleep. If the presenting symptom is excessive daytime somnolence or fatigue, the problem may have to be reframed as one of insomnia.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Insomnia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Take a thorough sleep and health history. Find out when the patient’s insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, phenylpropanolamine, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?
Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he often finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient’s spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.
Assess the patient’s emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations, and note behavior that may indicate alcohol withdrawal.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vision Disturbances:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Ocular Disorders
Congenital Anomalies
Globe
A small eye may be normal histologicallyor may be malformed and associated with coloboma or persistenceof fetal vasculature. Coloboma, a notch or gap of any ocular structurelocated in fundus or iris, may cause impaired vision if macula,optic nerve, or retina is involved. Persistence of fetal vasculatureis discussed in section Vitreous.
Lens
Absenceof lens is called congenital aphakia, which is rare.Small or dislocated lens may causesevere myopia.See section on Cataracts. Cornea
Small orlarge corneas may be associated with ocular malformations, otherpathologic lesions, and refractive errors.Measurement of corneal size is madein the horizontal direction. Small cornea is <10 mm in newbornsand <11 mm in older children, whereas large cornea is >12mm in newborns and >13 mm after age 2. Iris
Aniridia(absence of iris tissue) is autosomal-dominant disorder that maybe associated with cataracts, nystagmus, optic nerve hypoplasia,and glaucoma.WAGR syndrome (Wilms tumor–aniridia–genitourinaryanomalies–mental retardation) is caused by chromosomaldeletion at 11p13.Rieger syndrome causes ectopic pupil(corectopia) or multiple pupils (polycoria). Also may be associatedwith glaucoma. Vitreous
Persistenceof fetal vasculature was formerly called persistent hyperplasticprimary vitreous.Results in formation of dense vitreousband that can extend from posterior lens to optic disc. Usuallyunilateral and is characterized by small eye that often has whitepupillary reflex.Associated abnormalities include cataracts,glaucoma, and retinal detachment. Refractive Errors
Disturbancesin specific optical properties of eye.Primary refractive errors are myopia,hyperopia, and astigmatism. Anisometropia occurs when there areunequal refractive errors.Normal vision can usually be restoredby proper lens correction if no other problem exists. Myopia
Myopic children have normal near vision butblurry distance vision. This disorder is often first noticed inschool-aged children, when they complain that they cannot clearlysee writing on blackboard in school.
Hyperopia
Children with hyperopia have more difficultywith near vision and must accommodate for clearer focus. They areprone to develop accommodative esotropia.
Astigmatism
Resultsfrom small differences in radius of curvature of cornea or lens.Parallel rays of light enter eye and focus at different points ratherthan at 1 point, so retinal image is blurred.Can occur as isolated finding or withmyopia or hyperopia.Glasses or contact lenses can compensatefor astigmatism. Anisometropia
May cause difficulty in using eyes togetherand may lead to strabismus or amblyopia.
Strabismus
Strabismus(crossed eyes or squint) is misalignment of eyes and occurs in about3% of pediatric population. Can be normal during maculardevelopment in first 4 mos of life, but its persistence after thisage is abnormal.Without proper treatment during infancyand early childhood, strabismus can lead to amblyopia with lossof vision in nonfixing eye. Small deviation of eye turning in (esotropia)or out (exotropia) may produce severe loss of vision.2 diagnostic tests used to detect strabismusare corneal light reflex test in infants and more accurate covertest in preschool- and school-aged children.When child looks straight ahead atsmall flashlight, corneal light reflex is normally in middle ofeach pupil. If reflex is off center in 1 pupil compared with theother, strabismus exists.Using cover test in child with strabismus,when normal eye is covered, uncovered eye moves to fix on light.When normal eye is uncovered, nonfixing eye shifts back to its abnormalposition. Because most children with strabismusare asymptomatic, it is important to test for strabismus on eachwell-child visit. When physician diagnoses strabismus, ophthalmologicconsultation is mandatory. Amblyopia
Is a decreasein vision without detectable lesions of eye. Strabismus and anisometropiaare most common causes.To detect amblyopia when it is stillreversible, vision testing must be performed well before schoolage. Optimal time is 3–4 yrs of age. Before this age, testingof visual acuity is subjective, although good fixation and followingwithout nystagmus or strabismus indicate good visual function. Detectionof amblyopia before 4 yrs of age offers best chance of successfultreatment, but older children may respond well to treatment. Trauma
Cornealabrasion, foreign body, contusion with hyphema formation, lacerationof globe, perforation of eye, and burns may cause defective vision.History and exam of eye including slit-lampexam are diagnostic. Visual acuity should always be measured whentrauma to eye has occurred. Infection
N. gonorrhoeae, herpes simplex virus, cytomegalovirus,T. gondii, and Toxocara species can cause serious eye infections,resulting in loss of vision. These infections are discussed in Chap. 36, Jaundice, and Chap. 54, Red Eye.
Cataracts
Are opacitiesof the crystalline lens of the eye that may interfere with the development andmaintenance of normal vision.May present with leukocoria, nystagmus,strabismus, photophobia, visual inattentiveness, or irregular orabsent red reflex. Older children are aware of decreased visualacuity in affected eye.Although cataracts can often be seenby focal illumination with penlight, direct ophthalmoscopy confirmstheir presence.Table74.1 lists common causes of cataracts in infants andchildren.Children of any age who have a suspectedcataract should be referred for ophthalmologic consultation. >>
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Insomnia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Take a thorough sleep and health history. Find out when the patient's insomnia began and the circumstances surrounding it. Is the patient trying to stop using a sedative? Does he take a central nervous system (CNS) stimulant, such as an amphetamine, pseudoephedrine, a theophylline derivative, cocaine, or a drug that contains caffeine, or does he drink caffeinated beverages?
Find out if the patient has a chronic or acute condition, the effects of which may be disturbing his sleep, particularly cardiac or respiratory disease or painful or pruritic conditions. Ask if he has an endocrine or neurologic disorder, or a history of drug or alcohol abuse. Is he a frequent traveler who suffers from jet lag? Does he use his legs a lot during the day and then feel restless at night? Ask about daytime fatigue and regular exercise. Also ask if he commonly finds himself gasping for air, experiencing apnea, or frequently repositioning his body. If possible, consult the patient's spouse or sleep partner because the patient may be unaware of his own behavior. Ask how many pillows the patient uses to sleep.
Assess the patient's emotional status, and try to estimate his level of self-esteem. Ask about personal and professional problems and psychological stress. Also ask if he experiences hallucinations, and note behavior that may indicate alcohol or drug withdrawal. After reviewing complaints that suggest an undiagnosed disorder, perform a physical examination.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
SLEEP APNEA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A thorough examination of the upper respiratory system is essential: It
may be wise to get an otolaryngologist to do this. A CBC to rule out anemia
and arterial blood gases to rule out anoxia and hypercarbia may be helpful.
Spirometry, chest x-ray, echocardiogram (ECG), and arm-to-tongue circulation
time will help to rule out pulmonary and cardiovascular disorders.
Ultimately, overnight polysomnography will be required to secure the
diagnosis. A pulmonologist or otolaryngologist ought to be consulted before
ordering this expensive test.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
INSOMNIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
In the approach to the diagnosis, every physician should take the time
to talk to the patient about possible reasons for fear or hostility. A
nagging wife or mother-in-law, financial worries, a strict boss, or fear of
losing a job are just a few examples of problems that can be handled with
some sympathetic professional help. A good physical and neurologic
examination may reveal an organic cause. The laboratory evaluation will be
based on suspicion of one or more of the diseases mentioned above and will
use the list of tests that follows this
discussion. A skull x-ray, electroencephalogram (EEG), CT scan, and possibly
a spinal tap are indicated if a neurologic disorder is strongly suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
GAIT DISTURBANCES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup depends on the presence or absence of other neurologic
signs. If a peripheral nerve lesion is suspected, a workup for diabetes and
a careful history for alcoholism and porphyria are expected. A suspected
spinal cord lesion requires x-rays of the spinal column, spinal tap,
Schilling test, and possibly a myelogram or magnetic resonance imaging
(MRI). When the lesion is believed to be in the brain or brainstem, an MRI
or computed tomography (CT) scan are almost axiomatic before a spinal tap or
other radiocontrast studies are considered. A neurologist or neurosurgeon
can best decide how the workup should be conducted.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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