Diagnostic Tests for Osteoporosis
Osteoporosis: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Osteoporosis
includes:
Osteoporosis Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Osteoporosis:
- Osteoporosis & Bone Health: Home Testing:
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Breast Cancer: Related Home Tests:
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 of 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 the diagnostic tests for Osteoporosis.
BONE MASS OR SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL MASS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FEMORAL MASS OR SWELLING:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Clinical laboratory tests. No special tests are necessary, apart from those usually ordered in the course of routine care.
B. Diagnostic imaging. The diagnosis is made by x-ray study, but further studies may be indicated to delineate the lesion better. Initial evaluation begins with routine radiography. Certain features help to determine the “biologic activity” or aggressiveness and growth rate of a lesion, which, combined with location and clinical and epidemiologic data can lead to a decision to order additional imaging studies (5).
1. Plain radiography. In a study of 709 cases of solitary bone lesions, 40 unicameral bone cysts (UBCs) were analyzed according to demographic, anatomic, and radiographic features (6). Of the 40, 33 (83%) were in long bones and 7 were in the pelvis or calcaneus. All 40 UBCs were geographic, medullary, and lytic. None had an associated soft-tissue mass. Pathologic fractures were present in 55% and 10% had fallen fragment signs; 98% had no cortical break and 88% had well-defined margins. In their conclusion, the authors found a quantitative sensitivity of 80% and specificity of 93% that included the radiographic features of metaphyseal, diaphyseal, or flat bone location; geographic, lytic, or medullary based; no matrix, no satellite lesions, no subarticular extension, no soft-tissue mass, and no cortical break; and a central location in long bones.
2. Magnetic resonance imaging has multiplanar imaging and better contrast sensitivity, allowing it to help differentiate benign lesions from malignant ones. The signal intensity on spin-density images can indicate the type of fluid and the presence of septa, and can show if the lesion is fibrous or not. T2-weighted images can show presence or absence of soft-tissue mass. The relationship to the epiphysial plate can be seen well. In addition to causing encroachment into the physis, a large cyst can cause subchondral collapse, joint incongruity, and avascular necrosis (4).
3. Serial repeat x-ray study. If electing to follow the cyst, serial plain x-ray studies can be done, cyst diameter measurement taken, or computer assisted densitometric image analysis of serial radiographs obtained.
Diagnostic assessment
The key to the diagnosis of bone cyst is the typical appearance on x-ray film. When a deviation from the expected image is seen, try to ascertain that the lesion is not a more serious one, either by referral or further imaging. “Active cysts,” which abut the growth plate, have the potential to cause damage and should be followed carefully or treated. Fracture of the cyst is commonly the presenting sign.
References
1. Capanna R, Campanacci DA, Manfrini M. Unicameral and aneurysmal bone cysts. Orthop Clin North Am 1996;27:605–614.
2. Lokiec F, Wientroub S. Simple bone cyst: etiology, classification, pathology and treatment modalities. J Pediatr Orthop Part B 1998;7(4):262–273.
3. Leither A, Windhager R, Lang S, Hass OA, et al. Aneurysmal bone cyst: a population based epidemiological study and literature review. Clin Orthop 1999;363:176–179.
4. Gupta AK, Crawford AH. Solitary bone cyst with epiphyseal involvement: confirmation with magnetic resonance imaging. A case report and review of the literature. J Bone Joint Surg Am 1996;78:911–915.
5. Deely D, Schweitzer ME. Imaging evaluation of the patient with suspected bone tumor. In: Taveras JM, Ferrucci JT, eds. Radiology: diagnosis-imaging-intervention. Philadelphia: Lippincott-Raven Publishers 1998;5(74):1–6.
6. Lee JH. Reinus WR, Wilson AJ. Quantitative analysis of the plain radiographic appearance of unicameral bone cysts. Invest Radiol 1999;34(1):28–37.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Low Back Pain:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Clinical laboratory tests. Testing will be guided by the differential diagnosis as determined by the history and physical examination. If the back pain is felt to be of musculoskeletal origin, no test may be indicated. A urinalysis can help rule out hematuria or infection, if the pain is thought to be urologic or as a result of trauma. If the history suggests a medical problem, the considered diagnoses will determine the laboratory work. Extensive medical workup may be needed for a primary or metastatic malignancy. A calcium level should always be measured to identify a potentially lethal hypercalcemia. Rheumatologic studies may be indicated if a connective tissue disease (e.g., ankylosing spondylitis or rheumatoid arthritis) is suspected. If the pain is thought to be secondary to an urgent or life-threatening condition, have pertinent tests done expeditiously.
B. Diagnostic imaging. In the absence of “red flags,” lumbar spine films are not indicated for musculoskeletal sounding low back pain of less than 1 month duration (1). Neurologic emergencies (e.g., major spine trauma, cauda equina syndrome) require magnetic resonance imaging (MRI) studies. It is usually unproductive to order an MRI for straightforward lumbar muscular strain or for initial evaluation of simple disc herniation, as the prevalence rate of nonsignificant abnormal findings is high. A bone scan may be helpful when tumor, infection, or occult fracture is suspected. Electromyography may be useful to assess for nerve root dysfunction when symptoms are questionable.
Diagnostic assessment
The most common cause of low back pain in the outpatient setting is musculoskeletal strain. Although temporarily very debilitating, muscle strain can be conservatively treated and usually has few long-term complications. Variations from this basic presentation must be recognized to identify more structurally significant or medically threatening problems. Clues to these other diagnoses, which are found in the history, are reinforced by abnormalities in the physical examination; they are found less often by diagnostic testing.
The following “red flags” suggest possible urgent diagnoses. A history of recent trauma or motor vehicle accident can signify a vertebral fracture or subluxation. Fever can indicate an infection of the spine or pyelonephritis (Chapter 2.6). Recent genitourinary instrumentation or other invasive procedure can precede this presentation. Weight loss, other constitutional symptoms, or pain at rest (or at night) may suggest cancer (Chapter 2.13). Neurologic abnormalities can signify nerve dysfunction or cord compression. Urinary or fecal incontinence or retention, saddle area perineal numbness, or anal sphincter incompetence suggests cauda equina syndrome. A sudden tearing sensation in the back with associated hypotension can be caused by a rupturing abdominal aortic aneurysm.
References
1. Bigos SJ. Acute low back problems in adults. Clinical Practice Guideline. No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; December 1994.
2. Alvarez JA, Hardy Jr. RH. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician 1998;57:1825–1834.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Mediastinal Mass:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. Clinical laboratory tests will depend on the index of suspicion, based on the most common diagnoses in the anatomic location. These may include complete blood count, erythrocyte sedimentation rate, lactic dehydrogenase, alpha fetoprotein, beta fraction human growth hormone, serum calcium, parathormone, gamma globulins, serum antiacetylcholine receptor antibody, purified protein derivative skin test, and HIV antibody screening.
B. Imaging studies. Any patient, but especially smokers or exsmokers, with unexplained peripheral adenopathy, unexplained cough, or any of the aforementioned symptoms, should have a chest x-ray study after no more than 2 to 3 weeks of symptomatic treatment. Any mediastinal mass seen requires a CT with iodinated bolus. The indications for mediastinal MRI are suspected vascular lesion, equivocal CT findings, posterior or paravertebral masses and neurogenic tumors, and suspected tumor recurrence so that scarring can be delineated from tumor. The MRI should be ordered with T1- and T2-weighted images and gadolinium-enhanced T1 images.
Diagnostic assessment
Correlation of the clinical and imaging picture is paramount in deciding the extent of the investigation of a mediastinal mass, because of the fairly predictable location pattern of various lesions. A patient with acute, searing chest pain and mediastinal widening will need emergent attention for thoracic aortic dissection. An anterior solid mass in a patient with cough and weight loss demands a tissue diagnosis and, if operable, surgical extirpation. A posterior cystic mass in a healthy patient may allow close follow-up. However, much overlap is seen (6), and diagnostic accuracy is better based on direct clues (e.g., tissue diagnosis) and on solid clinical judgment to include surgical diagnosis or treatment or medical or oncologic methods, if inoperable.
References
1. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part I: Tumors of the anterior mediastinum. Chest 1997;12(2):511–522.
2. Giron J, Fajadet P, Sans N, et al. Diagnostic approach to mediastinal masses. Eur J Radiol 1998;27(1):21–42.
3. Laurent F, Latrabe V, Lecesne R, et al. Mediastinal masses: diagnostic approach. Eur Radiol 1998;8(7):1148–1159.
4. Mediastinal or hilar enlargement. In: Burgener FA, Kormano M. Differential diagnosis in conventional radiology, 2nd revised ed. London: Thieme Medical Publishers, 1991.
5. Strollo DC, Rosado-de-Christenson ML, Jett JR. Primary mediastinal tumors. Part II. Tumors of the middle and posterior mediastinum. Chest 1997;112(5):
1344–1357.
6. Ahn JM, Lee KS, Goo JM, Song KS, Kim SJ, Im JG. Predicting the histology of anterior mediastinal masses: comparison of chest radiography and CT. J Thorac Imaging 1996;11(4):265–271.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Scrotal Mass:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
Either radioisotope scans or color Doppler ultrasound can be used to confirm or rule out testicular torsion. Specificities of 95% and 97% are reported (2). False-negative results do occur, however, producing lower sensitivities (86% and 80%, respectively) (2). In this series, most false-negative results occurred either in cases of prolonged torsion in which the testicles were no longer salvageable or in cases of intermittent torsion. Ultrasound can be helpful in differentiating some masses (e.g., hydrocele from solid mass, testicular from extratesticular). However, ultrasound showed a disappointing ability to differentiate malignant from benign masses in children (4). Aspiration of a spermatocele usually reveals dead sperm (1). Pyuria is almost always present in epididymitis, but it has also been found in up to 27% of patients with torsion ( >five white blood cells per high power field) (5). Similarly, leukocytosis suggests an infectious cause but it has also been found in 33% of patients with torsion (5).
Diagnostic assessment
Each type of scrotal mass has a typical presentation, and most can be readily diagnosed based on history and physical examination. However, considerable overlap is seen in the presentation and laboratory or imaging studies of these conditions, which makes establishing a diagnosis challenging in some cases. If the diagnosis of testicular torsion cannot be rapidly and confidently excluded, emergent referral is strongly recommended. If testicular torsion is not suspected but a diagnosis is not clear after the history, physical examination, and appropriate studies, less urgent consultation is recommended.
References
1. Junnila J, Lassen P. Testicular masses. Am Fam Physician 1998;57:685–692.
2. Lewis AG, Bukowski TP, Jarvis PD. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30:277–282.
3. Son KA, Koff SA. Evaluation and management of the acute scrotum. Prim Care 1985;6:637–646.
4. Aragona F, Pescatori E, Talenti E. Painless scrotal masses in the pediatric population: prevalence and age distribution of different pathological conditions—a 10-year retrospective multicenter study. J Urol 1996;155:1424–1426.
5. Kattan S. Spermatic cord torsion in adults. Scand J Urol Nephrol 1994;28:277–279.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Low Back Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
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
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