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Diseases » Osteoporosis » Diagnosis
 

Diagnosis of Osteoporosis

Diagnostic Test list for Osteoporosis:

The list of medical tests mentioned in various sources as used in the diagnosis of Osteoporosis includes:

Osteoporosis Diagnosis: Book Excerpts

Tests and diagnosis discussion for Osteoporosis:

Osteoporosis: NWHIC (Excerpt)

A family medical history and bone mass measurements are part of a complete assessment. Often a bone fracture is the first sign of osteoporosis. Ask your doctor to help you better understand your own risk and become aware of prevention and treatment options.

Routine x-rays can't detect osteoporosis until it's quite advanced, but other radiological methods can. The Food and Drug Administration (FDA) has approved several kinds of devices to estimate bone density. Most require far less radiation than a chest x-ray. Doctors consider a patient's medical history and risk factors in deciding who should have a bone density test. Readings are compared to a standard for the patient's age, sex and body size. Different parts of the skeleton may be measured, and low density at any site is worrisome. Bone density tests are useful for confirming a diagnosis of osteoporosis if a person has already had a suspicious fracture, or for detecting low bone density so that preventive steps can be taken. (Source: excerpt from Osteoporosis: NWHIC)

Osteoporosis - Age Page - Health Information: NIA (Excerpt)

The most exact way to measure bone density is by a DEXA-scan (dual-energy x-ray absorptiometry). This is done on the whole body. Ask your doctor about this test if you think you are at risk for osteoporosis or if you are a woman around the age of menopause or older.

The DEXA-scan can show whether you are at risk for a fracture. If you have already broken a bone and your doctor thinks you might have osteoporosis, the test can confirm the diagnosis. If more than one test is done at least a year apart, your doctor can compare the test results over time. Then he or she can see if the treatment has succeeded in slowing your bone loss.

The test results are reported as a number. If your doctor says your result was –2.5 SD (standard deviation) or more, this means you have osteoporosis. A test finding of –1SD to –2.5SD means you have some bone loss. This is known as osteopenia, and you are at risk of developing osteoporosis. (Source: excerpt from Osteoporosis - Age Page - Health Information: NIA)

Diagnosis of Osteoporosis: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Osteoporosis:

Diagnostic Tests for Osteoporosis: Online Medical Books

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


BONE MASS OR SWELLING: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a history of trauma? Trauma, of course, may cause fractures and subperiosteal hematomas.
  2. Is the patient a child or an adult? Children are more likely to have Ewing's tumors, scurvy, rickets, syphilis, battered baby syndrome, osteosarcoma, osteomas, and osteochondromas. Adults are more likely to have a giant cell tumor, metastasis, osteomyelitis, osteogenic sarcoma, fibrosarcoma, multiple myeloma, generalized fibrocystic disease, Paget's disease, acromegaly, and chondromas.
  3. Are the lesions single or focal or are they multiple or diffuse? Multiple and diffuse lesions in children are often due to scurvy, rickets, syphilis, and battered baby syndrome. Multiple lesions or diffuse lesions in adults are often due to metastasis, multiple myeloma, generalized fibrocystic disease, Paget's disease, acromegaly, and chondroma. Single lesions in children are more likely to be fracture, osteomyelitis, hematoma, Ewing's tumor, osteosarcoma, osteomas, and osteochondromas. Single lesions in adults are often due to a giant cell tumor, osteomyelitis, fracture, hematoma, osteogenic sarcoma, and fibrosarcoma, but may be due to a metastasis.
  4. Are the lesions usually painful? Painful lesions in children are more likely to be due to fracture, osteomyelitis, hematoma, Ewing's tumors, scurvy, syphilis, battered baby syndrome, and rickets. Painful lesions in adults may be due to a giant cell tumor, metastasis, osteomyelitis, fracture, hematomas, osteogenic sarcoma, fibrosarcomas, and multiple myeloma.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, arthritis panel, serum protein electrophoresis, and plain films of the involved bones. A skeletal survey may be necessary. Bone scans are often useful. A search for a primary tumor may require chest x-ray, upper GI series, barium enema, intravenous pyelogram, mammography, prostatic examination, PSA titer, thyroid scans, lymph node biopsy, and bone marrow examinations.

CT scans of the area may help differentiate the mass or swelling. Needle biopsy or exploratory surgery and bone biopsy may be necessary before deciding what surgical approach should be undertaken.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HEAD MASS OR SWELLING: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

A skull x-ray will help distinguish the bone lesions, whereas aspiration or biopsy will help distinguish the others. Referral to the appropriate specialist would be the most cost-effective approach.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

VULVAL OR VAGINAL MASS: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it tender? A tender vulval or vaginal mass would suggest vulvitis, hematoma, acute bartholinitis, or urethral caruncle.
  2. Is it reducible? A reducible vulval or vaginal mass would suggest pudendal hernia, varicocele, cystocele, rectocele, and uterine prolapse.
  3. Is the rectal examination abnormal? The rectal examination will be abnormal when there is an impacted feces or rectal carcinoma.

DIAGNOSTIC WORKUP

Referral to a gynecologist or urologist can obviate an expensive diagnostic workup in most cases. The primary care physician may wish to treat acute bartholinitis or vulvitis, however. A culture and sensitivity is the only procedure required in those cases.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEMORAL MASS OR SWELLING: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is it reducible? If the mass is reducible, it is most likely a femoral hernia or saphenous varix.
  2. Is there an associated kyphotic curvature of the spine? The findings of a kyphotic curvature of the spine suggest a psoas abscess, which is usually tuberculous.
  3. Is the mass firm and ovoid? A firm, ovoid mass suggests an enlarged lymph node or an ectopic testis.
  4. Is there resonance or bowel sounds over the mass? These findings suggest a femoral hernia.
  5. Is the corresponding half of the scrotum empty? These findings suggest an ectopic testis.

DIAGNOSTIC WORKUP

Surgical consultation may be wise at the outset. A reducible mass would suggest a femoral hernia, but an upper GI series with a small bowel follow-through would confirm this diagnosis. Of course, if it is felt that the femoral hernia is irreducible, this study would not be done, and exploratory surgery would be indicated. If the mass is suspected to be a lymph node, a biopsy should be done. If the mass is suspected to be an abscess, an incision and drainage should be done. If tuberculosis is suspected, a tuberculin test as well as an AFB smear and culture should be done. If the mass is suspected to be a saphenous varix, venography will confirm the diagnosis. Exploratory surgery of the groin will clarify the diagnosis in confusing cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  1. Is it painful? A painful rectal mass should suggest perirectal abscess, thrombosed hemorrhoid, anal ulcer, ruptured ectopic pregnancy, tubo-ovarian abscess, and pelvic appendix.
  2. Is it soft or cystic? The presence of a soft or cystic mass would suggest internal hemorrhoids, polyps, intussusception, villous tumor, granular proctitis, ovarian cyst, and blood or pus in the cul-de-sac.
  3. Is it hard? The presence of a hard lesion would suggest a fecal impaction, foreign body, retroverted uterus, enlarged prostate, malignant deposits in the pouch of Douglas, stricture, and carcinoma.
  4. Is there associated bleeding? The presence of bleeding should make one suspect carcinoma above all else, but it may be due to internal hemorrhoids, polyps, intussusception, villous tumors, or granular proctitis.

DIAGNOSTIC WORKUP

Routine laboratory tests include a CBC, sedimentation rate, and urinalysis. A smear and culture should be made of any rectal or vaginal discharge. Most cases will be diagnosed by anoscopy and proctoscopy. A pelvic ultrasound and CT scan of the abdomen and pelvis may be useful in evaluating ectopic pregnancy and other gynecologic disorders. Ultrasound of the prostate may also be done to evaluate a prostatic mass. A gynecologist, proctologist, or urologist should be consulted in difficult cases.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Low Back Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Lumbosacral muscle strain
    –Most common etiology of low back pain
    –Most common cause of disability in adults <45 years old
    –Aggravated by movement, better with rest
  • Lumbar disc herniation
    –Especially of L4-L5 and L5-S1
    –Usually with unilateral radiation down the leg in a dermatomal pattern
    –Increased pain with sitting
    • Spinal stenosis
      –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
      –Increased pain with standing
    • Sacral-iliac joint dysfunction
      –Especially in young, thin women or in pregnancy
      –Unilateral upper buttock pain, relieved with movement
    • Vertebral fracture
      –Often associated with trauma or osteoporosis
    • Spondylolisthesis
      –Especially in young athletes
    • Secondary gain (e.g., drug seeking, disability or liability issue)
    • Extraspinal causes (e.g., radiation from kidney stones)
    • Systemic causes (<1%)
      –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
      –Infection: Osteomyelitis, abscess
      –Abdominal aortic aneurysm
      –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
      –Cauda equina syndrome
      –Paget's disease

    Workup and Diagnosis

    • History and physical are the most important diagnostic tools
      –Evaluate for range of motion, sensation, strength, straight leg raise test, reflexes, and neurovascular status
    • Imaging studies (e.g., X-ray, MRI, CT scan, myelogram, discogram) are indicated if “red flags” are present, if pain or limited function is refractory to treatment, or if trauma has occurred
    • Evaluate for “red flags” that may indicate serious conditions—if present, further workup is necessary (e.g., lumbosacral X-ray, CBC, ESR, calcium, electrolytes, alkaline phosphatase, bone scan, metastatic workup)
      –Red flags that suggest fracture: Major trauma, minor trauma, or strenuous lifting in an older or osteoporotic patient
      –Red flags that suggest tumor or infection: Age >50 or <20, history of cancer, constitutional symptoms (weight loss, fever), IV drug use, immunosuppression, pain worse at night
      –Red flags that suggest cauda equina syndrome: Saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in leg
    • If red flags are absent, no imaging is necessary for 4–6 weeks; if pain persists, an MRI is the most useful study
    '>>'>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Rectal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Hemorrhoids
  • Rectal prolapse
  • Rectal cancer
  • Rectal polyp
  • Prostate cancer
  • Prostatitis
  • Endometriosis
  • Presacral neurogenic tumor
  • Rectal intussusception
  • Anal cancer (2% of colorectal cancers)
    –Anal canal tumors (above the anal verge) include adenocarcinoma, melanoma, and epidermoid tumors
    –Anal margin tumors (below the anal verge) include squamous cell carcinoma, verrucous (from condyloma acuminatum), basal cell carcinoma, Bowen's disease, and Paget's disease of the anus
  • Foreign body
  • Less common diagnoses (“zebras”) include rectal carcinoid, lymphoid hyperplasia, malignant lymphoma, lipoma, dermoid cyst, teratoma, rectal duplication, and leiomyosarcoma

Workup and Diagnosis

  • History should include changes in bowel habits or consistency of stool, and family history of colorectal cancer
    –Bleeding is the most common symptom associated with benign and malignant lesions; melena suggests upper GI bleeding, blood on toilet paper suggests anal fissure or hemorrhoids, bright red separate from stool suggests hemorrhoids, clots in stool suggests colonic source
    –Pain is usually associated with benign pathology
  • Fecal occult blood testing may be used for screening
  • Digital rectal exam and anoscopy are used initially to distinguish many anorectal lesions
  • Endoscopy (sigmoidoscopy and/or full colonoscopy) with biopsy of all polyps and suspicious lesions
  • Barium enema is indicated if colonoscopy unavailable
  • Endorectal ultrasound is necessary to evaluate for potential rectal cancer, to appropriately stage tumor invasion and lymph node status, and to direct appropriate treatment
  • Manometry may be indicated in incontinent patients

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Scrotal Masses: Differential Diagnosis
(In a Page: Signs and Symptoms)

Painful masses

  • Torsion of the spermatic cord
    –Testicle rides higher on affected side
    –Neonate to early 20s
    –Sudden pain in one testicle, followed by swelling and erythema of scrotum
  • Epididymitis
    –Testicle position is normal; tenderness at top and posterior of testicle
    –Childhood to old age
    –<35 years: Chlamydia, gonorrhea
    –>35 years: Enterobacteriaceae
  • Orchitis
    –Testicle position normal
    –Usually with epididymitis due to E. coli, Klebsiella, Pseudomonas; mumps
    • Strangulated hernia (vascular compromise)
    • Trauma
      Nonpainful masses
    • Hernia
    • Varicocele
      –A collection of dilated tortuous veins posterior to and above testis
    • Testicular cancer
      –Most common at ages 15–35
      –Gradual onset, though may only be noticed incidentally following trauma
    • Spermatocele
      –Firm, cystic mass containing sperm above and posterior to testis
    • Hydrocele
      –Covers anterior surface of the testicle
      –Seen in infants but usually closes before 1 year of age, then reappears in men over 40
    • Scrotal swelling
      –Edema from cardiac, hepatic, or renal failure
    • Epididymal cyst
      –More common in males with in utero DES exposure
  • Sperm granuloma
    –Usually at the site of a prior vasectomy
  • Less common etiologies include torsion of the appendices of the testis and epididymis, urinary extravasation, lipoma of spermatic cord, and pyogenic or granulomatous orchitis

    • Workup and Diagnosis

    • History and physical examination including abdomen, back, genitalia, and digital rectal examination
      –Onset/duration of symptoms, evidence of trauma, past medical history (e.g., cryptorchidism, testicular atrophy or dysgenesis), family history (e.g. testicular cancer significantly increases risk), sexual activity, and history of GU instrumentation
      –Constitutional: Fever, weight loss, pain, face (e.g., parotid glands are enlarged in mumps), breast (e.g., gynecomastia), penis (e.g., ulcers, plaques, induration, urethral discharge), scrotum, and testicles
      –Compare size, position, and tenderness of testicles; transilluminate all masses; palpate spermatic cord and inguinal canals (explore for hernias, hidden testicles, cord tenderness); and digital rectal exam
      –Lift testicle up over symphysis pubis: Pain relieved in epididymitis (Prehn's sign); no change with torsion
    • Initial laboratory testing may include CBC, urinalysis, urethral gram stain and culture
    • Ultrasound is indicated in all patients; include Doppler flow study if torsion is suspected
      –Intratesticular masses are considered to be cancer until proven otherwise
    • If solid mass is found, consider chest X-ray, CT of abdomen, serum tumor markers (AFP, β-hCG), LDH, electrolytes, BUN/creatinine, calcium, PT/PTT, and obtain urology consult and consider hematology-oncology consult

    '>

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    Source: In a Page: Signs and Symptoms, 2004

    LOW BACK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic exam should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive.

    If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    BACK MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    With skin lesions, excision or biopsy is frequently the best approach. Masses of the deeper structures cannot be approached as aggressively until certain conditions have been ruled out by computed tomography (CT) scans and bone scans. If a meningocele or similar congenital lesion is suspected, a neurosurgeon must be consulted.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    EPIGASTRIC MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

    The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    EXTREMITY MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    If the lesion is suspected to arise in the skin, simple biopsy or excision is the best approach. Deeper masses require careful examination, x-rays of the bones and soft tissue, bone scans, CT scans, ultrasonographic studies, and phlebography, arteriography, or lymphangiography. Surgical exploration of the area may be the only means to accomplish a specific diagnosis.

    Approach to the Diagnosis

    Because the extremities are not considered vital areas, the primary method of diagnosing the cause of a mass is exploration and biopsy. This is all well and good when the lesion is on the skin or subcutaneous tissue; however, when the mass is in the deeper tissues, it is wise to utilize diagnostic test to determine what the mass is before exploration. If the mass is suspected to be a varix or aneurysm, ultrasonography can be extremely useful in defining it. If the mass is attached to or thought to originate in bone, x-rays of the area and bone scans are useful. If it is uncertain what tissue the mass originates from, a CT scan can be used to help define it. Before ordering any of the above tests, it is best to consult a general or orthopedic surgeon to help select the most appropriate test for the case at hand.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    HYPOGASTRIC MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to a urologist is in order.

    Once the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy in women of childbearing age. A pregnancy test is done and if this is positive, ultrasonography may be done particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant.

    Once a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ORAL OR LINGUAL MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A biopsy or excision is the best approach to the diagnosis. If a systemic disease is suspected because of a lesion, appropriate studies for these are listed below.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RIGHT UPPER QUADRANT MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately. When an RUQ mass is discovered unexpectedly or on a routine physical examination, one may proceed more deliberately. Ultrasonography will help determine if the mass is a gallbladder, a liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin. An intravenous pyelogram (IVP), urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    HEAD MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes excision or biopsy of skin lesions, skull x-rays, CT scans, bone scans, and, if necessary, a bone biopsy. A neurosurgeon should be consulted before ordering expensive diagnostic tests.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    LEFT LOWER QUADRANT MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to this diagnosis includes a careful pelvic and rectal examination, a search for the presence of blood in the stool, a history of weight loss, tenderness of the mass, fever and other symptoms, and a laboratory workup. As mentioned above, an enema may diagnose and treat a fecal impaction. A surgical consult is wise at this point. Stool examination (for blood, ova, and parasites), sigmoidoscopy, and barium enemas are the most useful diagnostic procedures other than a colonoscopy. Arteriography and gallium scans (for diverticular and other abscesses) and the CT scan have become useful additions to the diagnostic armamentarium. Peritoneoscopy and exploratory laparotomy are still necessary in many cases.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    LEFT UPPER QUADRANT MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The presence or absence of other symptoms and signs is the key to the clinical diagnosis of an LUQ mass. The presence of jaundice would suggest the mass is a large spleen. The presence of blood in the stool would suggest carcinoma of the colon. The presence of hematuria would suggest the mass is renal in origin. An enema should be done to exclude fecal impaction before an extensive workup is performed.

    A conservative workup will include a CBC, sedimentation rate, urinalysis, chemistry panel, platelet count, stool for occult blood, coagulation profile, and a flat plate of the abdomen. On the basis of these results, the clinician can determine whether to do an upper gastrointestinal (GI) series, barium enema, IVP, or CT scan of the abdomen. Another approach would be to do the CT scan immediately. In the long run, the latter approach may be more cost-effective. It is usually prudent to get a surgical or gastroenterology consult to help decide between the two approaches.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    NASAL MASS OR SWELLING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RIGHT LOWER QUADRANT MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    As with other abdominal masses, its important to look for other symptoms and signs that will help determine the origin of the mass. If there are fever and chills, an appendiceal or diverticular abscess is possible. Blood in the stools suggests a diagnosis of colon carcinoma. If there is amenorrhea or vaginal bleeding in a woman of childbearing age, an ectopic pregnancy most be considered. A long history of chronic diarrhea with or without blood in the stools suggests Crohn disease.

    The initial workup will include a CBC, sedimentation rate, chemistry panel, stool for occult blood, pregnancy test, and flat plate of the abdomen. If there is fever and an acute presentation, consultation with a general surgeon to consider an immediate exploratory laparotomy is indicated.

    With a more insidious onset of the RLQ mass, the clinician has a choice of ordering a CT scan of the abdomen and pelvis after performing the initial diagnostic studies or proceeding systematically with a barium enema, IVP, or small-bowel series to determine the origin of the mass. A gastroenterology or gynecology consult may be the best way to resolve this dilemma.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Low birth weight: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 382 and 383.) Follow with a routine neonatal examination.

    » READ BOOK EXCERPT ONLINE »

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

    Osteoporosis: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Differential diagnosis must exclude other causes of rarefying bone disease, especially those affecting the spine, such as metastatic cancer and advanced multiple myeloma. The differential diagnosis should also exclude osteomalacia, osteogenesis imperfecta tarda, skeletal hyperparathyroidism, and hyperthyroidism. Initial evaluation attempts to identify the specific cause of osteoporosis through the patient history.

    ❑ Bone mineral density testing is performed in dual-energy X-ray absorptiometry (DEXA) and measures the mineralization of bones. It’s the gold standard for evaluating osteoporosis.

    ❑ A spine computed tomography scan shows demineralization. Quantitative computed tomography can evaluate bone density but is less available and more expensive than DEXA.

    ❑ X-rays show fracture or vertebral collapse in severe cases.

    ❑ Urine calcium can provide evidence of bone turnover but is limited in value. Newer tests include urinary N-telopeptide to help diagnose osteoporosis.

    » READ BOOK EXCERPT ONLINE »

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

    Low birth weight: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age, pages 488 and 489.) Follow with a routine neonatal examination.

    » READ BOOK EXCERPT ONLINE »

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

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

    A. Pain. Is this a new patient with sudden onset of severe pain? Is there a history of trauma, mild or severe? Is this a patient with a new bone cyst picked up incidentally on x-ray study? Or is a known bone cyst being followed? Does the patient come in complaining of pain? Or does the patient wait until asked about pain? Significant pain may indicate a traumatic or spontaneous fracture. Is there tenderness elicited over the cyst area? Usually bone cysts are painless, unless they fracture or are growing rapidly. If there is pain or tenderness associated, consider referral or further imaging to differentiate from a more serious lesion.

    B. Disability, weakness. Has the little-league baseball player been having trouble with his overhand throwing? Is the swimmer having difficulty with the dolphin stroke? The patient may be guarding with exercise because of pain that occurs only then. Unless the bone cyst is near the growth plate (epiphysis), it is unlikely to produce impairment of function, but if it abuts the epiphysis, growth arrest with physis damage is likely caused by the cyst itself, not trauma (4).

    C. Distortion, growth, rate of growth. When examining the child, do the limbs appear different lengths? Have they been measured? If near an epiphysis a bone cyst can impair growth of the limb, causing shortening. These cases need referral early.

    Physical examination

     A. Focused physical examination (PE). Bone cyst is a diagnosis that should be kept in mind during routine examinations of children, even those not suspected of harboring bone cysts. However, once it appears on x-ray, remember to examine the area on every visit. This should include careful palpation of the bone and entire limb, looking for tender areas or associated soft tissue masses. Comparative measurement should be done with the other limb in any cases of deviation from normal or any protrusion of bone or soft tissue, looking for signs of progression between visits. All these should prompt referral, because they may be signs that the cyst is actually another lesion, or that it is growing, heading for impending fracture, or impinging on the epiphysis.

     B. Additional PE. Routine growth charts should be maintained meticulously. Measurement of leg and arm lengths to ascertain whether growth is being interfered with is especially pertinent if the bone cyst is near the epiphysial growth plate.

    » READ BOOK EXCERPT ONLINE »

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

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

     The history should include evaluation for “red flag” conditions.

    A. Pain characteristics. Assess the nature of the pain, along with the onset and duration of the symptom. Is there any radiating pain, leg weakness, or paresthesia? Pseudoclaudication is suggestive of spinal stenosis. Pain radiating below the knee is more likely to be a true radiculopathy (1). Nerve root compression is highly unlikely without sciatic pain (1). Was the onset after a traumatic event? A seemingly insignificant episode (e.g., a minor fall) may be a “red flag” for fracture in an elderly patient. Are there alleviating or exacerbating factors? Does the pain limit the patient physically or socially? Is there a history of previous back problems or back surgery?

    B. Review of systems. Look for associated symptoms that can indicate a “red flag” condition or an underlying medical cause. Gastrointestinal and genitourinary symptoms are particularly important, especially incontinence (Chapter 10.10).

     C. Psychosocial information. Has the patient initiated any new activities? If work-related, assess typical job tasks. Investigate whether the back pain could have any relationship, sexual, or mood implications. Sexual activity can be severely affected simply because of pain, but sexual dysfunction can also result from neurologic abnormalities associated with the cause of the back pain. Back pain is associated with depression and poor sleep patterns. Drug-seeking behavior may be exhibited along with a complaint of back pain. Addiction may have resulted from former or on-going treatment of the pain. Legal issues can complicate the diagnosis and treatment of back pain. Ask the patient whether litigation involving the back pain is under consideration.

    Physical examination

    Evaluation should be both general and specific. It is prudent to leave the potentially most painful parts of the examination to the end.

     A. General. Examination includes auscultation of the heart and assessment of peripheral pulses and blood pressure. Abdominal examination should focus on possible causes of back pain (Table 12.5). Assess gait.

     B. Neurologic. The lower extremity examination includes motor strength, deep tendon reflexes, sensation, proprioception, and certain functional maneuvers (Table 12.6). Romberg and Babinski reflexes should also be assessed. Rectal examination should assess sphincter tone, which can be compromised in sacral root dysfunction. In the primary care setting, most clinically significant disc herniations will be detected by the following limited examination: dorsiflexion of the great toe and ankle, Achilles reflex, light touch sensation of the medial (L 4), dorsal (L5), and lateral (S1) aspect of the foot, and the straight leg raise (SLR) test (1).

     C. Musculoskeletal. Assess range of motion of the spine and lower extremities. Perform the SLR test passively with the patient supine. Note the angle of leg elevation precipitating pain. A positive test for sciatica is buttock pain radiating to the posterior thigh, and perhaps to the lower leg and foot. Sciatica, with pain and resistance on internal rotation of the hip, can indicate piriformis muscle spasm or strain. The SLR test is usually negative in spinal stenosis (2). Percussion of the spine and upper pelvis helps to identify areas of localized tenderness, as in fracture, metastatic disease, and some rheumatologic conditions. Palpate standard trigger points looking for fibromyalgia. Check for paraspinal muscle spasm. Measure thigh and calf circumferences to look for muscular atrophy.

    » READ BOOK EXCERPT ONLINE »

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

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

     A. Most mediastinal masses, including lymphomas, do not cause symptoms; however, it is important to pay early attention even to vague symptoms because most symptomatic patients with a mediastinal tumor will have a malignancy. Patients may be completely asymptomatic or their complaints can relate to the underlying disease process: myasthenia gravis or anemia from red cell aplasia, with thymoma; flushing, diarrhea, or Cushing’s syndrome, with thymic carcinoid; fatigue and irritability with parathyroid adenoma; fever, night sweats, and pruritus with lymphoma or Hodgkin’s; cough, wheezing, dysphagia, or chest pain, with compression or invasion of mediastinal organs (5). A personal or family history of cancer or aneurysms might be significant. Be especially alert to patients with prior tumors, even if benign. Some lesions can recur after many years (thymoma).

     B. Possible symptoms include fatigue, general weakness, cough, pruritus, chest pain, fever, night sweats, wheezing, dysphagia, stridor, voice change, hoarseness, weight loss, paresthesias, pain, proximal muscle weakness, swelling of face, and venous distention of neck (superior vena cava syndrome).

    Physical examination

    A. A general examination before an x-ray study gives clue to a mediastinal mass: vital signs, especially temperature, heart rate, and weight; check for pallor, skin lesions, lymphadenopathy, thyromegaly, splenomegaly, other abdominal or pelvic organomegaly or masses, rashes, weakness; auscultate lungs for wheezes, rales, and rhonchi.

     B. Focused reexamination after a mass is detected. Vital signs, especially temperature, heart rate, and documentation of weight loss; check carefully for cervical adenopathy (suitable for biopsy), evidence of thyromegaly, voice quality, airway patency sitting and supine; and observe the swallowing function. Auscultate the lungs for wheezes, rales, rhonchi; the heart for pericardial rubs; recheck for adenopathy (total body), check skin for melanoma, check testes for masses, and repeat the pelvic examination for ovarian masses.

    » READ BOOK EXCERPT ONLINE »

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

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

    A. Pain. Is the mass painful? How painful? Testicular torsion usually presents with severe pain. Torsion of a testicular or epididymal appendage, strangulated hernias, orchitis, or epididymitis can also be very painful. Varicocele, hydrocele, spermatocele, and testicular tumors are typically painless, but may at times present with a dull ache or heaviness of the scrotum.

    B. Inciting event. Did the mass first appear after vigorous activity or testicular trauma? Torsion is often precipitated by one of these factors, whereas a new swelling following minor trauma can suggest bleeding associated with a tumor.

     C. Patient age. Based on a review of 238 testicular masses in children, torsion of an appendage is the most common cause of acute masses in children aged up to 13 years. Above this age epididymitis and testicular torsion become more common (2). The incidence of testicular torsion peaks in the age group 13 to 15 years (2), but it can also occur in both middle-aged males and neonates. Indeed, torsion accounts for 83% of acute scrotal masses in children aged less than 1 year (2). The average age for patients with testicular cancer is 32 years (1). Hydrocele, epididymitis, varicocele, and hernias are more common in adults; as with most scrotal masses, however, they occur over a wide range of ages.

     D. Duration. How long has the mass been present? Torsion typically presents with sudden onset of symptoms, leading patients to seek care soon after appearance of the mass. Other acute conditions can also have an abrupt onset. Many benign scrotal masses have been noted for some time by the patient. Abrupt appearance of a varicocele in an older man can signal venous obstruction. In such cases, consider renal tumor with spermatic vein occlusion if the varicocele is on the left and vena cava obstruction if it is on the right.

     E. Symptoms of infection. Is there a history of fever, penile discharge, mumps, or any other infection recently? Epididymitis often presents with discharge and mild fever. A high fever often accompanies orchitis. Mumps orchitis typically occurs 3 to 4 days after the parotitis. Many other infections, including tuberculosis and syphilis, can produce epididymitis or orchitis.

    F. Previous history. Have the symptoms previously appeared? Patients with torsion may have had similar, milder symptoms in the past (torsion that spontaneously resolved). Patients with chronic epididymitis generally describe an initial severe bout that has been followed by milder recurrences.

     G. Other associated symptoms. Are there any other symptoms? Nausea often accompanies torsion and orchitis.

    Physical examination

    A. Palpation of scrotum and contents:

     1. Determine the orientation of the testicle. A torsed testicle is usually retracted upward and rotated to an abnormal position. This may be indicated by an epididymis that appears to lie in an abnormal location (normally, the head of the epididymis lies at the superior pole of the testicle and its body extends posterolateral along the testicle). Comparison with the other testicle may help with this determination. Normal position does not rule out torsion, however, as the testicle may have rotated a full 360°, or swelling can make accurate assessment of the position difficult.

     2. Assess for swelling and tenderness. Torsion, orchitis, and epididymitis all develop swelling and tenderness soon after onset. The swelling often obscures normal anatomy.

     3. Determine location of mass. Appendices of the epididymis and testicle can extend from the superior pole of either structure. Spermatocele is most commonly found superior and posterior to the testicle. Varicocele occurs in a similar location, most commonly on the left side. In epididymitis, the epididymis is usually diffusely swollen, which makes it difficult to distinguish epididymis from testicle.

     4. Assess the consistency of the mass. A varicocele typically has the consistency of a bag of worms. Hydrocele and spermatocele usually have a cystic consistency. Hydrocele can become tenser as the day progresses (because of the dependent position).

     B. Assess the cremasteric reflex. When the inner thigh is lightly stroked, the testicle on that side should rise noticeably. Absence of this reflex suggests torsion of the testicle (3).

     C. Elevate the testicle. This usually relieves the pain of epididymitis but not of torsion (3).

     D. Transilluminate the mass. Hydrocele and spermatocele will transilluminate.

     E. Examine the patient in both the supine and standing positions. Hernias and varicocele usually become more prominent on standing. Have the patient perform the Valsalva maneuver while standing, which may further accentuate these findings.

     F. General examination. Tumors can be associated with metastases or gynecomastia (Chapter 14.2).

    » READ BOOK EXCERPT ONLINE »

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

    Low Back Pain: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Musculoligamentous strain

    ❑ Lumbar disc herniation

    ❑ Osteoarthritis

    ❑ Compression fracture

    ❑ Pyelonephritis

    ❑ Secondary gain

    ❑ Scoliosis

    ❑ Spondylolisthesis

    ❑ Metastatic cancer

    ❑ Spinal stenosis

    ❑ Transverse process fracture

    ❑ Pancreatic cancer

    ❑ Ankylosing spondylitis

    ❑ Sacroiliitis

    ❑ Aortic dissection

    ❑ Cauda equina syndrome

    ❑ Vertebral osteomyelitis

    ❑ Epidural abscess

    Diagnostic Approach

    Radicular pain has such a high sensitivity for nerve root compression that its absence makes important disc herniation unlikely. Not all radicular pain is due to a herniated disc however. Other causes include spinal stenosis, ligamentous hypertrophy, deep lumbar muscle spasm, and deep trochanteric bursitis.

    Back pain at rest or unassociated with posture/movement should increase the suspicion of tumor, fracture, infection, or referred visceral pain. Spinal tenderness is a sensitive but not specific indicator. Clues to metastatic cancer include a history of cancer, unexplained weight loss, and signs of cord compression, such as motor weakness of the legs, urinary or fecal incontinence, and absent anal reflex. Recent bacterial infection, injection drug use, or immune suppression (from steroids, chemotherapy, or HIV) should raise suspicion for infection. Fever occurs in osteomyelitis (50%), epidural abscess (83%), and tuberculosis (27%).

    A red flag for fracture in a young adult is major trauma, such as a fall from a height or a motor vehicle accident. In older adults, minor trauma or strenuous lifting can cause a compression fracture.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Osteoporosis: Diagnosis
    (Handbook of Diseases)

    Differential diagnosis must exclude other causes of rarefying bone disease, especially those affecting the spine, such as metastatic carcinoma and advanced multiple myeloma. Initial evaluation attempts to identify the specific cause of osteoporosis through the patient history. Diagnostic tests include the following:

    ❑ X-rays show typical degeneration in the lower thoracic and lumbar vertebrae. The vertebral bodies may appear flattened and may look denser than normal.

    ❑ Bone mineral density (BMD) shows demineralization. Loss of bone mineral becomes evident in later stages.

    ❑ Dual- or single-photon absorptiometry allows measurement of bone mass, which helps to assess the extremities, hips, and spine.

    ❑ Serum calcium, phosphorus, and alkaline phosphatase levels are all within normal limits, but parathyroid hormone level may be elevated.

    ❑ Bone biopsy shows thin, porous, but otherwise normal-looking bone.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Low birth weight: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    As soon as possible, evaluate the neonate's neuromuscular and physical maturity to determine gestational age. (See Ballard Scale for calculating gestational age.) Follow with a routine neonatal examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    LOW BACK PAIN: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Our first priority in a patient who presents with low back pain is to rule out anything serious such as a herniated disc or cauda equina tumor. A pelvic and rectal examination must be performed to exclude a pelvic tumor or prostate carcinoma. A careful neurologic examination must be done. If one is too busy to do that, referral to an orthopedic surgeon or neurologist is indicated. The neurologic examination should include an SLR test, femoral stretch test, careful sensory examination, and an assessment for asymmetric reflexes. It is wise to carefully measure the thighs and calves to reveal muscular atrophy. Any findings to support a diagnosis of radiculopathy are a reasonable indication for a CT scan or MRI of the lumbar spine. However, it may be wise to have a neurologist or neurosurgeon examine the patient first because these tests are expensive. If the patient has normal neurologic, pelvic, and rectal examinations, it is perfectly legitimate to manage the patient conservatively for a while without any testing other than clinical. Close follow-up is important in these cases, however. Should the pain persist despite rest and conservative treatment, a more thorough diagnostic workup is indicated regardless of the lack of objective findings. This will include plain films or CT scan and an arthritis panel.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    BACK MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    With skin lesions, excision or biopsy is frequently the best approach. Masses of the deeper structures cannot be approached as aggressively until certain conditions have been ruled out by computed tomography (CT) scans and bone scans. If a meningocele or similar congenital lesion is suspected, a neurosurgeon must be consulted.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    EXTREMITY MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    If the lesion is suspected to arise in the skin, simple biopsy or excision is the best approach. Deeper masses require careful examination, x-rays of the bones and soft tissue, bone scans, CT scans, ultrasonographic studies, and phlebography, arteriography, or lymphangiography. Surgical exploration of the area may be the only means to accomplish a specific diagnosis.

    Approach to the Diagnosis

    Because the extremities are not considered vital areas, the primary method of diagnosing the cause of a mass is exploration and biopsy. This is all well and good when the lesion is on the skin or subcutaneous tissue; however, when the mass is in the deeper tissues, it is wise to utilize diagnostic tests to determine what the mass is before exploration. If the mass is suspected to be a varix or aneurysm, ultrasonography can be extremely useful in defining it. If the mass is attached to or thought to originate in bone, x-rays of the area and bone scans are useful. If it is uncertain what tissue the mass originates from, a CT scan can be used to help define it. Before ordering any of the above tests, it is best to consult a general or orthopedic surgeon to help select the most appropriate test for the case at hand.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    FACE MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    If infection is suspected, smears and cultures of exudates should be done. X-rays of the skull, sinuses, and jaw may be helpful. A computed tomography (CT) scan will be more definitive. If neoplasm or granuloma is suspected, a biopsy or excision will be necessary. If there is still doubt about the etiology, an oral surgeon or otolaryngologist should be consulted.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    ORAL OR LINGUAL MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    PULSATILE MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Ultrasonography will usually confirm the diagnosis of these lesions, but a CT scan or angiography may be necessary, particularly when surgical intervention is planned. A cardiovascular surgeon should be consulted before ordering these expensive tests.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SKIN MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A biopsy or excision is the best approach to the diagnosis. If a systemic disease is suspected because of a lesion, appropriate studies for these are listed below.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Epigastric Mass: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs are very helpful in determining the origin of an epigastric mass. If there is jaundice, the mass is probably an enlarged liver. Fever and chills suggests a subphrenic abscess displacing the liver downward or an abscessed gallbladder. A mass associated with a history of anorexia and wasting suggests pancreatic or gastric carcinoma. A history of alcoholism suggests that the mass is an enlarged liver or pancreatic pseudocyst. Blood in the stool suggests carcinoma of the stomach or colon. A history of constipation would warrant a cleansing enema to rule out a fecal impaction before ordering an expensive workup. If the mass pulsates, one would consider an aortic aneurysm in the differential diagnosis.

    The initial workup should include a CBC, urinalysis, chemistry panel, amylase and lipase levels, stool for occult blood, and flat and upright x-rays of the abdomen. If a presentation is acute, a general surgeon should be consulted to consider immediate exploratory laparotomy. If the development was more insidious and the patient is in no acute distress, a more systematic workup can be done at this point. Based on the results of the initial workup, one can proceed with an upper GI series, a barium enema, or ultrasonography of the gallbladder and pancreas. However, a more expeditious route to the diagnosis would be to order a CT scan of the abdomen. It is wise to consult a surgeon or gastroenterologist to help decide what method would be the most cost-effective and prudent.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Hypogastric Mass: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Before the clinician can evaluate a hypogastric mass, it is important to have the patient empty his or her bladder. If the mass is still present, catheterization for residual urine or ultrasonography can determine if the mass is a distended bladder due to a neurogenic bladder or bladder neck obstruction. If there are objective neurologic findings, there may be a neurogenic bladder and the patient should be referred to a neurologist. If the clinician suspects bladder neck obstruction, a referral to a urologist is in order. After the possibility that the mass is a distended bladder has been excluded, one should consider ruling out pregnancy in women of childbearing age. A pregnancy test is done: If the test is positive, ultrasonography may be done particularly if an ectopic pregnancy is suspected or the patient denies that she could be pregnant. After a distended bladder and pregnancy have been removed from consideration, the next step would be a CT scan of the abdomen and pelvis. It is probably wise to consult a gynecologist, general surgeon, or urologist before ordering this expensive test. Their wisdom may make the test unnecessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    CHEST WALL MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to this diagnosis is again a good clinical history and physical examination along with correlation of signs and symptoms. Chest x-ray films with special views and tomography will diagnose most cases, but a biopsy, arteriography, CT scans, and exploratory surgery may be necessary, especially if the lesion turns out to be noninfectious. It is important not to be fooled by a congenital anomaly (e.g., pigeon breast).

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Right Upper Quadrant Mass: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Acute onset of the RUQ mass with a history of trauma is no doubt a laceration or contusion of the liver or kidney: A surgeon should be consulted immediately. When an RUQ mass is discovered unexpectedly or during a routine physical examination, one may proceed more deliberately. Ultrasonography will help determine if the mass is a gallbladder, liver, or pancreatic cyst. A CBC, chemistry profile, and liver panel will help determine if the mass is hepatic in origin. An intravenous pyelogram (IVP), urinalysis, or urine culture will help determine if it is renal in origin. However, a CT scan can resolve the dilemma quickly in most cases so it may be the most cost-effective approach. Then, one can determine which specialist to refer the patient to without hesitation. It is important to remember that whereas most masses will require referral to a specialist, fecal impactions and abdominal wall hematomas can be handled by the primary care physician.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    HEAD MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The approach to the diagnosis includes excision or biopsy of skin lesions, skull x-rays, CT scans, bone scans, and, if necessary, a bone biopsy. A neurosurgeon should be consulted before ordering expensive diagnostic tests.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    NASAL MASS OR SWELLING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The diagnosis is not difficult except in the case of granulomas and carcinomas, when skillful biopsy and culture are necessary. In Wegener midline granuloma, a search for alveolitis and glomerulonephritis will help to determine the diagnosis. Serum for ANCA antibodies is often diagnostic.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Mediastinal Mass: Mediastinal Mass - DIAGNOSIS
    (The 5-Minute Pediatric Consult)

    General goal is to establish diagnosis promptly and begin treatment as indicated, because condition may progress rapidly and become life threatening. If you suspect a malignancy, the child should be immediately referred to an oncologist.

    » READ BOOK EXCERPT ONLINE »

    Source: The 5-Minute Pediatric Consult, 2008


     » Next page: Signs of Osteoporosis

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