Diagnosis of Pain

• Fracture
  –Radial head fracture is most common: Usually due to a fall on an outstretched arm, resulting in pain with supination
  –Olecranon fracture: Pain with extension
  –Distal humerus fractures are less common
• Dislocation
  –Nursemaid's elbow (subluxation of the radial head) occurs in young children who were pulled by an outstretched arm; children will refuse to move the arm
  –In adults, dislocations generally occur secondary to falling on an outstretched arm; 80% are associated with an olecranon fracture
• Bursitis: Due to trauma, inflammation, infection

• Epicondylitis
  –Degeneration of the tendinous insertion at the lateral or medial epicondyles
  –Lateral epicondylitis (“tennis elbow”): Due to extensor muscle overuse (results in pain with pronation and wrist dorsiflexion)
  –Medial epicondylitis (“golfer's elbow”): Due to flexor muscle overuse (results in decreased grip strength and pain with pronation or wrist flexion)
• Ulnar nerve entrapment
  –Usually in the groove of the posterior aspect of the medial epicondyle
  –Occurs acutely after direct trauma or with prolonged pressure or overuse
  –Causes acute medial aching with numbness and tingling in fourth and fifth digits

• TMJ disorders
  –Associated with unilateral or bilateral achy pain and diffuse tenderness of the masseter and temporalis muscles
  –Exaggerated by jaw use
  –Joint may be tender to palpation
  –“Clicking” sounds are often present
  –More common in females age <50

• Giant cell (temporal) arteritis
  –Unilateral pain in older patients
  –Headache, jaw claudication, and vision loss
• Mucosal lesions (buccal mucosa, hard and soft
  palate, floor of mouth, or oropharynx)
  –Aphthous ulcers
  –Herpes simplex or coxsackievirus B
  –Cancer
  –Tongue or lip lesions
• Paranasal sinus pathology
  –Most common pathology is maxillary
  sinusitis secondary to viral URI
  –Pain is often referred to the upper molars
• Salivary gland pathology, including inflammation (e.g., parotiditis), ductal stone, or neoplasm
• Headache with radiation to the jaw
• Referred pain from cardiac, cervical spine, pulmonary, or throat disease
• Neuralgias (e.g., trigeminal, glossopharyngeal)
• Neuropathies
  –Systemic neuropathies (e.g., HIV, diabetes)
  –Dental/alveolar neuropathies, usually
  subsequent to extrinsic trauma (e.g., blow to face, dental surgical intervention)
• Behavioral disorders
• Primary neoplasms of the maxilla, mandible, or major salivary gland
• Metastases to mandible, maxilla, or TMJ
• Herpes zoster or post-herpetic neuralgia
• Fibromyalgia
• Rheumatologic disease (e.g., Sjögren's syndrome)
• Systemic arthritis (e.g., rheumatoid arthritis)

Workup and Diagnosis

• History and physical examination, with focus on the head and neck
  –Review onset, character, and pattern of pain; past medical and surgical history; associated symptoms (e.g., weight loss, sinus pain, skin complaints); and complete review of systems, including screening for local and systemic pathology and a cervical evaluation for muscle, neural, or skeletal referred pain
  –Perform a thorough oral exam of the buccal mucosa, lips, hard palate, soft palate, posterior pharynx, floor of mouth, and the top, sides, and undersurface of the tongue
  –Perform a head, neck, ear, nose, cardiac, pulmonary, and lymphatic exam
  –Suspect dental pathology until proven otherwise

• Initial workup is aimed at assessing the mouth and jaw for dental, periodontal, or TMJ disorders
• Appropriate laboratory studies are based upon the suspected diagnosis (e.g., CBC and ESR for temporal arteritis)
• Imaging studies may include Panorex films, sinus X-ray, CT scan, and/or MRI
• Therapeutic trial of medications (e.g., NSAIDs)
• Temporal artery biopsy is indicated if ESR elevated
• Biopsy any suspicious lesion
• Referral to a dental or medical specialist may be necessary

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

• Degenerative joint disease (osteoarthritis)
• Ligamentous injury
  –ACL: Positive Lachman (more sensitive) and anterior drawer test
  –PCL: Positive thumb sign (more sensitive) and posterior drawer test
  –MCL: Pain and/or increased laxity with valgus stress
  –LCL: Pain and/or increased laxity with varus stress
• Meniscus tear
  –Patient may complain of pain and locking; positive McMurray circumduction test
• Patellofemoral syndrome
• Iliotibial band syndrome
  –Pain along the lateral aspect of the knee accompanied by a palpable or audible snapping
  –Occurs almost exclusively in runners
• Pes anserine bursitis
  –Patients complain of pain along the medial aspect of the knee (at pes anserinus insertion)
  –Caused by repetitive movement that creates an inflammatory response
• Joint effusion
  –May be secondary to osteoarthritis, inflammatory arthritis, ligament injury, gout, pseudogout, or infection
• Joint infection (septic joint)
  –Staphylococcus aureus is most common
  –Neisseria gonorrhoeae is common in adolescents and young adults
  –Salmonella is common in sickle cell patients
  –Haemophilus influenzae is common in children
• Osteochondritis dissecans (OCD)
  –Osteonecrosis of subchondral bone
  –Most commonly seen in the knee
  –Patient reports a gradual onset of pain
  –Exam reveals tenderness of the affected area with manipulation
• In the pediatric population, consider Osgood-Schlatter disease, physeal injury, and discoid meniscus
• Hip or foot/ankle disease with referred pain to the knee
• Malignancy
• Osteomyelitis

Workup and Diagnosis

• History and physical examination are often diagnostic
  –Inspect the patient's gait for limitations of motion or other abnormalities
  –Visually assess symmetry between the knees: Note swelling, deformity, erythema, and muscle atrophy
  –Palpate: Note tenderness, warmth, and crepitus
  –“Milk the joint” to elicit an effusion
  –Test for range of motion (active and passive)
  –Perform McMurray circumduction test and ligament testing (e.g., Lachman test, anterior/posterior drawer tests, thumb sign, varus/valgus stress tests)
• X-rays are often indicated
  –AP, lateral, and merchant or sunrise films of both knees
  –When possible, also obtain weight-bearing A/P films
  –Merchant and sunrise X-rays of the patella are used to evaluate alignment and injury to the patella
  –On occasion, tunnel views of the knee are useful (e.g., for OCD)
• Joint aspiration should be performed in patients with joint effusions; fluid analysis includes cell count with differential, crystals, Gram stain, and culture
• MRI may not be necessary during initial evaluation, but may help with confirmation of specific injuries and surgical planning (e.g., PCL tear, meniscus tear, OCD)
• Bone scan may be used to evaluate malignancy or infection
• In some cases, blood work may include CBC, ESR, C-reactive protein, alkaline phosphatase, and uric acid

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Neck Stiffness/Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Trauma
  –Paraspinal neck stiffness: Commonly due to motor vehicle collisions (“whiplash”) or abnormal sleep posture
  –Cervical spine fracture with spasm of neck muscles
  –Subarachnoid hemorrhage: Most commonly due to ruptured cerebral aneurysm
  –Epidural hematoma
  –SCIWORCA: Spinal Cord Injury Without Radiographic Abnormality occurs in pediatric patients with ligamentous laxity and hypermobility of the cervical spine
  –Rotary atlantoaxial subluxation: Subluxation of the cervical spine at C1-C2 level, resulting in sternocleidomastoid spasm with tilting of the head toward the affected side and chin pointed toward the ipsilateral side
• Infection
  –Meningitis: Often bacterial (e.g., Neisseria meningitidis, Streptococcus pneumoniae) or viral (e.g., HIV, Epstein-Barr virus, enterovirus, herpes simplex virus)
  –Cervical lymphadenitis
  –Tonsillopharyngitis
  –Epiglottitis
  –Retropharyngeal abscess
  –Epidural abscess
  –Discitis
• Torticollis: Idiopathic sternocleidomastoid spasm, resulting in tilting of the head toward the affected side with the chin pointed to the contralateral side
• Inflammatory
  –Rheumatoid arthritis
  –Ankylosing spondylitis
  –Degenerative joint disease
• Tumors (especially leptomeningeal metastases)
• Dystonic reaction: Idiosyncratic drug reaction, often to psychiatric medications (e.g., haloperidol, prochlorperazine)

Workup and Diagnosis

• History and physical examination focusing on evidence of trauma and infection
  –All patients with possible traumatic injury should be maintained in a cervical collar and backboard until diagnostic workup is complete
• Initial labs may include CBC, electrolytes, BUN/creatinine, calcium, glucose, and ESR
• Blood cultures are indicated if infectious etiologies are suspected
• Lumbar puncture with CSF analysis is useful in cases of suspected infection or subarachnoid hemorrhage
• Cervical spine radiographs are indicated in trauma or neck infection (may reveal prevertebral soft-tissue swelling)
• Head CT scan without contrast may show bleeding in cases of subarachnoid hemorrhage (fails to reveal subarachnoid blood in 10% of cases)
• Neck CT scan may be indicated in suspected soft tissue disease (e.g., retropharyngeal abscess) or occult vertebral fracture if not adequately visualized on plain films
• MRI of the spine may be indicated in suspected epidural abscess or epidural hematoma

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pelvic Pain - Female: Differential Diagnosis
(In a Page: Signs and Symptoms)

Acute pain (<6 months)

• Pregnancy-related
  –Ectopic pregnancy
  –Threatened abortion
  –Incomplete abortion
  –Septic abortion
  –Ruptured corpus luteal cyst
• Gynecologic (noncyclic)
  –Ovarian cyst
  –Pelvic inflammatory disease
  –Tubo-ovarian abscess
  –Vaginitis/cervicitis
  –Ovarian torsion
  –Uterine fibroids
  –Pelvic (ovarian, uterine, urinary) neoplasm
  –Pelvic floor prolapse (cystocele/rectocele)
• Gynecologic (cyclic pain)
  –Primary dysmenorrhea
  –Endometriosis
  –IUD
  –Mittelschmerz (midcycle ovulation)
• Nongynecologic
  –Irritable bowel syndrome
  –UTI/pyelonephritis
  –Nephrolithiasis
  –Appendicitis
  –Diverticulitis
  –Sexual abuse/trauma
  –Abdominal aortic aneurysm
  –Mesenteric ischemia/infarction
• 
  Chronic pain (>6 months)
• Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
  –Pelvic adhesions
  –Interstitial cystitis
  –Inflammatory bowel disease
  –Adenomyosis
  –Leiomyoma (fibroids)
  –Hernia (femoral or inguinal)
  –Depression
  –Irritable bowel syndrome
  –Diverticulosis or diverticular abscess
  –Lymphoma
• Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria

Workup and Diagnosis

• History and physical examination
  –Note the nature, severity, onset, radiation, duration of pain; relation to menstrual cycle, intercourse, or other activities; chronic versus acute; chance of pregnancy
  –Note associated symptoms: Fever, nausea, vomiting, dysuria, frequency, vaginal bleeding/discharge, abdominal or back pain
  –Screen for domestic violence and sexual abuse
  –Full abdominal and pelvic exams, including speculum, bimanual, and rectal exam
• Laboratory studies may include urine pregnancy test, urinalysis, urine Gram stain and culture, cervical cultures for Chlamydia and gonorrhea, and wet mount of vaginal smear
• Consider ultrasound if ovarian cyst, torsion, or mass is suspected, or to evaluate for intrauterine versus ectopic pregnancy
• Diagnostic laparoscopy for acute abdomen or endometriosis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

• Trauma and sports related injuries
  –Acromioclavicular dislocation (“separated shoulder”)
  –Sternoclavicular dislocation
  –Glenohumeral dislocation
  –Proximal humeral fractures

• “Impingement syndrome”
  –Progressive degeneration and inflammation of the subacromial contents (rotator cuff and subacromial bursa) in part due to compression between the acromion and the head of the humerus
  –May result in rotator cuff tear

• Rotator cuff strain, tear, or rupture
  –May occur acutely (secondary to trauma) or, more commonly, due to a relatively mild (e.g., reaching overhead) insult to a chronically degenerative cuff
• Degenerative joint disease
• Tendonitis
• Subacromion and/or subcapsular bursitis
• AC joint inflammation
• Calcific tendonitis
  –Deposition of calcium crystals in the rotator cuff with resulting inflammation and severe pain
• Suprascapular nerve entrapment
• Bicipital tendonitis
• Adhesive capsulitis
  –Thickened, scarred joint capsule and “frozen shoulder” due to prolonged postinjury or postsurgery immobilization
• Cervical disc disease and radiculopathy
• Gout
• Pseudogout
• Connective tissue disease (e.g., rheumatoid arthritis, SLE)
• Brachial plexus injury
• Septic arthritis
• Referred pain from MI, cholecystitis, splenic injury
• Malignancy (e.g., apical lung)
• Lyme disease
• Fibromyalgia
• Thoracic outlet syndrome
• Reflex sympathetic dystrophy
• Rib dislocation/rib pain
• Acute axillary vein thrombosis

Workup and Diagnosis

• History and physical examination
  –Inspection for asymmetry, dislocation, or atrophy
  –Note range of motion, strength, sensory, crepitus, pain with passive and/or active motion
  –Perform a complete neurovascular exam
• Plain X-rays of shoulder; cervical spine films and chest X-ray may also be useful
• X-ray or CT scan may identify chronic, degenerative arthritis
• Shoulder MRI evaluates the anatomy of the rotator cuff and associated soft tissue; may differentiate partial from complete tears
• EMG can help discern nerve entrapments, cervical disc disease, or brachial plexus injury
• Diffuse shoulder or acromioclavicular pain may require workup for medical etiologies, including ESR, ANA, rheumatoid factor, and TSH

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Wrist & Hand Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Carpal tunnel syndrome
  –Most common cause of significant wrist discomfort and morbidity
  –Associated with repetitive use activities (e.g., typing)
  –Pain and numbness symptoms result from entrapment of the median nerve under the transverse ligament
• Overuse injury
• Osteoarthritis
• Tenosynovitis (DeQuervain's) of the radial wrist
  –Results from inflammation of the tendon sheaths of the extensor pollicis brevis and abductor pollis longus
  • Ganglion cysts
    –Common growths of tendons and ligaments in the wrist area occurring on both the dorsal and ventral surface
    –They are compressible, round, often tender, and mobile
  • Trauma
    –The most common mechanism of injury is a fall on the outstretched hand
    –The most commonly fractured carpal bone is the scaphoid
    –Other mechanisms include direct blows, crush injuries, fall on an angulated wrist, and severe twisting motions
  • Fibromyalgia
  • Compartment syndrome
  • Chest or shoulder masses, resulting in compression of lymphatic or venous systems
  • Venous thrombosis of the subclavian or distal veins
  • Flaccid paralysis following a CVA
  • Angioedema secondary to hymenoptera sting
  • Rheumatologic disease
  • Peripheral neuropathy
  • Insect or animal bite/sting
  • Infection (e.g., staphylococcus aureus, streptococci)

  Workup and Diagnosis

  • History and physical examination of the hand, wrist, elbow, and shoulder
    –Tinel's sign is positive if pain is elicited by tapping the anterior wrist
    –Phalen's sign is positive if wrist flexion for >30 seconds elicits pain or numbness
  • Lab investigation is usually unnecessary, but may include rheumatoid factor, ANA, ESR, CBC, uric acid, TSH, β-hCG (pregnancy test)
• Standard X-rays include PA, lateral, and oblique views
• EMG and nerve conduction studies are indicated if carpal tunnel syndrome or other neuropathy is suspected
• Arthrocentesis with crystal analysis may be indicated if warmth and redness are noted in the wrist and MCP joints
• Bone scan may be necessary to evaluate for avascular necrosis, occult fracture, or bone infection
• Rarely, CT or MRI is indicated
• Shoulder/chest CT may be indicated to evaluate for masses resulting in nerve entrapment or vascular compromise

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

• Inversion sprain (85% of ankle sprains)
  –Results in pain, swelling, and ecchymosis of the lateral malleolar area
  –Damage occurs to the three ligaments of inferior fibula (anterior and posterior talofibular and calcaneofibular ligaments) and peroneal muscle

• Degenerative joint disease
  –Pain is present upon waking in the
  morning; relieved by mild activity
  –Grinding/popping occurs with motion

• Inversion/eversion injury of subtalar joint
  –Results in pain while walking on uneven ground
• Syndesmosis injury (“high ankle sprain”)
  –Stretching of the interosseous membrane
  –Results in pain at the lower leg
• Avulsion fracture of the distal fibula
  –Results in persisting lateral malleolar pain
  –Difficult to differentiate from the
  epiphyseal line on X-ray
• Repetitive injury with disruption of the ankle retinaculum
  –Results in chronic pain of the posterior aspect of the ankle
• Poor shoe alignment
• Bimalleolar fracture
• Trimalleolar fracture: Bimalleolar fracture plus a fracture of the lateral aspect of the distal tibia
• Neoplasm
• Peroneal nerve entrapment
• Diabetic (Charcot's) arthropathy

Workup and Diagnosis

• History and physical examination
  –Ankle, foot, and lower leg examination
  –Always evaluate neurovascular status, including pulses, color, and capillary refill
  –Observation of bones and soft tissues, color, swelling
  –Anterior/posterior drawer test: Ankle is held in one hand and the lower tibia is pushed and pulled to evaluate for instability
  –Range of motion should be evaluate both actively and passively (grinding or popping suggests DJD)
• Ottawa ankle rules are used to determine whether an X-ray of
  the ankle is necessary following trauma
  –Tenderness of the distal 6 cm of the fibula or tibia
  –Tender navicular area
  –Tender proximal fifth metatarsal
  –Cannot bear weight (at least four steps)
• Standard three-view ankle X-rays, stress views (inversion or eversion), and consider foot series or lower leg series
• Lateral X-rays in plantar- or dorsiflexion may help evaluate for anterior or posterior impingement
• CT or MRI may be indicated to clarify findings on plain films and to evaluate cartilage, nerves, tendons, ligaments
• Muscle strength and range of motion testing

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Scrotal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Testicular torsion
  –Twisting of the spermatic cord and vessels, resulting in testicular ischemia
  –Patients present with an excruciatingly painful swollen testicle with or without a history of previous milder episodes (intermittent torsion)
  –May occur at any age (including in utero)

• Torsion of the appendix testis
  –May be difficult to distinguish clinically from testicular torsion
  –Typically, pain is less severe and the onset less acute (over several days as opposed to several hours)
  –Most common ages 7–12 years

• Testicular trauma
  –Blunt trauma occurs as saddle injuries, in sports such as soccer and baseball, and during altercations

• Epididymitis
  –Inflammation of the epididymis usually secondary to bacteria
  –Rare before puberty and often seen in sexually active young men with acutely swollen and painful testis
  –Pain is usually less acute in onset than torsion

• Inguinal hernia
  –Incarcerated inguinal hernia may present as a painful, edematous scrotum
• Orchitis
  –Inflammation of the testes due to viral infection; classically mumps
  –Patient presents with an acutely swollen, red testicle(s)
  –Uncommon since widespread vaccination
• Henoch-Schönlein purpura
  –Vasculitis characterized by palpable purpura usually in the lower half of the body
  –Painful testicular swelling can be a sign of this disorder
  • Varicocele
    –A collection of dilated veins in the scrotum
    –Usually painless, but occasionally patients may complain of chronic nagging pain and discomfort (especially during physical activity)
    –Presents after puberty

  Workup and Diagnosis

  • History
    –History of trauma, viral symptoms, rash
    –Sexual history and history of STDs
    –Past medical history of similar episodes
  • Physical exam
    –With testicular torsion, the absence of the cremasteric reflex is one of the most characteristic features; the affected testis is also often higher and more horizontal than the contralateral testis
    –In epididymitis and orchitis, elevation of the testis improves the pain, and the cremasteric reflex is usually preserved
    –In torsion of the appendix testis, a bluish dot may be seen in the superior portion of the affected testis
    –A hernia often can be felt extending from the inguinal area into the scrotum
    –A varicocele is described as feeling like a “bag of worms,” and is best examined with the patient standing
  • Urinalysis
    –Normal in patients with torsion
    –Pyuria is a feature of epididymitis
  • Doppler ultrasound is indicated for patients in whom the physical exam is not diagnostic; it may be bypassed by the surgeon in the interest of time when the exam is very specific for testicular torsion

» READ BOOK EXCERPT ONLINE »

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

Otalgia (Ear Pain): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

External ear

• Otitis externa
  –Pinnae and especially tragus, are exquisitely tender
• Impacted cerumen
  –Hearing loss and aural fullness
• Foreign body
  –Items such as beads, toys, and even extruded tympanostomy tubes
• Trauma
  –Any object inserted into the ear canal may cause trauma, including Q-tips
• Perichondritis
  –Inflammation or infection of the cartilage of the pinna and canal, sparing the lobule (since there is no cartilage there)
• Myringitis
  –Tympanic membrane granulation or de-epithelialization

Middle ear/mastoid
• Acute otitis media
  –Otalgia may precede middle ear effusion
• Otitis media with effusion
  –May occur in the absence or presence of an active infection
• Eustachian tube dysfunction
  –Negative intratympanic pressure
• Barotrauma
  –Pretreatment with topical nasal decongestants may be effective prophylaxis
• Mastoiditis
  –Associated with postauricular pain and normal tympanic membrane/middle ear

Non-otologic (secondary)
• Cranial nerve referred pain
  –III: Dental infection, temporal-mandibular joint (TMJ) syndrome
  –VII: Herpes zoster oticus (Ramsay Hunt syndrome)
  –IX: Tonsillitis, pharyngitis
  –X: Laryngitis, GERD, thyroiditis
• Cervical nerve referred pain
  –Neck infections, lymph nodes, cysts
  –Cervical spine disorders
• Paranasal sinusitis
• Migraines
• Neuralgias

Workup and Diagnosis

• History
  –Onset, duration, and specific quality of pain
  –Ability to localize (may distinguish otologic from nonotologic)
  –Associated otologic symptoms: Otorrhea, hearing loss, imbalance, prior ear surgery, antecedent events
  –Pain associated with mastication, swallowing, voice change, purulent rhinorrhea
• Otologic exam
  –Inspection and palpation of pinna, tragus, and preauricular area, and mastoid bone
  –Direct otoscopy for signs of external- or middle-ear infection or inflammation
  –Obstructing cerumen or foreign bodies must be removed to evaluate deeper structures
• Complete head and neck exam
  –Nose and nasal cavities, oral cavity, and pharynx (particularly teeth and tonsils), TMJ
  –Examination of nasopharynx and larynx may require fiberoptic endoscopy
• Tympanometry, if middle ear status (fluid, retraction, perforation) is not evident from otoscopy
• CT or MRI
  –Useful to delineate extent of cholesteatoma, mastoiditis, petrous apicitis, tumor
  –May be necessary to evaluate either otologic disease or an ill child with nonotologic source (rule out abscess or tumor)

» READ BOOK EXCERPT ONLINE »

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

Abdominal Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Epigastric pain

• Peptic ulcer disease/GERD
  –May be due to Helicobacter pylori or NSAID use
• Gallbladder disease
  –Most commonly with hemolytic disorders
• Pancreatitis
  –Trauma and idiopathic are common causes

Periumbilical pain
• Functional abdominal pain/IBS
  –Most common cause of nonorganic pain
  –Occurs in children 3–15 years old
• Appendicitis
  –Periumbilical pain moves to RLQ
• Gastroenteritis (virus, bacteria, parasite)
• Carbohydrate intolerance
  –Lactase, fructase, trehelase deficiency
• Abdominal migraine
• Drugs
  –Antibiotics, anticonvulsants, bronchodilators
• Small bowel bacterial overgrowth
• Streptococcal pharyngitis
  Suprapubic pain
• Urinary tract infection
  –With dysuria, fever, foul-smelling urine
  –Pyelonephritis may have CVA tenderness
• Constipation
  –Accounts for 3% of visits to pediatrician
  –May have a palpable fecal mass
• Urinary retention
• Hydrometrocolpos
  –Associated with imperforate hymen
  –Cyclic pain with onset of menstrual cycle

Right lower quadrant pain
• Appendicitis
• Ovarian torsion
• Pelvic inflammatory disease
• Ectopic pregnancy
• Mittelschmerz
  –Pain midcycle with ovulation
• Inflammatory bowel disease
  –Classic for terminal ileal Crohn disease
• Iliopsoas abscess
• Inguinal hernia
• Right lower lobe pneumonia

Workup and Diagnosis

• History
  –Type of pain, location, radiation, duration
  –Relieving and worsening factors including foods
  –Awakens from sleep, activity level, emesis, diarrhea
  –Nausea, hematochezia, melena, fever, dysuria, hematuria
  –Sexual activity, anorexia, headache, cough, rashes
  –Stool frequency, joint complaints
• Surgical history: Previous abdominal surgery
• Social history: Stressors, changes in school or family
• Physical exam
  –Height, weight, temperature, pulse
  –General appearance, hydration status
  –Pharyngeal erythema/exudates, abdominal tenderness
  –Psoas sign, obturator sign, palpable masses
  –Rectal exam including hemoccult
  –Rashes, joint swelling, vaginal exam
• Labs: Geared toward history and physical findings
  –Consider CBC with differential, urinalysis, and culture
  –stool for culture and O&P
  –Amylase and lipase, LFTs, H. pylori antibody (IgG)
  –Hydrogen breath test for sugar intolerance
  –Pregnancy test, vaginal cultures
  –Throat culture
• Consider KUB or obstruction series
• Abdominal CT scan with contrast versus ultrasound
• Pelvic ultrasound for torsion, ectopic pregnancy, abscess, hydrometrocolpos

» READ BOOK EXCERPT ONLINE »

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

Back Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Muscular strain, disk herniation
  –Most common in adolescents who are involved in competitive or contact sports; may be occupational
• Spondyloarthropathy
  –Ankylosing spondylitis is found primarily in boys, characterized by sacroiliitis, LE oligoarthritis, and may be associated with IBD
  • Malalignment
    –Scoliosis: Idiopathic form is most common in girls, may be familial, may be secondary to neurologic disorder
    –Hyperlordosis
  • Infectious
    –Diskitis: Characterized by spine stiffness and muscular spasm, Staphylococcus aureus is the usual pathogen, blood culture may be positive
    –Vertebral osteomyelitis: Exquisite point tenderness, pathogen may be S. aureus, Streptococcus pneumoniae, or others such as tuberculosis or brucellosis
    –Acute transverse myelopathy: Generally follows an upper respiratory tract infection; characterized by back pain, distal weakness and paresthesias at the midthoracic level
  • Urinary tract
    –Urinary tract infection: Most common in postpubertal girls, occurrence in boys or prepubertal girls may require evaluation for urinary tract anomalies, especially if recurrent
    –Urolithiasis: Associated with hypercalcuria, cystinuria, Lesch-Nyhan; characterized by intense flank pain and hematuria
  • Malignancy
    –Primary spinal cord or column tumors (osteogenic sarcoma, neuroblastoma)
    –Metastatic tumors (neuroblastoma)
    –Bone marrow infiltration (leukemia, lymphoma)
  • Gynecologic
    –Menstrual cramps
    –PID
    –Endometriosis

  Workup and Diagnosis

  • History
    –Onset, duration, location of symptoms
    –History of trauma, heavy lifting, overuse, athletics
    –Systemic symptoms such as fever, irritability
    –Menstrual and sexual history
    –Past medical history of similar complaints, orthopedic conditions, general medical conditions
    –Family history of scoliosis, rheumatic disease
  • Physical exam
    –General appearance, fever, irritability
    –Spinal contour, symmetry
    –Gait, posture
    –Range of motion limitations
    –Point tenderness, SI tenderness
    –Associated neurologic findings (sensation, strength, DTRs)
  • Labs
    –If rheumatologic condition is suspected, consider CBC, ESR, ANA, RF, HLA typing
    –If infectious process is suspected, obtain CBC, ESR
    –Urine microscopy and culture
  • Studies
    –Plain films can reveal fractures such as spinal compression fractures, disk space abnormalities, and sacroiliac abnormalities associated with spondyloarthrosis
    –MRI may be required to discover disk herniation, disk space infection, tumors

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

Chest Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Musculoskeletal
  –Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
  –Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
  –Injury to chest wall

• Pulmonary
  –Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
  –Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
  –Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
  –Pneumonia: Chest pain secondary to cough or pleural involvement
  –Pneumothorax can occur spontaneously, especially in tall, thin athletes

• Gastrointestinal
  –GERD and PUD: Burning, substernal pain with eating, worse at night
  –Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis

• Cardiac: Rare in children
  –Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
  –Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
  –MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
  –Aortic dissection: Consider if features or history of Marfan syndrome is present

Workup and Diagnosis

• History
  –Activity at onset, (chest pain with exercise is a red flag!), precipitating/relieving factors, quality of pain (sharp vs dull)
  –Associated symptoms (shortness of breath, diaphoresis, cough/wheeze, nausea/vomiting), recent illness, response to eating, sleeping, different foods (caffeine, chocolate, spicy, or high-fat foods)
  –Personal/family history of asthma, allergies, eczema
  –Recent diagnosis of heart disease or death in a family member often generates fear in the patient or parent, prompting the evaluation of chest pain
  –Social history: Recent life stressors (school problems, family discord, etc.); drug use, especially cocaine
• Physical exam
  –Reproducible with palpation likely musculoskeletal
  –Chest exam: Wheezing, rales, crepitus
  –Cardiac exam: Usually normal, even with cardiac causes; pericarditis is associated with rub
• Chest X-ray for infiltrates, pneumonia, pneumothorax
• ECG and cardiac enzymes are rarely required but relatively inexpensive and readily available, and can rule out MI and provide reassurance for families
• Cardiac stress test
  –Continuous ECG monitoring while the patient exercises to evaluate for coronary insufficiency
  –Used for patients with exercise-induced chest pain and/or coronary abnormalities

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

Hip Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthitis
  –Surgical emergency due to irreversible chondrolysis and epiphyseal injury
  –Acute process leading to decreased hip range of motion, severe pain with passive range of motion
• Slipped capital femoral epiphysis (SCFE)
  –Typically in obese, adolescent males with aching groin, hip, or knee
  –May have externally rotated hip position and gait
• Legg-Calvé-Perthes
  –Presents at younger age than SCFE (3–8 years old)
  –Five times greater incidence in boys than girls
  –Pain in hip or knee, decreased active and passive ROM, and Trendelenburg gait
• Developmental dysplasia of the hip (DDH)
  –Early diagnosis with newborn exam finding of easily dislocatable hip
  –Older infants have limited hip abduction
• Osteomyelitis
  –Vague symptoms may make this a difficult diagnosis
  –Limp, fever, pain in the proximal thigh or pseudoparalysis of an extremity in an infant may be the only sign
• Fracture
  –Consider accidental and nonaccidental trauma
  –Pain, limited ambulation, limited active and passive ROM, or inability to bear weight
• Transient monoarticular synovitis
  –Often preceded 1–2 weeks by upper respiratory infection
  –Antalgic gait, moderate pain in hip, groin, or knee, and uncomfortable range of motion
• Neoplasia
  –Although primary bone disorders do not generally present with hip pain, other malignancies such as acute leukemia may initially present with bone or joint pain
• Vertebral osteomyelitis/diskitis
  –Referred pain from lumbrosacral region may present as hip pain

Workup and Diagnosis

• Despite urgency of surgical emergencies, a thorough history is essential
  –Onset and duration of symptoms, location, and character of pain
  –Previous trauma, preceding illness, or associated symptoms
  –Past medical history/family history: Bone, hematologic, and metabolic disorders
• Labs
  –CBC with differential, platelets, PT/INR, ESR, CRP

• Radiographic evaluation
  –Plain X-ray: AP pelvis and frog-leg lateral of the pelvis, full length femur, and knee films
  –CT scan: Helps define bony anatomy especially with 3D reconstruction images
  –MRI may demonstate joint effusion in synovitis and infection, marrow edema in osteomyelitis, physeal widening in SCFE, or occult fracture such as femoral neck stress fracture
  –Ultrasound for newborn DDH

• Nuclear medicine
  –Triple-phase bone scan may be helpful when the diagnosis is questionable, or if differentiating between bone and joint infections
• Interventional radiology
  –Joint aspiration to evaluate for septic arthritis

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

Knee Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthritis
  –Characterized by redness, swelling or effusion, warmth, pain with active and passive ROM, fever or chills
  –Requires urgent evaluation and diagnosis

• Osgood-Schlatter disease (OSD)
  –Repetitive microtrauma to the bone-tendon junction where patellar tendon inserts into the secondary ossification center of the tibial tubercle
  –Onset at early adolescence, more often in athletes

• Sinding-Larsen-Johansson disease
  –Similar to OSD, except localized to distal pole of the patella

• Meniscal pathology
  –Meniscal tears are usually associated with acute trauma, and involve pain and swelling with mechanical symptoms such as popping, clicking, or locking
  –Discoid meniscus: Mechanical symptoms and plain X-rays show squaring, widening, and cupping

• Ligamentous injury
  –Medial collateral ligament sprain via overuse injury or valgus force to knee
  –Anterior cruciate ligament tear associated with sport noncontact pivoting injury, associated with a “pop” and immediate swelling
  –Posterior cruciate tear associated with direct trauma to anterior tibia or hyperflexion with plantar flexed foot
  –Lateral collateral ligament injury is rare

• Osteochondritis dissecans
  –Trauma resulting in separation of subchondral bone and cartilage at lateral aspect of medial femoral condyle
• Patellar subluxation/dislocation
  –Lateral displacement of patella associated with increased Q angle, genu valgum, and femoral anteversion (more common in women)
• Bursitis
  –Chronic friction over pes anserine, iliotibial band, or capsular bursa leads to inflammation and thickening of the bursa
• Bipartite patella
  –Common variant of patellar ossification

Workup and Diagnosis

• History
  –Specific location, duration, onset, aggravating or alleviating factors, and pain characteristics
  –Previous trauma, preceding illness, or associated symptoms
  –Past medical history and family history including bone, hematologic, or metabolic disorders
• Physical exam
  –Bilateral hip, knee, and ankle exam
  –Redness, warmth, effusion, active and passive ROM
  –Palpate joint line, patella, tibial tubercle, pes anserine, and medial/lateral ligaments
  –Patella tracking or apprehension, varus/valgus stress, Lachman, and anterior posterior drawer tests
  –Crepitus along the flexion arc and McMurray test
• Labs
  –Often not needed unless concerned about infection
  –CBC with differential, platelets, PT/INR, ESR, CRP
  –Knee aspirate for cell count and differential with Gram stain, culture, and crystals
• Radiography
  –Plain X-ray: Screening knee films include AP, lateral, Merchant views
  –AP pelvis and frog-leg lateral of the pelvis or femur films if indicated by exam findings
• MRI to show soft tissues such as meniscus and ligaments
  –May demonstate joint effusion in synovitis/infection, marrow edema in osteomyelitis, ligament rupture

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

FOOT, HEEL, AND TOE PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Special considerations in the approach to the diagnosis of foot pain include examining the shoes for abnormal areas of wear and tear, measuring the arches, palpating the joints for maximal tenderness, and ordering laboratory tests for joint disease (page 341). Nerve blocks and lidocaine injections in the plantar fascia and other areas of maximum tenderness will assist in diagnosis. Abnormal weight distribution is diagnosed by quantitative scintigraphs. A therapeutic trial of proper-fitting shoes and arches may be indicated. Weight control is essential in the obese. Referral to a podiatrist or orthopedic surgeon is often necessary.

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Source: Differential Diagnosis in Primary Care, 2007

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

In cases of hypogastric pain, it is most important to do a good pelvic and rectal examination. Because the most common cause of hypogastric pain is cystitis or other urinary tract infection, it is essential to examine the urine (personally) and to do a culture sensitivity and colony count regardless of the findings on routine urinalysis. A vaginal culture should also be done in females on special media for Chlamydia and gonococcus to help rule out PID. Urethral smear and culture is done if there is a urethral discharge. Acute hypogastric pain may require a flat plate of the abdomen, CBC, chemistry panel, and amylase level depending in the seriousness of the patient’s condition. A general surgeon may need to be consulted. Ultrasonography may be ordered to further evaluate any suspicious pelvic mass. A pregnancy test should be ordered in women of childbearing age. Three conditions that must be ruled out in the female patient are ruptured ectopic pregnancy, PID, and endometriosis. That is why a gynecologist should be consulted early if these conditions are suspected in the acute cases. Chronic cases may need an IVP and cystoscopy if a urinary tract infection, stone, or neoplasm is suspected. If a problem in the lower bowel is suspected, colonoscopy or barium enema may be necessary. If there is any question about a perforated bowel or mesenteric infarction, a CT scan of the abdomen and pelvis should be done first.

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Source: Differential Diagnosis in Primary Care, 2007

ABDOMINAL PAIN, GENERALIZED: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

If the onset is acute, a general surgeon should be consulted at the outset. Ominous signs include boardlike rigidity, rebound tenderness, and shock with nausea and vomiting. Hyperactive bowel sounds of a high-pitched tinkling character with distention and obstipation suggest intestinal obstruction. On the other hand, normal bowel sounds, little distention, good vital signs, and minimal tenderness suggest gastroenteritis or other diffuse irritation of the bowel.

It is wise to pass a nasogastric tube and attach to suction and proceed with a CBC, urinalysis, an immediate flat plate and upright of the abdomen, chest x-ray, serum amylase and lipase levels, and chemistry panel. Sometimes, lateral decubitus films are necessary to reveal the stepladder pattern of intestinal obstruction. A pregnancy test should be ordered if age and gender dictates it.

If these tests fail to confirm the clinical diagnosis and the patient’s condition is deteriorating, it is probably wise to proceed with an exploratory laparotomy immediately. If the patient’s condition is stable, one may order more diagnostic tests depending on the location of the pain and other symptoms and signs. For example, if the pain seems more localized to the RUQ, a gallbladder ultrasound or nuclear scan may be ordered. If it is still considered generalized, perhaps a CT scan of the abdomen and pelvis is indicated. Monitoring vital signs and doing repeated CBCs, serum amylase levels, and flat plates of the abdomen are useful in borderline cases.

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Source: Differential Diagnosis in Primary Care, 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 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.

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Source: Differential Diagnosis in Primary Care, 2007

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

The association of other symptoms and signs found on a good history and physical examination is most important in pinpointing the diagnosis. Thus, arm pain with tenderness and limitation of motion at the elbow suggests tennis elbow, gout, or rheumatoid arthritis. Arm pain with loss of sensation in the distribution of the median nerve suggests carpal tunnel syndrome. Injection of lidocaine into bursa or trigger points may be diagnostic.

The laboratory workup should include x-rays of the involved area and of the cervical spine, especially if there is a radicular distribution of the pain. If there are focal neurologic signs, a neurologist should be consulted before ordering an MRI: A cervical rib will not be missed in this way. An ECG and myocardial enzymes may be necessary to exclude a myocardial infarct, and an exercise tolerance test will help exclude coronary insufficiency. Arteriogram, phlebogram, lymphangiogram, electromyogram (EMG) with nerve conduction studies, myelogram, and nerve blocks will be necessary in specific cases.

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Source: Differential Diagnosis in Primary Care, 2007

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

The diagnosis of a painful breast is usually made by taking a careful history. What drugs are the patient taking? Associated symptoms and signs (see sections on bloody discharge, page 90 and swelling, page 92) are also important. A culture of the discharge, mammography, and serum, estrogen, and prolactin levels may be important, but referral to an endocrinologist is wise when the history does not provide a simple solution, especially when the pain is bilateral. Biopsy (frozen section) is necessary when tumor is suspected and mammography is equivocal, because faith in mammography has declined somewhat in recent years.

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Source: Differential Diagnosis in Primary Care, 2007

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

A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there are significant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often be necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done to rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

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Source: Differential Diagnosis in Primary Care, 2007

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

In the approach to the diagnosis, the traumatic conditions and arthritic disorders will probably stand out. A diagnostic dilemma occurs when the elbow looks normal and has good movement. Nevertheless, most of these cases are caused by tennis elbow, myositis, and fasciitis. Thus, a simple injection at the trigger point will assist the diagnosis and give the patient immediate and sometimes lasting relief. If this is unsuccessful, referral to an orthopedic surgeon is wise.

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Source: Differential Diagnosis in Primary Care, 2007

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

The approach to the diagnosis of midepigastric pain is identical to that for generalized abdominal pain (see page 22).

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Source: Differential Diagnosis in Primary Care, 2007

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

The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tenometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.

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Source: Differential Diagnosis in Primary Care, 2007

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

The approach to the diagnosis of face pain includes a careful history and physical with a good neurologic examination. The sinuses are transilluminated and x-rays may be performed. The teeth and occlusion are examined carefully and possibly x-rayed. A histamine test may be indicated. The busy physician may want to refer the patient to a neurologist immediately, but this will obviously take away the challenge.

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Source: Differential Diagnosis in Primary Care, 2007

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

The diagnosis of flank pain usually involves careful examination of the urine and a urine culture, an IVP, and plain films of the abdomen and spine. If these are negative, bone scans, arteriogram, and other tests listed below may be required. CT has eliminated the need for exploratory laparotomy in many cases.

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Source: Differential Diagnosis in Primary Care, 2007

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

In the approach to the diagnosis of groin pain, a mass or tender structure is usually present in the groin. If the mass is a lymph node, careful examination of the genitalia and lower extremities will often show the cause, but a urethral or vaginal smear and culture may be necessary to show gonorrhea. Investigation of the genitourinary (GU) tract and the GI tract for causes of referred pain is then undertaken, if the mass is reducible a hernia is likely and referral to a surgeon is in order. Incarcerated hernias, of course, demand immediate referral.

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Source: Differential Diagnosis in Primary Care, 2007

HAND AND FINGER PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

In diagnosis, most of these conditions will be obvious on inspection. The difficulty arises when the hand looks normal. Then one must check for the following:

1. Carpal tunnel syndrome by tapping the volar aspect of the wrist (Tinel sign)
2. Brachial plexus neuralgia and scalenus anticus syndrome by Adson tests
3. Causalgia by stellate ganglion block to see if pain is relieved
4. Cervical spine disease by a roentgenogram, possibly a myelogram or MRI, and nerve blocks of the various roots. Referral to a neurologist is often necessary. In early rheumatoid arthritis, the joints may be normal on inspection but pain and stiffness of the hands and fingers in the morning is an excellent clue.

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Source: Differential Diagnosis in Primary Care, 2007

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

The history and physical examination will allow differentiation of many of the conditions listed above. For example, the history of trauma suggests sprain, fracture, or contusion. Remember fractures of the hip can occur in the elderly without a history of trauma. A positive straight leg raising (SLR) test suggests a herniated disc or other cauda equina pathology. X-ray of hip and lumbosacral spine will help rule out fracture or osteoarthritis but CT scan, bone scan, or an MRI may be necessary. If x-rays and laboratory examinations are negative, a trial of lidocaine injections into the greater trochanter bursa or other trigger points may be diagnostic.

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Source: Differential Diagnosis in Primary Care, 2007

Breast pain [Mastalgia]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it's intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a nursing mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced flulike symptoms or sustained injury to the breast? Has she noticed a change in breast shape or contour?

Ask the patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?

Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient's arms raised above her head and then with her hands pressed against her hips.

Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Common causes and associated findings.)

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

Abdominal pain: History and physical examination

(Handbook of Signs & Symptoms (Third Edition))

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests that the patient may have obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last period, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was the last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Common causes and associated findings, pages 14 to 17.)

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

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

If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right upper quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts movement. Also ask if heat, rest, or drugs relieve it. Finally, ask about preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

If a patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Common causes and associated findings.)

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

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

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient's expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin color, especially in the patient's legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient's posture if pain doesn't prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski's reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜" (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, position the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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

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

If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.

Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Common causes and associated findings, pages 136 and 137.)

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

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

If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

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

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

If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

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

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

Begin the patient history by asking him to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, a headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders such as chest pain in a patient with an MI.)

Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛" (3 cm) or more than 2⅜"  (6 cm) between the upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

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

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

If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he’s taking and whether they have helped to relieve his leg pain.

Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient’s range of motion (ROM) in the hip and knee. Also, check reflexes with the patient’s leg straightened and raised, noting action that causes pain. Then compare both legs for symmetry, movement, and active ROM. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit associated pain.

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

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

If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Common causes and associated findings, pages 432 and 433.)

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

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

If the patient reports rectal pain, inspect the area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.

After the examination, proceed with your evaluation by taking the patient’s history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Make sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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

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

Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate. Obtain an exudate specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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

Pain disorder: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

For characteristic findings in patients with this condition, see Diagnosing pain disorder, page 476.

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

Complex regional pain syndrome: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

There’s no laboratory test for CRPS, so the diagnosis is based on the patient’s history and clinical findings. A history of injury to an extremity may point to CRPS. Bone X-rays may aid in ruling out other conditions, such as osteomyelitis and stress fractures, which cause similar signs and symptoms. Additional tests may include bone scans, nerve conduction studies, and thermography (a test to show temperature changes and lack of blood supply in the painful area of the affected limb). With early diagnosis, prognosis improves.

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

Breast pain [Mastalgia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it’s intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a breast-feeding mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced any flulike symptoms or sustained an injury to the breast? Has she noticed any change in breast shape or contour?

Ask your patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?

Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient’s arms raised above her head and then with her hands pressed against her hips.

Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Causes and associated findings, page 134.)

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

Eye pain [Ophthalmalgia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s eye pain doesn’t result from a chemical burn or from acute angle-closure glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of severe pain that developed suddenly. Does he have headaches? If so, find out how often and at what time of day they occur.

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the eyelids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 322.)

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

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

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain—for example, is it dull, sharp, stabbing, or burning? Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have an obstruction of a hollow organ.

If pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient the date of her last menses and if she has had changes in her menstrual pattern or dyspareunia.

Also ask about appetite changes and the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Perform a physical examination. Take the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

Auscultate for bowel sounds and characterize their motility. Percuss all quadrants, noting the percussion sounds. Palpate the entire abdomen for masses, rigidity, and tenderness. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. (See Abdominal pain: Causes and associated findings, pages 16 to 21.)

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

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

If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right-upper-quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts any movements. Also ask if heat, rest, or drugs relieve it. Finally, ask about any preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

Next, perform a focused examination. Observe the way the patient walks, sits, and holds his arm. Inspect the entire arm, comparing it with the opposite arm for symmetry, movement, and muscle atrophy. (It’s important to know if the patient is right- or left-handed.) Palpate the entire arm for swelling, nodules, and tender areas. In both arms, compare active range of motion, muscle strength, and reflexes.

If the patient reports numbness or tingling, check his sensation to vibration, temperature, and pinprick. Compare bilateral hand grasps and shoulder strength to detect weakness.

If the patient has a cast, splint, or restrictive dressing, check for circulation, sensation, and mobility distal to the dressing. Ask the patient about edema and if the pain has worsened within the last 24 hours.

Examine the neck for pain on motion, point tenderness, muscle spasms, or arm pain when the neck is extended with the head toward the involved side. (See Arm pain: Causes and associate findings.)

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

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

If life-threatening causes of back pain are ruled out, continue with a complete history and physical examination. Be aware of the patient’s expressions of pain as you do so. Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescription and over-the-counter drugs.

Next, perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask about unusual sensations in the legs, such as numbness and tingling. Observe the patient’s posture if pain doesn’t prohibit standing. Does he stand erect or tend to lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk—first on his heels, then on his toes; protect him from falling as he does so. Weakness may reflect a muscular disorder or spinal nerve root irritation. Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. Evaluate the strength of the extensor hallucis longus by asking the patient to hold up his big toe against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜” (1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, place the patient in a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica. Also, note the range of motion of the hip and knee.

Palpate the flanks and percuss with the fingertips or perform fist percussion to elicit costovertebral angle tenderness.

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

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

If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.

Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated findings, pages 164 to 167.)

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

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

Begin by characterizing the patient’s facial pain. Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or worsens it? Ask the patient to point to the painful area. If facial pain is recurrent, have him describe a typical episode. Review his medical and dental history, noting especially previous head trauma, dental disease, and infection.

Carefully examine the face and head. Inspect the ear for vesicles and changes in the tympanic membrane to rule out referred ear pain. Inspect the nose for deformity or asymmetry. Evaluate the condition of the mucous membranes and septum as well as the size and shape of the turbinates. Characterize any secretions. Palpate the frontal, ethmoid, and maxillary sinuses for tenderness and swelling.

Evaluate oral hygiene by inspecting the teeth for caries, percussing any diseased teeth for pain, and asking the patient about any sensitivity to hot, cold, or sweet liquids or foods. Have him open and close his mouth as you palpate the temporomandibular joint for tenderness, spasm, locking, and crepitus.

Examine the function of cranial nerves V and VII. To evaluate cranial nerve V, instruct the patient to clench his teeth. Then palpate the temporal and masseter muscles and evaluate muscle contraction. Test pain and sensation on his forehead, cheeks, and jaw. Next, test the corneal reflex by lightly touching the cornea with a piece of cotton.

To evaluate cranial nerve VII, inspect the face for symmetry and then have the patient perform facial movements that demonstrate facial muscle strength—raising his eyebrows, frowning, showing his teeth, closing his eyes tightly, and wrinkling his nose. (See Major nerve pathways of the face.)

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

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

If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

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

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

Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)

Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth? Less than 1 ⅛” (3 cm) or more than 2⅜” (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

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

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

If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask what medications he’s taking and whether they have helped to relieve his leg pain.

Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient’s range of motion in the hip and knee. Also, check reflexes with the patient’s leg straightened and raised, noting any action that causes pain. Then compare both legs for symmetry, movement, and active range of motion. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit any associated pain.

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

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

If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there is not a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings, pages 548 to 551.)

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

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

If your patient reports rectal pain, inspect the area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Check for inflammation and other lesions. A rectal examination may be necessary.

After examination, proceed with your evaluation by taking the patient’s history. Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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

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

Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

Next, carefully examine the pharynx, noting redness, exudate, or swelling. Examine the oropharynx, using a warmed metal spatula or tongue blade, and the nasopharynx, using a warmed laryngeal mirror or a fiber-optic nasopharyngoscope. Laryngoscopic examination of the hypopharynx may be required. (If necessary, spray the soft palate and pharyngeal wall with a local anesthetic to prevent gagging.) Observe the tonsils for redness, swelling, or exudate; if exudate is present, obtain a specimen for culture. Then examine the nose, using a nasal speculum. Also, check the patient’s ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

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

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

 A. Trauma rarely causes significant damage to the testicle. Traumatic damage is extremely rare in prepubertal patients (4). Unless the testicle is ruptured or a secondary torsion occurs, pain from trauma usually resolves in less than 1 hour (4). Severe pain or evidence of testicular rupture associated with minor trauma is suggestive of occult tumor (1,4).

 B. Symptoms and disease course

1. Testicular torsion is the most common cause of scrotal pain in first year of life (3). It is frequently misdiagnosed as colic, or an intraabdominal disorder. The highest incidence occurs between the ages of 12 to 18 years (5). Testicular torsion causes acute pain with testicular swelling and scrotal erythema, and nausea and vomiting are common.

2. Torsion of testicular appendage. Torsion is common between the ages of 10 to 15 years; however, it is rare in neonates and adults (5). Pain can last several days with malaise and may not localize to the scrotum initially, but presents as lower abdominal pain.

 3. Epididymitis is the most common cause of acute scrotal pain in adults (1). It is rare in prepubertal children (5). In infants or young children, suspect urogenital anomaly or dysfunction (3). The onset can be abrupt or insidious. Fever, voiding symptoms, or both are common (4). Scrotal edema and erythema can occur, but less commonly than that seen with torsion (5).

 4. Orchitis is usually caused by extension of epididymitis inflammation to the testis (4). Mumps orchitis, which is seen only after puberty in 20% of mumps cases, is usually unilateral (70%). It is declining in the United States because of immunization (5).

 C. Sexual activity is an important factor in all age groups. In prepubertal children, rule out abuse or self-experimentation. In adolescents and adults, infection and trauma can occur from sexual practices. A good history is especially important.

D. Recurrent pain. A history of previous ipsilateral pain is associated with a 44% incidence of testicular torsion (1). Consider multiple causes. Is previous pain similar or different from the current episode?

 E. Infection. Look for a history of urinary tract infection (UTI), dribbling, urgency, dysuria, and incomplete emptying (Chapter 10.1). Consider reflux, obstruction, chronic prostatitis, and unusual sexual practices.

 F. Concurrent illness. Possibilities include Henoch–Schönlein purpura, mononucleosis, Buerger’s disease, coxsackie B virus, and polyarteritis nodosa (1,4). Also consider incarcerated hernia or thrombosed varicocele (1).

Physical examination

 A. Observation. Especially in the very young, it is important to quietly observe the patient before initiating an examination (4). Is he quiet or active? Playing or fussing? Is there guarding?

 B. Referred pain. The neonate or young child with abdominal pain always deserves an examination of the scrotum (2,4).

C. Scrotum. Edema and redness are found in torsion and epididymitis. They occur early in testicular torsion. If pain is present longer than 24 hours and no scrotal changes are noted, torsion is unlikely (4). Discoloration suggests trauma but it can also be seen with delayed diagnosis of torsion and epididymitis. Check for the cremasteric reflex, which rules out testicular torsion if present on the painful side (2,4). Its presence must be demonstrated on the nonpainful side to be reliable indicator. Unilateral swelling without skin changes suggests hernia or hydrocele (4). In torsion, pain increases when the scrotum is elevated; it decreases with epididymitis (Prehn’s sign) (5) (Chapter 10.7).

D. Penis. Look for discharge, redness, and trauma. Partial hypospadius suggests possible other genitourinary anomalies. A higher incidence of UTI is seen in the uncircumcised neonate.

 E. Testes. Are they present or absent? Examine the inguinal canal. Evaluate for high versus low, transverse versus vertical lie. High, transverse testicle suggests torsion (4). Evaluate size, shape, and tenderness. The testicle with torsion will become swollen early in the process, however, the appendage with torsion does not cause a difference is testicular size (2). Feel and look for a palpable mass on the margin of the testis. Transilluminate for the “blue dot sign” to diagnosis torsion in the appendage (4,5). Does tenderness involve the entire testicle or is it asymmetric (4)?

 F. Other. Rule out other causes, examine skin for petechiae, and look for adenopathy. Examine the abdomen and flank for a source of referred pain or signs of trauma. Fever is not usually present with a testicular torsion (unless delayed), but can be found in epididymitis (4).

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

Chest Pain, Atypical: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of the chest pain. Important questions to ask: What is the quality of pain? Where is it located? What is its duration and intensity? What symptoms accompany the pain? Does anything trigger the chest pain or make the pain better or worse? Is there any relationship between exertion and the pain?

 B. Determining the likelihood of ischemic heart disease. Four major features in the initial history and physical examination can be used to determine the likelihood of IHD. They are in order of importance:

 1. Angina description (definite angina, probable angina, probably not angina, and not angina).

 2. Prior myocardial infarction [by history, or electrocardiographic (EKG) findings].

3. Age (risk of IHD increases with age).

4. Number of risk factors (e.g., diabetes, smoking, hypercholesterolemia, and hypertension).

 C. Features suggesting nonanginal pain. Features suggesting nonanginal pain include pleuritic pain (sharp or knifelike pain brought on by respiratory movements or cough), pain localized with one finger, pain reproduced by movement or palpation of the chest wall or arms, constant pain lasting for days, and very brief episodes of pain lasting a few seconds (1).

 D. Other key considerations. Key considerations in the history include the following:

1. All presentations of chest pain should be taken seriously until proven to be benign.

2. The description of pain can be greatly influenced by socioeconomic status, education, culture, and personality.

3. A review of cardiac risk factors is appropriate for all patients who present with chest pain.

4. Red flags suggesting a noncardiac, life-threatening condition include tachypnea, dyspnea, and hypoxemia.

5. Sharp, stabbing, or pleuritic qualities do not completely exclude an ischemic cause (Chapter 8.5). In the Multicenter Chest Pain Study, IHD was diagnosed in 22% of patients coming to the emergency room with a sharp quality pain (2).

Physical examination

No reliable physical signs can be used to determine whether a patient with atypical chest pain has ischemic heart disease. The main purpose of the examination is to assess the patient for evidence of complications from atherosclerotic disease (e.g., peripheral vascular disease, cerebrovascular disease, and congestive heart failure). Pay attention to findings on the vascular examination (e.g., peripheral artery bruits, retinal arteriolar changes, the presence of a cardiac gallop) and for signs of the consequences of diminished myocardial contractility (e.g., lower extremity edema or pulmonary crackles) (Chapter 7.5).

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

Chest Pain, Substernal: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of pain in stable angina

 1. Quality. The pain of angina pectoris is often not described as a pain at all. Instead, it is frequently referred to as a squeezing, heaviness, or pressure sensation lasting 5 to 10 minutes. Diaphoresis, dyspnea, nausea, and vomiting often accompany the discomfort. Pain that is sharp, stabbing (especially if exacerbated by deep inspiration), pain reproducible with chest wall palpation, and pain lasting seconds or days to weeks is less likely to be from CAD.

 2. Location. Generally, angina is poorly localized in the retrosternal area, anterior chest, or epigastrium and typically radiates to the left arm, neck, or jaw.

 3. Precipitating and alleviating factors. Angina is often precipitated by conditions that increase myocardial oxygen demand, most commonly physical exertion, emotional stress, or cold weather. It is relieved promptly with rest or sublingual nitroglycerin.

 B. Characteristics of pain in unstable angina. According to the clinical practice guidelines recently developed by the Agency for Health Care Policy (1), unstable angina is defined as:

1. Angina at rest lasting greater than 20 minutes.

 2. New onset angina (< 2 months) precipitated by walking one to two blocks or by climbing one flight of stairs at a normal pace.

 3. Angina that is more frequent, longer in duration, or occurring at a lower threshold.

C. Risk factors. The Framingham Heart Study along with numerous other large epidemiologic studies has established the following risk factors for   CAD (2):

1. Sex and age: men aged 45 years or older; women aged 55 years or older; women with premature menopause without hormone replacement.

2. Family history: MI or sudden death occurring in a first-degree male relative aged 55 years or younger or in a first-degree female relative aged 65 years or younger.

3. Smoking: in men who smoke one pack per day, a three- to fivefold risk for CAD compared with nonsmokers. Those who quit smoking can reach the same risk level of nonsmokers within 2 years of stopping.

4. Hypertension: blood pressure greater or equal to 140/90 (Chapter 7.8).

5. Cholesterol: total cholesterol greater than 200; low-density lipoprotein (LDL) greater than 130; high-density lipoprotein (HDL) less than 35. An HDL level above 60 is protective.

6. Diabetes mellitus: a twofold increase in CAD, compared with nondiabetics (Chapter 14.1).

Physical examination

 A. Focused physical examination. This should include vital signs (notably blood pressure). During a symptomatic episode, the finding of a mitral regurgitation murmur, S₃ or S₄ gallop, bruits or precordial lift all suggest a high likelihood of CAD. Findings of xanthelasma, tendinous xanthomata, tobacco-stained teeth and fingernails, and decreased or asymmetrical peripheral pulses indicate the likely presence of cardiac risk factors. >

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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.

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

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

A. Timing of the pain. What is the onset and duration of the pain? Was there a specific inciting incident or trauma? When does the pain occur? Pain wakening the patient from sleep may suggest a malignancy. Is pain present at rest? Does movement or weightbearing exacerbate the symptom? Any associated joint stiffness?

B. Location of the pain. Localization to the joint is typical in osteoarthritis (OA). Exceptions are hip OA, where pain can localize to the groin or thigh, and OA of the spine, where pain can localize to the buttocks. Radiation of the pain may suggest periarticular or neuropathic problems.

C. Associated symptoms. Fever, night sweats, or weight loss may suggest an infectious cause or an underlying systemic illness. Rash can occur with infectious or inflammatory arthritides.

 D. Medical history. Many medical problems can be associated with an inflammatory or a degenerative arthritis (Table 12.7). Knowledge of prior joint surgery or prosthesis placement is important. A history of childhood joint disease (e.g., slipped capital epiphysis) or bone disease (e.g., osteochondritis dissecans) can predispose to early onset degenerative joint disease.

 E. Social history. The patient’s support system is especially important if severe functional impairment is present. The employment or recreational history may indicate a risk of repetitive joint trauma. Sexual risk factors and a history of alcohol or intravenous (IV) drug abuse are important.

F. Medications. What medication or treatment has been used and what was the response? A history of systemic steroid use can lead to osteonecrosis of the femoral head.

Physical examination

Is discomfort apparent? Is fever present? Assess the patient’s gait and note if a mobility aide is used. Inspect the joint for surgical or traumatic scars, muscle atrophy, deformity, joint swelling, and erythema. Palpate for warmth, tenderness, and effusion. Evaluate joint range of motion (ROM). If active ROM is full and normal, evaluation of passive ROM is unnecessary. Pain with active, but not passive ROM suggests a periarticular process. Depending on the joint involved, palpate the relevant periarticular structures and perform the appropriate provocative maneuvers. Examine for rash.

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

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

A. History of present illness. Medication use, alcohol and tobacco history, and menstrual history in women are vital. When did the pain begin and what are the characteristics of the pain? Use the “OPQRST” approach outlined below to question the patient about pain characteristics.

 1. O: Onset of pain. Pain of sudden onset or that awakens a patient from sleep can represent appendicitis, leaking abdominal aortic aneurysm, ectopic pregnancy, pancreatitis, or perforating ulcer. Gradual onset of pain can represent cholecystitis, diverticulitis, inflammatory bowel disorders, or pancreatitis. Longstanding pain without debility that is worsened by emotional stress is suggestive of irritable bowel syndrome.

 2. P: Palliative or Provocative factors (diet, exercise, sleep, bowel movement, and so on).

3. Q: Quality of pain—pain descriptors are often associated with specific causes:

a. “Burning” pain—ulcer

b. “Agony”—pancreatitis

c. “Shearing” or “tearing”—abdominal aortic aneurysm

d. “Colicky” or “cramping”—cholecystitis, bowel obstruction, urolithiasis, irritable bowel syndrome

e. “Constant ache”—appendicitis, peritonitis, herpes zoster

4. R: Radiation or Referred—pain from appendicitis, simple colic, and bowel obstruction from strangulation or volvulus is often first felt in the epigastrium. Abdominal causes may result in referred or radiating pain to extraabdominal sites:

a. Abdominal aortic aneurysm—to the midback

b. Biliary colic—to the right scapula

c. Renal colic—to the costovertebral angles, testicle, or thigh

d. Hernias—to the genitalia

5. Extraabdominal pathology can cause referred pain to the abdomen.

a. Cardiac ischemia—to the epigastrium

b. Scrotal pathology—to the abdomen

6. S: Severity—level of intensity (some use a 1–10 scale)

 7. T: Time or Temporal relationships—with meals, after bowel movement, menses, and so on

 B. Past medical history. Is there a history of previous abdominal or pelvic surgery? Prior abdominal surgery increases the risk for bowel incarceration, obstruction, and strangulation. Fallopian tube surgery and prior pelvic inflammatory disease (PID) increase a woman’s risk for ectopic pregnancy (Chapter 11.3).

C. Review of systems. Are there associated symptoms that point to a specific etiology? Chills and fever suggest infectious causes (UTI, PID, prostatitis, and pneumonia). Emesis occurring before the onset of pain is associated with appendicitis; with the onset of pain, cholecystitis or urolithiasis; after onset of pain, gastroenteritis. Late onset or feculent emesis suggests bowel obstruction; bilious emesis occurs in cholecystitis. Postprandial right upper quadrant pain is common in cholecystitis. Diarrhea with a recent travel history suggests dysentery or parasitic infections. Genitourinary complaints (dysuria, frequency, hematuria, vaginal discharge, and dypareunia) should prompt evaluation for UTI, sexually transmitted disease, and PID.

Physical examination

A thorough, targeted physical examination, directed by a complete history, leads to a correct diagnosis in most cases (2).

Complete vital signs are essential. Tachycardia or hypotension can indicate hypovolemia and the need for urgent intervention (Chapter 7.12). Rapid, shallow breaths occur with peritoneal irritation. Inspect the abdomen for distention (obstruction), pulsations (AAA), or scars from past surgery. High-pitched hyperactive bowel sounds occur with bowel obstruction. Palpation and percussion help localize tenderness, organomegaly, and masses. Pain with movement, rebound tenderness, or rigidity are indicative of peritonitis and should prompt surgical consultation.

Cardiovascular, pulmonary, and digital rectal and genitourinary examinations should be included in all evaluations of significant abdominal pain. The pelvic examination must be done to exclude ectopic pregnancy and PID. Among patients in whom pregnancy is a possibility, the presence of peritoneal signs, cervical motion tenderness, or lateral (or bilateral) abdominal or pelvic tenderness should raise concern about possible ectopic pregnancy (3).

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

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

A. Pain characteristics. What is the pattern of onset, quality, location, duration, and intensity of the pain? What, if anything, helps relieve the pain? A report of a sensation of being “clubbed in the back of the leg” or “shot in the calf,” along with an audible pop or snap sound, suggests an acute Achilles tendon rupture (ATR) (1). Cramping calf pain may indicate a metabolic disturbance or a denervating disease. Numbness and burning pain or an electric-shock sensation, may indicate a neurological process. A “creeping and crawling” sensation deep within the muscles of the legs and thighs that is somewhat relieved with movement of the extremity is suggestive of restless leg syndrome (RLS).

 B. Preceding events. Was the pain preceded by any specific activity or trauma? Any recent prolonged inactivity? Unilateral calf pain after a period of immobility, especially in the presence of risk factors (e.g., lower extremity venous disease, oral contraceptive use), is DVT until proved otherwise. If the patient presents with a history of direct trauma to the calf, a compartment syndrome or intramuscular hematoma should be suspected. Pain occurring at night and disrupting sleep is suggestive of RLS or arterial disease.

 C. Associated symptoms. Coexisting symptoms can help to differentiate the cause of the pain. Any fever or back or knee pain should be noted. Ask about leg swelling, bruising, weakness, tingling, or other changes in sensation.

D. Pertinent medical history. Does the patient smoke? Is there a history of any form of arthritis, or a Baker’s cyst? Any recent hip, knee, gynecologic, or lower abdominal surgery? Is the patient pregnant or postpartum? Pertinent medical illnesses include peripheral vascular disease, varicosities, malignancy, hematologic disorders, and diabetes. Acquired immune deficiency syndrome has been associated with a syndrome of calf pain, swelling, and tenderness along with cutaneous hyperesthesia to light touch. The syndrome is believed to be caused by hyperalgesic thrombophlebitis (2).

E. Family history. A family history of DVT or inherited causes of hypercoagulability increase the risk for DVT (3).

Physical examination (PE)

 A. Initial PE. Is the patient febrile? Inspect the patient’s back and check the curvature of the spine. Examine both legs from the groin and buttocks down for size, symmetry, skin color, pigmentation, hair distribution, and venous pattern. Note any skin lesions. Palpate lower extremity pulses and check for edema. Assess capillary refill. Note the temperature of the leg, especially over the area of pain. Palpate the calf for localized tenderness or a cord, which can indicate a superficial or deep thrombophlebitis. Feel for any increased firmness of the calf muscles. Palpate for masses, swelling, or tenderness in the lower back and entire leg. Check the mobility and flexibility of the spine and note if movement provokes any distal pain or weakness. Examine the knee and ankle joints on the affected side. Assess joint range of motion (ROM) and muscle strength. Check lower extremity reflexes and perform a good peripheral sensory examination.

 B. Additional PE. If evaluation suggests arterial insufficiency, assess for postural color changes by elevating the patient’s leg 60°. If ATR is suspected, perform a Thompson test. With the patient prone, squeeze the calf muscle just distal to its maximal girth. Plantar flexion of the foot is the normal result, indicating an intact Achilles tendon. A positive Homan or Lowenberg sign is suggestive of DVT. However, these signs are neither sensitive or specific for the diagnosis (4,5).

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

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

 As with any pain, the onset, duration, and pattern of the pain must be assessed. The location, intensity, character, and radiation are important historical elements. Aggravating or relieving factors are important, especially as they relate to the urinary, musculoskeletal, or gastrointestinal systems as well as the relationship of pain to sexual activity or menstruation. Systemic symptoms such as fatigue and anorexia are often present. A medication history (e.g., use of birth control pills or over-the-counter medications) should be obtained. The past obstetric, gynecologic, and general surgical histories are extremely important.

It should be noted that women with a history of pelvic inflammatory disease are four times more likely to develop chronic pelvic pain. The list of possibilities for the condition is substantial. A person with intestinal, sexual, urinary, musculoskeletal, and systemic symptoms may be suffering from a psychiatric disorder (e.g., depression) and an acknowledged or remote history of sexual abuse. Often this information is possible to obtain only when the provider creates an atmosphere of mutual respect and trust.

Dyspareunia is often present. Cyclic pain that is related to menstruation usually points to a gynecologic problem. Pain referred to the anterior thigh, pain associated with irregular uterine bleeding, or new onset dysmenorrhea may have a uterine or ovarian cause. Urethral tenderness, dysuria, or bladder pain suggests interstial cystitis or a urethral problem (Chapter 10.1). Pain on defecation, melana, bloody stools, or abdominal pain with alternating diarrhea and constipation can point toward pelvic floor problems, irritable bowel syndrome, or inflammatory bowel diseases.

Physical examination

 A. The general condition of the patient should be noted. Does the patient look chronically ill, which may suggest a pelvic lesion or an inflammatory bowel disorder? Does the patient appear anxious, stressed, or inappropriate?

 1. Can the patient point to the pain with one finger? If so, this can indicate that the pain may have a discrete source.

2. An examination of the lower back, sacral area, and coccyx, including a neuologic examination of the lower extremities, is necessary. Herniated disc, exaggerated lumbar lordosis, and spondylolisthesis can all cause pelvic pain.

 3. Examine the abdomen, looking for surgical scars, distension, and palpable tenderness, particularly in the epigastrium, flank, back, or bladder.

 B. A thorough pelvic examination is the most important part of the evaluation.

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

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

A. Pain characteristics. What is the exact location of the pain? Pain arising from the lumbar spine is perceived in the buttock and, less commonly, in the groin and anterior thigh. This must be differentiated from radicular pain arising from the spine. True hip pain more often localizes to the anterior midgroin or midthigh area. Lateral hip or thigh pain most likely represents trochanteric bursitis (1). How is the pain described? A “snapping” type discomfort is most commonly caused by iliotibial band syndrome. Constant pain can indicate infection or cancer.

B. Involved joints. Hip osteoarthritis (OA) can have a monarticular onset, or other joints may be involved. Of hip OA patients, 20% will develop bilateral involvement.

C. Precipitating factors. Has there been a recent fall or other trauma? In an elderly or an osteoporotic patient, hip fracture can occur after a very minor incident. A contusion over the greater trochanter can lead to persistent bursitis; a contusion over the iliac crest, to a tear of the muscle aponeurosis. Has there been any preceding athletic or overuse activity that could cause muscle strain? Ischial bursitis usually develops after prolonged sitting.

D. Other symptoms. Bacterial involvement of the hip joint can be accompanied by fever and shaking chills (2). Other symptoms may be present in cancer, pelvic, intraabdominal, or retroperitoneal pathology. Sciatica commonly accompanies trochanteric bursitis.

 E. Past medical history. Any prior hip problems or hip surgery? A patient with a hip replacement may develop loosening of prosthetic components, which can be a source of pain, or can seed the joint during a recent infection or invasive procedure. Aseptic necrosis of the femoral head is more likely in patients with sickle cell disease. Previous occult hip fracture or delayed treatment, can also lead to aseptic necrosis. Patients receiving long-term steroids may manifest constant hip pain. Congenital or developmental defects are found in 80% of patients with hip OA.

Physical examination

 A. General. If referred pain is suspected, evaluate the appropriate organ system. Palpate the groin and thigh for hernias, lymph nodes, and vascular cords. Assess gait. An unwillingness to bear weight suggests fracture, even with a negative preliminary x-ray finding. Check the neurovascular status of the distal extremity after any traumatic episode.

 B. Musculoskeletal. Observe the involved extremity. In femoral neck fractures, the involved leg may appear slightly shortened and externally rotated. Intertrochanteric fractures can cause the involved leg to be internally rotated and shortened. Evaluate the spine, including the straight leg raise test, if spinal pathology is being considered. Compression of the patient’s pelvis with the patient side lying may localize pain to the sacroiliac joint. Check for leg length discrepancy by measuring each extremity from the anterior superior iliac spine (ASIS) to the medial malleolus; for hip joint shortening, measure from the ASIS to the greater trochanter.

Palpate the greater trochanter, ischial tuberosity, and surrounding muscle groups for tenderness. The hip joint is not easily palpated; palpable warmth is produced only when intensely inflamed. Document joint range of motion. Nondisplaced or impacted fractures may not be painful, except at extremes of motion. Pain in all directions suggests intraarticular disease. Pain arising from the hip is typically elicited at the extreme ranges of motion, as well as with motion against resistance. With the patient supine, bend the uninvolved leg at the knee and hip and bring it toward the chest. Watch the opposite hip for flexion (Thomas test), indicating a flexion contracture of that hip. Loss of internal rotation occurs early in OA, followed by the loss of extension, adduction, and flexion. Pain and an inability to fully abduct or extend the hip can also be seen in rheumatoid arthritis (RA). Trochanteric bursitis may present with pain on external rotation only. Muscle strain (e.g., a “groin pull”) will produce pain on passive stretch or resisted contraction of the involved muscles only. In iliotibial band syndrome, the “snapping” of the band may be audible and palpable as the hip is flexed and extended. Document any muscle weakness or muscle atrophy.

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

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

A. Age and etiology. The patient’s age is an important factor in determining the likelihood of certain knee problems. Because of stronger ligaments, avulsion fracture (anterior intercondylar eminence of the tibia, tibia tubercle) is more common in younger age groups, whereas ligamentous rupture occurs in older persons. Patellar dislocations and apophysitis are more likely in growing adolescents.

 B. Trauma. Understanding the mechanism of injury and estimating the acceleration or deceleration and torsional forces across the knee joint, predict the likelihood of occult fractures and internal derangement. Patients describing a popping sensation during a rotational or twisting injury, followed by an immediate swelling, usually have internal derangement of either meniscal or ligamentous components, or both. Locking of the knee suggests a “bucklehandle” meniscal tear obstructing normal hingejoint activity of the femoraltibial joint.

 C. Alleviating or exacerbating factors. Patellofemoral syndrome (PFS) or chrondromalacia patella is associated with anterior knee pain that worsens going up or down stairs or with prolonged sitting. Morning stiffness that improves with mild activity, but worsens as the day progresses, is typical of degenerative arthritis (osteoarthritis). The stiffness of rheumatoid arthritis (RA) generally does not improve with activity. Patients with multiple joint pains should be questioned about fever or skin rash to rule out infectious or inflammatory joint disease.

Physical examination

Both knees, as well as the hip, ankle, and foot on the affected side, should be examined. The knees are inspected for symmetry, signs of quadriceps or calf wasting, and any obvious swellings, discoloration, or pallor. Thigh, knee, calf circumference, and leg length are measured to document any asymmetry. Measurement of the quadriceps or Q angle (normal <15°) is important to evaluate anterior knee pain. Inability to perform full knee flexion and extension will highlight any effusion. Neurovascular supply should also be evaluated.

In nonacute circumstances, the suprapatellar bursa is milked to determine if effusion is present. The patellar apprehension test may detect patellar dislocation; the patellar grind test is used to detect PFS. Evaluation of patellofemoral tracking within the femoral groove also helps make the latter diagnosis as the patella will track laterally in PFS, leading to the characteristic “jockey cap” patella. The knee should be carefully palpated for tenderness of the patellotibial insertion (Osgood-Schlatter’s disease), the body of the infrapatellar tendon (tendinitis), the insertion of the tendon on the patella (Sinding-Larsen-Johannson disease), medial and lateral joint line (potential meniscal pathology), pes anserine bursa (bursitis), or iliotibial band insertion. Plica, a painful, thickened band of exuberant synovium, can also be diagnosed by palpitation of the medial and lateral joint lines.

Ligamentous testing is done next. Test the posterior cruciate ligament through the posterior drawer sign. Use the Lachman test for the anterior cruciate ligament, or, in obese patients, the anterior drawer sign. The medial collateral ligament is tested in zero and 15° of flexion by applying a valgus stress to the knee. The lateral collateral ligament is tested similarly using a varus stress. McMurray’s test may detect a meniscal tear. A duck walk test can also be used to look for a posterior meniscal tear. The patient’s gait is observed, specifically looking for forefoot varus and heel valgus, Morton’s foot deformity, and femoral anteversion, all of which can accentuate valgus stress on the knee and lead to a painful overuse syndrome. >

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

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

A. General. Patient age and occupation are important. An individual’s job can involve awkward or prolonged body positioning (1). Some of the conditions listed in Table 12.8 can present with fever or with constitutional or other musculoskeletal symptoms. More diagnosis-specific symptoms may be present (e.g., chest pain with a myocardial infarction).

B. Pain characteristics. What is the character, location, frequency, and duration of pain? Tumors of the cervical spine can present with unremitting neck pain that is worse at night. Referred neck pain from intrathoracic pathology is more often located anteriorly.

C. Precipitating factors. Any prior history of neck problems? Has there been any preceding neck trauma or change in work or avocational activities? A history of collision trauma may warrant consideration of concurrent head injury. Is there any relationship of the pain to a particular neck position or movement? Careful questioning may be needed to uncover this latter information, but it is crucial to determining the mechanism of pain production. Have there been any emotional stressors?

D. Associated symptoms. Is headache present? Any paresthesia, dyskinesia, or weakness of the trunk or upper or lower extremities? Bladder dysfunction can occur with a central spinal cord injury. What is the distribution of any radicular pain? An increase in radicular symptoms with coughing or sneezing suggests nerve root impingement (2).

Physical examination

 A. General. After any cervical spine injury, order an x-ray study first to rule out an unstable injury. Assess gait, which can be impaired with a cervical myelopathy. Notice neck posture (3). Torticollis can occur secondary to trauma, muscle strain, vertebral subluxation, viral infection or from a psychogenic cause. Examine other head and neck structures (e.g., lymph nodes) and the temporomandibular joints (1). Look for meningeal signs, if appropriate.

 B. Musculoskeletal examination. Palpate for muscle tenderness or spasm in the neck and head. Tender trigger points may be found in fibromyalgia. Assess active and passive range of motion (ROM) of the neck and shoulders. ROM is not affected with referred sources of pain. Decreased passive ROM may be seen in rheumatoid arthritis (RA), ankylosing spondylitis (AS), disseminated idiopathic skeletal hyperostosis (DISH), compression fractures, and cervical spondylosis. Active contraction or stretching of strained muscles or ligaments will precipitate pain.

 C. Neurologic examination. Include the examination of cranial nerves, motor function, tone, and reflexes of the upper and lower extremities. Look for muscle atrophy. Check pinprick and light touch sensation in the upper extremities, looking for a dermatomal pattern of loss. Evaluate cerebellar, vibration, and position sense in the legs. The exact level of nerve root involvement cannot be precisely known from the physical examination because of overlapping innervation (2) (Table 12.9). A Spurling’s test (extension and rotation of the head and neck while applying downward pressure to the top of the head) that precipitates radicular symptoms is very suggestive of nerve root pathology (1).

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

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

A. Characteristics of the pleuritic pain. What is the acuity of the pain, its location, and exacerbating features?

 1. Acute onset suggests sudden development as viral or idiopathic pleurisy, PE, pneumonia, or pneumothorax.

Insidious onset suggests a slower inflammatory or irritative process usually resulting in a pleural effusion with the pain generally diminishing as fluid accumulates (Chapter 8.4).

2. Pleuritic chest pain localizes above the underlying pleural pathology through intercostal innervation.

 3. Through phrenic innervation, shoulder pain can indicate ipsilateral diaphragmatic involvement, usually by abdominal pathology (Table 8.1).

 4. Substernal pain improved by leaning forward suggests pericarditis (Chapter 7.1).

5. Provocation of pain by shoulder movement indicates a musculoskeletal cause.

B. Focused review of systems. What symptoms or history accompany the pain that might suggest a respiratory infection, PE, or malignancy? A nonproductive cough is nonspecific, and a productive cough suggests infection. Hemoptysis suggests malignancy, tuberculosis, or pulmonary embolism. A fever suggests infection but can occur with PE. Recent surgery or lower extremity trauma or swelling increase the risk for PE. Unexplained weight loss suggests malignancy or tuberculosis (TB).

C. Past medical history. Past history can provide clues to the cause including malignancy, recent myocardial infarction, uremia, lupus, and rheumatoid arthritis.

D. Other history. Inquire about oral contraceptives (PE risk), TB, or asbestos exposure.

Physical examination

 A. Focused physical examination. This should include vital signs with attention to temperature and respiratory rate and examination of the chest. Tenderness to palpation indicates a musculoskeletal cause. Dullness to percussion suggests pleural effusion or parenchymal pathology and hyperresonant percussion indicates pneumothorax. On auscultation, a pleural friction rub is the only sign of pleurisy; crackles suggest pneumonia; and decreased breath sounds indicate pneumothorax or effusion. The examination result is frequently normal.

 B. Additional physical examination. Abdominal tenderness can suggest a subdiaphragmatic process (Table 8.2, Abdominal). Lower extremity edema, tenderness, or Homans’ sign can imply deep vein thrombosis (DVT) and PE. Lymphadenopathy can represent lymphoma or metastatic disease.

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

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

A. Characteristics of the pain. What is the onset, location, radiation, severity, and duration of the pain? Is there any instability, weakness, stiffness, or locking? Are there exacerbating or alleviating maneuvers? Has there been any associated trauma? What was the mechanism of injury? Any associated neurologic or systemic symptoms? Is there a history of prior shoulder problems? Are other joints involved?

Physical examination

Observe the shoulder for symmetry, motion, and signs of injury. Palpate all bony structures [including the acromioclavicular (AC) joint and bicipital groove]; check cervical spine range of motion (ROM) and the neurovascular status of the affected arm. If fracture is suspected, obtain an x-ray study. If finding on the x-ray is negative, proceed with passive and active ROM testing of the shoulder. Assess muscle strength and perform provocative tests for specific suspected pathology (Table 12.12) (1).

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

Periarticular Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Tendinitis

❑ Bursitis

❑ Tenosynovitis

❑ Myofascial pain

❑ Radicular pain

❑ Gout

❑ Fibromyalgia

❑ Polymyalgia rheumatica

❑ Reflex sympathetic dystrophy

Diagnostic Approach

Periarticular pain occurs with use of a muscle group rather than movement of the joint per se. Principal symptoms are pain, stiffness, limited function, and sleep disturbance. Stiffness on awakening implies inflammation.

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Source: Field Guide to Bedside Diagnosis, 2007

Radicular Pain/Dysesthesias: Diagnostic Overview
(Field Guide to Bedside Diagnosis)

Upper Extremity

❑ Median nerve

❑ Ulnar nerve

❑ Radial nerve

❑ Axillary nerve

❑ Brachial plexus nerve

❑ Long thoracic nerve

❑ Thoracic outlet syndrome

❑ Reflex sympathetic dystrophy

❑ Syringomyelia

Lower Extremity

❑ Sciatic nerve

❑ Lateral femoral cutaneous nerve

❑ Common peroneal nerve

❑ Femoral nerve

❑ Obturator nerve

❑ Posterior tibial nerve

Cranial

❑ Facial nerve

❑ Trigeminal nerve

Diagnostic Approach

Paresthesias (numbness, pins and needles, hyperesthesia) are nerve-impingement symptoms. The patient usually requires prompting to be specific about distribution.

Motor function of nerve roots includes the following: C5—shoulder abduction; C6—wrist extension; C7—forearm extension at the elbow; C8, T1—digital abduction and adduction; L2, 3, 4—knee extension; L5—ankle and large toe dorsiflexion; and S1—plantar flexion. Reflex function of nerve roots includes the following: C5, 6—biceps; C7, 8—triceps; L2, 3, 4—knee jerk; and S1—ankle jerk.

Atrophic weakness of the arms and spastic weakness of the legs suggests cervical spondylosis or amyotrophic lateral sclerosis. Cervical spondylosis has pain from the neck to the back of the shoulders to the wrist, which is aggrevated by arm movement. ALS has paresthesias and sensory impairment.

Beware compartment syndrome, which may be a limb-threatening emergency. There will be an injury to a compartment-bound muscle, which develops into progressive, severe, local pain. Distal paresthesias are a common early symptom—even when the distal pulse is bounding and perfusion seems good.

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Source: Field Guide to Bedside Diagnosis, 2007

Chronic/Recurrent Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Irritable bowel syndrome

❑ Peptic ulcer disease

❑ Cholecystitis

❑ Chronic pancreatitis

❑ Inflammatory bowel disease

❑ Intermittent mesenteric ischemia

❑ Pancreatic cancer

❑ Gastric cancer

❑ Endometriosis

❑ Recurrent intestinal obstruction

❑ Sickle cell anemia

❑ Radiculopathy

❑ Adrenal insufficiency

❑ Lead poisoning

❑ Porphyria

Diagnostic Approach

Examining a patient during an episode of pain is important for diagnosis. A significant proportion of patients with chronic abdominal pain will remain undiagnosed despite extensive testing. For these patients, repeated history and examination, during which one looks for new symptoms or any change in the pattern of symptoms, may eventually yield a formulation.

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Source: Field Guide to Bedside Diagnosis, 2007

Pleuritic Chest Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Costochondritis

❑ Pneumonia

❑ Rib fracture

❑ Pulmonary embolism

❑ Pleurisy

❑ Pneumothorax

❑ Pericarditis

❑ Lung cancer

❑ Pneumomediastinum

❑ Splenic infarction

Diagnostic Approach

Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Cardiac pain is almost never pleuritic (LR 0.2), sharp or stabbing (LR 0.3), positional (LR 0.3) or reproduced by palpation (LR 0.3).

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Nonpleuritic Chest Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Chest wall pain

❑ Angina

❑ Unstable angina

❑ Myocardial infarction

❑ Gastroesophageal reflux

❑ Herpes zoster

❑ Thoracic root compression

❑ Panic disorder

❑ Aortic stenosis

❑ Aortic dissection

❑ Mediastinal mass

❑ Biliary disease

Diagnostic Approach

It is essential to maintain a high index of suspicion (low threshold for investigation) for critical problems; however, most chest pain has a benign cause. The patient with myocardial ischemia often is reluctant to label the symptom as “pain.” Instead descriptors are used such as squeezing, pressure, tightness, fullness, a heavy weight on the chest, burning (attributed to indigestion),
or a toothache (when jaw radiation is present). A closed fist held to the sternum is commonly employed to explain the symptoms. Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Recurrent episodic pain or persistent pain lasting days is unlikely to represent a critical problem. Pain lasting a few seconds or pain that is sharp or stabbing in quality is almost never ischemic, especially if reproducible by palpation
or movement.

Syncope with chest pain should raise suspicion of aortic dissection,
ruptured aortic aneurysm, pulmonary embolism, or critical aortic stenosis. “Angor anomie,” a sense of impending doom, is found in serious conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and to a lesser extent, panic disorder. Sternal pain may be caused by xiphoidalgia, myelomatosis, ankylosing spondylitis, osteomyelitis, or traumatic fracture.

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Source: Field Guide to Bedside Diagnosis, 2007

Ear Pain/Discharge: Differential Overview
(Field Guide to Bedside Diagnosis)

Ear Pain

❑ Acute otitis media

❑ Acute otitis externa

❑ Eustachian dysfunction

❑ Temporomandibular joint arthritis

❑ Traumatic tympanic membrane rupture

❑ Foreign body, external auditory canal

❑ Erysipelas

❑ Herpes zoster oticus

❑ Dental abscess

❑ Frostbite

❑ Relapsing polychondritis

❑ Malignant otitis externa

❑ Acute mastoiditis

❑ Nasopharyngeal cancer

Ear Discharge

❑ Otitis externa

❑ Eczematoid dermatitis

❑ Low-viscosity cerumen

❑ Otitis media with perforation

❑ Foreign body

❑ Psoriasis

❑ Herpes zoster oticus

Diagnostic Approach

If ear pain is present without ear findings, consider referred pain from the tonsils, teeth, trachea, or temporomandibular joint. Ear pain may be an early sign of nasopharyngeal carcinoma. Lesions of the anterior portion of the tongue refer pain in front of the ear whereas the posterior one-third of the tongue refers pain to within the ear.

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Source: Field Guide to Bedside Diagnosis, 2007

Facial / Dental / Temporomandibular Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Maxillary sinusitis

❑ Dental infection

❑ Temporomandibular joint dysfunction

❑ Myofascial masseter pain

❑ Migraine

❑ Trigeminal neuralgia

❑ Frontal sinusitis

❑ Ethmoid sinusitis

❑ Sphenoid sinusitis

❑ Parotitis

❑ Parotid calculus

❑ Orbital fracture

❑ Mandibular fracture

❑ Maxillary fracture

❑ Myocardial infarction

❑ Connective tissue disease

❑ Temporal arteritis

❑ Cavernous sinus thrombosis

❑ Glossopharyngeal neuralgia

Diagnostic Approach

The V1 ophthalmic branch of the trigeminal innervates the forehead, cornea (corneal reflex), dorsum of the nose, and anterior cranial dura. The V2 maxillary branch innervates the upper lip, lateral nose, upper cheek, anterior temple, upper jaw and teeth, roof of the mouth, and middle cranial dura. The V3 mandibular branch innervates the lower lip, chin, posterior cheek, external ear, mucosa of the lower mouth, anterior two-thirds of the tongue, and parts of the anterior and middle cranial dura.

Pain provoked by hot, cold, or sweet foods is usually dental in origin. Neuralgia may produce a similar pain, but the pain will have a refractory period after an initial response. Pain increased by chewing suggests trigeminal neuralgia, temporomandibular joint pain, or jaw claudication. Pain increased by swallowing and taste is consistent with glossopharyngeal neuralgia. Objective sensory loss persisting after the pain is an important clue to organic disease.

Epidemiologic studies reveal that temporomandibular joint tenderness is common, occurring in 35% of asymptomatic people, clicking in 25%, crepitus in 8%, and jaw deviation in 15%.

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Source: Field Guide to Bedside Diagnosis, 2007

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Scrotal Pain/Swelling: Differential Overview
(Field Guide to Bedside Diagnosis)

Pain Predominant

❑ Epididymitis

❑ Testicular torsion

❑ Prostatitis

❑ Referred pain

❑ Trauma

❑ Orchitis

❑ Torsion of the appendix testis

❑ Inguinal hernia/incarcerated

Swelling Predominant

❑ Varicocele

❑ Inguinal hernia

❑ Hydrocele

❑ Spermatocele

❑ Sebaceous cyst

❑ Testicular cancer

Diagnostic Approach

Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.

Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.

Referred pain can be differentiated from scrotal pathology by a normal testicular examination.

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Abdominal Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Generalized/Periumbilical

❑ Gastroenteritis

❑ Obstipation

❑ Small bowel obstruction

❑ Large bowel obstruction

❑ Mesenteric ischemia

❑ Peritonitis

❑ Abdominal aortic dissection

❑ Sickle cell crisis

Right Upper Quadrant/Epigastrium

❑ Hepatitis

❑ Biliary colic

❑ Peptic ulcer disease

❑ Pyelonephritis

❑ Acute cholecystitis

Right Lower Quadrant

❑ Appendicitis

❑ Inflammatory bowel disease

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Ovarian torsion

Left Upper Quadrant

❑ Pancreatitis

❑ Splenic infarction

❑ Pyelonephritis

❑ Myocardial infarction

Left Lower Quadrant

❑ Inflammatory bowel disease

❑ Diverticulitis

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ovarian torsion

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Sigmoid volvulus

Diagnostic Approach

Acute abdominal pain is a classic symptom that can herald conditions ranging from the trivial to the life-threatening. The accurate diagnosis and timely management of abdominal pain requires an understanding of the mechanisms of pain, recognition of typical patterns of clinical presentation, a broad differential of common causes, and an index of suspicion for variant presentations and unusual causes. The ultimate disposition decision may require a repeated history and physical examination over several hours. Narcotic analgesics should be withheld until a diagnosis is established because they can mask the expression of diagnostic characteristics of the disease. History indicates the diagnosis in 85% to 90% of cases. Consider organs located in the region of maximal pain and the time-course of onset. An intrathoracic source must always be considered with upper abdominal pain. Physical examination can demonstrate peritoneal inflammation and rebound tenderness by eliciting pain with gentle percussion of the abdomen as opposed to sharp release of the depressed hand. Muscular rigidity or “guarding” is an early sign of peritoneal inflammation. Auscultation may reveal silence, consistent with ileus or advanced peritonitis, hyperactive high-pitched sounds with early bowel obstruction, or a friction rub with splenic infarct or hepatic metastases. Pelvic and rectal examinations are mandatory in every patient who has abdominal pain.

Parietal pain, caused by inflammation of the parietal peritoneum, is
a sharp, steady, aching pain, well-localized over the inflamed area, and
accentuated by pressure. Tonic reflex spasm of the abdominal musculature is present. Visceral pain, caused by obstruction of a hollow viscera, is classically intermittent and cramping, but distension may produce dull, steady pain. The patient with visceral pain will writhe incessantly, while the patient with parietal pain lies still in bed. Referred pain is aching and perceived to be near the surface, accompanied by skin hyperalgesia and increased tone of the abdominal wall. Vascular occlusion can be recognized by severe pain out of proportion to physical findings in a patient with vascular disease or atrial fibrillation. Visceral pain is perceived at the level the nerves enter the spinal cord. An example is gallbladder pain which may be first perceived at the scapula, then later in the right upper quadrant when the somatically innervated overlying parietal peritoneum is inflamed.

If the patient is well one moment, then has excruciating pain, which is maximal at onset, consider a ruptured hollow viscera or a vascular event, such as myocardial infarction or ruptured aortic aneurysm.

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Knee Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Osteoarthritis

❑ Patellofemoral pain

❑ Collateral ligament sprain

❑ Meniscal tear

❑ Anterior cruciate tear

❑ Infrapatellar quadriceps tendinitis

❑ Acute monoarticular arthritis

❑ Prepatellar bursitis

❑ Anserine bursitis

❑ Hamstring injury

❑ Baker cyst

❑ Septic joint

❑ Iliotibial band syndrome

❑ Hemarthrosis

❑ Patellar fracture

❑ Patellar dislocation

❑ Osteochondritis desiccans

❑ Osteonecrosis

Diagnostic Approach

Careful questioning about the mechanism of injury is most important. Overuse injury or undue stress caused by unbalanced walking is a common source. A sensation of “giving away” on stepping down is a symptom of posterior horn meniscus or anterior cruciate tear. Joint line pain is seen in osteoarthritis, high-grade collateral ligament injury, meniscal tear, and tibial plateau fracture. Pain located medially several centimeters below this is due to anserine bursitis or low-grade medial collateral ligament injury. Anterior knee pain is found in injury to the quadriceps mechanism or large joint effusions. Popliteal pain is usually due to a large knee effusion.

Systematically stress the knee in each direction, looking for pain and/or laxity, comparing with the contralateral side. The range of motion may be limited by effusion, by a meniscal tear, or by a loose body. True locking, with ability to flex but not extend fully, occurs 10 degrees short of full extension. A McMurray maneuver is performed by rotating the tibia on the femur medially with the knee flexed at 90 degrees and then extending the knee, then repeating the process with lateral rotation. A painful “clunk” with medial rotation indicates a lateral meniscus tear, and the same finding with lateral rotation suggests a medial meniscus tear. An anterior drawer sign is elicited as pain and a laxity when the tibia is pulled forward with the knee at 90 degrees, indicating anterior cruciate injury. A Lachman manuver, performed at 15 degrees flexion, is more sensitive. With effusion the hollows of the knee are filled, and a transmitted fluid wave can be elicited.

In acute knee injury, the Ottawa Knee Rule minimizes the number of x-rays without missing a significant fracture. Obtain an x-ray if: (a) age is >54, (b) there is tenderness at the head of the fibula, (c) there is isolated patellar tenderness, (d) there is an inability to flex the knee to 90 degrees, or (e) there is an inability to bear weight immediately and take four steps in the E.R.

Palpable clicks are not necessarily pathologic; they may be caused by the semitendinosus tendon slipping over the medial condyle or the iliotibial band slipping over the lateral condyle.

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Source: Field Guide to Bedside Diagnosis, 2007

Ankle/Foot Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

Ankle Pain

❑ Ankle sprain

❑ Fibular fracture

❑ Achilles tendinitis

❑ Acute gout

Foot Pain

❑ Plantar fasciitis

❑ Acute gout

❑ Hallux valgus (bunion)

❑ Sciatica

❑ Metatarsalgia

❑ Metatarsal stress fracture

❑ Tibialis anterior tendinitis

❑ Pes planus

❑ Calcaneal fracture

❑ Interdigital neuroma

❑ Posterior tibial nerve entrapment

❑ Compartment syndrome

Diagnostic Approach

In acute ankle injury, ability to bear weight for four steps and absence of bone tenderness at the posterior edge or the tip of either malleolus rule out a significant fracture (Ottawa ankle rule).

In acute foot injury, ability to bear weight for four steps and absence of bone tenderness at the navicular or the base of the fifth metatarsal rule out a significant midfoot fracture (Ottawa foot rule).

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Source: Field Guide to Bedside Diagnosis, 2007

Elbow Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑Lateral epicondylitis

❑Olecranon bursitis

❑Medial epicondylitis

❑Bicipitoradialis tendinitis

❑Cubital tunnel syndrome

❑Radial head fracture

❑Septic arthritis

❑Gout

❑Osteoarthritis

❑Elbow dislocation

❑Ruptured distal biceps tendon

❑Epitrochlear lymphadenitis

❑Cervical radiculopathy

Diagnostic Approach

Pain arising from within the elbow joint is poorly localized between the lateral epicondyle and the olecranon, and there is inability to straighten the elbow. Referred pain to the elbow is vague, not affected by elbow movement, but increased by movement of the neck or shoulder.

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Source: Field Guide to Bedside Diagnosis, 2007

Eye Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Sinusitis

❑ Migraine

❑ Acute glaucoma

❑ Orbital cellulitis

❑ Zoster prodrome

❑ Orbital fracture

❑ Keratitis

❑ Scleritis

❑ Iritis

❑ Optic neuritis

❑ Temporal arteritis

Diagnostic Approach

A foreign body sensation occurs with a foreign body, corneal abrasion, or keratoconjunctivitis sicca. Itching is associated with allergic and vernal conjunctivitis. Photophobia occurs with iritis and herpes simplex keratitis. Deep pain suggests acute glaucoma or posterior scleritis. Pain on eye movement is found with optic neuritis, sinusitis, and influenza.

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Source: Field Guide to Bedside Diagnosis, 2007

Flank Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ureteral calculus

❑ Acute pyelonephritis

❑ Latissimus strain

❑ Perinephric abscess

❑ Renal infarction

❑ Renal trauma

❑ Renal cancer

❑ Mononeuritis

❑ Papillary necrosis

Diagnostic Approach

Renal pain occurs with stretching of the capsule and distension of the collecting system. The pain is usually severe and aching, with nausea, vomiting, and ileus. There may be hyperesthesia in the T 9 to 10 dermatome.

Ureteral pain begins in the costovertebral angle and radiates to the lower abdomen, upper thigh, testis, or labia. The pain is excruciating, with crescendo waves of colic. The patient writhes but is unable to obtain relief. Hyperesthesia over the T 12 dermatome often occurs along with tenderness over the kidney or ureter.

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Source: Field Guide to Bedside Diagnosis, 2007

Complex regional pain syndrome: Diagnostic tests
(Handbook of Diseases)

There is no laboratory test for CRPS, so the diagnosis is based on the patient’s history and clinical findings. A history of injury to an extremity may point to CRPS. Bone X-rays may aid in ruling out other conditions, such as osteomyelitis and stress fractures, which cause similar signs and symptoms. With early diagnosis, prognosis improves.

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Source: Handbook of Diseases, 2003

Abdominal pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition permits, obtain his history. Ask whether he has had this type of pain before. Because some patients report abdominal pain as indigestion or gas pain, it’s important to ask the patient to describe his pain in detail. For example, is it dull, sharp, stabbing, or burning? Ask him where the pain is located and whether it radiates to other areas. If a language barrier exists between you and the patient, use a pain rating scale with visual cues such as faces.

Ask the patient about factors that relieve the pain or make it worse. For example, do movement, coughing, exertion, vomiting, eating, elimination, or walking relieve the pain or worsen it? Ask him when the pain began and whether it’s intermittent or constant. If pain is intermittent, ask about the duration of a typical episode.

Intermittent, cramping abdominal pain suggests obstruction of a hollow organ. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity.

Ask the patient about substance abuse and a history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Has he experienced increased flatulence, constipation, diarrhea, or changes in stool consistency? When was the patient’s last bowel movement? Ask about urinary frequency, urgency, or pain. Is the urine cloudy or pink?

Physical examination

Obtain the patient’s vital signs, and assess skin turgor and mucous membranes. Inspect his abdomen for distention or visible peristaltic waves and, if indicated, measure his abdominal girth.

Auscultate for bowel sounds in all four quadrants for at least 10 to 15 seconds and characterize their motility. Listen for systolic bruits in such locations as the abdominal aorta, renal artery, or iliac artery. (See Auscultating for vascular sounds.)

Percuss all quadrants, noting the percussion sounds.

ALERT: Abdominal percussion or palpation is contraindicated in patients with suspected abdominal aortic aneurysm, those who have received abdominal organ transplants, and children with suspected Wilms’tumor. If performing abdominal percussion or palpation in patients with suspected appendicitis, use extreme caution to avoid precipitating a rupture.

Palpate the entire abdomen for masses, rigidity, and tenderness. Involuntary rigidity is generally asymmetrical, evident on inspiration and expiration, unaffected by relaxation techniques, and painful when the patient sits up using his abdominal muscles alone. Check for costovertebral angle (CVA) tenderness, abdominal tenderness with guarding, and rebound tenderness. Peritonitis and appendicitis can cause rebound tenderness. Because appendicitis may be accompanied by increased abdominal wall resistance and guarding, perform the maneuver for rebound tenderness only once — repeating the maneuver can rupture an inflamed appendix. (See Eliciting rebound tenderness, page 4.)

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

Back pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Ask the patient where the pain is located; back pain in some areas can signal the presence of a life-threatening condition.

Act Now: If the patient reports acute, severe back pain, quickly obtain his vital signs and perform a rapid evaluation to rule out life-threatening causes. If he describes deep lumbar pain unaffected by activity, observe for a pulsating epigastric mass. Presence of this sign may indicate a dissecting abdominal aortic aneurysm. Withhold food and fluids because the patient may require emergency surgery. Prepare for I.V. fluid replacement and oxygen administration.

If he reports severe epigastric pain that radiates through the abdomen to the back, assess for absent bowel sounds and abdominal rigidity and tenderness. These symptoms may indicate a perforated ulcer or acute pancreatitis. Start an I.V. line for fluids and medications, administer oxygen, insert a nasogastric tube, and withhold food.

If the patient complains of scapular area back pain, especially if accompanied by shortness of breath or diaphoresis, give oxygen via a nasal cannula or mask and obtain a 12-lead electrocardiogram to rule out myocardial infarction.

After you have ruled out potential life-threatening causes of back pain, continue to obtain the patient’s history. Observe him for expressions of pain while gathering information. Ask about previous injuries and illnesses, dietary habits, alcohol intake, and cigarette smoking. Inquire about medications, including past and present prescriptions, use of over-the-counter drugs, and disease processes or pain control regimens.

Ask the patient about the onset of his back pain. Were there precipitating factors? Ask the patient to rate the pain on a standardized pain scale. Ask him for details about the pain — is it burning, stabbing, throbbing, or aching? Constant or intermittent? If it’s intermittent, does it occur at a specific time of day? Does the pain radiate? Is there associated weakness? Does he experience repetitive pain or different types of pain? What, if anything, lessens the pain? What aggravates it? The patient’s answers will help identify the cause of his back pain. For example, visceral referred back pain is indicated if the patient states that the pain isn’t affected by activity and rest. In contrast, spondylogenic-referred back pain is likely if the pain increases with activity and decreases with rest. Pain of neoplastic origin is indicated if the patient reports that he can obtain relief by walking and that the pain increases at night.

Physical examination

Perform a thorough physical examination. Observe skin color, especially in the patient’s legs, and palpate skin temperature. Palpate femoral, popliteal, posterior tibial, and pedal pulses. Ask the patient about unusual sensations in the legs, such as numbness and tingling. If pain doesn’t prevent standing, observe the patient’s posture — does he stand erect or lean toward one side? Observe the level of the shoulders and pelvis and the curvature of the back. Ask the patient to bend forward, backward, and from side to side while you palpate for paravertebral muscle spasms. Note rotation of the spine on the trunk. Palpate the dorsolumbar spine for point tenderness. Then ask the patient to walk — first on his heels, then on his toes (stand close by during these tests so that you can assist the patient if he falls). Weakness may reflect a muscular disorder or spinal nerve root irritation.

Place the patient in a sitting position to evaluate and compare patellar tendon (knee), Achilles tendon, and Babinski’s reflexes. (See How to elicit Babinski’s reflex.) Evaluate the strength of the extensor hallucis longus by asking the patient to keep his great toe firmly in place against resistance. Measure leg length and hamstring and quadriceps muscles bilaterally. Note a difference of more than ⅜"(1 cm) in muscle size, especially in the calf.

To reproduce leg and back pain, assist the patient into a supine position on the examining table. Grasp his heel and slowly lift his leg. If he feels pain, note its exact location and the angle between the table and his leg when it occurs. Repeat this maneuver with the opposite leg. Pain along the sciatic nerve may indicate disk herniation or sciatica.

Note the range of motion of the hip and knee. Palpate the flanks and percuss with your fingertips or fist to reveal the presence of costovertebral angle (CVA) tenderness.

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

Chest pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Ask the patient to rate the pain using a standardized pain rating scale. Is the pain a dull, aching, pressurelike sensation, or sharp, stabbing, and knifelike? Is it constant or intermittent? If it’s intermittent, ask how long an episode lasts. Ask him about precipitating, aggravating, or alleviating factors. Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Ask about medications he’s taking, if any, including recent dosage or schedule changes.

ALERT: Chest pain in perimenopausal women may be difficult to diagnose because it may present atypically. Fatigue, nausea, dyspnea, and shoulder or neck pain are symptoms more likely to signal an MI in women than in men.

Physical examination

Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Check for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.

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

Eye pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

Physical examination

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)

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

Flank pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

Physical examination

During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.

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

Jaw pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Where on the jaw does he feel pain? Does the pain radiate to other areas? Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints. Also ask about aggravating or alleviating factors.

Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. (Keep in mind that jaw pain may accompany more characteristic signs and symptoms of life-threatening disorders, such as chest pain in a patient with an MI.)

Physical examination

Focus your physical examination on the jaw. Inspect the painful area for redness, and palpate for edema or warmth. Facing the patient directly, look for facial asymmetry indicating swelling. Check the TMJs by placing your fingertips just anterior to the external auditory meatus and asking the patient to open and close, and to thrust out and retract his jaw. Note the presence of crepitus, an abnormal scraping or grinding sensation in the joint. (Clicks heard when the jaw is widely spread apart are normal.) How wide can the patient open his mouth ? Less than 1⅛" (3 cm) or more than 2⅜" (6 cm) between upper and lower teeth is abnormal. Next, palpate the parotid area for pain and swelling, and inspect and palpate the oral cavity for lesions, elevation of the tongue, or masses.

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

Neck pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient hasn’t sustained trauma, inquire about the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there a particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

Physical examination

Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion (ROM) in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings.)

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

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

If the patient has no life-threatening signs or symptoms, take his history. Ask him if he has had this type of pain before. Have him describe the pain — for example dull, sharp, stabbing, or burning. Ask if anything relieves the pain or makes it worse. Ask the patient if the pain is constant or intermittent and when the pain began. Constant, steady abdominal pain suggests organ perforation, ischemia, or inflammation or blood in the peritoneal cavity. Intermittent, cramping abdominal pain suggests the patient may have obstruction of a hollow organ.

If the pain is intermittent, find out the duration of a typical episode. In addition, ask the patient where the pain is located and if it radiates to other areas.

Find out if movement, coughing, exertion, vomiting, eating, elimination, or walking worsens or relieves the pain. The patient may report abdominal pain as indigestion or gas pain, so have him describe it in detail.

Ask the patient about substance abuse and any history of vascular, GI, GU, or reproductive disorders. Ask the female patient about the date of her last menses, changes in her menstrual pattern, or dyspareunia.

Ask the patient about appetite changes. Ask about the onset and frequency of nausea or vomiting. Find out about increased flatulence, constipation, diarrhea, and changes in stool consistency. When was his last bowel movement? Ask about urinary frequency, urgency, or pain. Is his urine cloudy or pink?

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

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

If the patient reports arm pain after an injury, take a brief history of the injury from the patient. Then quickly assess him for severe injuries requiring immediate treatment. If you’ve ruled out severe injuries, check pulses, capillary refill time, sensation, and movement distal to the affected area because circulatory impairment or nerve injury may require immediate surgery. Inspect the arm for deformities, assess the level of pain, and immobilize the arm to prevent further injury.

If the patient reports continuous or intermittent arm pain, ask him to describe it and to relate when it began. Is the pain associated with repetitive or specific movements or positions? Ask him to point out other painful areas because arm pain may be referred. For example, arm pain commonly accompanies the characteristic chest pain of myocardial infarction, and right shoulder pain may be referred from the right-upper-quadrant abdominal pain of cholecystitis. Ask the patient if the pain worsens in the morning or in the evening, if it prevents him from performing his job, and if it restricts any movements. Also ask if heat, rest, or drugs relieve it. Finally, ask about any preexisting illnesses, a family history of gout or arthritis, and current drug therapy.

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

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

If life-threatening causes of back pain are ruled out, continue with a complete history. Be aware of the patient’s expressions of pain as you do so.

CULTURAL CUE:A patient’s cultural background may impact his response to pain. For example, a patient of Irish descent may have a stoic response. A Jewish patient or one of Italian descent may be more vocal. The Navajo patient may view pain as a way of life. A patient of Filipino descent may regard pain as a chance to atone for past transgressions.

Obtain a medical history, including past injuries and illnesses, and a family history. Ask about diet and alcohol intake. Also, take a drug history, including past and present prescriptions and over-the-counter drugs as well as herbal remedies.

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

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

Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it’s intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a nursing mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced any flulike symptoms or sustained any injury to the breast? Has she noticed any change in breast shape or contour?

Ask your patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.

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

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

If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?

Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.

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

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

If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

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

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

Begin by characterizing the patient’s facial pain. Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or worsens it? Ask the patient to point to the painful area. If facial pain is recurrent, have the patient describe a typical episode. Review the patient’s medical and dental history, noting especially previous head trauma, dental disease, and infection.

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

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

If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.

Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.

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

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

Begin the patient history by asking the patient to describe the pain’s character, intensity, and frequency. When did he first notice the jaw pain? Did it arise suddenly or gradually? Where on the jaw does he feel pain? Does the pain radiate to other areas?

Sharp or burning pain arises from the skin or subcutaneous tissues. Causalgia, an intense burning sensation, usually results from damage to the fifth cranial, or trigeminal, nerve. This type of superficial pain is easily localized, unlike dull, aching, boring, or throbbing pain, which originates in muscle, bone, or joints.

Ask about recent trauma, surgery, or procedures, especially dental work. Ask about associated signs and symptoms, such as joint or chest pain, dyspnea, palpitations, fatigue, headache, malaise, anorexia, weight loss, intermittent claudication, diplopia, and hearing loss. Also ask about aggravating or alleviating factors.

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

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

If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he’s taking and whether they have helped to relieve his leg pain.

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

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

If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

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

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

Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.

Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.

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

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

Ask the patient when he first noticed the pain and have him describe it. Has he had throat pain before? Is it accompanied by fever, ear pain, or dysphagia? Review the patient’s medical history for throat problems, allergies, and systemic disorders.

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

Abdominal Pain: Clinical Features and Diagnosis: Acute Abdominal Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Neonates

Colic

Necrotizing Enterocolitis