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Diseases » Pain Disorder » Tests
 

Diagnostic Tests for Pain Disorder

Contents
  1. Pain Disorder: Introduction
  2. Symptoms of Pain Disorder
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Alternative Diagnoses
  6. Misdiagnosis

Pain Disorder Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Pain Disorder:

Pain Disorder Diagnosis: Book Excerpts

Diagnostic Tests for Pain Disorder: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Pain Disorder.

ABDOMINAL PAIN, CHRONIC RECURRENT: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, sensitivity, colony count, chemistry panel, serum amylase and lipase, pregnancy test, stool for occult blood, and stools for ovum and parasites. A chest x-ray, EKG, and flat plate of the abdomen should also be done. A urine porphobilinogen will help exclude porphyria.

If these tests are negative, then an upper gastrointestinal (GI) series, esophagogram, and gallbladder ultrasound would be done for upper abdominal pain; an IVP would be done for flank pain; and a barium enema and sigmoidoscopy would be performed for lower abdominal pain.

If these studies are inconclusive, a gastroenterologist should be consulted for endoscopic procedures. If there is upper abdominal pain, esophagoscopy, gastroscopy, and duodenoscopy would be performed. Endoscopic retrograde cholangiopancreatography (ERCP) may be required to diagnose cholangitis or common duct stones. If there is lower abdominal pain, colonoscopy would be performed. A CT scan of the abdomen and pelvis is a useful diagnostic tool also. Gallium scans may detect a diverticular abscess or other localized area of chronic inflammation. Pelvic ultrasound may be useful in lower abdominal pain, especially in females. Aortography and angiography will be useful in abdominal angina. Lymphangiography can be helpful in discovering retroperitoneal tumors. Ultimately, exploratory laparotomy may still be necessary in some cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

ABDOMINAL PAIN, ACUTE: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

It is wise to consult a general surgeon at the outset. All patients with acute abdominal pain should have a stat, flat, and upright plate of the abdomen, a chest x-ray to rule out pneumonia, an electrocardiogram (EKG) to rule out myocardial infarction, and a complete blood count (CBC), urinalysis, amylase, and chemistry panel. Sometimes lateral decubitus films of the abdomen are necessary to show the step ladder pattern of intestinal obstruction. A pregnancy test is ordered when age and sex dictate it!

When these tests fail to confirm the clinical diagnosis, x-ray contrast studies or ultrasound may be necessary. For example, an intravenous pyelogram (IVP) can be done for a suspected renal calculus. Serial cardiac enzymes may confirm a myocardial infarction. Gallbladder ultrasound can be done to confirm cholecystitis and cholelithiasis. A nuclear scan of the gallbladder with iminodiacetic acid derivatives is very accurate in detecting acute cholecystitis. Ultrasonography may also help diagnose impending rupture of an abdominal aneurysm or ectopic pregnancy. A peritoneal tap may diagnose a ruptured ectopic pregnancy. Laparoscopy should also be considered. A urine porphobilinogen helps exclude porphyria. A double enema may help diagnose intestinal obstruction. A computed tomography (CT) scan of the abdomen is the next logical step.

If the diagnosis remains in doubt, an exploratory laparotomy must be done before the patient's condition deteriorates. The only case where this might be risky is acute pancreatitis. If this is suspected and the serum amylase is repeatedly normal, a quantitative urine amylase or peritoneal tap may confirm the diagnosis. Endoscopy may need to be done to diagnose a peptic ulcer, gastritis, gastric tumor, or reflux esophagitis. In obscure cases of appendicitis and diverticulitis, a contrast barium enema may help confirm the diagnosis. Angiography can diagnose an aneurysm or mesenteric infarction.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

BACK PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

All patients with back pain need to have a CBC, urinalysis, and probably a urine culture, as well as a chemistry panel. A sedimentation rate should be done if rheumatoid arthritis is suspected. All patients should also have plain x-rays of the thoracic and/or lumbar spine. It is very important to get anterior posterior views, as well as oblique and lateral views. At this point it is wise to observe the results of conservative therapy before ordering expensive diagnostic tests. If there is doubt about the diagnosis at this point, a neurologic or orthopedic specialist may be consulted. If there is radiation of the pain into the extremities or around the trunk and definite neurologic findings, one should proceed to a CT scan or MRI immediately. The CT scan costs about half as much as the MRI and usually will show any significant herniated disks, primary or metastatic tumor. Even without radiation of pain into the extremities or definite neurologic findings, a patient with persistent back pain should have a CT scan or MRI. EMG will be useful in identifying radiculopathy.

When all these studies are negative, it might be wise to get a bone scan because this will show the increased uptake of the sacroiliac joints in rheumatoid spondylitis. Also, one should test for the HLA B27 antigen. In the event that all of the above studies are negative, the possibility of a non-neurologic condition or nonorthopedic condition causing the back pain should be considered. Perhaps abdominal ultrasound should be done to rule out an aortic aneurysm. Perhaps a pelvic tumor or prostatic tumor should be reconsidered. Perhaps there is a pancreatic tumor that is causing the back pain. Occasionally, combined myelography and CT scan is the only way to identify a lesion. Exploratory surgery is rarely necessary. Older patients should have a serum protein electrophoresis (for multiple myeloma) and acid phosphatase or PSA to rule out prostatic carcinoma.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

BREAST PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there is a fever and discharge, a culture and sensitivity of the discharge should be done before beginning antibiotics. When there is a localized tender mass, referral to a general surgeon should be made. Patients with bilateral breast pain without any masses identified should have a pregnancy test. If this is negative and the pain is associated with the menstrual cycle, they should be treated as having premenstrual tension. A gynecologist may need to be consulted. If there is persistent bilateral breast pain in a young unmarried female, perhaps a psychiatrist should be consulted.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

CHEST PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

All patients should have a CBC, sedimentation rate, chemistry panel, VDRL test, chest x-ray, and EKG. If there is sputum, a smear and culture should be done as soon as possible.

If a myocardial infarction is suspected, then serial EKGs and tests for the isoenzyme of creatine kinase (CK-MB) should be done if the initial EKG and enzymes do not show any significant changes. Serum cardiac troponin levels may also be diagnostic of a myocardial infarct. Thallium-201 scintigraphy is useful in diagnosing both myocardial infarction and coronary insufficiency. Exercise tolerance tests may help diagnose coronary insufficiency. Immediate coronary angiography should be undertaken if the condition deteriorates. This can be followed by immediate balloon angioplasty, reperfusion therapy, or bypass surgery.

If a pulmonary embolism is suspected, arterial blood gases and a ventilation-perfusion scan should be done. d -dimer testing of whole blood is a sensitive test of pulmonary embolus. Pulmonary angiography may need to be done if these are negative and pulmonary embolism is still strongly suspected.

If esophageal disease is suspected, an upper GI series with esophagogram should be done; this can be followed with esophagoscopy and gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus) may reproduce the exact pain and distinguish esophageal reflux from a cardiac source of the pain. Ambulatory pH monitoring may also diagnose reflux esophagitis.

If pericarditis is suspected, echocardiography and possibly a CT scan of the chest and pericardium may be necessary. Coronary angiography may be necessary to diagnose coronary insufficiency. Echocardiography is also helpful in diagnosing mitral valve prolapse and the various myocardiopathies. Twenty-four-hr Holter monitoring is useful in diagnosing many causes of intermittent chest pain.

Referral to a cardiologist or pulmonologist may be appropriate at any point in this workup. Dissecting aneurysm may be confirmed by a CT scan or MRI of the chest.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EXTREMITY PAIN, LOWER EXTREMITY: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Often bursitis and myofascitis can be diagnosed by the dramatic relief obtained from a lidocaine injection. If there is clear-cut joint pathology, an x-ray of the joints, arthritis profile, and synovial fluid analysis will usually provide a diagnosis. MRI is useful in the diagnosis of a torn meniscus. If a deep-pain thrombophlebitis is suspected, venous Doppler ultrasound, impedance plethysmography, or a contrast venogram may be done. If an arterial embolism or chronic peripheral arterial disease is suspected, femoral angiography can be done. If a herniated disk or other pathology of the lumbar spine is suspected, plain films of the lumbar spine should be obtained. It might be wise at this point also to obtain a CBC, sedimentation rate, and chemistry panel to determine the alkaline phosphatase, calcium, and phosphorus. In older males, tests for acid phosphatase and PSA should be done.

If these tests are unrevealing, it is wise to refer the patient to a neurologic specialist before any more expensive tests are ordered. He will probably order a CT scan of the lumbar spine and may do nerve conduction velocity studies, EMG examinations, or dermatomal SSEP studies as indicated. In difficult neurologic problems, a combined myelography and CT scan is preferred over MRI. Bone scans will help diagnose obscure fractures and osteomyelitis, both of the lumbar spine and the lower extremities.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EXTREMITY PAIN, UPPER EXTREMITY: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

X-rays of the affected joints need to be done if there is tenderness or limitation of motion. Further workup of joint pain can be found on page 279 . When there are abnormal neurologic findings, an x-ray of the cervical spine, nerve conduction velocity studies, and EMG examinations need to be done. Referral to a neurologist should be made for these tests. If there is a typical radicular pain and a herniated cervical disk is strongly suspected, MRI of the cervical spine should be done. This is an expensive test, but when there are obvious signs of radiculopathy, it is worthwhile. Perhaps dermatomal somatosensory studies should be done when there is confusion about whether a herniated disk is pathologic. If a vascular lesion is suspected, angiography and venography should be ordered. ANA and nail fold capillary loop dilation and dropout study may diagnose Raynaud's phenomena; a small injection of lidocaine and steroids locally may be diagnostic in cases of carpal tunnel syndrome.

When there is intermittent pain, an exercise tolerance test should be done to exclude coronary insufficiency. A stellate ganglion block may be helpful in diagnosing reflex sympathetic dystrophy. Remember that other nerve blocks may be done and one should not hesitate to call an anesthesiologist for help in this area. Various forms of bursitis may be diagnosed by a therapeutic trial of lidocaine and corticosteroid injections.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EYE PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The primary care specialist may want to treat cases of obvious conjunctivitis without a culture and sensitivity. However, a smear and culture is useful especially if Neisseria is suspected. A smear may also reveal eosinophils suggesting allergic conjunctivitis. The primary care specialist may also use fluorescein dye to diagnose a foreign body. Most primary care physicians feel competent to use tonometry to diagnose glaucoma and may feel competent to use a slit lamp. However, when there is any doubt about the diagnosis, the most cost-effective approach is to refer the patient to an ophthalmologist.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FACE PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The first thing to determine is whether there is an infectious or neoplastic process in the structures underlying the face. X-rays of the sinuses and teeth and CT scans of the sinuses and brain may be necessary to further elucidate this. An x-ray of the temporomandibular joint may be helpful. An MRI of the temporomandibular joint is the procedure of choice to rule out pathology of this joint. Referral to a dentist to evaluate the patient's teeth or to an ear, nose, and throat specialist to evaluate sinusitis may be necessary.

To rule out cluster headaches or atypical migraine, a histamine test may be done. It may be wise to see the patient during an attack so that superficial temporal artery compression can be done to rule out migraine and/or a shot of sumatriptan succinate can be given, which should provide immediate results in cluster headache and atypical migraine.

A trial of carbamazepine (Tegretol®) can be given in cases of suspected trigeminal neuralgia, but referral to a neurosurgeon for an alcoholic injection of the maxillary or mandibular branches of trigeminal nerve will more likely make the diagnosis and solve the patient's problem.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FLANK PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests include a CBC, sedimentation rate, chemistry panel, urinalysis, and urine culture. An intravenous pyelogram is the next logical step. If these fail to make a definitive diagnosis, one should consider ordering an abdominal ultrasound or a CT scan of the abdomen. If a renal infarction is suspected, aortography and renal angiography may be ordered. When the above tests are all negative, one should consider x-rays of the lumbosacral spine and MRI of the thoracic and lumbar spine. Consulting a urologist is prudent before ordering expensive diagnostic tests.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FOOT AND TOE PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, VDRL test, and an x-ray of the foot. If the peripheral pulses are diminished, Doppler studies and angiography should be considered. If there is diffuse swelling and erythema, venography may need to be done. If there are neurologic findings, nerve conduction velocity studies and electromyograms (EMGs) may be helpful. Consider bone scans, CT scans, and arthroscopy if the above tests are negative. An MRI may be needed to diagnose stress fractures. Abnormal weight distribution is diagnosed by quantitative scintigraphs. It is wise to refer the patient to an orthopedic surgeon or podiatrist before ordering expensive diagnostic tests.

 

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

GIRDLE PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Patients with a rash, particularly if it is vesicular and in a dermatomal distribution, may be treated for herpes zoster before doing an extensive diagnostic workup. However, one should remember that herpes zoster may be associated with an underlying neoplasm, particularly Hodgkin's disease.

If a patient does not have a rash, routine laboratory tests include a CBC, chemistry panel, sedimentation rate, VDRL test, serum B 12 , and folic acid. In addition, x-rays of the chest, ribs, and thoracic spine should be done. If these are normal and the diagnosis remains in doubt, one should consult a neurologist. If none is available, MRI of the thoracic spine may be ordered. A spinal tap may be done to help rule out multiple sclerosis and tabes dorsalis. SSEP studies can be done to diagnose multiple sclerosis. A thoracic myelogram is occasionally necessary in confusing cases.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HEEL PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

In addition to a plain x-ray of the foot, a CBC, sedimentation rate, chemistry panel, and arthritis panel should be done. A bone scan may disclose an occult fracture. Response to a trigger point injection should be evaluated. If the diagnosis is still in doubt, referral to an orthopedic surgeon or podiatrist should be made before ordering expensive diagnostic tests such as a CT scan or MRI.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

HIP PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

A CBC, sedimentation rate, chemistry panel, arthritis panel, tuberculin test, and x-rays of the lumbosacral spine and hip will diagnose 90% of the cases. These are relatively expensive in comparison to MRI. A bone scan may be necessary to diagnose occult fractures. A serum protein electrophoresis will help diagnose multiple myeloma. A trigger point injection of the greater trochanter bursa or ischiogluteal bursa will assist in the diagnosis of these conditions. An orthopedic surgeon should be consulted before ordering MRI of the lumbar spine or hip. However, MRI is especially important if the diagnosis of avascular necrosis is suspected.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

JAW PAIN: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine diagnostic studies include a CBC, sedimentation rate, chemistry panel, arthritis panel, and an x-ray of the teeth and jaw. X-ray of the sinuses may be helpful. At this point referral to a dentist or oral surgeon should be made if there is still diagnostic difficulty. He may order an MRI of the temporomandibular joint, which is the procedure of choice in evaluating this joint. If all tests are negative or equivocal, perhaps a psychiatric referral is in order.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

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

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).

Testing

 A. Probability of IHD based on history. Prior to testing, the probability of IHD can be inferred by the estimates made by Diamond and Forrester (3). Examples of these estimates include (a) high probability situations (probability > 75%)—men aged more than 40 years and women aged more than
50 years with typical anginal symptoms; (b) moderate probability situations (probability > 50%)—men aged more than 40 years and women aged more than 60 years with atypical features; (c) low probability situations (probability < 20%)—men aged less than 40 years and women aged less than 50 with atypical features.

 B. Response to nitroglycerin (NTG). Response of chest pain to sublingual NTG can be used (with caution) as an adjunct for determining whether a patient’s chest pain is from IHD. For example, a prompt response (< 3 minutes) increases the probability of IHD; however, it should be noted that esophageal spasm and biliary colic may also respond favorably to this intervention. Conversely, failure to respond to NTG should not be used to exclude the possibility of IHD.

 C. Response to a gastrointestinal (GI) cocktail. It is common practice in many emergency room and urgent care settings to give a patient a GI cocktail that typically contains a liquid antacid, xylocaine, and an antispasmodic. No reliable studies exist on the diagnostic accuracy of this intervention.

 D. Resting ECG. A normal resting ECG cannot be used as the sole criterion to rule out the presence of ischemic heart disease.

 E. Exercise testing. The standard provocative test for patients with atypical chest pain who have at least a moderate risk for IHD is the exercise treadmill test. During exercise, the patient is monitored for symptoms of chest pain, heart rate, blood pressure response to exercise, arrhythmias, and ST-segment changes. A significant test includes an ST-segment depression of at least
1.0 mm below the baseline. It is important that the patient achieve a vigorous heart rate response to exercise. Approximately 20% of patients with an abnormal exercise tolerance test (ETT) have significant ST-segment changes occurring only at maximal or near-maximal heart rate changes. Therefore, when reviewing an ETT report, if the maximal heart rate achieved was less than 85% of the predicted heart rate, the results of the test should be interpreted more cautiously.

 F. Other diagnostic tests. Some patients should not undergo the standard ETT for a number of reasons. These include the inability to exercise because of gait or instability problems and underlying ECG abnormalities that make the standard ETT unreadable (e.g., left ventricular hypertrophy with strain and left bundle branch block). If the patient is able to exercise, the preferred test will be either an exercise echocardiogram or an exercise thallium test. If the patient is unable to exercise, test options include a dobutamine echocardiogram and a dipyridamole (Persantine) thallium test. A divergence of opinion is seen as to which of these tests is best; however, each has higher sensitivity and specificity than the standard ETT.

Diagnostic assessment

The key to the diagnosis of atypical chest pain remains in the clinical history. An assessment of the probability of ischemic heart disease should be made on all patients. Those with a very low probability of IHD should not undergo diagnostic testing because, given the problems of sensitivity and specificity, the results will have little or no impact on the management of the patient. Critical pathways for triage have been proposed to help identify intermediate and high risk patients (4,5).


References

1. Panju AA, Hemmelgard BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA 1998;280:1256–1263.

2. American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274–299.

3. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–1358.

4. Nichol G, Walls R, Goldman L, et al. A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact. Ann Intern Med 1997;127:996–1005.

5. Braunwald E, Mark DB, Jones RH. Diagnosing and managing unstable angina: quick reference guide for clinicians, Number 10. AHCPR Publication No.94-0603. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute; 1994.>>>>

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

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

 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.

Testing

 A. ECG. Despite the availability of a number of tests, the history remains very important in determining the likelihood of CAD in a patient with substernal chest pain. It is important to avoid using a normal ECG as “rule out” criteria, as many patients with unstable angina or even an acute MI may initially have a normal ECG. The diagnosis of CAD can be based on characteristic changes in the ST-T wave morphology during a symptomatic episode. Specifically, ST segment elevation greater than or equal to 1 mm in two or more consecutive leads is highly suggestive of an acute MI and is associated with the highest morbidity and mortality rate (3). ST segment depression of greater than or equal to 1 mm or T-wave inversion in two or more contiguous leads also strongly suggests ischemia or acute MI. The presence of Q waves greater than or equal to 0.04 seconds indicates previous MI. However, Q waves occurring in lead III alone may be a normal finding. As patients with initially normal ECG are still at risk for life-threatening complications and death (3% and 1%, respectively), it is important to follow serial ECGs for any evolution (3).

 B. Creatinine kinase. The most widely used laboratory test for the detection of MI is the creatinine kinase enzyme. The isoenzyme, CK-MB, is abundant in the myocardium and, therefore, is sensitive and specific for myocardial injury. With acute MI, the MB fraction typically begins to rise within 6 hours of symptom onset, peaks at 18 hours, and falls after 24 hours. Total CK and CK-MB should be measured every 6 to 8 hours for a 24-hour period.

C. Troponin I and T. Both troponin I and T proteins are located on the contractile apparatus of the myocardium. These proteins are highly sensitive for myocardial injury. The prospective study conducted by Hamm et al. showed that in the 47 patients diagnosed with acute MI, 94% were positive for troponin T and 100% for troponin I (4). In addition, the negative predictive value of troponin T was 98.9% and that of troponin I was 99.7% (4).

 D. Noninvasive and invasive testing. Both exercise and pharmacologic stress tests are used to assess for CAD in patients with stable angina. Unstable angina, uncontrolled hypertension, severe aortic stenosis, unstable arrythmias, and recent MI (4–6 weeks) are contraindications to stress testing.

 1. Exercise ECG is a relatively inexpensive test with an overall sensitivity and specificity of 50% to 70%. It is most useful for those patients with a moderate pretest probability. Protocols are used to incrementally increase treadmill speed and elevation until the maximal heart rate for age is achieved. The ECG is monitored for ST depression and any ventricular arrythmias. The patient is also monitored for any fall in blood pressure or complaints of chest discomfort or dyspnea.

 2. Exercise ECG with thallium or technetium sestamibi. The use of these radioisotopes improves the sensitivity and specificity of exercise ECG to approximately 90%. Thallium is distributed in proportion to blood flow. Areas of decreased uptake during exercise followed by normal uptake at rest suggest ischemia, whereas areas of persistent defect indicate infarction. Technetium is a newer agent with the advantage of a slow washout and added contrast, which results in fewer false-positive findings than thallium.

3. Exercise echocardiogram. This method detects wall motion abnormalities during exercise and has comparable sensitivity and specificity to exercise ECG. It is preferred in patients with abnormal resting ECGs and in patients with a low pretest probability. The disadvantages include difficulty imaging obese patients and the need to image as close to peak exercise as possible.

 4. Dipyridamole or adenosine stress testing. The use of intravenous coronary vasodilators (dipyridamole or adenosine) in combination with a radioisotope (thallium or technetium sestamibi) is useful in patients who are unable to exercise. Areas of redistribution suggest ischemia, whereas areas of persistent defects indicate infarction. The use of phosphodiesterase inhibitors and the presence of reactive airway disease are contraindications.

5. Dobutamine echocardiogram. This method is also used for those who are unable to exercise. Dobutamine increases myocardial oxygen demand by increasing contractility and essentially “exercises” the heart. The echo monitors for any wall motion abnormalities.

 6. Coronary angiography. Considered the “gold standard” test, this procedure provides the most detailed structural information of all the tests discussed. It is indicated in those patients who are at high risk for CAD by noninvasive tests and for those with persistent symptoms despite medical therapy. As diagnosis is closely tied to therapy, only those patients who are candidates for invasive procedures (e.g., percutaneous transluminal coronary angioplasty or coronary artery bypass graft) should be considered.

Diagnostic assessment

 In patients presenting with substernal chest pain, the key to diagnosis involves quickly and accurately assessing for the likelihood of myocardial ischemia or infarction. An initial history, physical examination, and ECG will help in the risk assessment of the patient for significant CAD. Those who are at high to intermediate risk need to then be evaluated for presence of unstable angina. Once established, further steps involve the simultaneous evaluation with serial ECGs and enzymes along with therapy to reduce ischemia. Cardiac angiography is the final step in evaluation and treatment. For those at low risk for CAD and not meeting criteria for unstable angina, further evaluation involves noninvasive diagnostic testing with the possibility for cardiac angiography and revascularization.


References

1. Braunwald E, Mark DB, Jones RH. Unstable angina: diagnosis and management. Clinical Practice Guideline Number 10. AHCPR Publication No. 94-0602. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, US Department of Health and Human Services, March 1994.

2. Anderson KM, Wilson PWF, Odell PM. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83:356–362.

3. Karlson BW, Hallgren HP, Liliequist JA. Emergency room prediction of mortality and severe complication in patients with suspected acute myocardial infarction. Eur Heart J 1994;15:1558–1565.

4. Hamm CW, Goldmann BU, Heeschen C. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I.
N Engl J Med 1997;337:1648–1653.>

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

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

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

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

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

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

Testing

 A. Clinical laboratory tests. Testing will be guided by the differential diagnosis as determined by the history and physical examination. If the back pain is felt to be of musculoskeletal origin, no test may be indicated. A urinalysis can help rule out hematuria or infection, if the pain is thought to be urologic or as a result of trauma. If the history suggests a medical problem, the considered diagnoses will determine the laboratory work. Extensive medical workup may be needed for a primary or metastatic malignancy. A calcium level should always be measured to identify a potentially lethal hypercalcemia. Rheumatologic studies may be indicated if a connective tissue disease (e.g., ankylosing spondylitis or rheumatoid arthritis) is suspected. If the pain is thought to be secondary to an urgent or life-threatening condition, have pertinent tests done expeditiously.

 B. Diagnostic imaging. In the absence of “red flags,” lumbar spine films are not indicated for musculoskeletal sounding low back pain of less than 1 month duration (1). Neurologic emergencies (e.g., major spine trauma, cauda equina syndrome) require magnetic resonance imaging (MRI) studies. It is usually unproductive to order an MRI for straightforward lumbar muscular strain or for initial evaluation of simple disc herniation, as the prevalence rate of nonsignificant abnormal findings is high. A bone scan may be helpful when tumor, infection, or occult fracture is suspected. Electromyography may be useful to assess for nerve root dysfunction when symptoms are questionable.

Diagnostic assessment

The most common cause of low back pain in the outpatient setting is musculoskeletal strain. Although temporarily very debilitating, muscle strain can be conservatively treated and usually has few long-term complications. Variations from this basic presentation must be recognized to identify more structurally significant or medically threatening problems. Clues to these other diagnoses, which are found in the history, are reinforced by abnormalities in the physical examination; they are found less often by diagnostic testing.

The following “red flags” suggest possible urgent diagnoses. A history of recent trauma or motor vehicle accident can signify a vertebral fracture or subluxation. Fever can indicate an infection of the spine or pyelonephritis (Chapter 2.6). Recent genitourinary instrumentation or other invasive procedure can precede this presentation. Weight loss, other constitutional symptoms, or pain at rest (or at night) may suggest cancer (Chapter 2.13). Neurologic abnormalities can signify nerve dysfunction or cord compression. Urinary or fecal incontinence or retention, saddle area perineal numbness, or anal sphincter incompetence suggests cauda equina syndrome. A sudden tearing sensation in the back with associated hypotension can be caused by a rupturing abdominal aortic aneurysm.


References

1. Bigos SJ. Acute low back problems in adults. Clinical Practice Guideline. No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; December 1994.

2. Alvarez JA, Hardy Jr. RH. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician 1998;57:1825–1834.

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

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

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.

Testing

 No studies are routinely indicated for all cases of monarticular joint pain.

 A. Imaging studies. Radiographs may be warranted if evaluation suggests degenerative joint disease, but they are not necessarily indicated at initial presentation. Radiographic findings of OA, which are more prevalent than symptomatic disease, can be found in 85% of patients aged 65 years (1). Radiographic study is clearly indicated if the pain is chronic, or if there is a history of recent trauma, night pain, or childhood joint disease. In cases of acute inflammatory arthritis, radiographs will likely reveal soft tissue swelling and not provide diagnostic certainty, but could exclude other diseases. Bone scans are not helpful, as they will be positive in all forms of arthropathy. Computed tomography or magnetic resonance imaging scans are not indicated in the routine initial evaluation of monarticular joint pain.

B. Laboratory testing. In the presence of an inflamed joint, a complete blood count and erythrocyte sedimentation rate (ESR) may help distinguish a septic or inflammatory condition from crystal-induced arthritis. Rheumatoid factor or antinuclear antibody may be positive in inflammatory arthritis (Chapters 16.3 and 17.3). Serologic testing for syphilis should be done when gonococcal infection is suspected. Serum uric acid, Lyme titers, and human immunodeficiency virus testing may be warranted. The uric acid level may be normal during an acute gouty attack.

C. Joint aspiration. Fluid analysis is necessary in all cases of suspected septic arthritis, and for the definitive diagnosis of presumed crystal-induced arthropathy at initial presentation. Fluid should be analyzed for cell count and crystals and sent for Gram’s stain, culture, and sensitivity. Patients with immune compromise or tuberculosis require culture for mycobacteria and opportunistic organisms. In suspected septic arthritis, Gram’s stain and culture of the blood, skin lesions, cervix, urethra, pharynx, and rectum may be indicated.

Diagnostic assessment

The history and physical examination usually determine whether the cause of joint pain is inflammatory or degenerative. Occasionally, an acute, inflammatory appearing monarthritis, with a mildly elevated ESR, can be the initial presentation of degenerative disease. OA typically presents with a slow, insidious progression of symptoms over months to years. The pain is achy, brought on by joint use, and relieved by rest. Short-lived (<30 minutes) stiffness may be apparent in the morning and after inactivity.

Gouty arthritis is seen most frequently in men aged more than 30 years. Of patients, 50% present classically with inflammation in the first metatarsal joint of the foot. In women, upper extremity joint involvement predominates. Synovial fluid analysis will reveal monosodium urate crystals or calcium pyrophosphate crystals in the case of pseudogout. Synovial white blood cell (WBC) count suggests inflammation (3,000–50,000 cells/µL). Synovial fluid should be cultured, even if crystals are identified, as bacterial infection can coexist. When in doubt, a diagnostic or therapeutic trial of colchicine can be considered.

Infectious arthritis should be considered with any inflamed joint. Risk factors include an immunocompromised state, a damaged or prosthetic joint, sexual promiscuity, and alcohol or intravenous drug abuse. Onset is usually rapid, over hours to days. Gonococcal arthritis can present with a few days of migratory polyarthralgias. In septic arthritis, the joints commonly affected are the knees, hips, and shoulders. Severe joint pain, swelling, and limited ROM suggest the diagnosis, especially if high fever is present. An elevated WBC count, with a left shift, is present in more than 50% of cases. Definitive diagnosis is dependent on arthrocentesis. Synovial fluid WBC count of greater than 50,000 is supportive of infection. A negative Gram’s stain finding does not rule out infection. Gonococcal arthritis can present with a lower synovial fluid WBC count and the synovial fluid culture is positive in only 25% of cases (2).

Lyme arthritis has an acute, oligoarticular onset and especially affects large joints, most commonly the knee. Symptoms tend to be episodic and are associated with marked swelling, often disproportionate to the amount of pain. Presentation can be weeks to months after the initial infection, and the patient may be unable to give a history of tick bite or the erythema chronicum migrans rash (3). Serology and Western blot testing for Lyme disease should be positive.


References

1. Baker DG, Schumacher HR. Acute monoarthritis. N Engl J Med 1993;329:1013–1020.

2. Zimmerman B, Lally EV, Liu NYN. Infectious agents and the musculoskeletal system. In: Noble J, ed. Textbook of primary care, 2nd ed. St. Louis: Mosby, 1996.

3. Sigal LH. Musculoskeletal manifestations of Lyme arthritis. Rheum Dis Clin North Am 1998;24:323–351.>

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

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

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).

Testing

A. Clinical laboratory tests. Human chorionic gonadotrophin should be obtained if the patient has any potential for pregnancy. If appendicitis is suspected, sensitivity approaches 96% when both the total white blood cell count and neutrophil counts are elevated. Overall, however, hemograms do not by themselves often result in a change of disposition. Serum electrolytes are generally of little diagnostic value, except for the anesthesia provider if surgery is contemplated.

Urinalysis may identify urinary infection or calculi. Liver function tests in patients with right upper quadrant pain may help differentiate hepatitis and hepatobiliary disease (Chapter 9.8). Serum amylase is not a specific test for pancreatitis; it can be elevated in many other conditions that cause abdominal pain. Serum lipase has a higher sensitivity and specificity for pancreatitis than total amylase (4).

B. Diagnostic imaging

1. Plain films. Plain radiographs have utility primarily when attempting to identify specific abdominal pathology such as renal stones, perforated viscus, or bowel obstruction. They can detect as little as 5 ml of free air. Up to five air-fluid levels of less than 2.5 cm in length may be normal; however, dilation of the small bowel beyond 2.5 cm suggests obstruction.

 2. Ultrasonography. Abdominal and pelvic sonograms are rapid, inexpensive, and noninvasive. They are especially accurate in detecting hepatobiliary, pancreatic, aortic, pelvic, and renal pathology.

 3. Computed tomography (CT). Consider for patients with challenging presentations. CT is valuable in identifying abscesses, hematomas, and pancreatitis, and in evaluating solid organs and the abdominal vascular system; it is remarkably useful in evaluating patients with trauma. Magnetic resonance imaging has not proved particularly beneficial in the evaluation of acute abdominal pain.

Diagnostic assessment

The critical key is to identify the patient with an acute surgical abdomen. Physical examination coupled with a careful history narrows the differential diagnosis so that confirmation can be made by appropriately selected laboratory and imaging studies. In most cases, a good clinical history augmented by a focused physical examination leads to a correct diagnosis with limited need for further testing. Extremes of age, an impaired immune system, use of pain medications, and obesity can complicate the evaluation. Surgical consultation should be obtained immediately for patients with abdominal pain accompanied by peritoneal signs or shock.


References

1. Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. Am J Emerg Med 1995;13:301–303.

2. Silen W, ed. Cope’s early diagnosis of the acute abdomen, 19th ed. New York: Oxford University Press, 1996.

3. Dart RG. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med 1999;33;283–290.

4. Gwozdz GP, Steinberg WM, Werner M, Henry JP, Pauley C. Comparative evaluation of the diagnosis of acute pancreatitis based on serum and urine enzyme assays. Clin Chim Acta 1990;187:243–254.

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

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

 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).

Testing

 A. Blood tests. No laboratory tests are necessary unless the history or PE suggests an infectious process or a metabolic disorder. In these cases, obtain a complete blood count (CBC) with differential, creatine phosphokinase (CPK), blood urea nitrogen, creatinine, electrolytes, calcium, magnesium, and thyroid-stimulating hormone.

 B. Diagnostic imaging. Radiographs are useful if fracture or bony injury is suspected. Duplex ultrasound is used to evaluate for DVT, but can also detect masses, popliteal cysts, or incomplete rupture of the Achilles tendon (5). The definitive radiographic test for both symptomatic and asymptomatic DVT is venography. Sensitivity and specificity are greater than 90%; however, the test is invasive and costly compared with duplex ultrasound (4,5). In symptomatic cases, the sensitivity and specificity of duplex ultrasound is also very good, as long as a negative test is followed up with a repeat study in 5 to 7 days if clinical suspicion remains high (4,5). Magnetic resonance imaging has comparable sensitivity and sensitivity to venography and gives more information regarding surrounding soft tissue structures when the clinical assessment is not straightforward (4).

Diagnostic assessment

The diagnosis of DVT is unreliably made without objective testing. Of patients presenting with suspected DVT, 75% will actually have a nonthrombotic cause of leg pain (4). The patient with acute calf pain that develops after athletic activity, a tender calf muscle, and pain and decreased muscle strength with passive ankle or knee ROM likely has a muscle tear or sprain. Acute calf pain, with posterior ankle swelling and an abnormal Thompson test, is characteristic of ATR. Claudication-type calf pain, possibly bilateral, with decreased peripheral pulses and decreased capillary refill, suggests arterial disease. The pseudoclaudication of lumbar spinal stenosis is provoked by ambulation or posture change (e.g., standing straight at the waist). A ruptured Baker’s cyst typically produces calf pain along with erythema and diffuse swelling of the calf and ankle. A clinical history of calf pain and fever, with an open wound or a well-demarcated area of erythema, is suggestive of cellulitis. Calf pain, gastrocnemius weakness, swelling, and increased CPK levels are suggestive of localized myositis. An additional symptom of fever, with calf erythema and an abnormal CBC, may indicate pyomyositis. An intramuscular hematoma or compartment syndrome will often present with pain out of proportion to the physical signs, which can include increased firmness of the calf muscles and localized ecchymosis and swelling.


References

1. Schuberth J. Achilles tendon trauma. In: Scurran B, ed. Foot and ankle trauma, 2nd ed. New York: Churchill Livingston, 1996.

2. Banerjee A. The assessment of acute calf pain. Postgrad Med J 1997;73:86–88.

3. Harris J, Abramson N. Evaluation of recurrent thrombosis and hypercoagulability. Am Fam Physician 1997;56:1591–1596.

4. Weinmann EE, Salzman EW. Deep vein thrombosis. N Engl J Med 1994;331:
1630–1641.

5. Anand S. Does this patient have deep vein thrombosis? JAMA 1998;279:1094–1099.

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

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

 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.

Testing (3)

 If no obvious cause is apparent, it is reasonable to obtain a complete blood count, urine analysis, sedimentation rate, and serum chemistry profile. A pelvic ultrasound may be helpful when the pelvic examination is inconclusive. Laparoscopy is best used to diagnose a definite pelvic mass. Laparoscopy has been used extensively in the past but various studies have shown a 66% negative laparoscopy rate for patients with chronic pelvic pain. A multidisciplinary approach using medical, psychologic, environmental, and nutritional disciplines showed decreased pain after 1 year.

Diagnostic assessment

 Chronic pelvic pain has a wide differential diagnosis (1). These complex problems can be assessed using a multisystems approach. Whereas gastrointestinal, gynecologic, musculoskeletal, and psychiatric conditions can cause chronic pelvic pain, a thorough gynecologic history and pelvic examination are the cornerstones of the diagnostic assessment. Few laboratory tests are helpful. A pelvic ultrasound is useful when the pelvic organs cannot be adequately assessed during the physical examination. A team approach, coordinated by a trusted family physician, can bring much relief to patients with this frustrating clinical problem.


References

1. Ryder RM. Chronic pelvic pain. Am Fam Physician 1996;54(7):2225–2232.

2. Stiege JF, Stout AL, Somkuti SG. Chronic pelvic pain in women: toward an integrative model. Obstet Gynecol Surv 1993;48:95–110.

3. Chan PD, Winkle CR, eds. Gynecology and obstetrics, 1999–2000. Laguna Hills, CA: Current Clinical Strategies Publishers; 1999:23–25.

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

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

 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.

Testing

A. Radiographs. A suspected hip fracture requires anteroposterior and lateral or “frog leg” hip films. A fracture of the femoral neck can be difficult to visualize. In trauma cases, lateral oblique films are needed to evaluate the acetabulum. Radiologic changes of OA are ubiquitous in older patients and do not rule out other causes of hip pain. Radiographs of a septic hip joint often reveal a “moth-eaten” appearance of the subchondral bone on both sides of the joint (2).

B. Clinical laboratory. The sedimentation rate and white blood cell count are normal in synovitis; leukocytosis and an elevated erythrocyte sedimentation rate may be seen with a septic joint. If a septic joint is suspected, synovial fluid aspiration must be done promptly, as a delay of a few hours increases the chance of substantial joint damage. Joint fluid should be examined for glucose, protein, crystals, Gram’s stain, culture, cell count, and differential. Fluoroscopic guidance is needed to confidently localize the joint space.

Diagnostic assessment

 A. Intraarticular disease. A deep, aching discomfort that is increased with weightbearing is characteristic of OA. In the later stages, hip OA can lead to rest or night pain. Femoral neck fractures occur most commonly in patients aged more than 50 years; intratrochanteric fractures occur at even older ages. Dislocation of the hip is rarely seen; it is most often associated with severe trauma.

Joint fluid analysis will assist in distinguishing a septic joint from a transient synovitis or crystal-induced arthropathy. Septic arthritis can lead to severe joint destruction within 2 to 3 weeks. Involvement of the hip joint in gout or pseudogout is rare. The femoral neck is a common site for metastatic cancer, which may lead to a pathologic fracture.

B. Referred pain. Lumbosacral disease is the most common cause of hip pain in a postadolescent, nonelderly individual (3).


References

1. Shbeeb MI, Matteson EL. Trochanteric bursitis. Mayo Clin Proc 1996;71:565–569.

2. Medsger TA, Jr. Diagnosis and treatment of arthritis. Emerg Med 1999;31:13–28.

3. Birnbaum JS. The musculoskeletal manual. Philadelphia: WB Saunders, 1986.

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

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

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.

Testing

 Most diagnoses can be made without an x-ray study or expensive diagnostic test.

 A. Ottawa rules. For acute injuries, the Ottawa knee rules are highly sensitive, but less specific, in determining the need for a plain knee x-ray study in adults (1). This decision rule has not been tested in children. The Ottawa rules recommend an x-ray study if any of the following are found: age 55 years or older, tenderness at the head of the fibula, isolated patellar tenderness, inability to flex the knee to 90°, or inability to bear weight immediately after the trauma (1).

 B. Radiographs and procedures. Testing depends on the diagnosis suspected, medicolegal requirements, and response to therapy. Knee films are important when surgical treatment of degenerative arthritis is considered, or if chondrocalcinosis, gout, RA, osteomyelitis, or osteochondritis dissecans should be ruled out. Magnetic resonance imaging (MRI) of the knee is a sensitive and specific test for detecting meniscal or ligament injury; however, it is no better than a consistent history, a positive McMurray’s or Lachman’s test, and medial joint line tenderness (2). MRI is indicated when a patient has a good history for internal derangement and a normal clinical examination, or fails to improve despite adequate conservative therapy. A bone scan is warranted when a stress fracture or cancer is suspected. Computed tomography may define bony pathology and, with arthrography, detect meniscal and ligamentous pathology when an MRI is contraindicated. Duplex ultrasound will rule out a deep venous thrombosis or detect a Baker’s cyst. Arthrocentesis can be used to diagnose gout, pseudogout, or septic arthritis, and to relieve pain and allow corticosteroid instillation. Arthroscopy is helpful when internal derangement is suspected and the probability of arthroscopic treatment is high.

Diagnostic assessment

 Clinical information may trigger further immediate diagnostic workup. Hemarthrosis could indicate internal derangement or fracture. Knee pain and a limp in a child with a normal knee examination suggests hip disease (Legg-Calvé-Perthes, slipped femoral capital epiphysis). Bony swelling and night pain suggest tumor; fever and joint swelling, infectious or inflammatory arthritis. A knee effusion with rash suggests gonorrhea, Reiter’s syndrome, or collagen vascular disease.

Of nontraumatic anterior knee pain, 70% is related to patellofemoral syndrome. Meniscal tears can develop in older patients without a trauma history. Knee pain in a growing adolescent is jumper’s knee (patellar tendinitis) or traction apophysitis until proved otherwise.


References

1. Steil IG. Derivation of a decision rule for the use of radiography in acute knee injuries. Ann Emerg Med 1995;26:405–413.

2. Gelb HJ, Glasgow SG, Sapega AA, Torg JS. Magnetic resonance imaging of knee disorders. Clinical value and cost-effectiveness in a sports medicine practice. Am J Sports Med 1996;24:99–103.>

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

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

 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).

Testing

A. Clinical laboratory testing. A complete blood count and erythrocyte sedimentation rate are warranted for suspected infection or neoplasm. A positive rheumatoid factor (RF) is found in more than two-thirds of patients with RA, but is also found in 10% to 20% of all elderly individuals. RF and antinuclear antibody are absent in AS. Creatine phosphokinase is elevated in myositis and, possibly, muscle trauma (Chapters 16.3 and 17.3).

 B. Diagnostic radiology. Cervical spine films are mandatory after any spine trauma (3). A cross-table lateral film is used to rule out an unstable fracture or dislocation (2). The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace (3). Cervical spine films are also useful for a vertebral compression fracture, cancer, and rheumatologic disorders. Cortical erosion of the vertebral body indicates an inflammatory process. Increased width of the prevertebral soft tissues can suggest a prevertebral hematoma. Degenerative changes in the vertebral joints, also called spondylosis, are very common with aging and do not correlate well with symptomatology (1,2). Computed tomography scans are excellent for definitive delineation of bony fracture anatomy, when necessary. Magnetic resonance imaging (MRI) is the most effective means to evaluate the soft tissues of the neck. An MRI will distinguish between neoplasm and degenerative disorders of the vertebrae, and visualize ligamentous injury, occult disc herniation, hematoma, or edema around the spinal cord. MRI may identify abnormalities that have no clinical significance (1).

C. Other. An electromyogram (EMG) can delineate the site of a particular nerve lesion or clarify the diagnosis when symptoms and physical examination are discordant (1). An EMG may be negative in nerve damage of less than 3 weeks’duration (1,2).

Diagnostic assessment

A. Spondylosis. Degenerative changes can encroach on the spinal canal or intervertebral foramina. Consider spondylosis-related symptoms in patients aged more than 40 years. Symptoms affect men twice as often as women. Common symptoms include a unilateral or bilateral occipital headache that is worse in the morning and radiates to the frontal region, upper chest, and shoulders.

 B. Radiculopathy or myelopathy. Radicular pain usually involves the proximal arm with more distal paresthesias (Table 12.9) (Chapter 4.6). Cervical myelopathy presents with upper extremity nerve root symptoms and long tract signs in the legs. Spasticity may be the most prominent neurologic change. Long tract signs in the legs occur uncommonly without root signs (2). Symptoms can be precipitated by neck movement. Myelopathy is more typically secondary to spondylosis rather than disc herniation.

 C. Rheumatologic. Axial involvement with RA may be limited to the upper cervical spine; atlantoaxial subluxation can present as occipital pain. Subluxation can cause cord compression. DISH has a characteristic appearance on x-ray film. It is the most common rheumatologic process affecting the cervical spine, but rarely causes symptoms (1). AS also affects the cervical spine. Gout and pseudogout usually do not.


References

1. Swezey RI. Chronic neck pain. Rheum Dis Clin North Am 1996;22:411–437.

2. Cailliet R. Neck and arm pain. Philadelphia: FA Davis, 1989.

3. Graber MA, Kathol M. Cervical spine radiographs in the trauma patient. Am Fam Physician 1999;59:331–342.

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

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

 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.

Testing

A. Clinical laboratory tests. Routine studies (e.g., complete blood count and metabolic panels) are of limited usefulness; leukocytosis in pneumonia, uremia, or hepatic abnormalities may suggest the cause.

 B. Diagnostic imaging. The chest x-ray (CXR) study is essential, potentially revealing pneumonia, neoplasm, pneumothorax, or pleural effusion; the decubitus view is sensitive at 100 ml effusion. Nonspecific findings of atelectasis, pulmonary parenchymal abnormalities, or both are seen in 68% of PE; pleural effusion is found in 48% of PE (3). The CXR study is commonly normal. Notably, PE and viral pleurisy frequently have a normal CXR study. Ultrasound has diagnostic and therapeutic adjunctive roles with pleural effusions and computed tomography has a role with both effusions and parenchymal abnormalities.

 C. Pleural effusion analysis. Diagnostic thoracentesis is indicated if the cause of the effusion and pain is not apparent (Diagnostic assessment of pleural effusion is discussed in Chapter 8.4.) Effusion associated with pleuritic pain is nearly always an exudate with a notable exception of PE which can be a transudate (4).

 D. Additional studies. V˙/Q˙ lung scan is typically obtained for any suspicion of PE. If the V˙/Q˙ scan is intermediate or has low probability for PE, then evaluating for possible DVT with leg impedance plethysomography or ultrasound is useful. If the DVT studies are negative and strong clinical suspicion for PE exists, then either a pulmonary angiogram or serial leg venous study can be obtained (3). Obtain an electrocardiogram and echocardiogram if pericarditis is suspected.

Diagnostic assessment

After performing a focused history and physical examination and excluding chest wall pain and other mimics (Table 8.2), order a CXR study, which may reveal an obvious cause (e.g., neoplasm, pneumonia, or pneumothorax). The CXR film may nonspecifically reveal a PE or, commonly, it may be normal. Causes of pleuritic pain with a normal CXR result are PE, viral or idiopathic pleurisy, and serositis, especially from systemic lupus (5). Viral pleurisy, usually Coxsackie virus B, is characterized by unilateral acute pleuritic pain, variable low-grade fever, and nonproductive cough with typically a normal CXR film, which is an indistinguishable presentation from PE—20% presenting with acute pleuritic pain to the emergency room have PE and approximately 50% have viral or idiopathic pleurisy (1,2). Hence, acute pleuritic pain without an obvious cause on history and physical examination and CXR film requires exclusion of PE. A possible exception to this tenet is the young adult (aged <40 years) who is highly unlikely to have a PE if all three of the following clinical features are absent:
(a) risk factors for or past history of venous thromboembolic disease, (b) physical findings of phlebitis, and (c) pleural effusion on CXR film (2). In the presence of an effusion without a clear cause of the pleuritic pain and PE either ruled out or clinically highly unlikely, a diagnostic thoracentesis is indicated. The effusion associated with pleuritic pain is nearly always an exudate. The most common causes of exudate in descending order of frequency are malignancy (most commonly lung cancer, breast cancer, lymphoma), pneumonia, PE, and viral, which together constitute 95% of these effusions (4).


References

1. Palevsky HI, Kelley MA, Fishman AP. Pulmonary thromboembolic disease. In: Fishman AP, ed. Fishman’s pulmonary diseases and disorders. New York: McGraw-Hill, 1997:1297–1329.

2. Hull RD, Raskob GE. Pulmonary embolism in outpatients with pleuritic chest pain. Arch Intern Med 1988;148:838–844.

3. Stein PD. Acute pulmonary embolism. Dis Mon 1994;XL(9):467–515.

4. Light RW. Pleural diseases, 3rd ed. Baltimore: Williams & Wilkins, 1995:75–82, 187–191.

5. Staton Jr GW, Ingram Jr RH. Disorders of the pleura, hila, and mediastinum. In: Dale DC, ed. Sci Am Med St. Louis: Mosby, 1997; 14RespIX:1–19.>

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

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

 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).

Testing

A. Clinical laboratory tests

 1. Urinalysis is not usually helpful. It is negative in most cases. If positive, the diagnosis is more likely epididymitis than torsion in the testicle or appendage (3,4).

 2. White blood cells (WBC). The finding of a leukocytosis is nonspecific. The WBC count is more commonly elevated in epididymitis. It can be elevated in appendiceal torsion and testicular torsion, especially after 24 hours (4).

3. Serology and erythrocyte sedimentation rate are not helpful in the assessment of acute pain.

B. Imaging

1. Doppler ultrasound

a. Gray-scale ultrasound. Real time, gray-scale ultrasound findings are nonspecific and not reliable for either epididymitis or testicular torsion. The testicle may appear normal early in torsion. Once changes are seen, irreversible damage may be present (5).

 b. Color Doppler imaging is much more reliable for the diagnosis of both torsion and epididymitis. In torsion there is a total absence of blood flow on the affected side as compared with the contralateral side; in epididymitis there is a marked increase in arterial blood flow as compared with the contralateral side (5).

 2. Nuclear scanning is of questionable value in the acute setting. It is declining in use as color Doppler becomes a primary diagnostic modality (5). It may effectively demonstrate ischemia but too late to save the testicle. It is useful in cases of trauma, asymptomatic mass, and when elective surgical exploration is contraindicated and Doppler studies are equivocal (2).

3. Magnetic resonance imaging provides a good view of the anatomy but is not useful in the acute setting (5).

Diagnostic assessment

 The two most important pieces of clinical history that determine the course and outcome in scrotal pain are the age of the patient and the time elapsed since pain onset. Severe unilateral pain of less than 6 hours duration, worsened by elevation of the testicle in an adolescent, is testicular torsion until proved otherwise at surgery. In the neonate, it is important that the scrotum be examined any time abdominal symptoms are present. Epididymitis in the infant or child is rare. When present, rule out congenital and functional anomalies. In adults, the primary cause of scrotal pain is epididymitis and the course is chronic. Unless the testicle is ruptured, trauma rarely causes scrotal pain that lasts longer than 1 hour. Testicular rupture from mild trauma must be evaluated for tumor. The best tool for evaluation of acute, unilateral pain is color Doppler ultrasonography. Laboratory tests are nonspecific and are helpful only as confirmatory in some causes. Most importantly, if there is any doubt to the diagnosis, then it is always appropriate to refer to a surgeon for exploration.


References

1. Morgan RJ, Parry JRW. Scrotal pain. Postgrad Med 1987;63(741):521–523.

2. Galejs LE. Diagnosis and treatment of the acute scrotum. Am Fam Physician 1999;59(4):817–824.

3. Lewis AG, Bukowski TP, Jarvis PD, Wacksman J, Sheldon CA. Evaluation of acute scrotum in the emergency department. J Pediatr Surg 1995;30(2):277–282.

4. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin North Am 1997;44(5):1251–1266.

5. Sandock DS, Herbener TE, Resnick MI. Disorders of the scrotum and its contents. In: Resnick MI, Older RA, eds. Diagnosis of genitourinary disease, 2nd ed. New York: Thieme-Stratton Inc.; 1997:465–483.

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

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

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).

Testing

A. Laboratory tests. A complete blood count (CBC) and analysis of synovial or bursal aspirate for cell count, Gram’s stain, and culture are obtained for suspected infectious arthritis or bursitis. Obtain an erythrocyte sedimentation rate (ESR), rheumatoid factor, antinuclear antibody, and aspirate for crystals for inflammatory arthritis.

 B. Radiographic study. Routine shoulder views are obtained for a history of acute trauma or chronic injury not responsive to conservative management. Special axillary or scapular Y views are needed if posterior dislocation is suspected. Views with and without weights may better assess for AC joint separation.

 C. Diagnostic injection. Anesthetic infiltration of the involved area may relieve symptoms and establish the diagnosis. Injection sites include the subacromial and intraarticular spaces, AC joint, and biceps tendon sheath (2).

 D. Other imaging studies. Computed tomography (CT) scan, magnetic resonance imaging (MRI), ultrasound, arthrography, fluoroscopy, and bone scan can be used when diagnosis is unclear or surgery is considered. MRI is superior for soft tissue pathology. Arthrography is useful for rotator cuff tears if MRI is unavailable or the patient is claustrophobic. A CT scan is useful to evaluate bony structures. Ultrasonography can identify moderate and full-thickness tears, but accuracy is operator-dependent. Bone scan can identify areas of bone remodeling (e.g., metastatic tumors, nonunion of fractures). Fluoroscopy allows dynamic assessment of fracture stability and can detect loose bodies or impingement (1).

Diagnostic assessment (3,4)

A. Nonshoulder origin. Painless ROM without localized tenderness suggests referred pain. Muscular sprain or strain presents with pain on active, but not passive, ROM and muscle tenderness or spasm; cervical disc herniation with radicular symptoms, neurologic findings, and an abnormal CT or MRI scan. Thoracic outlet symptoms include pain and numbness in the shoulder or arm (especially with head turning) and a positive Adson test.

 B. Shoulder origin, nontraumatic. Both inflammatory and infectious arthritis may present with a joint effusion and inflammatory signs on examination. Serologic testing may be positive in the former; joint aspirate analysis and culture will help differentiate the two. An x-ray study or bone scan can help to rule out osteomyelitis. Tumor presents with localized pain and a positive imaging study.

 C. Shoulder origin, acute traumatic

1. Fractures and contusions have point tenderness on examination. An associated pneumothorax should be ruled out with a clavicular fracture. Scapular fractures are infrequent, and usually occur with other severe thoracic injury. Contusions present with point tenderness on examination, but have no evidence of ligament injury and an x-ray study is negative.

 2. Shoulder separation is more common at the AC joint. An AC dislocation may occur secondary to a fall on an outstretched hand or the lateral shoulder. Pain and swelling are seen at the joint, and a crossover test is positive. An x-ray study can be negative. Sternoclavicular separation is usually associated with other severe injuries.

 3. Glenohumeral instability can develop with trauma. In anterior dislocation, the patient uses the other hand to hold the injured arm in abduction and external rotation. Visually, the acromion will be prominent. In the less-common posterior dislocation, the arm is held across the chest. Only an axillary or scapular x-ray view may show the displaced head.

 D. Shoulder origin, chronic traumatic

1. An AC joint sprain is usually caused by overuse, degenerative joint disease, or incorrect weightlifting. On examination, tenderness is found over the AC joint.

 2. Chronic glenohumeral instability occurs when recurrent trauma causes small labral or capsular tears. The patient presents with chronic or subacute pain and may report that the shoulder “pops” in and out. On examination, mild instability signs may be seen (Table 12.12).

3. Impingement syndrome is a common cause of shoulder pain.

a. Rotator cuff tendinitis most often involves the supraspinatus tendon and is secondary to overuse of the joint. It presents with diffuse pain in the anterior or lateral shoulder. The patient cannot sleep on the affected side. The shoulder is tender in the upper deltoid region or below the acromion. Seen are decreased ROM and pain, especially between 70° and 120° abduction; impingement signs are positive. The x-ray study is normal or shows calcific tendinitis or a prominent acromial spur.

 b. Subacromial bursitis is usually secondary to tendinitis and presents with the same findings. Inflammatory, infectious, or crystalline causes may need to be ruled out by joint fluid aspiration.

c. A rotator cuff tear develops with overuse or trauma in the presence of an underlying abnormality. On examination, supraspinatus weakness and positive impingement signs may be seen.

 d. Bicipital tendinitis is another overuse injury. Pain in the anterior shoulder radiates to the biceps and forearm. Examination findings include limited abduction, positive impingement signs, biceps tendon tenderness, and pain on resisted elbow flexion or wrist supination.

4. Adhesive capsulitis presents with chronic pain and stiffness, often following a period of prolonged immobility. It is especially common in elders. Decreased active and passive ROM occurs in all planes.


References

1. Howard TM, O’Connor FG. The injured shoulder: primary care assessment. Arch Fam Med 1997;6:376–384.

2. Larson HM, O’Connor FG, Nirschl RP. Shoulder pain: the role of diagnostic injections. Am Fam Phys 1996;53:1637–1643.

3. Glockner SM. Shoulder pain: a diagnostic dilemma. Am Fam Phys 1995;51:1677–1687.

4. Diagneault J, Cooney LM. Shoulder pain in older people. J Am Geriatr Soc 1998;46:
1144–1151.

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

Chronic/Recurrent Abdominal Pain: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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

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

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

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Source: Field Guide to Bedside Diagnosis, 2007

Scrotal Pain/Swelling: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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

Hip Pain: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Pain arising from the hip joint is aggrevated with or after use, particularly weight-bearing, and improved with rest. In contrast, constant pain, particularly pain at night, should suggest an infectious, inflammatory, or neoplastic process.

In disease of the hip joint, the earliest limitation is internal rotation with the hip hyperextended. The hip joint is palpated just below the inguinal ligament lateral to the femoral artery. Tenderness and/or crepitance are usually felt there with movement. Manual internal and external rotation of the hip with the knee and hip in flexion usually reproduces pain as does concussion of the heel with the examiner’s palm.

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Source: Field Guide to Bedside Diagnosis, 2007

Neck Pain: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

With neck pain after trauma, a cervical fracture must always be ruled out and the patient’s neck immobilized until this is ascertained.

Assess radicular signs of nerve compression as a marker for more serious pathology. The Spurling sign, production of radicular pain with extension and lateral neck rotation, suggests narrowing of the neural foramen. The Lhermitte sign, an electrical sensation radiating down the spine with neck flexion, is a sign of a spinal cord lesion.

With neck pain in the presence of headache or fever, actively consider meningitis.

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Source: Field Guide to Bedside Diagnosis, 2007

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

Perform a physical assessment. 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 Assessing abdominal vascular sounds.)

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

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

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.

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

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

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

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

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.

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

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

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.

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

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

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the lids 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 272.)

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

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

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. (See Associated Disorder: Sinusitis.)

Evaluate oral hygiene by inspecting the teeth for caries, percussing any diseased teeth for pain, and asking the patient about 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 — have him raise his eyebrows, frown, show his teeth, close his eyes tightly, and wrinkle his nose. (See Major nerve pathways of the face, page 278.)

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

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

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

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

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" (2.9 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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

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

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 any 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 any associated pain.

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

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

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’s no history of neck trauma, and palpate the cervical lymph nodes for enlargement.

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

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

Inspect the rectal 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.

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

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

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

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

  • Completehistory and reliable physical exam are far more valuable than anylab test or radiograph in diagnosis.
  • Ability of physician to make diagnosislargely depends on consideration of all possibilities, knowledgeof how they present, and planned orderly approach.
  • Age, type of onset, character and locationof pain, and associated findings are useful in diagnosis.
  • Abdominal pain of sudden onset is mostlikely to occur with intussusception, perforation of viscus, ortorsion of fallopian tube or ovary. Pain of gradual onset usuallyoccurs with appendicitis, pancreatitis, and cholecystitis. Severeintermittent pain may occur with gastrointestinal, genitourinary,or biliary tract obstruction.
  • Pain of peritonitis is diffuse, constant,and exacerbated by movement.
  • More recurrent or chronic pain usuallyoccurs with constipation, sickle cell pain episodes, and inflammatorybowel disease.
  • Lesions of stomach, duodenum, pancreas,and biliary tract commonly cause epigastric pain. Small bowel andproximal colon lesions usually produce umbilical pain. Distal colonlesions may cause hypogastric pain, whereas rectal lesions may producesacral pain.
  • Irritation of diaphragm may cause shoulderpain, and gallbladder disease may produce pain at right scapula.
  • Lesions involving ureter or femalegenital tract may produce lower abdominal and pelvic pain.
  • Most important diagnostic goal is todistinguish abdominal pain that may be life threatening.

  • 2 clinicalcircumstances represent potentially serious disease and requireimmediate investigation: (a) abdominal pain associated with biliousvomiting, persistent vomiting, or abdominal distension, and (b)abdominal pain associated with either localized or diffuse reboundtenderness. Very few clinical problems require such urgent operativeintervention that orderly approach needs to be abandoned. Only exceptionis massive exsanguinating hemorrhage.
  • Children in whom the diagnosis is uncertainshould be admitted to hospital and observed.

  • Period of active observation is extremeimportance and is safe.
  • Most causes can be diagnosed at thebedside by careful and often repeated clinical observations.
  • Initial lab tests are CBC with differential,UA, urine culture, analysis of stool for blood, ESR, chest and abdominalradiography, and abdominal U/S.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Back Pain: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • History,physical exam, and spine radiographs are usually diagnostic of congenital spineanomalies, fractures, Scheuermann disease, spondylolysis, and spondylolisthesis.
  • MRI is procedure of choice to confirmdiagnosis of herniated disc.
  • Fever usually occurs with inflammatorydisorder or infection affecting spine. When fever accompanies backpain, CBC and erythrocyte sedimentation rate should be performed.
  • Nuclear scintigraphy is useful, especiallywith suspected osteomyelitis, discitis, or sacroiliac joint infection.
  • Aspirate or biopsy of lesion shouldbe strongly considered with suspected osteomyelitis. Blood culturemay reveal organism, but yield is often low.
  • Spine radiographs are useful in diagnosisof vertebral spine and intraspinal masses.
  • CT and MRI are valuable in diagnosingtumors as well as spinal epidural abscess.
  • For all tumors except possibly osteoidosteoma, histologic exam is necessary for diagnosis.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Chest Pain: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Most commoncauses of chest pain in pediatric population are idiopathic, musculoskeletal,and psychologic.
  • If complaint has been present for >6mos, organic cause is less likely.
  • History and physical exam are diagnosticin many cases.
  • Chest radiography should be performedwith localized rib or bone pain, any respiratory distress, or suspectedpulmonary disorder.
  • With suspected heart disease, ECG shouldbe performed.
  • 2-D echocardiography may be necessary,depending on suspected diagnosis.
  • Psychologic causes must be substantiatedby clinical psychologic evidence.
  • Children in whom no definite causecan be found are more likely to complain recurrently, presumablyfor secondary gain.
  • In adolescence, chest pain is frequentcomplaint, but it is usually benign. Knowledge about recent lifeevents and individual's beliefs about the symptom are importantin managing this problem.

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    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Breast pain [Mastalgia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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 breast-feeding? 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Eye pain [Ophthalmalgia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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 the patient wear contact lenses? How often are they removed or replaced if they're disposable? Does he have headaches? If so, find out how often and at what time of day they occur.

    During the physical examination, don'tmanipulate 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.)

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Abdominal pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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 in his own words. Ask him if the pain is dull, sharp, stabbing, or burning and to rate his pain on a scale, such as the visual analog scale, FACES pain scale, or verbal numeric scale for intensity of pain. 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 to point 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 menstrual cycle, 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Arm pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient reports arm pain after an injury, take a brief history of the injury from the patient. 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. 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Back pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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, surgeries, and illnesses, and a family history. Ask about diet and alcohol intake. Take a drug history, including past and present prescriptions, over-the-counter drugs, and herbal medicines. Ask the patient to rate the pain according to a pain scale and describe the type and location of his pain.

    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 3⁄89 (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. 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Chest pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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. Ask when the pain began and if the patient ever experienced this type of pain in the past. 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? Ask him to rate the pain on a pain scale. 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. Place the patient on a cardiac monitor and evaluate his heart rhythm. Also, look for jugular vein distention and peripheral edema. Note the feel of his skin. Is it cool and clammy or warm and diaphoretic? Auscultate his chest for extra heart sounds. 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Flank pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's condition isn't critical, take a thorough history. Ask about the onset of his pain 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Jaw pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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 1⁄89 (3 cm) or more than 23⁄89 (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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Leg pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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've 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Neck pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    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? Does any particular event precipitate the pain? Also, ask about other symptoms, such as headaches or back pain. 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 (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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Rectal pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin 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.

    Be 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 stools, 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 and drug history.

    Then inspect the rectal 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Throat pain: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when he first noticed the pain, and have him describe it. Has he had throat pain before? How was it treated? 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 and the nasopharynx. 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. Also, check the patient's ears, especially if he reports ear pain. Finally, palpate the neck and oropharynx for nodules or lymph node enlargement.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Pain Disorder

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