Diseases » Muscle conditions » Diagnosis

Diagnosis of Muscle conditions

Muscle conditions Diagnosis: Book Excerpts

• Ask the following questions - CRAMPS, MUSCULAR
• Ask the Following Questions - MUSCULAR ATROPHY
• Differential Diagnosis - Muscle Weakness – Distal
• Differential Diagnosis - Muscle Weakness – Proximal
• Approach to the Diagnosis - MUSCULAR CRAMPS
• Approach to the Diagnosis - MUSCULAR ATROPHY
• History and physical examination - Muscle flaccidity [Muscle hypotonicity]
• History and physical examination - Muscle weakness
• History and physical examination - Muscle spasms [Muscle cramps]
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• History and physical examination - Muscle spasticity [Muscle hypertonicity]
• History and physical examination - Accessory muscle use
• History and physical examination - Muscle atrophy [Muscle wasting]
• Diagnosis - Muscular dystrophy
• History and physical examination - Muscle flaccidity [Muscle hypotonicity]
• History and physical examination - Muscle weakness
• History and physical examination - Muscle spasms [Muscle cramps]
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• History and physical examination - Muscle spasticity [Muscle hypertonicity]
• History and physical examination - Accessory muscle use
• History and physical examination - Muscle atrophy [Muscle wasting]
• Differential Overview - Muscle Cramps
• History - Muscle spasms
• History - Muscle weakness
• History - Accessory muscle use
• History - Muscle spasms
• History - Muscle spasticity
• History and physical examination - Muscle flaccidity [Muscle hypotonicity]
• History and physical examination - Muscle weakness
• History and physical examination - Muscle spasms [Muscle cramps]
• History and physical examination - Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]
• History and physical examination - Muscle spasticity [Muscle hypertonicity]
• History and physical examination - Accessory muscle use
• History and physical examination - Muscle atrophy [Muscle wasting]
• Approach to the Diagnosis - MUSCULAR ATROPHY
• Approach to the Diagnosis - MUSCULAR CRAMPS

Diagnostic Tests for Muscle conditions: Online Medical Books

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

CRAMPS, MUSCULAR: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a history of drug ingestion? Many drugs produce muscular cramps. The most notable are the diuretics.
2. Are there absent or diminished peripheral pulses? Absent or diminished peripheral pulses suggest the cramps are due to ischemia from peripheral arteriosclerosis or arterial embolism.
3. Are the femoral pulses diminished? Diminished femoral pulses suggest a Leriche syndrome or saddle embolism of the terminal aorta.
4. Is there hypertension? Hypertension suggests aldosteronism and chronic glomerulonephritis.
5. Are the cramps limited to one extremity? Limitation of the cramps to one extremity suggests an occupational neurosis (professional cramps).
6. Is there a positive Chvostek's and/or Trousseau's sign? These are signs of tetany, as might be associated with hypoparathyroidism, uremia, alkalosis, and other causes.
7. Is there fever? Fever is associated with dehydration, heat stroke, and many infectious diseases that cause cramps.

DIAGNOSTIC WORKUP

All patients should have a CBC, sedimentation rate, chemistry panel, electrolytes, and urinalysis. If there is associated diminished or absent peripheral pulses, then Doppler studies and arteriography should be done. If the cramps are acute in onset, time should not be wasted in performing these studies. Magnetic resonance angiography is an excellent alternative to invasive angiography, but it is expensive. If there is associated hypertension, then 24-hr urine aldosterone and plasma renin studies should be done. If there are positive Trousseau's and/or Chvostek's signs, a thorough investigation for hypoparathyroidism should be done. A single serum calcium and phosphorus and alkaline phosphatase is not enough, but repeated studies should be done. In addition, 24-hr urine collection for calcium and serum parathyroid hormones should be done. An endocrinologist should probably be consulted if there is any doubt about the existence of hypoparathyroidism or any of the other causes of hypocalcemia.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

1. Is it focal or diffuse? Focal muscular atrophy would suggest poliomyelitis, early spinal muscular atrophy, peripheral vascular disease, and sympathetic dystrophy. However, occasionally it is an indication of an early spinal cord tumor, herniated disk, or peroneal muscular atrophy. It can also be a sign of an entrapment syndrome of one of the peripheral nerves. Focal muscular atrophy with hyperactive reflexes suggests amyotrophic lateral sclerosis, multiple sclerosis, spinal cord tumors, or syringomyelia.
2. Are the reflexes hypoactive or hyperactive? Muscular atrophy with hypoactive reflexes suggests peripheral neuropathy, poliomyelitis, spinal muscular atrophy, myasthenia gravis, peripheral vascular disease, sympathetic dystrophy, herniated disk, early spinal cord tumor, and peroneal muscular atrophy. Muscular atrophy with hyperactive reflexes suggests multiple sclerosis, spinal cord tumors, syringomyelia, and amyotrophic lateral sclerosis.
3. Are there associated sensory changes? The finding of muscular atrophy with sensory changes suggests a peripheral neuropathy, Guillain-Barré syndrome, Friedreich's ataxia, multiple sclerosis, transverse myelitis, a herniated disk, spinal cord tumor, and peroneal muscular atrophy. It may also suggest syringomyelia.
4. Are the reflexes normal? The presence of normal reflexes suggests anorexia nervosa, tuberculosis, metastatic malignancy, and hyperthyroidism.

DIAGNOSTIC WORKUP

The basic workup includes a CBC, sedimentation rate, urinalysis, chemistry panel, ANA titer, serum protein electrophoresis, and VDRL test. Additional muscle enzymes may be ordered such as serum aldolase and CPK. A 24-hr urine collection for creatinine and creatine may be done.

At this point, it is best to consult a neurologist. He will probably order nerve conduction velocity studies and EMGs of the involved extremities. He also will be best qualified to determine the need for CT scans or MRIs of the brain or spine, as well as the particular study to order in each individual case. At times, spinal fluid analysis and muscle biopsies may be necessary to solve the problem. Also, a Tensilon test or acetylcholine receptor antibody titer may be ordered in suspected myasthenia gravis.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Muscle Weakness – Distal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Guillain-Barré syndrome (GBS)
  –Acute, acquired, or monophasic
  –Ascending weakness and parasthesias
• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
• Compression neuropathy
  –Trauma
  –Neoplasm (e.g., plexiform neurofibroma in neurofibromatosis type 1)
• Charcot-Marie-Tooth
  –Defect in peripheral myelin protein
  –Causes distal segmental demyelination
  –Manifested by distal muscle atrophy and weakness
• Drug-induced
  –Phenytoin
  –Isoniazid
  –Nitrofurantoin
  –Vincristine
  –Zidovudine
• Spinal muscular atrophy
• Juvenile segmental spinal muscular atrophy
• Miller-Fisher syndrome
  –Clinical triad of ataxia, ophthalmoplegia, and areflexia
• Tick paralysis
• Juvenile amyotrophic lateral sclerosis
• Giant axonal neuropathy
• Vitamin B12 deficiency
• Toxic neuropathy
  –Arsenic
  –Lead
  –Mercury
  –Thallium
  –Glue sniffing
• Uremic neuropathy
• Idiopathic axonal neuropathy
• Hereditary distal myopathy
• Inclusion body myopathy
• Rheumatoid arthritis
• Refsum disease
• Metachromatic leukodystrophy
• Krabbe disease
• Cockayne syndrome
• Conversion reaction
  –Usually fluctuating and unpredictable

Workup and Diagnosis

• History
  –Acute vs chronic, associated sensory findings, associated systemic/neurologic abnormalities
  –Family history (family members may not be affected to same degree)
  –Toxic exposures
• Physical exam
  –Abnormal gait can be the presenting symptom of either proximal or distal leg weakness
  –Stumbling, especially with foot eversion or dorsiflexion
  –Weakness of the hand muscles (e.g., difficulty writing, opening jars, or working with tools)
  –Inspect muscle for atropy, hypertrophy, fasciculations, myotonia, cogwheeling
  –Palpate muscles for tenderness
  –Mirror movements, hypotonia, spasticity/rigidity
  –Assess strength and power with push/pull testing, functional hop in place, knee bends, posture
  –Pronator drift, standing on toes/heels, symmetry
  • Labs
    –Serum CK
    –In neuropathic disorders, CK is usually normal or mildly increased; moderate to severe elevation of CK suggests myopathy
  • Electromyogram/nerve conduction studies
    –Demonstrate the extent, chronicity, and categorization
  • Muscle biopsy
    –Histochemistry, EM, enzymatic/genetic testing

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

Muscle Weakness – Proximal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Duchenne and Becker muscular dystrophy
• Spinal muscular atrophy
• Spinal cord disorders
  –Trauma
  –Myelitis
  –Neoplasm
  –AVM
  –Hemorrhage
  –Tansverse myelitis
• Limb-girdle myasthenia
• Dermatomyositis
• Congenital myopathies
  –Central core disease
  –Myotubular
  –Nemaline (rod)
  –Congenital fiber-type disproportion
• Facioscapulohumeral syndrome
• Limb-girdle muscular dystrophies
• Glycogen storage myopathies
• Endocrine myopathies
  –Hypo- and hyperthyroidism
  –Hyperparathyroidism
  –Adrenalism
• Polymyositis
• GM2 gangliosidosis
• Pompe disease
  –Glycogen storage disease type II
  –Acid maltase deficiency
• McArdle disease
• Carnitine deficiency
• Fatty acid oxidation defects
• Mitochondrial disorders
• Steroid-induced myopathy
• Slow channel syndrome
• Toxins
  –Organophosphates
  –Aminoglycosides
  –Tetrodotoxin (pufferfish)
• Conversion reaction
• Myasthenia gravis

Workup and Diagnosis

• History: Age upon reaching developmental milestones, abnormal gait, toe walking, easy fatigability, muscle cramps, facial weakness, cardiac, respiratory, GI problems, dark urine
• Physical exam: Muscle mass, texture and tenderness, scoliosis, cardiac exam, skin rashes, joint contractures
• Neurologic exam
  –Muscle strength and tone
  –Gowers sign
  –Mental status, eye movements
  –Facial movements, tongue fasciculations
  –Muscle stretch reflexes and sensory responses
  –Stance and gait
  –Spinal cord disorders, examine dermatomal sensory loss, anal wink, cremasteric reflex
• Labs: Muscle enzymes (CPK, aldolase); electrolytes, TSH, lactate, pyruvate, carnitine; ANA, RF, genetic testing for muscular dystrophy and spinal muscular atrophy; hexosaminidase, acetylcholine receptor antibodies, myoglobin in urine (muscle breakdown)
• EMG/nerve conduction studies
  –Differentiates dysfunction of the anterior horn cell, muscle, or neuromuscular junction
• Muscle biopsy for metabolic, inflammatory, and congenital myopathies; distinguishes myopathy from anterior horn cell disease
• MRI of the spine for spinal cord disorder
• Tensilon test for myasthenia

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

MUSCULAR CRAMPS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, one should look for absent or diminished pulses in the extremity involved, Chvostek and Trousseau signs of tetany, and neurologic signs of an upper motor neuron lesion. An occupational history may disclose that the patient is a miner or iron-worker or is exposed to excessive heat on the job. Occupations such as painters, writers, seamstresses and compositors suggest the so-called professional cramps. Adson signs are positive in thoracic outlet syndrome. Cramps in the legs produced by walking a certain distance suggest peripheral arteriosclerosis and Leriche syndrome. The initial laboratory workup involves a CBC, urinalysis, chemistry panel, and electrolytes. If a vascular cause is suspected, ultrasonography and perhaps venography or angiography may be indicated

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Source: Differential Diagnosis in Primary Care, 2007

MUSCULAR ATROPHY: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Focal atrophy of a muscle often means a damaged peripheral nerve or root. If there are visible fasciculations, a lesion of the spinal cord or root is most likely. Electromyography will determine which portion of the nerve is affected. It will also be helpful in diagnosing muscle disease. Muscle biopsy is valuable to rule out trichinosis, dermatomyositis, or muscular dystrophy. If there are fasciculations, a spine x-ray, spinal tap, and myelography or MRI may be necessary to establish the diagnosis. Sedimentation rate, CRP, RA titer, ANA, and tuberculin tests may be necessary.

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Source: Differential Diagnosis in Primary Care, 2007

Muscle flaccidity [Muscle hypotonicity]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in distress, ask about the onset and duration of muscle flaccidity and precipitating factors. Ask about associated symptoms, notably weakness, other muscle changes, and sensory loss or paresthesia.

Examine the affected muscles for atrophy, which indicates a chronic problem. Test muscle strength, and check deep tendon reflexes (DTRs) in all limbs.

» READ BOOK EXCERPT ONLINE »

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

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

Begin by determining the location of the patient’s muscle weakness. Ask if he has difficulty with specific movements such as rising from a chair. Find out when he first noticed the weakness; ask him whether it worsens with exercise or as the day progresses. Also ask about related symptoms, especially muscle or joint pain, altered sensory function, and fatigue.

Obtain a medical history, noting especially chronic disease, such as hyperthyroidism; musculoskeletal or neurologic problems, including recent trauma; a family history of chronic muscle weakness, especially in males; and alcohol and drug use.

Focus your physical examination on evaluating muscle strength. Test all major muscles bilaterally. (See Testing muscle strength, pages 418 and 419.) When testing, make sure that the patient’s effort is constant; if it isn’t, suspect pain or other reluctance to make the effort. If the patient complains of pain, ease or discontinue testing and have him try the movements again. Remember that the patient’s dominant arm, hand, and leg are somewhat stronger than their nondominant counterparts. Besides testing individual muscle strength, test for range of motion (ROM) at all major joints (shoulder, elbow, wrist, hip, knee, and ankle). Also test sensory function in the involved areas, and test deep tendon reflexes (DTRs) bilaterally.

» READ BOOK EXCERPT ONLINE »

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

Muscle spasms [Muscle cramps]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in distress, ask when the spasms began. Is there a particular activity that precipitates them? How long did they last? How painful were they? Did anything worsen or lessen the pain? Ask about other symptoms, such as weakness, sensory loss, or paresthesia.

Evaluate muscle strength and tone. Then, check all major muscle groups and note whether movements precipitate spasms. Test the presence and quality of all peripheral pulses, and examine the limbs for color and temperature changes. Test the capillary refill time (normal is less than 3 seconds), and inspect for edema, especially in the involved area. Observe for signs and symptoms of dehydration such as dry mucous membranes. Obtain a thorough drug and diet history. Ask the patient if he has had recent vomiting or diarrhea. Finally, test reflexes and sensory function in all extremities.

» READ BOOK EXCERPT ONLINE »

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

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the abdominal rigidity is localized or generalized. Is it always present? Has its site changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Also, check for a visibly distended bowel loop. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

» READ BOOK EXCERPT ONLINE »

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

Muscle spasticity [Muscle hypertonicity]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When you detect spasticity, ask the patient about its onset, duration, and progression. What, if any, events precipitate its onset? Has he experienced other muscular changes or related symptoms? Does his medical history reveal an incidence of trauma or a degenerative or vascular disease?

Take the patient’s vital signs, and perform a complete neurologic examination. Test reflexes and evaluate motor and sensory function in all limbs. Evaluate muscles for wasting and contractures.

During your examination, keep in mind that generalized spasticity and trismus in a patient with a recent skin puncture or laceration indicates tetanus. If you suspect this rare disorder, look for signs of respiratory distress. Provide ventilatory support, if necessary, and monitor the patient closely.

» READ BOOK EXCERPT ONLINE »

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

Accessory muscle use: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient’s condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, or fever.

Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.

Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.

Perform a detailed chest examination, noting an abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing.

» READ BOOK EXCERPT ONLINE »

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

Muscle atrophy [Muscle wasting]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when and where he first noticed the muscle wasting and how it has progressed. Also ask about associated signs and symptoms, such as weakness, pain, loss of sensation, and recent weight loss. Review the patient’s medical history for chronic illnesses; musculoskeletal or neurologic disorders, including trauma; and endocrine and metabolic disorders. Ask about his use of alcohol and drugs, particularly steroids.

Begin the physical examination by determining the location and extent of atrophy. Visually evaluate small and large muscles. Check all major muscle groups for size, tonicity, and strength. (See Testing muscle strength, pages 418 and 419.) Measure the circumference of all limbs, comparing sides. (See Measuring limb circumference.) Check for muscle contractures in all limbs by fully extending joints and noting pain or resistance. Complete the examination by palpating peripheral pulses for quality and rate, assessing sensory function in and around the atrophied area, and testing deep tendon reflexes (DTRs).

» READ BOOK EXCERPT ONLINE »

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

Muscular dystrophy: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis depends on typical clinical findings, family history, and diagnostic test findings. If another family member has muscular dystrophy, its clinical characteristics can indicate the type of dystrophy the patient has and how he may be affected.

Electromyography typically demonstrates short, weak bursts of electrical activity or high-frequency, repetitive waxing and waning discharges in affected muscles. Muscle biopsy shows variations in the size of muscle fibers and, in later stages, shows fat and connective tissue deposits; dystrophin is absent in Duchenne’s dystrophy and diminished in Becker’s dystrophy. Serum creatine kinase is markedly elevated in Duchenne’s, but only moderately elevated in Becker’s and facioscapulohumeral dystrophies.

Immunologic and molecular biological assays available in specialized medical centers facilitate accurate prenatal and postnatal diagnosis of Duchenne’s and Becker’s muscular dystrophies and are replacing muscle biopsy and elevated serum creatine kinase levels in diagnosing these dystrophies. These assays can also help to identify carriers.

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

Muscle flaccidity [Muscle hypotonicity]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in distress, ask about the onset and duration of muscle flaccidity and any precipitating factors. Ask about associated symptoms, notably weakness, other muscle changes, and sensory loss or paresthesia.

Examine the affected muscles for atrophy, which indicates a chronic problem. Test muscle strength, and check deep tendon reflexes in all limbs.

» READ BOOK EXCERPT ONLINE »

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

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

Begin by determining the location of the patient’s muscle weakness. Ask if he has difficulty with specific movements, such as rising from a chair. Find out when he first noticed the weakness; ask him whether it worsens with exercise or as the day progresses. Also ask about related symptoms, especially muscle or joint pain, altered sensory function, and fatigue.

Obtain a medical history, noting especially chronic disease such as hyperthyroidism; musculoskeletal or neurologic problems, including recent trauma; family history of chronic muscle weakness, especially in males; and alcohol and drug use.

Focus your physical examination on evaluating muscle strength. Test all major muscles bilaterally. (See Testing muscle strength, pages 530 and 531.) When testing, make sure the patient’s effort is constant; if it isn’t, suspect pain or other reluctance to make the effort. If the patient complains of pain, ease or discontinue testing and have him try the movements again. Remember that the patient’s dominant arm, hand, and leg are somewhat stronger than their nondominant counterparts. Besides testing individual muscle strength, test for range of motion at all major joints (shoulder, elbow, wrist, hip, knee, and ankle). Also test sensory function in the involved areas, and test deep tendon reflexes bilaterally.

» READ BOOK EXCERPT ONLINE »

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

Muscle spasms [Muscle cramps]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in distress, ask when the spasms began. Is there any particular activity that precipitates them? How long did they last? How painful were they? Did anything worsen or lessen the pain? Ask about other symptoms, such as weakness, sensory loss, or paresthesia.

Evaluate muscle strength and tone. Then, check all major muscle groups and note whether any movements precipitate spasms. Test the presence and quality of all peripheral pulses, and examine the limbs for color and temperature changes. Test capillary refill time (normal is less than 3 seconds), and inspect for edema, especially in the involved area. Observe for signs and symptoms of dehydration such as dry mucous membranes. Obtain a thorough drug and diet history. Ask the patient if he has had recent vomiting or diarrhea. Finally, test reflexes and sensory function in all extremities.

» READ BOOK EXCERPT ONLINE »

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

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the rigidity is localized or generalized. Is it always present? Has its location changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Then explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Also check for a visibly distended bowel loop. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and to determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

» READ BOOK EXCERPT ONLINE »

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

Muscle spasticity [Muscle hypertonicity]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Once you detect spasticity, ask the patient about its onset, duration, and progression. What, if any, events precipitate onset? Has he experienced other muscular changes or related symptoms? Does his medical history reveal any incidence of trauma or degenerative or vascular disease?

Take the patient’s vital signs, and perform a complete neurologic examination. Test reflexes and evaluate motor and sensory function in all limbs. Evaluate muscles for wasting and contractures.

During your examination, keep in mind that generalized spasticity and trismus in a patient with a recent skin puncture or laceration indicates tetanus. If you suspect this rare disorder, look for signs of respiratory distress. Provide ventilatory support, if necessary, and monitor the patient closely.

» READ BOOK EXCERPT ONLINE »

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

Accessory muscle use: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, and fever.

Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.

Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and about occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.

Perform a detailed chest examination, noting abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing. (See Accessory muscle use: Causes and associated findings, page 30.)

» READ BOOK EXCERPT ONLINE »

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

Muscle atrophy [Muscle wasting]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when and where he first noticed the muscle wasting and how it has progressed. Also ask about associated signs and symptoms, such as weakness, pain, loss of sensation, and recent weight loss. Review the patient’s medical history for chronic illnesses; musculoskeletal or neurologic disorders, including trauma; and endocrine and metabolic disorders. Ask about his use of alcohol and drugs, particularly steroids.

Begin the physical examination by determining the location and extent of atrophy. Visually evaluate small and large muscles. Check all major muscle groups for size, tonicity, and strength. (See Testing muscle strength, pages 530 and 531.) Measure the circumference of all limbs, comparing sides. (See Measuring limb circumference.) Check for muscle contractures in all limbs by fully extending joints and noting any pain or resistance. Complete the examination by palpating peripheral pulses for quality and rate, assessing sensory function in and around the atrophied area, and testing deep tendon reflexes.

» READ BOOK EXCERPT ONLINE »

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

Muscle Cramps: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ordinary muscle cramp

❑ Overuse

❑ Dehydration

❑ Drugs/toxins

❑ Hypokalemia

❑ Hyponatremia

❑ Hyperventilation

❑ Vascular insufficiency

❑ Restless legs syndrome

❑ Hypocalcemia

❑ Dystonia

❑ Amyotrophic lateral sclerosis

❑ Hemifacial spasms

❑ Spinal cord lesion

❑ Muscle enzyme deficiency

❑ Myotonic dystrophy

❑ Black widow spider bite

❑ Tetanus

Diagnostic Approach

Nocturnal leg cramps are common and easily recognized. They are due to muscle overuse, structural conditions such as flat feet, prolonged sitting, standing on hard floors, extracellular volume depletion, or electrolyte imbalance.

Generalized cramps suggest chronic disease of the motor neuron such as amyotrophic lateral sclerosis. Cramps recurrent and localized to one muscle group suggest nerve root disease. Myotonia is difficulty releasing a grip (handshake or doorknob) that improves with repeated contractions.

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Source: Field Guide to Bedside Diagnosis, 2007

Muscle spasms: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in distress, ask when the spasms began. Is there any particular activity that precipitates them? How long do they last? How painful are they? Does anything worsen or lessen the pain? Ask about other symptoms, such as weakness, sensory loss, or paresthesia.

Physical examination

Evaluate muscle strength and tone. Then, check all major muscle groups and note whether any movements precipitate spasms. Test the presence and quality of all peripheral pulses, and examine the limbs for color and temperature changes. Test capillary refill time (normal is less than 3 seconds), and inspect for edema, especially in the involved area. Observe for signs and symptoms of dehydration such as dry mucous membranes. Obtain a thorough drug and diet history. Ask the patient if he has had recent vomiting or diarrhea. Finally, test reflexes and sensory function in all extremities.

» READ BOOK EXCERPT ONLINE »

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

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

Determine the location of the patient’s muscle weakness. Ask if he has difficulty with specific movements such as rising from a chair. Find out when he first noticed the weakness; ask him whether it worsens with exercise or as the day progresses. Also ask about related symptoms, especially muscle or joint pain, altered sensory function, and fatigue.

Obtain a medical history, noting especially chronic disease such as hyperthyroidism; musculoskeletal or neurologic problems, including recent trauma; family history of chronic muscle weakness, especially in males; and alcohol and drug use.

» READ BOOK EXCERPT ONLINE »

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

Accessory muscle use: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s condition allows, question him thoroughly. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, or fever.

Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.

Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function testing or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the patient’s family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.

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

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

If the patient isn’t in distress, ask when the spasms began. Is there any particular activity that precipitates them? How long did they last? How painful were they? Did anything worsen or lessen the pain? Ask about other symptoms, such as weakness, sensory loss, or paresthesia. Obtain a thorough drug and diet history. Ask the patient if he has had recent vomiting or diarrhea.

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

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

If you detect spasticity, ask the patient about its onset, duration, and progression. What, if any, events precipitate onset? Has he experienced other muscular changes or related symptoms? Does his medical history reveal any incidence of trauma or degenerative or vascular disease?

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

Muscle flaccidity [Muscle hypotonicity]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in distress, ask about the onset and duration of muscle flaccidity and precipitating factors. Ask about associated symptoms, notably weakness, other muscle changes, and sensory loss or paresthesia.

Examine the affected muscles for atrophy, which indicates a chronic problem. Test muscle strength, and check deep tendon reflexes (DTRs) in all limbs. Then perform a complete neurologic examination.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle weakness: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Begin by determining the location of the patient's muscle weakness. Ask if he has difficulty with specific movements such as rising from a chair. Find out when he first noticed the weakness; ask him whether it worsens with exercise or as the day progresses. Also ask about related symptoms, especially muscle or joint pain, altered sensory function, and fatigue.

Obtain a medical history, noting especially chronic disease, such as hyperthyroidism; musculoskeletal or neurologic problems, including recent trauma; a family history of chronic muscle weakness, especially in males; and alcohol and drug use.

Focus your physical examination on evaluating muscle strength. Test all major muscles bilaterally. (See Testing muscle strength, pages 410 and 411.) When testing, make sure that the patient's effort is constant; if it isn't, suspect pain or other reluctance to make the effort. If the patient complains of pain, ease or discontinue testing and have him try the movements again. Remember that the patient's dominant arm, hand, and leg are somewhat stronger than their nondominant counterparts. Besides testing individual muscle strength, test for range of motion (ROM) of all major joints (such as shoulder, elbow, wrist, hip, knee, and ankle). Also test sensory function in the involved areas, and test deep tendon reflexes (DTRs) bilaterally.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle spasms [Muscle cramps]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in distress, ask when the muscle spasms began. Does a particular activity precipitate them? How long do they last? How painful are they? Did anything worsen or lessen the spasm? Ask about other symptoms, such as muscle weakness, sensory loss, or paresthesia.

Evaluate muscle strength and tone. Then, check all major muscle groups and note whether movement precipitate spasms. Test the presence and quality of all peripheral pulses, and examine the limbs for color and temperature changes. Test the capillary refill time (normal is less than 3 seconds), and inspect for edema, especially in the involved area. Observe for signs and symptoms of dehydration such as dry mucous membranes. Obtain a thorough drug and diet history. Ask the patient if he has had recent vomiting or diarrhea. Finally, test reflexes and sensory function in all extremities.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal rigidity [Abdominal muscle spasm, involuntary guarding]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's condition allows further assessment, take a brief history. Find out when the abdominal rigidity began. Is it associated with abdominal pain? If so, did the pain begin at the same time? Determine whether the abdominal rigidity is localized or generalized. Is it always present? Has its site changed or remained constant? Next, ask about aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.

Explore other signs and symptoms. Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Check for a visibly distended bowel loop or pulsations. Next, auscultate bowel sounds. Perform light palpation to locate the rigidity and determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle spasticity [Muscle hypertonicity]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When you detect muscle spasticity, ask the patient about its onset, duration, and progression. What, if any, events precipitate its onset? Has he experienced other muscular changes or related symptoms? Does his medical history reveal an incidence of trauma or a degenerative or vascular disease?

Take the patient's vital signs, and perform a complete neurologic and musculoskeletal examination. Test reflexes and evaluate motor and sensory function in all limbs. Evaluate muscles for wasting and contractures.

Alert

During your examination, keep in mind that generalized spasticity and trismus in a patient with a recent skin puncture or laceration indicates tetanus. If you suspect this rare disorder, look for signs of respiratory distress. Provide ventilatory support, if necessary, and monitor the patient closely.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Accessory muscle use: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, sputum production, or fever.

Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders, such as heart failure, which may lead to pulmonary edema; inquire about neuromuscular disorders, such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.

Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function tests or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.

Perform a detailed chest examination, noting an abnormal respiratory rate, pattern, or depth. Assess the patient's chest for equal expansion during inspiration. Check the trachea for midline position. Assess the color, temperature, and turgor of the patient's skin, and check for clubbing. Auscultate the lungs for adventitious breath sounds.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Muscle atrophy [Muscle wasting]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when and where he first noticed the muscle wasting and how it has progressed. Also ask about associated signs and symptoms, such as weakness, pain, loss of sensation, and recent weight loss. Review the patient's medical history for chronic illnesses; musculoskeletal or neurologic disorders, including trauma; and endocrine and metabolic disorders. Ask about his use of alcohol and drugs, particularly steroids.

Begin the physical examination by determining the location and extent of atrophy. Visually evaluate small and large muscles. Check all major muscle groups for size, tonicity, and strength. (See Testing muscle strength, pages 410 and 411.) Measure the circumference of all limbs, comparing sides. (See Measuring limb circumference.) Check for muscle contractures in all limbs by fully extending joints and noting pain or resistance. Complete the examination by palpating peripheral pulses for quality and rate, assessing sensory function in and around the atrophied area, and testing deep tendon reflexes (DTRs).

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

MUSCULAR ATROPHY: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Focal atrophy of a muscle often means a damaged peripheral nerve or root. If there are visible fasciculations, a lesion of the spinal cord or root is most likely. Electromyography will determine which portion of the nerve is affected. It will also be helpful in diagnosing muscle disease. Muscle biopsy is valuable in ruling out trichinosis, dermatomyositis, or muscular dystrophy. If there are fasciculations, a spine x-ray, spinal tap, and myelography or MRI may be necessary to establish the diagnosis. Sedimentation rate, CRP, RA titer, ANA, and tuberculin tests may be necessary.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

MUSCULAR CRAMPS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, one should look for absent or diminished pulses in the extremity involved, Chvostek and Trousseau signs of tetany, and neurologic signs of an upper motor neuron lesion. An occupational history may disclose that the patient is a miner or iron-worker or is exposed to excessive heat on the job. Occupations such as painters, writers, seamstresses, and compositors suggest the so-called professional cramps. Adson signs are positive in thoracic outlet syndrome. Cramps in the legs produced by walking a certain distance suggest peripheral arteriosclerosis and Leriche syndrome. This is also a sign of spinal stenosis. The initial laboratory workup involves a CBC, urinalysis, chemistry panel, and electrolytes. If a vascular cause is suspected, ultrasonography and perhaps venography or angiography may be indicated.

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Source: Differential Diagnosis in Primary Care, 2007

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