Diseases » Lymphedema » Diagnosis

Diagnosis of Lymphedema

Lymphedema Diagnosis: Book Excerpts

• Ask the following questions - EDEMA, GENERALIZED
• Ask the Following Questions - LYMPHADENOPATHY
• Ask the following questions - EDEMA, LOCALIZED
• Ask the Following Questions - PERIORBITAL EDEMA
• Differential Diagnosis - Lymphadenopathy
• Differential Diagnosis - Periorbital Edema
• Differential Diagnosis - Peripheral Edema
• Differential Diagnosis - Edema
• Differential Diagnosis - Lymphadenopathy
• Differential Diagnosis - Periorbital Edema
• Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
• Approach to the Diagnosis - LYMPHADENOPATHY, GENERALIZED
• History and physical examination - Edema, generalized
• History and physical examination - Lymphadenopathy
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the leg
• Diagnosis - Pulmonary edema
• History and physical examination - Edema, generalized
• History and physical examination - Lymphadenopathy
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the face
• History and physical examination - Edema of the leg
• History - Edema
• History - Lymphadenopathy, Generalized
• History - Lymphadenopathy, Localized
• Differential Overview - Edema
• Differential Overview - Lymphadenopathy
• Diagnosis - Pulmonary edema
• History - Edema, generalized
• History - Edema, facial
• History - Edema, generalized
• History - Lymphadenopathy
• History - Edema of the arm
• History - Edema of the face
• History - Edema of the leg
• Clinical Features and Diagnosis - Edema
• Clinical Features and Diagnosis Localized Lymphadenopathy - Lymphadenopathy
• History and physical examination - Edema, generalized
• History and physical examination - Lymphadenopathy
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the face
• History and physical examination - Edema of the leg
• Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
• Approach to the Diagnosis - LYMPHADENOPATHY, GENERALIZED

Diagnostic Tests for Lymphedema: Online Medical Books

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EDEMA, GENERALIZED: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Does the edema pit on pressure? Edema that pits on pressure is more likely to be due to heart, liver, or kidney disease. Edema that does not pit on pressure is more likely due to myxedema or lymphedema.
2. Is there hepatomegaly? If there is hepatomegaly, one should consider liver disease such as cirrhosis or cardiac disease.
3. Is there ascites? If there is ascites along with hepatomegaly, cirrhosis of the liver is the most likely cause of the edema. However, one should not forget constrictive pericarditis. If there is no ascites along with the hepatomegaly, then congestive heart failure should be considered.
4. Is there jugular vein distention? Jugular vein distention certainly would be most suggestive of congestive heart failure, but other causes of jugular vein distention include superior vena cava syndrome due to a mediastinal mass such as carcinoma of the lung and constrictive pericarditis. Right heart failure secondary to pulmonary emphysema and fibrosis can also cause jugular vein distention.
5. Is there an abnormal urinary sediment? If there is an abnormal urinary sediment, consider nephritis, whether it might be due to chronic glomerulonephritis or whether it is secondary to diabetes mellitus or a collagen disease.
6. Is the patient taking any drugs that could cause the edema? Among the drugs that should be considered are corticosteroids, progesterone, estrogen, anti-inflammatory drugs such as naproxen (Naprosyn®) and ibuprofen (Motrin®), antihypertensive drugs such as methyldopa (Aldomet®) and clonidine hydrochloride, calcium channel blockers, beta-adrenergic blockers, and antidepressants.

DIAGNOSTIC WORKUP

A CBC should be done to rule out significant anemia that may be the cause of the edema. If there is anemia, we need to determine its source. Liver function tests are done to rule out liver disease, and serum protein electrophoresis and tests for BUN and creatinine should be done to exclude renal disease. The urinalysis is very important both for the routine studies and also to examine the urinary sediment for diseases such as chronic glomerulonephritis and collagen disease. If there is significant loss of protein in the urine, one should be considering nephrosis. An EKG, chest x-ray, and venous pressure and circulation time will be extremely helpful in diagnosing congestive heart failure, but pulmonary function tests can be done as the vital capacity is significantly reduced in this disease. When there is a strong suspicion of congestive heart failure, echocardiography or radionuclide-gated blood pool scintigraphy should be done to determine the left ventricular ejection fraction (LVEF). A value of less than 45% is considered abnormal. A thyroid profile should be done to diagnose myxedema. A CT scan of the chest will help diagnose constrictive pericarditis. Occasionally, the edema is due to an abdominal tumor. A CT scan of the abdomen and pelvis will be helpful in those cases. Contrast lymphangiography may be necessary to diagnose lymphedema.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

1. Is there a history of drug ingestion? Many drugs can cause lymphadenopathy; the most notable is Dilantin, but the antibiotics, aspirin, iodides, and certain antihypertensive drugs can cause lymphadenopathy also.
2. Is the lymphadenopathy focal or diffuse? If the adenopathy is focal, one should look for an infectious process in the area supplied by the respective lymph nodes. For example, if there is occipital node enlargement, one would look for ringworm, dermatitis of the scalp, furunculosis, pediculosis, and cellulitis. However, infectious mononucleosis and rubella may begin with enlargement of these nodes.
3. Is there fever? The presence of fever should make one think of infectious mononucleosis, brucellosis, dengue fever, toxoplasmosis, and Still's disease, among other diseases.

DIAGNOSTIC WORKUP

Routine diagnostic tests include a CBC, sedimentation rate, nose and throat culture, and culture of material from any area supplied by the enlarged lymph nodes. Blood cultures are indicated in generalized lymphadenopathy. In addition, a chemistry panel should be done, as well as a heterophile antibody titer, brucellin antibody titer, febrile agglutinins, and VDRL test. A chest x-ray and flat plate of the abdomen may be helpful in diagnosing generalized lymphadenopathy. HIV testing is done in patients with a history of high-risk sexual behavior.

X-ray of the long bones may identify metastatic carcinoma, and x-ray of the hands may identify sarcoidosis. A bone marrow examination may identify leukemia or lymphoma. If an infectious process has been ruled out, biopsy of the local node may turn up metastatic carcinoma, Hodgkin's disease, and sarcoidosis. A tuberculin skin test should be done; a Brucellergen skin test and Kveim test may also need to be done. ANA and rheumatoid arthritis factor testing may need to be done to rule out a collagen disease. A lymphangiogram may turn up a lymphosarcoma or multiple metastatic lymph nodes. Liver biopsy is also occasionally necessary. Imaging studies of the abdomen and pelvis and the mediastinum are occasionally necessary. Mediastinoscopy may facilitate getting a tissue diagnosis. Before ordering these, a consultation with a hematologist or infectious disease specialist would be prudent.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EDEMA, LOCALIZED: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the edema acute or chronic? Acute edema, if it is localized, should always bring to mind a deep vein thrombophlebitis. It also should bring to mind acute lymphangitis, particularly if there is erythema in the area. Finally, it should also make one think of trauma or a focal infection such as cellulitis. Chronic localized edema, on the other hand, is more likely related to varicose veins or lymphedema.
2. Is the edema pitting or nonpitting? If the edema pits, it is more likely related to inflammation or venous incompetence. If it is nonpitting, it is more likely due to obstruction of the lymphatics, i.e., lymphedema.
3. Is there erythema, a rash, or focal tenderness, or all three? Erythema and focal tenderness would suggest cellulitis, lymphangitis, thrombophlebitis, angioneurotic edema, insect bite, or snake bite. It also would suggest a sprain or contusion. Focal tenderness alone with pitting edema and no significant erythema or rash would suggest a deep vein thrombophlebitis. When there is no erythema or tenderness in a case of pitting edema of a localized nature, one should consider varicose veins or, in the lower extremities, a popliteal cyst that might be obstructing the veins on a chronic basis.
4. If the edema is of the lower extremities, is there a positive Homans' sign? A positive Homans' sign should always be looked for because this would suggest a deep vein thrombophlebitis. Action must be taken immediately in such cases.

DIAGNOSTIC WORKUP

A venous ultrasound study, impedance plethysmography, and contrast venography are very useful in the diagnosis of deep vein thrombophlebitis. d -dimer testing is also a sensitive indicator of active deep vein thrombophlebitis and the need for anticoagulants. Patients with suspected cellulitis or osteomyelitis should have a CBC, sedimentation rate, and cultures of the blood or any fluid that is available from the site of the lesion, either direct or by aspiration. X-rays and CT scans of the involved area are useful as well. Bone scans are often of value in diagnosing osteomyelitis and fractures. Lymphangiography will be helpful in the diagnosis of carcinomatosis or lymphedema from other causes. A CT scan of the abdomen or pelvis may also demonstrate the malignant lymph nodes. A thyroid profile will diagnose cases of pretibial myxedema due to thyrotoxicosis. Patients with upper extremity edema should have a chest x-ray and CT scan of the mediastinum to determine the causes of superior vena cava syndrome.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

1. Is there a periorbital or facial rash? The presence of a periorbital or facial rash should suggest contact dermatitis, angioneurotic edema, trichinosis, and herpes zoster. Remember, herpes zoster is usually unilateral.
2. Is there a generalized edema? The presence of generalized edema suggests myxedema, cirrhosis, acute and chronic glomerulonephritis, congestive heart failure, and other disorders.
3. Is there fever? The presence of fever suggests acute sinusitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, and neurosyphilis.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, chest x-ray, VDRL test, and x-ray of the sinuses and orbits. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. A CT scan of the brain and sinuses probably ought to be done in these cases, but why not get an ear, nose, and throat or neurologic consultation first?

If there is generalized edema, the workup should proceed as outlined on page 138 .

Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. Superior vena cava syndrome may be diagnosed by a chest x-ray in many cases, but a CT scan of the mediastinum may be necessary.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

Generalized lymphadenopathy (e.g., cervical, supraclavicular, axillary, and inguinal lymphadenopathy; hepatomegaly; splenomegaly)

• Infection
  –Tuberculosis
  –Secondary syphilis
  –Mononucleosis
  –HIV/AIDS
  –Kawasaki's syndrome
  –Typhoid fever
• Hypersensitivity reactions
  –Serum sickness
  –Drugs (e.g., hydantoin, phenytoin, hydralazine, allopurinol, primidone)
• Lymphoma
• Leukemia
• Connective tissue disorders (e.g., SLE, rheumatoid arthritis)
• Sarcoidosis
• Metastatic cancer [especially with left supraclavicular lymphadenopathy (Virchow's node) associated with abdominal malignancies, including stomach, pancreas, gallbladder, testis/ovary, kidney, and prostate cancers]
• Endocrine disorders (e.g., hyperthyroidism, hypoadrenalism)
• Amyloidosis
• Castleman's syndrome (angiofollicular lymph node hyperplasia)
• Kikuchi's disease
  Localized lymphadenopathy
• Reactive hyperplasia, local inflammation (e.g., dermatitis, vaccination, trauma)
• Infection
  –Viral: Mononucleosis, CMV, HIV, rubella, mumps
  –Bacterial: Streptococcus, tuberculosis, salmonella, cat-scratch disease (due to Bartonella henselae); gonorrhea, Chlamydia, and other sexually transmitted diseases (inguinal)
  –Parasitic: Malaria, toxoplasmosis
  –Fungal: Histoplasmosis, coccidioidomycosis
  • Lymphoma or metastatic disease (e.g. head and neck squamous cell cancer leads to cervical lymphadenopathy)

  Workup and Diagnosis

  • History and physical examination
    –Note extent of lymphadenopathy (localized or generalized), size of nodes, texture, presence or absence of nodal tenderness (tenderness suggests infection), signs of inflammation over the node, skin lesions, petechiae, splenomegaly, and hepatomegaly
    –Thorough ENT examination in adult patients with cervical adenopathy and/or a history of tobacco use
    –Supraclavicular and epitrochlear lymphadenopathy carry a high risk of malignancy or other abnormality and are rarely normal or reactive
    –Lymph nodes greater than 1 cm, and particularly greater than 2 cm, are likely to be pathologic
  • Initial labs may include CBC, peripheral smear, ESR, CRP, uric acid, PPD, blood cultures, viral titers for specific organisms (e.g., HIV, CMV, toxoplasmosis, rubella), and serologies for brucellosis and typhoid
    –Atypical lymphocytes may indicate a viral illness
    –Immature leukocytes/blasts may indicate leukemia
    –Leukocytosis often indicates infection
  • Chest X-ray and/or abdominal ultrasound may be used to evaluate for lymphadenopathy
  • Biopsy is the gold standard for diagnosis
    –Strongly consider biopsy if node is >2.0 cm, associated with abnormal chest X-ray, and/or age >40 years
  • Bone marrow aspiration may be necessary in some cases to rule out an underlying malignancy

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Source: In a Page: Signs and Symptoms, 2004

Periorbital Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Conjunctivitis
• Allergy
  –Systemic (e.g., reaction to medication, urticaria/angioedema)
  –Local (e.g., insect bite)
• Contact dermatitis/dermatitis medicamentosa
• Chalazion
  –Zeis or Meibomian gland obstruction of eyelid
• Orbital disease (see “Proptosis/Exophthalmos” entry)
• Preseptal/periorbital cellulitis
• Acute dacryocystitis (infection of the lacrimal ducts)
• Orbital fat herniation through attenuated or dehiscent orbital septum and/or orbicularis oculi muscle (aging changes)
• Herpes simplex/zoster
• Blepharitis/dermatitis
• Trauma/postsurgical (e.g., orbital fracture)
• Dermatomyositis/polymyositis
  –Associated with a heliotropic (violet colored) rash on the upper eyelids
• Chemical, ultraviolet, or thermal burn
• Cardiac failure (generalized edema)
• Renal failure
• Nephrotic syndrome
• Blepharitis/rosacea
• Dacryoadenitis
• Hypothyroidism
  –Associated with fatigue, pretibial edema, and delayed relaxation of reflexes
• Superior vena cava syndrome
• Sebaceous gland carcinoma
• Squamous or basal cell carcinoma
• Discoid lupus
• Ocular cicatricial pemphigoid (symblepharon)

Workup and Diagnosis

• History should include symptom course, exposure history (allergens, irritants, chemicals, ultraviolet, or thermal injury), associated symptoms, past medical and family history, and medication history
• Physical exam, including a full ophthalmologic exam for erythema, tenderness, cutaneous vesicles, discharge, proptosis, vision changes, and conjunctival injection or chemosis
• Initial laboratory evaluation may include CBC with differential, electrolytes, BUN, creatinine, TSH, ESR, ANA, albumin, and urinalysis
• Culture and Gram stain of eye discharge if infection is considered
• Consider CT/MRI of orbits, neck, and/or chest as appropriate
• Consider biopsy of suspicious or persistent lesions
• Consider echocardiogram if heart failure is being considered
• Consider ophthalmology consultation

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Source: In a Page: Signs and Symptoms, 2004

Peripheral Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Venous insufficiency
  –Caused by incompetent venous valves
  –Skin characteristically has superficial varicose veins associated with a reddish-brown pretibial discoloration (“venous stasis skin changes”)
  –Swelling is typically worse after legs are held in a dependent position and is least noticeable after a night's sleep
• Congestive heart failure
  –Associated with pitting peripheral edema
  –Other signs of heart failure include a third heart sound, cardiomegaly, and hepatomegaly
• Cellulitis
  –Usually unilateral
  –Edematous legs are typically red, warm, and inflamed
  –The patient may exhibit signs of systemic toxicity with fever and leukocytosis
  • Deep venous thrombosis
    –Typically unilateral swelling
    –May exhibit a palpable cord representing a thrombosed vein
    –Homan's sign (pain in the calf with passive dorsiflexion of the foot)
    –Virchow's triad (hypercoagulable states, venous stasis, and vessel injury) are risk factors
  • Cirrhosis
    –Advanced liver disease results in hypoalbuminemia and poor venous return through cirrhotic liver tissue
    –Other stigmata of chronic liver disease include caput medusae, ascites, and spider angiomata
  • Nephrotic syndrome
    –Glomerular damage results in protein loss and decreased oncotic pressure
  • Less common etiologies (“zebras”) include filariasis (lymphatic infection by Wuchereria bancrofti worm), myxedema (seen in patients with severe hypothyroidism), Milroy's disease (congenital lymphedema), chronic lymphedema (e.g., lymphatic damage due to surgery, such as vein harvesting for CABG), and gout

  Workup and Diagnosis

  • History and physical examination should focus on time course, associated symptoms (e.g., dyspnea, urinary changes, fever), unilateral versus bilateral involvement, pitting versus nonpitting edema, and risk factors for DVT
  • Initial labs may include CBC, electrolytes, BUN/creatinine, urinalysis, coagulation studies, LFTs, serum albumin, and thyroid function tests
  • Chest X-ray may reveal signs of pulmonary edema or cardiomegaly
  • Duplex ultrasound of the legs is useful in diagnosing deep venous thrombosis
  • Echocardiography may reveal a depressed ejection fraction in cases of congestive heart failure
  • Blood cultures are often indicated in immunocompromised or systemically ill patients
  • Renal or liver biopsy may be necessary to diagnose cirrhosis or renal pathology leading to nephrotic syndrome

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Source: In a Page: Signs and Symptoms, 2004

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

• Kidney disease (nephrotic syndrome)
  –Insidious onset, periorbital and lower extremity edema, abdominal distension
  –Various types include minimal change disease (MCNS), focal segmental glomerulosclerosis, acute and chronic glomerulonephritis
• Chronic renal failure from any cause may result in impaired fluid excretion
• Liver disease from any cause resulting in impaired production of albumin
• Congestive heart failure (CHF)
• Protein losing enteropathy
  –Menetrier disease (typically CMV), inflammatory bowel disease, neuroblastoma, intestinal lymphangiectasia, trypsinogen deficiency
• Celiac disease
• Sepsis, with capillary leak (movement of fluid out of the blood vessels into the interstitium)
• Hereditary angioneurotic edema
  –Intermittent swelling of extremities
  –Often preceded by trauma
  –Decreased C4 and C1 esterase inhibitor
• Rocky Mountain spotted fever
• Stevens-Johnson syndrome
• Vitamin E deficiency
• Hypothyroidism
• Severe malnutrition
  –Marasmus (calorie deficiency)
  –Kwashiorkor (protein deficiency)
• Zinc deficiency
• Hydrops fetalis
• Impaired lymphatic drainage
  –Milroy disease
  –Meigs syndrome
  –Yellow nail syndrome
  –Lymphedema praecox
• Filariasis (nematode infection resulting in elephantiasis)
• Immobility including placement of body casts and paralysis

Workup and Diagnosis

• History
  –Onset, duration, severity
  –History of heart, kidney, or liver disease; GI bleeding, hypertension, weight gain, feeding intolerance
  –Chest pain, shortness of breath, orthopnea (cardiac disease), jaundice, acholic stools, abdominal distension, GI bleeding (liver disease), oliguria, facial edema, headache or vision changes (hypertension), diarrhea, fever

• Physical exam
  –Blood pressure (hypo- or hypertension), cardiac exam (JVD, murmur)
  –Hepatomegaly, splenomegaly, ascites, scleral icterus
  –Periorbital, lower extremity or presacral edema, abdominal distension, poor peripheral perfusion

• Labs
  –Urinalysis (no proteinuria excludes renal protein loss)
  –Serum chemistries: Albumin, triglycerides, liver transaminases
  –Stool for α-1 antitrypsin for protein-losing enteropathy
  –Prothrombin time (impaired hepatic function)

• Abdominal ultrasound (for liver or kidney disease)
• Studies depending on clinical situation
  –Echocardiogram/ECG for cardiac failure
  –Renal biopsy (if kidney disease other than MCNS is suspected)
  –GI imaging or endoscopy

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

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

• Infectious
  –Viral (URI, varicella, EBV, CMV, HIV, rubella, mumps, measles)
  –Bacterial (strep, staph, mycobacterium, atypical mycobacterium, brucellosis, tularemia, syphilis, chlamydia)
  –Fungal (histoplasmosis, coccidioidomycosis)
  –Protozoal (toxoplasmosis, malaria)
  –Scalp infection

• Allergy
  –Seasonal or individual
• Inflammatory
  –Kawasaki disease
  –Sarcoidosis
  –Cat-scratch disease (Bartonella henselae)
  –Drug-induced (phenytoin, isoniazid, hydralazine, dapsone, procainamide, allopurinol)
• Malignancy
  –Leukemia
  –Hodgkin disease
  –Non-Hodgkin lymphoma
  –Neuroblastoma
  –Rhabdomyosarcoma
  –Histiocytic disorder
• Collagen vascular disease or systemic illness
  –Rheumatoid arthritis
  –Systemic lupus erythematosus
  –Serum sickness
  –Autoimmune hemolytic anemia
  –Cystic fibrosis
• Immunodeficiency
• Storage diseases
  –Gaucher disease
  –Niemann-Pick disease
• Non-lymph node masses simulating lympadenopathy
  –Thyroglossal duct cysts
  –Branchial cleft cysts
  –Cystic hygroma
  –Hemangioma
  –Teratoma
  –Thymoma
  –Inguinal hernia

Workup and Diagnosis

• History
  –Duration, fever, weight loss, night sweats
  –Sore throat, rash, limp, joint swelling/pain, bone pain
  –Sexual history and HIV risk factors
  –Exposures: Food contamination, pets (e.g., kittens)
  –Immunizations, recurrent infections, meds, allergies
  –Long-standing or unexplained skin rash, transfusions
  –Family history of autoimmune/inflammatory diseases
• Physical exam
  –All lymph node chains: Size, tenderness, fluctuance, consistency, warmth, surrounding erythema
  –Splenomegaly, hepatomegaly
  –Trauma or animal/insect bites along lymph drainage
  –Rash, including “eczema,” lesions, petechiae, purpura
  –Signs of respiratory compromise
  –Scalp for signs of infection
  –Genitalia for signs of sexually transmitted disease
  • Labs
    –Common: CBC/peripheral smear, ESR, LDH, electrolytes, BUN, Cr, LFT, uric acid, EBV, CMV, B. henselae titers, PPD, throat culture
    –Less common: ANA, ACE level, anti-dsDNA, specific infection titers, immunodeficiency workup
  • Studies
    –Chest X-ray; bone marrow exam; biopsy or I&D of node, echo/ECG, biopsy of rash

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

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

• Periorbital cellulitis
  –Also described as preseptal cellulitis (infection is anterior to the orbital septum and thus does not affect the orbit or globe)
  –Usual pathogens are streptococcal species, Staphylococcus aureus, and Haemophilus influenzae

• Orbital cellulitis
  –Also described as postseptal and affects the preseptal structures as well as the extraocular muscles and the optic nerve
  –Bacterial pathogens are the same as periorbital cellulitis and may reflect direct spread
  –May be accompanied by orbital abscess and may spread via the sinuses to the brain

• Other infections
  –Conjunctivitis
  –Sinusitis
  –Dental abscess
• Allergic reaction
  –Conjunctivitis
  –Urticaria/angioedema
  –Drug reaction
• Local ocular causes
  –Insect bites
  –Contact dermatitis
  –Trauma
  –Foreign body
• Systemic disorders with generalized edema
  –Hypoproteinemia
  –Renal disease
  –Congestive heart failure
• Malignancy
  –Neuroblastomas: Associated with ecchymoses, “raccoon eyes,” and proptosis
  –Leukemia: Associated with fever, fatigue, anemia, bone pain, lymphadenopathy, splenomegaly

Workup and Diagnosis

• History
  –Onset, duration, progression of symptoms
  –Presence of pain or pruritus
  –History of trauma
  –Systemic symptoms such as fever
• Physical exam
  –Temperature, vital signs, growth parameters
  –Proptosis
  –Ocular range of motion
  –Full physical exam including heart, lung, and extremities
• Labs
  –Electrolytes, BUN, creatinine
  –Serum protein and albumin
  –CBC and blood culture if infection is suspected
  –ESR, LDH if malignancy is suspected
• Studies
  –CT to distinguish periorbital cellulitis from orbital cellulitis
  –CT or MRI to discover orbital or cranial tumors
  –CXR if CHF is suspected
  –Renal ultrasound to evaluate the architecture of the kidneys, Doppler to evaluate renal flow, DMSA to evaluate renal parenchyma if edema is generalized

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

EDEMA OF THE EXTREMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Bilateral pitting edema of the lower extremities is usually due to congestive heart failure, nephrosis, or cirrhosis of the liver. Venous pressure and circulation time will rule out congestive heart failure but echocardiography can be more definitive. Serum and urine osmolality can be helpful also. If there is nephrosis, there will be significant lowering of the serum albumin level and proteinuria. Liver function studies will usually confirm cirrhosis or liver disease but ultrasonography can reveal ascites to assist in the diagnosis. Nonpitting edema of the lower extremities will usually be due to lymphatic obstruction but hypothyroidism can be ruled out with a free T4 assay or TSH. Unilateral edema of the lower extremities suggest deep vein thrombosis, which can be confirm by Doppler ultrasound studies, plethysomography, or contrast venography. A CT scan of the chest will help diagnose constrictive pericarditis, which is rarely found today. Spirometry and arterial blood gas analysis will diagnose pulmonary emphysema with cor pulmonale.

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Source: Differential Diagnosis in Primary Care, 2007

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

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

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Source: Differential Diagnosis in Primary Care, 2007

Edema, generalized: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the
day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

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

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

Ask the patient when he first noticed the swelling and whether it’s located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.

Palpate the entire lymph node system to determine the extent of lymphade-nopathy and to detect other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they’re fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.

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

Edema of the arm: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema Pitting or nonpitting? page 240.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

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

Edema of the leg: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 240.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans' sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

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

Pulmonary edema: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Clinical features of pulmonary edema permit a working diagnosis. Arterial blood gas (ABG) analysis usually shows hypoxia; the partial pressure of arterial carbon dioxide is variable. Profound respiratory alkalosis and acidosis may occur. Chest X-ray shows diffuse haziness of the lung fields and, commonly, cardiomegaly and pleural effusions. Ultrasound (echocardiogram) may show weak heart muscle, leaking or narrow heart valves, and fluid surrounding the heart. Pulmonary artery catheterization helps identify left-sided heart failure by showing elevated pulmonary wedge pressures. This helps to rule out acute respiratory distress syndrome — in which pulmonary wedge pressure is usually normal.

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

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

When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

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

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

Ask the patient when he first noticed the swelling, and whether it’s located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.

Palpate the entire lymph node system to determine the extent of lymphadenopathy and to detect any other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they’re fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.

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

Edema of the arm: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema’s severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting? page 292.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare the radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

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

Edema of the face: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 292.) Next, take vital signs and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.

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

Edema of the leg: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or any recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 292.) Because leg edema may compromise arterial blood flow, palpate or use a handheld Doppler device to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.

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

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

A. Onset. When the onset of edema is sudden, consider the following possible causes: cellulitis, deep venous thrombosis (DVT), compartment syndrome, trauma, and exacerbation of chronic problems (systemic disease, medications, venous insufficiency, lymphedema).

When the onset is gradual, consider the causes listed below.

B. Clinical course. Is the edema intermittent or recurrent, or is it chronic?

C. Painful edema most likely results from (3):

1. Cellulitis

2. Trauma

3. Ruptured Baker’s cyst

4. Compartment syndrome

5. DVT

D. Painless edema or bilateral edema usually results from a systemic cause.

E. Associated systemic symptoms

1. Fever and chills can be caused by cellulitis, lymphangitis, or venous thrombosis.

2. Dyspnea and orthopnea suggest that the edema is of cardiac origin.

3. Either a history of streptococcal throat infection or recurrent urinary tract infection (UTI) points to renal causes.

F. Medications that can be associated with edema include the following: diazoxide, minoxidil, hydralazine, calcium channel blockers, alpha- and beta-blockers, reserpine, guanethidine, nonsteroidal antiinflammatory drugs (NSAIDs), carbenicillin, amantadine, lithium, phenothiazines, thioridazine, monoamine oxidase (MAO) inhibitors, corticosteroids, testosterone, estrogen, progesterone, or interleukin-2 (2, 3).

G. Endocrine diseases

1. Hypothyroidism can present with pretibial myxedema (Chapter 14.4).

2. Cushing’s syndrome can cause edema.

H. Miscellaneous causes of edema. These include:

1. Pregnancy

2. Sodium overload

3. Malnutrition

4. Stopping laxatives

5. Prolonged dependent position

6. Cyclic edema in women

7. Lymphatic obstruction (neoplastic, parasitic, iatrogenic)

8. Idiopathic

Physical examination

 A. Generalized edema manifests in the most dependent area (e.g., pedal edema in ambulatory patients, presacral edema in bedbound patients).

B. Peripheral edema (3)

1. Sparing of the feet suggests lipedema.

2. Pitting edema present for more than 3 months usually indicates a low serum protein level. Chronic edema can have fibrosis as well.

3. Assessment of color

a. Redness suggests infection or phlebitis.

b. A red-blue color suggests DVT.

c. A slightly cyanotic color bilaterally suggests CHF (Chapter 7.5).

d. The presence of ecchymosis suggests trauma.

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

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

 should focus on those common causes of generalized lymphadenopathy.

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

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

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

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

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

Physical examination

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

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

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

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

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

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

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

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

 A comprehensive history is critical in evaluating lymphadenopathy. It is important to elicit as accurately as possible the time course of the process. Progressive enlargement of a lymph node over several weeks or months suggests an underlying malignancy or granulomatous inflammation (e.g., tuberculosis or sarcoidosis). However, reactive lymphadenopathy can also persist for months. The presence of localizing or systemic signs (e.g., weight loss, night sweats, rash, or fever) suggests a particular pathologic process. Epidemiologic clues such as exposure to cats may suggest cat scratch disease. A history of contact with a new sexual partner raises the possibility of a sexually transmitted disease. Manifestations of regional lymphadenopathy within the thorax or abdomen can present as cough, shortness of breath, abdominal pain, urinary frequency, or intestinal obstruction. Rarely, pain in an area of lymphadenopathy following alcohol ingestion is the presenting symptom of Hodgkin’s disease.

Physical examination

On physical examination, the first question that needs to be answered is whether the structure being palpated is truly a lymph node. Parotid enlargement, thyroid masses, sternocleidomastoid tumors, dermoid cysts, hemangiomas, or other tumors occasionally mimic lymphadenopathy. Thoroughly examine the anatomic region or regions drained by the affected nodes. Carefully note the characteristics of the lymph nodes and surrounding tissues. Tender lymph nodes that are mobile often represent lymphadenitis or acute inflammation. Matted, hard lymph nodes that are fixed to surrounding tissue imply an underlying metastatic carcinoma. Rubbery, nontender nodes may be seen in lymphoma.

In otherwise healthy children, lymph nodes up to 2.5 cm in diameter, particularly in the inguinal, suboccipital, and cervical regions, may be seen (3). In adults, lymph nodes larger than 1 cm in diameter should arouse suspicion, and nodes larger than 3 cm are highly suggestive of a malignant process (2). In both children and adults, supraclavicular lymph nodes larger than 1 or 2 cm in diameter should be investigated aggressively.

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

Edema: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Congestive heart failure

❑ Venous insufficiency

❑ Hypoalbuminemia

❑ Drugs

❑ Cirrhosis

❑ Deep vein thrombosis

❑ Inferior vena cava obstruction

❑ Lymphatic obstruction

❑ Glomerular injury

❑ Idiopathic edema

❑ Myxedema

❑ Lipedema

❑ Toxemia

❑ Cyclical edema

❑ Refeeding

❑ Filariasis

❑ Milroy

Diagnostic Approach

The degree of edema is influenced by membrane permeability, hydrostatic pressure, and/or oncotic pressure. Edema implies an increase in interstitial volume of several liters. Low protein fluids (hypoalbuminemia, cardiac, and venous edema) pit easily and recover quickly on release. High protein fluids (cellulitis, lymphedema) resist pitting and recover slowly.

The distribution of the edema combined with an estimation of the jugular venous pressure (JVP) can help differentiate heart failure, cirrhosis, renal sodium retention and nephrotic syndrome. Anasarca suggests cardiac, renal, or hepatic disease. Splenomegaly is found more often in patients with cirrhosis than those with congestive heart failure.

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Source: Field Guide to Bedside Diagnosis, 2007

Lymphadenopathy: Differential Overview
(Field Guide to Bedside Diagnosis)

Generalized

❑ Infectious mononucleosis

❑ Drugs

❑ Connective tissue disease

❑ HIV infection

❑ Sarcoidosis

❑ Serum sickness

❑ Toxoplasmosis

❑ Secondary syphilis

Localized

❑ Regional infection

❑ Lymphadenitis

❑ Hodgkin lymphoma

❑ Cat-scratch disease

Diagnostic Approach

Palpable adenopathy is present in half of healthy young adults. Red flags for malignancy include a node larger than 2 cm in size and enlarging, age older than 40 years, weight loss greater than 10%, and a supraclavicular node. Constitutional symptoms such as fever, night sweats and weight loss should prompt further evaluation. On occasion, reactive lymphadenopathy may persist for months, but observation for enlargement over time is a useful tool to select which patients need biopsy. Nodes with an irregular shape and firm rubbery consistency suggest malignancy. Matted nodes or those fixed to the deep fascia also suggest malignancy.

Coexistence of splenomegaly implies a systemic illness such as lymphoma/leukemia, infectious mononucleosis, systemic lupus, sarcoidosis, or toxoplasmosis.

Structures that may be mistaken for cervical lymph nodes include the parotid gland, thyroglossal and branchial cysts, an abscess, a lipoma, thyroid nodules, submaxillary infections, or dental infections.

Tenderness is usually associated with an infectious etiology. Fluctuation or suppuration occuring over a few days is usually due to staphylococcal or streptococcal infection. Progression over weeks to months occurs with tuberculosis, atypical mycobacteria, Bartonella (cat-scratch disease), sporotrichosis or rare cases of anthrax, plague, tularemia, chancroid, or lymphogranuloma venereum.

The location of adenopathy narrows the differential:

Anterior cervical  Unilateral: pharyngitis, thyroid cancer, nasopharyngeal cancer, or buccal infection. Bilateral: pharyngitis, mononucleosis, sarcoidosis, or toxoplasmosis.

Preauricular  They are common in oculoglandular fevers such as adenoviral conjunctivitis, rubella, tularemia, and leptospirosis. These are also commonly found in infection in the cheek, eyelid, ear, or temporal scalp. If a source is not evident, look for a retinal melanoma.

Posterior auricular  Consider infectious mononucleosis, rubella, otitis media, lymphoma, or head and neck malignancy.

Right supraclavicular  Consider an intrathoracic (lungs, mediastinum, or esophagus) malignancy.

Left supraclavicular  A sentinel or Virchow node, draining the thoracic duct, suggests intra-abdominal malignancy (stomach, gallbladder, pancreas, kidneys, testicles, ovaries, or prostate).

Axillary  Drainage is from the arm, chest wall, and breast, so consider breast malignancy, upper extremity infection such as cat-scratch disease, or Hodgkin lymphoma.

Epitrochlear  Consider secondary syphilis (bilateral), hand infection (unilateral), sarcoidosis and rheumatoid arthritis (helps differentiate from osteoarthritis).

Inguinal  A lower extremity infection or sexually transmitted disease (primary syphilis, genital herpes, chancroid, lymphogranuloma venereum) are the usual causes. Regional metastases from the skin (e.g. melanoma) or genital organs also occur. A femoral hernia can be confused with adenopathy.

Occipital  Consider scalp infection (especially pediculosis capitis), secondary syphilis, Hodgkin lymphoma, and tuberculosis.

Periumbilical  Consider abdominal malignancy.

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Source: Field Guide to Bedside Diagnosis, 2007

Pulmonary edema: Diagnosis
(Handbook of Diseases)

Clinical features of pulmonary edema permit a working diagnosis. The following tests are also helpful:

❑ Arterial blood gas (ABG) analysis usually shows hypoxia; partial pressure of arterial carbon dioxide varies. Profound respiratory alkalosis and acidosis may occur. Metabolic acidosis occurs when cardiac output is low.

❑ Chest X-ray films show diffuse haziness of the lung fields and, often, cardiomegaly and pleural effusions.

❑ Pulmonary artery catheterization helps identify left-sided heart failure by showing an elevated pulmonary artery wedge pressure (PAWP). This helps to rule out adult respiratory distress syndrome — in which PAWP is usually normal.

❑ An echocardiogram may reveal weak heart muscle, leaking or narrow heart valves, or fluid surrounding the heart.

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Source: Handbook of Diseases, 2003

Edema, generalized: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

When the patient’s condition permits, obtain a complete medical history. First, note when and where the edema began. Does it move throughout the course of the day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality? 

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Physical examination

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether his hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment. Also, obtain a baseline weight for this patient.

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

Edema, facial: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma and dental procedures.

Physical examination

Begin the physical examination by characterizing the edema. Is it localized and distributed over one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 128.) Next, take vital signs, and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.

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

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

When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Ask the patient to describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

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

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

Ask the patient when he first noticed the swelling and whether it’s located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.

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

Edema of the arm: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

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

Edema of the face: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

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

Edema of the leg: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury, surgery, or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

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

Edema: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Disorders with Normal Serum Albumin

Increased Capillary Permeability

Skin Disorders

Cellulitis,exfoliative dermatitis, and burns can cause increase in capillarypermeability and edema.

History and physical exam are diagnostic.

Allergic Reaction

Releaseof histamine and other vasoactive mediators can produce localizedor generalized edema.

Drugs, chemical exposure by inhalation,foods (especially milk, eggs, chocolate, nuts), and bee stings arecommon causes of allergic reactions.

Lips, eyelids, and face are frequentlyinvolved, and urticaria also may occur.

Wheezing, laryngospasm, and hypotensionmay be seen with anaphylactic reactions.

History and physical exam are usuallydiagnostic.

Vasculitis

Common causes of vasculitis causing edemainclude Kawasaki disease and collagen vascular disease.

Septicemia

Severe bacterial or rickettsial infectionscan cause increase in capillary permeability and edema.

Vitamin E Deficiency

Uncommonsince addition of vitamin E to infant formulas.

Preterm infants 4–6 wks ofage without normal intake of vitamin E may develop generalized edema,hemolytic anemia, and thrombocytosis.

Serum concentration of vitamin E islow.

Hereditary Angioedema

Deficiencyor functional defect of C1 inhibitor is responsible for this disorder,which is transmitted as autosomal-dominant trait. Gene locus hasbeen mapped to chromosome 11q11-q13.1.

In most common form (type I), serumlevels are 5–30% of normal and functional activityis diminished, whereas in type II, serum levels are normal or increased,but functional activity is decreased.

The 2 types are clinically indistinguishable.Episodic edema may involve face, trunk, and extremities. Most worrisomefeature is edema of larynx and upper airway. Episodes last severaldays, and interval between attacks can be days, months, or years.

Low serum C4 concentration is mostuseful screening test for this disease. Serum C3 concentration isnormal.

Diagnosis is confirmed by measurementof C1 inhibitor and assay of its activity.

Increased Hydrostatic Pressure

Increased Blood Volume

Administrationof excessive amounts of sodium or fluid can produce volume overloadand edema.

In cardiac failure, diminished renalblood flow leads to decrease in glomerular filtration rate (GFR)and edema.

Renal disease (e.g., glomerulonephritis)or any cause of renal failure also may lead to decrease in GFR andedema.

Increased Venous Pressure

Increasedvenous pressure from deep venous thrombosis, constrictive pericarditis, portalhypertension, or impaired venous drainage from tumor may produceedema.

Deep venous thrombosis in thigh orcalf produces pain and swelling of leg distal to thrombus. U/Sis usually diagnostic.

See Chap.30, Hepatomegaly, and Chap. 62, Splenomegaly,for discussion of constrictive pericarditis and portal hypertension.

Increased Lymph Pressure

Lymphedemais excessive accumulation of lymph in interstitial space and isprincipal cause of increased lymph pressure.

Can be congenital or acquired, sporadicor familial, and may appear at birth or in childhood or adolescence.

Abnormal development or dysfunctionof lymphatic vessels, lymph node obstruction, and venous stasisare common mechanisms producing lymphedema.

Common presentation is unilateral,painless edema of leg; however, pain may occur with massive edemaor cellulitis.

U/S and MRI are useful indetection of lymphatic malformations and obstructive lesions.

Disorders with Decreased Serum Albumin (Decreased OncoticPressure)

Disorders with Proteinuria

Any renaldisorder causing severe proteinuria may produce edema. Nephroticsyndrome and acute glomerulonephritis are common examples.

UA confirms presence of proteinuria.

See Chap.50, Proteinuria.

Disorders without Proteinuria

Acute and Chronic Liver Disease

Decreasein synthesis of albumin in liver produces hypoalbuminemia.

Serum albumin of <2.5 g/dLcauses decrease in plasma oncotic pressure and edema.

See Chap.30, Hepatomegaly, and Chap. 36, Jaundice, fordiscussion of causes of acute and chronic liver disease.

Gastrointestinal Disease

Loss ofserum albumin in GI tract leads to decreased plasma oncotic pressureand edema.

Causes of protein-losing enteropathyinclude cow milk protein sensitivity, cystic fibrosis, celiac disease,inflammatory bowel disease, and intestinal lymphangiectasia.

Screening test for protein loss instool is measurement of alpha₁-antitrypsinin spot stool sample.

See Chap.14, Diarrhea.

Protein-Calorie Malnutrition

Severe protein-caloriemalnutrition can produce edema because of decrease in serum albumin.

Growth failure, decreased muscle mass,diarrhea, hepatomegaly, anemia, pigment changes of hair and skin,fatigue, and apathy are other findings.

Edema resolves with adequate calorieand protein intake.

Congenital Albumin Deficiency

Severe edemaoccurs with congenital albumin deficiency, which is rare.

Very low or undetectable serum albuminconcentration in absence of other causes of hypoalbuminemia confirmsdiagnosis.

Hydrops Fetalis: Immune and Nonimmune

Hydrops fetalis is term used to describesevere generalized edema in fetus or newborn.Because of use of anti-D immune globulinfor Rh isoimmunization, most cases of hydrops are nonimmune type(Table 17.1 ). >

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Lymphadenopathy: Clinical Features and Diagnosis: Localized Lymphadenopathy
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Cervical

Cervicallymph nodes, which drain head and neck structures, include superficialand deep cervical chains.

Reactive hyperplasia (usually secondaryto viral upper respiratory infections [URIs] and pharyngitis)and cervical adenitis are most common causes of cervical node enlargement.Less common causes include Kawasaki disease and neoplastic disorders(leukemia, Hodgkin disease, non-Hodgkin lymphoma, neuroblastoma,rhabdomyosarcoma, thyroid carcinoma).

See Chap.42, Neck Masses.

Submandibular/Submental

Submandibularnodes drain buccal mucosa, side of nose, gums, upper lip, lateralpart of lower lip, and anterior part of tongue margin.

Submental nodes drain center portionsof lip and floor of mouth as well as skin of chin.

Reactive hyperplasia (viral URIs, pharyngitis,tonsillitis, herpetic gingivostomatitis, dental abscesses) and primaryadenitis (usually secondary to pyogenic infection with group A Streptococcusor S. aureus) are most common causes of lymph node enlargement inthese areas.

Preauricular

Preauricularnodes drain anterior and temporal regions of scalp, anterior aspectof external auditory canal, pinna, and lateral conjunctivae.

Causes of preauricular adenopathy includeoculoglandular syndrome (conjunctivitis and ipsilateral preauricularadenopathy), adenoviral infection (epidemic keratoconjunctivitis,pharyngoconjunctival fever), cat scratch disease (B. henselae infection),and tularemia.

Postauricular

Postauricularnodes drain temporal and parietal scalp, posterior wall of externalauditory canal, and upper half of pinna.

Causes of node enlargement are infectionsof scalp and infections caused by human herpesviruses 6 and 7, rubellavirus, and parvovirus B19.

Occipital

Occipitalnodes drain occipital region of scalp.

Common causes of occipital adenopathyare tinea capitis, seborrheic dermatitis, and scalp cellulitis/abscess.

Isolated adenopathy in this area mayoccur secondary to rubella infection and toxoplasmosis.

Supraclavicular

Supraclavicularnodes are located in supraclavicular triangle and drain entire head andneck, arms, superficial thorax, abdomen, lungs, and mediastinum.

Enlarged nodes without other cervicaladenopathy suggest mediastinal, lung, or abdominal disease, whichcan be infectious, inflammatory, or neoplastic.

Chest radiography may demonstrate enlargedmediastinal nodes, and chest CT can define location and extent.

Common causes of supraclavicular andmediastinal adenopathy include histoplasmosis, tuberculosis, catscratch disease, Hodgkin disease, non-Hodgkin lymphoma, and sarcoidosis.

Axillary

Axillarylymph nodes drain arm, chest wall, and upper lateral abdominal wall.Any local inflammation or infection in these areas may cause lymphnode enlargement.

Enlarged tender nodes may occur withcat scratch disease after bite or scratch by kitten or cat to fingers,hand, or forearm.

Rapid enlargement of firm, painlesslymph node in axilla with no identifiable inflammatory or infectiouscause suggests neoplastic process (e.g., Hodgkin disease or non-Hodgkinlymphoma). In this circumstance, lymph node biopsy is diagnostic.

Epitrochlear

Epitrochlearnodes drain distal arm and third, fourth, and fifth fingers.

Common causes of epitrochlear adenopathyare staphylococcal and streptococcal skin infections, infectiousmononucleosis, and cat scratch disease. Hodgkin disease also maypresent with enlarged epitrochlear nodes.

Inguinal

Inguinalnodes drain skin of lower extremities, penis, scrotum, perineum,gluteal region, and abdominal wall below umbilicus.

Most common cause of inguinal adenopathyis skin infection involving lower extremities. Genital infections(herpes simplex, lymphogranuloma venereum, chancroid, primary syphilis)also may cause enlarged inguinal nodes. Other causes of inguinaladenopathy include testicular tumors, metastatic lower extremitybone tumors, Hodgkin disease, cat scratch disease, and mycobacterialinfection.

Femoral

Enlarged femoral nodes are palpable on legbelow inguinal ligament and may enlarge secondary to superficialor deep infection of lower extremity.

Popliteal

Poplitealnodes drain knee joint and skin of lateral side of lower leg and foot.

Common cause of enlarged poplitealnodes are infections of lower leg, foot, or knee joint.

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Edema, generalized: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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

Ask the patient when he first noticed the swelling and whether it's located on one side of his body or both. Are the swollen areas sore, hard, or red? Ask the patient if he has recently had an infection or other health problem. Also ask if a biopsy has ever been done on any node because this may indicate a previously diagnosed cancer. Find out if the patient has a family history of cancer.

Palpate the entire lymph node system to determine the extent of lymphadenopathy and to detect other areas of local enlargement. Use the pads of your index and middle fingers to move the skin over underlying tissues at the nodal area. If you detect enlarged nodes, note their size in centimeters and whether they're fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node discrete, or does the area feel matted? If you detect tender, erythematous lymph nodes, check the area drained by that part of the lymph system for signs of infection, such as erythema and swelling. Also, palpate for and percuss the spleen.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the arm: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting?page 226.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the face: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting?page 226.) Next, take the patient's vital signs, and assess his neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the leg: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting?page 226.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans'sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

EDEMA OF THE EXTREMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Bilateral pitting edema of the lower extremities is usually due to CHF, nephrosis, or cirrhosis of the liver. Venous pressure and circulation time will rule out CHF, but echocardiography can be more definitive. Serum and urine osmolality can be helpful also. If there is nephrosis, there will be significant lowering of the serum albumin level and proteinuria. Liver function studies will usually confirm cirrhosis or liver disease, but ultrasonography can reveal ascites to assist in the diagnosis. Nonpitting edema of the lower extremities will usually be due to lymphatic obstruction, but hypothyroidism can be ruled out with a free thyroxine (T₄) or thyroid-stimulating hormone (TSH) assay. Unilateral edema of the lower extremities suggests deep vein thrombosis, which can be confirmed by Doppler ultrasound studies, plethysomography, or contrast venography. A CT scan of the chest will help diagnose constrictive pericarditis, which is rarely found today. Spirometry and arterial blood gas analysis will diagnose pulmonary emphysema with cor pulmonale.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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

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

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Source: Differential Diagnosis in Primary Care, 2007

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