Diagnosis of Myopathy
Myopathy Diagnosis: Book Excerpts
Diagnostic Tests for Myopathy: Online Medical Books
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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
» READ BOOK EXCERPT ONLINE »
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
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 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
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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?
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
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).
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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