Diagnosis of Myopia

• Physical exam
  –Obtain visual acuity and confrontation visual fields in both eyes
  –Redness, pain, photophobia
  –Pupillary evaluation: look for Marcus Gunn pupil, which usually differentiates optic nerve from other causes
  –Extraocular muscle evaluation
  –Perform a dilated fundus evaluation
  –Evaluate for proptosis

• Radiology
  –CT or MRI of orbits and brain is indicated for associated neurologic signs, history of trauma
• Evaluation for stroke if right- or left-sided
• Ophthalmology consultation for dilated retinal exam, evaluation, and management

» READ BOOK EXCERPT ONLINE »

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

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

• Familial short stature
• Constitutional delay of growth and puberty
• Hypothyroidism
• Growth hormone deficiency (GHD)
• GH resistance (Laron syndrome)
• Congenital hypopituitarism
  –Secondary to brain tumors
• Acquired hypopituitarism
  –After irradiation, surgery, and chemotherapy for neoplasms
  –Infectious
  –Infiltrative
  –Vascular
• Cushing syndrome
• Precocious puberty
  –Tall initially
  –Final height compromised
• Pseudohypoparathyroidism
• Rickets
• Genetic syndromes
  –Turner syndrome
  –Down syndrome
  –Noonan syndrome
  –Prader-Willi syndrome
• Intrauterine growth retardation
  –Silver-Russell syndrome
• Disorders of bone development
  –Achondroplasia/hypochondroplasia
  –Chondrodystrophies
• Psychosocial deprivation
• Malnutrition
• Chronic drug intake
  –Glucocorticoids
  –Methylphenidate
• Infectious
  –HIV
  –Tuberculosis
• Congenital heart disease
• Gastrointestinal
  –Celiac disease
  –Inflammatory bowel disease
  –Chronic liver disease
• Pulmonary
  –Cystic fibrosis
• Chronic renal disease
  –RTA
  –Renal failure
• Skeletal disorders

Workup and Diagnosis

• History
  –Neonatal hypoglycemia or jaundice, brain tumor or other malignancy and treatment, central nervous system infection, nutrition status, chronic illness
• Family history
  –Parents’ heights and puberty ages to judge child's growth relative to genetic potential (midparental target height), family history of chronic disease or endocrinopathy
• Physical exam
  –Anthropometrics (height, weight, sitting height), dysmorphic features, craniofacial midline abnormalities (pituitary disease), dentition maturation (delayed in hypothyroidism), chronic illness, Tanner staging for pubertal assessment, micropenis in boys (growth hormone deficiency)
• Bone age X-ray to evaluate skeletal maturation
• Labs
  –CBC with differential cell count, LFT, BUN, Cr, electrolytes
  –ESR, TSH, T4
  –Growth factors (IGF-I, IGFBP-3)
  –Celiac antibody panel (anti-tissue transglutaminase)
  –Karyotype in girls to rule out Turner syndrome
• If IGF-I and/or IGFBP-3 low, provocative growth hormone test to confirm GHD (must fail two tests)
• MRI of the brain with special cuts of the pituitary in any child diagnosed as having GHD

» READ BOOK EXCERPT ONLINE »

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

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

First, identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests  —  confrontation testing and the Amsler grid   —  may also help in identifying a scotoma.

Next, test the patient’s visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure are necessary.

Explore the patient’s medical history, noting especially eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.

» READ BOOK EXCERPT ONLINE »

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

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

Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss.) Don’t touch the eye if the patient has perforating or penetrating ocular trauma.

If the patient’s vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the visual loss occur abruptly, or did it develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask him about the location, intensity, and duration of any eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.

The first step in performing the eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 630.)

Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 521.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 206.)

» READ BOOK EXCERPT ONLINE »

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

Near drowning: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Diagnosis requires a history of near drowning, including the type of water aspirated along with characteristic features and auscultation of crackles and rhonchi if respirations are present or if the patient is being ventilated.

Arterial blood gas (ABG) analysis shows decreased oxygen content, low bicarbonate levels, and low pH. Electrolyte levels may be elevated or decreased, depending on the type of water aspirated. Leukocytosis may occur. Electrocardiogram shows arrhythmias and waveform changes.

» READ BOOK EXCERPT ONLINE »

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

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

First, identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests—confrontation testing and the Amsler grid—may also help in identifying a scotoma.

Next, test the patient’s visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure (IOP) are necessary.

Explore the patient’s medical history, noting especially any eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.

» READ BOOK EXCERPT ONLINE »

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

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

Sudden vision loss can signal an ocular emergency. Don’t touch the eye if the patient has a perforating or penetrating ocular trauma. (See Managing sudden vision loss, page 802.)

If the patient’s vision loss occurred gradually, ask him if it affects one eye or both and all or only part of the visual field. Is the vision loss transient or persistent? Did it occur abruptly or develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask about the location, intensity, and duration of any eye pain. Also, obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.

The first step in performing the eye examination is to assess visual acuity with the best available correction in each eye. (See Testing visual acuity, page 803.)

Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (see “Pupils, nonreactive,” page 654) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 246.)

» READ BOOK EXCERPT ONLINE »

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

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

 A. Nature of the scotoma. Try to establish whether the field loss is monocular or binocular. Binocular scotomas, which imply chiasmal or posterior chiasmal lesions, are vascular (stroke, transient ischemic attack, migraine, ruptured arteriovenous malformation) or compressive in nature (pituitary mass, meningioma, glioma). Establish with the patient the location of the defect. Scotomas that migrate through the visual field include vitreous floaters, vitreous hemorrhage, scintillating scotoma of migraine, and so forth. An altitudinal field loss is likely a prechiasmal lesion [i.e., optic nerve disease (e.g., ischemic optic neuropathy, glaucoma) or retina disease (e.g., detached retina, retina vascular occlusion)]. Central scotomas are commonly seen in optic nerve and macular lesions with macular degeneration by far the most common in the elderly. Macular holes, optic neuritis, toxic or metabolic optic neuropathy, central serous choroidopathy, maculopathy secondary to medications (hydroxychloroquine, thioridazine, chlorpromazine, quinine, tamoxifen), and others are examples of macular-induced central scotomas. Peripheral vision loss, if bilateral and homonymous, indicates a stroke opposite the side of field loss. Tumors, arteriovenous malformations, and migraines can cause hemianopias. Glaucoma, detached retina, retinitis pigmentosa, chronic papilledema, and previous laser treatment for diabetes are also common entities affecting peripheral vision.

 B. Onset and timing of scotoma. A scotoma of sudden onset will be secondary to some kind of vascular event: embolic, hypoperfusion, inflammatory, or hemorrhagic. Transient vision loss lasting seconds can occur with temporal arteritis, papilledema, or vertebrobasilar insufficiency. Visual loss lasting minutes to hours occurs in temporal arteritis or amaurosis fugax. Visual changes lasting weeks to months represent retinal vein occlusion, expanding compressive lesion, papilledema, and if associated with pain on eye movement, optic neuritis. Gradual progressive visual field loss occurs with compressive masses; however, acute expanding lesions from infectious, inflammatory (e.g., sarcoid, Tolosa-Hunt), aneurysmal, or apoplexy of a pituitary mass can cause rapid vision loss. Monocular vision loss after head trauma suggests injury to the intracanalicular portion of the optic nerve, compressive fracture of the sphenoid bone, or edema to the optic nerve. Emergent computed tomography (CT) scan with neurosurgical or ophthalmic consultation and high-dose intravenous steroids are needed.

 C. Associated symptoms. The presence of neurologic signs or symptoms can localize the area of the pathology. Amaurosis fugax implies ipsilateral internal carotid disease or cardiac disease. History of vertigo, diplopia, and urinary incontinence in a young patient with a monocular central scotoma implies multiple sclerosis. Older patients with acute monocular vision loss associated with periorbital pain and headaches, fatigue, jaw claudication, or muscle aches strongly suggests temporal arteritis. Transient dimming or loss of vision in one or both eyes with orthostatic changes can be seen with papilledema of intracranial hypertension. Progressive monocular visual loss with proptosis obviously implies an orbital mass (optic nerve glioma, meningioma, cavernous hemangioma), but asymmetric thyroid-related orbitopathy can present a similar picture. Monocular loss progressing over time without orbital signs can be seen with an intracanalicular or intracranial optic nerve mass.

 D. Past medical and social history. Diabetes and hypertension are the two most common causes of ischemic optic neuropathy (ION). ION presents as a sudden painless monocular vision loss, altitudinal in nature, with an APD. The risk of retinal vascular occlusions is much greater in patients with diabetes mellitus or hypertension. The risk is greater with tobacco use. A history of rheumatic fever, heart murmur, or cardiomyopathy is significant for an embolic source. Sudden vision loss without an APD in a diabetic patient is most likely a vitreous hemorrhage. An acquired immunodeficiency syndrome patient with a CD4 count less than 50 × 10³ with visual scotomas needs to be evaluated for cytomegalovirus retinitis. A history of alcohol abuse or a psychiatric patient with bilateral vision loss and change in mental status needs urgent chemistries for anion gap acidosis with hemodialysis if methanol ingestion is suspected. An intravenous drug user can suffer a vascular occlusion from talc.

Physical examination

A. Visual acuity. The vision of each eye should be assessed with spectacles or contact lenses in each eye independently. Central scotomas are seen with optic nerve, macular disease, or (rarely) an occipital tip lesion; and Snellen visual acuity will be decreased.

B. Visual fields. Confrontation field test is performed with each eye independently. Briefly flash several fingers in each of the four quadrants. Bilateral field loss in the same field of vision in each eye indicates injury posterior to the chiasm. Bitemporal field defects are seen with chiasmal lesions (pituitary masses, craniopharyngiomas, and others). Monocular field defects are seen in retina and optic nerve disease.

 C. Pupil examination. The presence of a prominent APD, which implies optic nerve injury, will help to differentiate central scotomas caused by macular disease. An APD is commonly seen with optic neuritis, optic neuropathy (ischemic and traumatic), asymmetric glaucomatous damage, optic nerve tumors, and central retinal artery or vein occlusion. An APD is not seen in early papilledema and minimally with macular degeneration, macular holes, or choroidopathy.

D. Fundus examination. Direct ophthalmoscopy can give a quick assessment of the red reflex (i.e., a dim red reflex in a diabetic with vitreous hemorrhage). Vitreous floaters can occasionally be seen as shadows in the red reflex. Examine the nerve for edema, pallor, or glaucomatous cupping. Macular scarring or pigmentary change is most commonly seen with macular degeneration.

 E. Other examinations. A neurologic assessment is needed for a patient with bilateral field loss, screening for contralateral paresis and other focal deficits, palpation of the temporal artery for tenderness or diminished pulse if the history suggests giant cell arteritis, as is auscultation of the carotids for bruits and the heart for a murmur in a patient with amaurosis fugax or stroke. Glaucoma can be screened with tonometry. Check arms and legs for signs of intravenous drug abuse.

» READ BOOK EXCERPT ONLINE »

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

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

Are historical features helpful? Historical findings are neither sensitive nor specific; however, some symptoms are associated with specific diseases. Regardless of the cause, people associate shortness of breath with words that describe a sense of “work” or “effort” to breathe. Asthma is associated with words that denote a sense of “tightness.” Patients with interstitial lung disease choose terms emphasizing the sense of “rapid” breathing. Did the patient select terms indicating difficulty with both inhalation and exhalation? This is often reported by patients with CHF (Chapter 7.5). Patients who are deconditioned select rapid, breathing more, or heavy to describe their dyspnea. Patients suffering from neuromuscular disorders select terms denoting rapid breathing or difficulty with inhalation. Is the patient aged less than 40 years? Are the patient’s symptoms episodic? Reactive airway disease and hyperventilation are associated with these terms (2).

Physical examination

In the physical examination, focus on signs of respiratory or cardiac disease. For the respiratory system, this means a careful examination starting at the nose. Specifically, on head, eyes, ear, nose, and throat examination look for evidence of obstruction, infection, or postnasal drip. Exclude obstruction, subcutaneous emphysema, or tracheal deviation. On cardiac examination, look for evidence of cardiomegaly, S₃ gallop, or hepatojugular reflux (HJR). In this setting, HJR is very specific for CHF (1). Assess the lungs for abnormal breath sound intensity, rales, wheezing, rhonchi, or tachypnea. Examine the chest for abnormal movements or deformities. Exclude abdominal masses, ascites, pregnancy, or abdominal distention. Evaluate the extremities for edema, tenderness, or asymmetry. Do a complete neurologic examination, and screen for weakness atrophy, sensory loss, and fasciculations.

» READ BOOK EXCERPT ONLINE »

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

Near drowning: Diagnosis
(Handbook of Diseases)

A history of near drowning along with characteristic features and auscultation of crackles and rhonchi is required for a diagnosis. Supportive tests include:

❑ arterial blood gas (ABG) analysis: shows hypercarbia, hypoxemia, and metabolic acidosis

❑ electrocardiography: may show arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Vision loss: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Sudden vision loss can signal an ocular emergency. Don’t touch the eye if the patient has perforating or penetrating ocular trauma.

If the patient’s vision loss occurred gradually, ask him if it developed over hours, days, or weeks. Does it affect one eye or both? Does it affect all or part of the visual field? Is the vision loss transient or persistent? What’s the patient’s age? Ask whether he has experienced photosensitivity, and ask him about the location, intensity, and duration of eye pain. Obtain an ocular history, including history of eye problems or systemic diseases that may lead to eye problems, such as infections, cancer, hypertension, diabetes mellitus, and thyroid, rheumatic, or vascular disease.

Physical examination

Assess visual acuity and determine the best available vision correction in each eye. (See Testing visual acuity.)

Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete, and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 306.) Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex and the effect of accommodation. (See Vision loss: Causes and associated findings, pages 308 and 309.)

» READ BOOK EXCERPT ONLINE »

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

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

Explore the patient’s medical history, noting especially any eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.

» READ BOOK EXCERPT ONLINE »

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

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

Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss, page 690.)

If the patient’s vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the visual loss occur abruptly, or did it develop over hours, days, or weeks? What is the patient’s age? Ask the patient if he has experienced photosensitivity, and ask him about the location, intensity, and duration of any eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.

» READ BOOK EXCERPT ONLINE »

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

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

Explore the patient's medical history, noting especially eye disorders, vision problems, or chronic systemic disorders. Find out if he takes medications or uses eyedrops.

Identify and characterize the scotoma, using such visual field tests as the tangent screen examination, the Goldmann perimeter test, and the automated perimetry test. Two other visual field tests—confrontation testing and the Amsler grid—may also help in identifying a scotoma.

Next, test the patient's visual acuity and inspect his pupils for size, equality, and reaction to light. An ophthalmoscopic examination and measurement of intraocular pressure are necessary.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Vision loss: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Sudden vision loss can signal an ocular emergency. (See Managing sudden vision loss, page 628.) Don't touch the eye if the patient has perforating or penetrating ocular trauma.

If the patient's vision loss occurred gradually, ask him if the vision loss affects one eye or both and all or only part of the visual field. Is the visual loss transient or persistent? Did the vision loss occur abruptly or did it develop over hours, days, or weeks? What's the patient's age? Ask the patient if he has experienced photosensitivity and ask him about the location, intensity, and duration of eye pain. You should also obtain an ocular history and a family history of eye problems or systemic diseases that may lead to eye problems, such as hypertension; diabetes mellitus; thyroid, rheumatic, or vascular disease; infections; and cancer.

The first step in performing an eye examination is to assess visual acuity, with best available correction in each eye. (See Testing visual acuity, page 629.)

Carefully inspect both eyes, noting edema, foreign bodies, drainage, or conjunctival or scleral redness. Observe whether lid closure is complete or incomplete and check for ptosis. Using a flashlight, examine the cornea and iris for scars, irregularities, and foreign bodies. Observe the size, shape, and color of the pupils, and test the direct and consensual light reflex (See “Pupils, nonreactive,” page 515.) and the effect of accommodation. Evaluate extraocular muscle function by testing the six cardinal fields of gaze. (See Testing extraocular muscles, page 197.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

 » Next page: Signs of Myopia

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Signs of Myopia
• Complications of Myopia
• Misdiagnosis of Myopia
• Misdiagnosis of Underlying Causes of Myopia
• Misdiagnosis of Medication Causes of Myopia

Tools & Services:

• Bookmark this page
• Take a survey relating to Myopia
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com