TREATMENTS &
RESEARCH

Search the
latest
treatment
information
here.

Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 

Diagnostic Tests for Respiratory infections

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

Respiratory infections Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Respiratory infections:

Respiratory infections Diagnosis: Book Excerpts

Diagnostic Tests for Respiratory infections: Online Medical Books

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

COUGH: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.

Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H 2 antagonist may also be diagnostic.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SORE THROAT: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

In a sore throat with typical exudates very suggestive of streptococcal pharyngitis, a throat culture may be all one needs before starting definitive antibiotic therapy. In the more difficult cases, screening for streptococcal antigens (streptozyme test and ASO titer) might be indicated. An ASO titer is particularly important when one suspects rheumatic fever. If the patient's streptococcal sore throat persists, a Monospot test and a culture for gonorrhea should be done. Although there are hardly any false-negative Monospot tests, there are 10% false positives, and that should be kept in mind. A blood smear for atypical lymphocytes may be helpful, as well as a heterophile antibody titer in those cases.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

Routine studies include a CBC, sedimentation rate, chemistry panel, urinalysis, chest x-rays, VDRL test, and tuberculin skin test. Serial blood cultures should be done on all patients. Febrile agglutinins usually should be done. An ASO titer or streptozyme test should be done to exclude rheumatic fever. RNA, ANA, and DNA tests should be done to look for lupus and other connective tissue disease. An HIV antibody titer may need to be ordered.

The next step is to culture any discharge or various body fluids that might be suspect. Thus, a urinalysis and urine culture should be done. A nose and throat culture should be done. A sputum smear and culture may need to be done. The next consideration is to do various serologic tests. A heterophile antibody titer should be done in teenagers. Febrile agglutinin tests may need to be done. Acute and convalescent phase sera for viral studies may need to be done.

Next one should do skin testing. Thus, histoplasmin, coccidioidin, and blastomycin skin testing should be done on patients with a cough. Trichinella skin testing may need to be done, as well as brucellin skin testing. A Kveim test might need to be done for suspected sarcoidosis.

The next step is to do plain x-rays of suspected areas. For instance, x-rays of the teeth may disclose an abscessed tooth. X-rays of the long bones may disclose a metastatic carcinoma.

The next step is contrast x-ray studies of various organ systems. An intravenous pyelogram may show a hypernephroma. A cholecystogram may show gallstones. An upper GI series and barium enema may show chronic pancreatitis or diverticulitis. Angiography may disclose periarteritis nodosa, aortitis or giant cell arteritis.

The next step is to do a CT scan of the abdomen and pelvis. If this is negative, consider a CT scan of the chest and mediastinum. Echocardiography may disclose valvular vegetations or an atrial myxoma.

Next, consider biopsying various organ systems. For instances, a lymph node biopsy may disclose a lymphoma or sarcoidosis. A muscle biopsy may disclose periarteritis nodosa, polymyositis, or trichinella.

Next one should do bone scans and gallium scans for possible metastasis, osteomyelitis, or localized abscesses.

If all these procedures fail to turn up a lesion, then an exploratory laparotomy may need to be done. A fibrin test may indicate Mediterranean fever, or urine for etiocholanolone may also indicate a relapsing type of fever. A urine test for porphobilinogen may diagnose porphyria.

The wisest move is to conduct this investigation with the help of an infectious disease specialist or a specialist in the body organ system most likely suspected of harboring the infection.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

FEVER, CHRONIC: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The diagnostic workup is similar to that for acute fever on page 168 .

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Cough, barking: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

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

Cough, productive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes. (See Productive cough: Common causes and associated findings, page 168.)

» READ BOOK EXCERPT ONLINE »

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

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

If the patient’s fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience other symptoms, such as chills, fatigue, or pain?

Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and the use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

Let the history findings direct your physical examination. Because a fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (SeeHow fever develops.)

» READ BOOK EXCERPT ONLINE »

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

Cough, nonproductive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed;  anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as a cough. Ask the patient at risk for TB — one born in another country, in contact with acute TB, or with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

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

Introduction: Respiratory Disorders: Assessment
(Professional Guide to Diseases (Eighth Edition))

Assessment of the respiratory system begins with a thorough patient history. Ask the patient to describe his respiratory problem. How long has he had it? How long does each attack last? Does one attack differ from another? Does any activity in particular bring on an attack or make it worse? What relieves the symptoms? Always ask whether the patient was or is a smoker, what and how often he smoked or smokes, and how long he smoked or has been smoking. Record this information in “pack years”—the number of packs of cigarettes per day multiplied by the number of smoking years. Remember to ask about the patient’s occupation, hobbies, and travel; some of these activities may involve exposure to toxic or allergenic substances.

If the patient has dyspnea, ask if it occurs during activity or at rest. What position is the patient in when dyspnea occurs? How far can he walk? How many flights of stairs can he climb? Has his exercise tolerance been decreasing? Can he relate dyspnea to allergies or environmental conditions? Does it occur only at night, during sleep? If the patient has a cough, ask about its severity, persistence, and duration; ask if it produces sputum and, if so, what kind. Have the patient’s cough habits and character of sputum changed recently?

Physical examination

Use inspection skills to check for clues to respiratory disease, beginning with the patient’s general appearance. If he’s frail or cachectic, he may have a chronic disease that has impaired his appetite. If he’s diaphoretic, restless, or irritable or protective of a painful body part, he may be in acute distress. Also, look for behavior changes that may indicate hypoxemia or hypercapnia. Confusion, lethargy, bizarre behavior, or quiet sleep from which he can’t be aroused may point to hypercapnia. Watch for marked cyanosis, indicated by bluish or ashen skin (usually best seen on the lips, tongue, earlobes, and nail beds), which may be due to hypoxemia or poor tissue perfusion.

Assess chest shape and symmetry at rest and during ventilation. Increased anteroposterior diameter (“barrel chest”) characterizes emphysema. Kyphoscoliosis also alters chest configuration, which in turn restricts breathing. Assess respiratory excursion and observe for accessory muscle use during breathing. The use of upper chest and neck muscles is normal only during physical stress.

Observe the rate and pattern of breathing because certain disorders produce characteristic changes in breathing patterns. For example, an acute respiratory disorder can produce tachypnea (rapid, shallow breathing) or hyperpnea (increased rate and depth of breathing); intracranial lesions can produce Cheyne-Stokes and Biot’s respirations; increased intracranial pressure can result in central hyperventilation and apneustic or ataxic breathing; metabolic disorders can cause Kussmaul’s respirations; and airway obstruction can lead to prolonged forceful expiration and pursed-lip breathing.

Also observe posture and carriage. A patient with COPD, for example, usually supports rib cage movement by placing his arms on the sides of a chair to increase expansion and leans forward during exhalation to help expel air.

Palpation of the chest wall detects areas of tenderness, masses, changes in fremitus (palpable vocal vibrations), or crepitus (air in subcutaneous tissues). To assess chest excursion and symmetry, place your hands in a horizontal position, bilaterally on the posterior chest, with your thumbs pressed lightly against the spine, creating folds in the skin. As the patient takes a deep breath, your thumbs should move quickly and equally away from the spine. Repeat this with your hands placed anteriorly, at the costal margins (lower lobes) and clavicles (apices). Unequal movement indicates differences in expansion, seen in atelectasis, diaphragm or chest wall muscle disease, or splinting due to pain.

Percussion should detect resonance over lung fields that aren’t covered by bony structures or the heart. A dull sound on percussion may mean consolidation or pleural disease. (See Characterizing and interpreting percussion sounds.)

Auscultation normally detects soft, vesicular breath sounds throughout most of the lung fields. Absent or adventitious breath sounds may indicate fluid in small airways or interstitial lung disease (crackles), secretions in moderate and large airways (rhonchi), and airflow obstruction (wheezes).

» READ BOOK EXCERPT ONLINE »

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

Cough, barking: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

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

Cough, productive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)

» READ BOOK EXCERPT ONLINE »

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

Cough, nonproductive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when his cough began and whether any body position, time of day, or specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has any pain associated with coughing, breathing, or activity, when did it begin and where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also ask about recent changes in his appetite, weight, exercise tolerance, or energy level; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

Cultural Cue: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB—those born in another country, those in contact with acute TB, and those with high-risk behaviors—about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note wheezing or “crowing” noises that occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

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

Fever [Pyrexia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience any other symptoms, such as chills, fatigue, or pain?

Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

Let the history findings direct your physical examination. (See Differential diagnosis: Fever, pages 338 and 339.) Because fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See How fever develops, page 340.)

» READ BOOK EXCERPT ONLINE »

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

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

 A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

 B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

Testing

A. Clinical laboratory tests. Most acute presentations of cough do not require blood, urine, or other laboratory tests. White blood count with differential and blood cultures are indicated for pneumonia. Gram’s stain and culture of sputum are rarely practical in the office. A purified protein derivative (PPD) test should be placed early if TB is suspected, unless the patient is known to be anergic or thought to have overwhelming active TB disease. Systemic causes require testing specific to the disease in question.

B. Radiologic tests. A chest x-ray study is not indicated for upper respiratory causes or bronchitis. It is only useful when pneumonia, TB, COPD, CHF, or cancer (primary or metastatic) are being considered. Computed tomography of the sinuses is more sensitive and specific than PE to differentiate sinusitis from other causes of cough.

C. Pulmonary function tests. The simple peak flow meter used with a therapeutic trial of bronchodilators will identify most cases of asthma. This important test should be supervised by the physician or an experienced nurse. Additional testing is suggested for COPD and pulmonary fibrosis.

D. Invasive tests. Bronchoscopy is useful for foreign body aspiration, cancer, or chronic interstitial lung disease. Esophageal pH monitoring will most likely confirm suspected GERD.

Diagnostic assessment

A thorough history is vital to accurate diagnosis. Acute cough is likely to be infectious. A pertinent observation is that physicians overtreat acute bronchitis with antibiotics. The literature suggests that most cases are viral in origin and antibiotics are ineffective. Chronic cough has a longer list of differential diagnoses. Asthma tends to be underdiagnosed in adults and children. Smoking-related causes should prompt educational intervention and workup, especially in older patients. GERD is a diagnosis often missed because it is not considered. Often, more than one office visit is needed to unravel the cause of chronic cough. Up to 80% of cases have multiple causes (5). Making an accurate diagnosis is essential to successful treatment. Of cough presentation, 90% can be adequately managed in the family physician’s office, although it can take 3 to 5 months to arrive at a correct diagnosis in some cases (2). Referral to a pulmonary specialist is needed only in complicated cases (e.g., cancer, occupational and connective tissue diseases, and failed therapy).


References

1. Weiss BD. 20 common problems in primary care. New York: McGraw-Hill, 1999.

2. Lawler WR. An office approach to the diagnosis of chronic cough. Am Fam Physician 1998;58(9):2015–2022.

3. Heath JM. Chronic bronchitis: primary care management. Am Fam Physician 1998;57(10):2365–2372, 2376–2378.

4. Irwin RS. Managing cough as a defense mechanism and as a symptom. A consensus report of the American College of Chest Physicians. Chest 1998;114:133S–181S.

5. Irwin RS. Silencing chronic cough. Hosp Pract 1999;34:53–60.>

» READ BOOK EXCERPT ONLINE »

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

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

A. The examination should include the skin, lymph nodes, eyes, nail beds, heart, lungs, abdomen, joints, nervous system, and genitourinary system, including rectal and bimanual pelvic examinations.

B. Infections will increase the pulse rate approximately 10 beats per minute for each 0.5°C (1.0°F) temperature increase.

C. When fever is present, the respiratory rate will frequently increase above the usual 12 to 14 breaths per minute.

D. Infections with Mycoplasma pneumonia, psittacosis, and typhoid fever are often associated with a relative bradycardia.

Testing.

 In cases of a fever in which the cause is unclear, a number of diagnostic tests may be useful, depending on history and physical examination. These include:

 A. Urinalysis with microscopic examination

B. Blood cultures, both aerobic and anaerobic

C. Blood tests: human immunodeficiency virus (HIV), rapid plasma reagent (RPR), antistreptolysin-O (ASO) titer, rheumatoid arthritis (RA) factor, antinuclear antibody (ANA), sedimentation rate, and serum enzymes and chemistries

D. Tuberculosis (TB) skin test

E. Spinal fluid examination

F. Diagnostic imaging: chest film, abdominal ultrasound, abdominal computed tomography (CT), bone scan

G. Biopsies: liver, bone marrow, lymph node, skin, muscle, temporal artery

Diagnostic assessment.

The approach to the febrile patient involves a number of considerations, including the patient’s age, clinical history, risk factors, community illness pattern, and physical presentation. In the family physician’s office, most febrile illnesses are the result of self-limited viral illnesses (e.g., upper respiratory infections). A number of cases of fever will be caused by bacterial infections (e.g., streptococcal pharyngitis or urinary tract infections). The challenge is to select those studies with the highest sensitivity and specificity to increase the probability of a correct diagnosis. When the diagnosis continues to be elusive, repeat the history and the physical examination. Special considerations in specific populations and certain types of fever include:

A. The elderly: 10% of elderly patients will fail to generate a febrile response with pneumonia (1). Fever in the elderly is more likely to indicate a bacterial infection than a fever in younger adults (2).

B. Fever of unknown origin (FUO). An FUO is characterized by the first three criteria listed below:

1. A temperature greater than 38.3°C (101.0°F) on several occasions

2. A duration of 3 weeks

3. Unclear cause after a full physical examination, routine blood tests, cultures, and chest x-ray studies

4. The cause of FUOs will be determined 90% of the time; it will often be a common illness that presents in an unusual manner.

5. Two leading causes of FUO are tuberculosis and infective endocarditis.

6. Other causes include hepatic or subphrenic abscess, neoplasm, and lymphomas such as Hodgkin’s disease.

C. Factitious fever. Factitious fever is a consideration in a patient with a complex emotional disorder. The absence of a normal diurnal pattern, pulse elevation, and diaphoresis may suggest a diagnosis of factitious fever.

D. Drug fever. Drugs are an important cause of noninfectious fever (3).

1. This is a diagnosis of exclusion and requires the fever to coincide with the prescribing of the drug and the resolution of the fever on discontinuing the medication.

2. Drug-associated fevers can be high and take several days to resolve.

3. Among the medications causing a fever are diphenylhydantoin, carbamazepine, histamine-2 (H2) blockers, methyldopa, allopurinol, sulfonamides, cephalosporins, and isoniazid.

E. Postoperative fever. The temporal relationship of the fever to the surgery may provide a clue to the primary source of the infection (4).

1. If fever duration is less than 48 hours, consider atelectasis of the lung.

 2. If duration is more than 3 days, consider urinary tract infection or infected intravascular device.

 3. If fever has been present more than 5 days, consider wound infection, intraabdominal abscess, or empyema.

 F. Hyperthermia. A disruption of thermoregulation can result from excessive heat production, inadequate heat dissipation, or hypothalamus malfunction (5).


References

1. Harper C, Newton P. Clinical aspects of pneumonia in the elderly veterans. J Am Geriatr Soc 1989;37:867–872.

2. Mellors JW, Horwitz RI, Harvey MR, et al. A simple index to identify occult bacterial infection in adults with unexplained fever. Arch Intern Med 1987;147:666–671.

3. Mackowiak PA, ed. Fever: basic mechanisms and management. New York: Raven Press, 1991:239.

4. Mackowiak PA, ed. Fever: basic mechanisms and management. New York: Raven Press, 1991:245.

5. Simon HB. Hyperthermia. N Engl J Med 1993;329(7):483–487.

» READ BOOK EXCERPT ONLINE »

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

Rash Accompanied by Fever: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Examine the lesions and their distribution carefully. Classify the rash as petechial, maculopapular, vesiculobullous, erythematous, or urticarial. Note the distribution of the rash. For instance, rubella and rubeola generally begin on the face and spread to the trunk, whereas RMSF petechiae tend to occur on the ankles and wrists first.

 B. Conduct a general physical examination. Areas of particular concern are:

 1. Head, eyes, ears, nose, and throat. The presence of Koplik’s spots is pathognomic for rubeola. The discovery of a tick lends support to the diagnosis of RMSF. Sinusitis may represent a source for meningococcemia. Pharyngitis in a young adult with diffuse erythema may be caused by C. haemolyticum. Mucous membrane swelling may indicate early anaphylaxis.

 2. Lung examination. Expiratory wheezing, especially in a patient who has recently received medications or contrast dye, can indicate anaphylaxis. Evidence of pneumonia is consistent with psittacosis and mycoplasma.

 3. Cardiac examination. Cardiovascular collapse is associated with meningococcemia and other sepsis. A new murmur (Chapters 7.6 and 7.7) may indicate subacute bacterial endocarditis in a patient with subungual or scleral petechiae.

 4. Genital examination. Purulent urethral drainage or evidence of pelvic inflammatory disease supports consideration of gonorrhea. A chancre would support a diagnosis of syphilis, although palmar lesions often occur well after healing of the initial chancre.

 5. Joint examination and extremities. A petechial rash near the ankles and wrists is suggestive of RMSF. Evidence of joint swelling supports a diagnosis of meningococcemia or gonococcemia. A maculopapular rash may be seen in juvenile rheumatoid arthritis and other rheumatologic conditions as well.

6. Neurologic examination. Evidence of meningitis supports a diagnosis of meningococcemia. Patients with RMSF may also have meningeal signs.

Testing

 should be directed by illnesses suspected, with life-threatening illnesses being tested for on reasonable suspicion. A complete blood count is generally useful, although life-threatening sepsis often presents without significant elevation of white blood count. In general, a blood culture should be obtained in all patients with petechial rashes and in those with signs of cardiovascular collapse.

Diagnostic assessment

Based on history and physical examination, the likelihood of various illnesses can be assessed. Patients who appear toxic should be treated as septic until initial laboratory and culture results can be evaluated (4).


References

1. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10(1):101–110.

2. Drolet BA, Baselga E, Esterly NB. Painful, purpuric plaques in a child with fever. Arch Dermatol 1997;133(12):1500–1501.

3. Anonymous. Fever, nausea, and rash in a 37-year-old man [clinical conference]. Am J Med 1998;104(6):596–601.

4. Dellinger RP. Current therapy for sepsis. Infect Dis Clin North Am 1999;13(2):
495–509.

» READ BOOK EXCERPT ONLINE »

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

Sore Throat: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

 Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Fever of Unknown Origin: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Fever of unknown origin (FUO), when a fever over 101°F (38.5°C) remains unexplained for longer than 3 weeks, is usually a result of infection (40%), neoplasm (20%), or collagen-vascular disease (20%). It is most commonly caused by an atypical presentation of a common disease. Always document the fever before pursuing the evaluation.

Consider relatively hidden (deep) sites: retroperitoneum (hematoma or infection), bone, dental, sinus, ovary, prostate, subphrenic (following abdominal surgery), renal, spleen, or prostheses. With FUO in a hospitalized patient, consider sequestered sites (e.g., sinuses in intubated patients or implanted hardware), indwelling lines, C. difficile, or drug reactions. With FUO in a neutropenic patient, consider catheters, perianal infections, Candida, and Aspergillus. Cardinal signs may be absent, e.g., meningitis with opportunistic pathogens without meningismus in 63%, and pneumonia without purulent sputum in 92%. Neutropenic fevers are usually due to bacteremia, with fungal organisms becoming predominant after 7 days of unremitting fever. Fever may also be due to the underlying neoplasm, drugs such as antibiotics, or blood products.

Examine for subtle clues:

• Petechial eruptions in meningococcemia and Rocky Mountain Spotted Fever

• Pustular lesions in gonococcemia or staphylococcal sepsis

• Ecthyma gangrenosum in Pseudomonas sepsis

• Splinter hemorrhages, conjunctival hemorrhages, Roth spots, Osler nodes, and Janeway lesions in endocarditis

• Choroidal tubercles in miliary tuberculosis and candidemia

• Splenomegaly in endocarditis, lymphoma, and cirrhosis

• Hepatic bruit or friction rub in subphrenic abscess

• Temporal artery or scalp tenderness or jaw claudication in giant cell arteritis

• Epitrochlear lymphadenopathy in syphilis

Extreme elevations of fever (.40°C) are found in heat stroke, hypothalamic dysfunction, meningitis, midbrain hemorrhage, falciparum malaria, Rocky Mountain Spotted Fever, typhus, sepsis, malignant hyperthermia, and hypernephroma.

Relative bradycardia occurs in salmonellosis (typhoid fever), meningitis with increased intracranial pressure, mycoplasma and legionella pneumonia, factitious fever, tularemia, brucellosis, mumps, hepatitis, and with concomitant beta blockers. Bradycardia in fever may also signal cardiac conduction abnormalities in acute rheumatic fever, Lyme disease, viral myocarditis, or endocarditis with valve ring abscess.

Relapsing fevers (days of fever alternating with days without) occur in brucellosis (fever with physical activity), Hodgkin disease, extrapulmonary tuberculosis, malaria, and Lyme disease. Hectic fever (difference between peak and trough .1.5°C) suggests abscess, pyelonephritis, ascending cholangitis, tuberculosis, lymphoma, and drug reactions. Absence of diurnal variation suggests a central source. Reversal of the diurnal pattern (“typhus inversus”) occurs with disseminated tuberculosis, typhoid fever, polyarteritis nodosa, and salicylate toxicity.

FUO in patients from the developing world include tuberculosis, typhoid, amebic liver abscesses, AIDS, and geographically restricted infections such as malaria, schistosomiasis, brucellosis, kala azar, filariasis, or Lassa fever. They may present after long incubation or latency periods.

When FUO lasts longer than 6 months, consider factitious fever, granulomatous hepatitis, neoplasm, Still disease, infection, collagen-vascular disease, or exaggerated circadian rhythm.

Patients who remain undiagnosed have a good prognosis (83% resolution in 1 year, 4% mortality).

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.

Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.

A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Cough, barking: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Observe the child for signs of respiratory distress. Note use of sternal or intercostal retractions or nasal flaring. Observe his skin for cyanosis and diaphoresis. Take his vital signs, noting respiratory rate and depth. Although stridor can be heard without a stethoscope, auscultate his lungs. Decreased breath sounds and crackles may be present.

» READ BOOK EXCERPT ONLINE »

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

Cough, productive: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

» READ BOOK EXCERPT ONLINE »

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

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

Begin by taking your patient’s vital signs. Let the history findings direct your physical examination. Because fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See Taking an accurate temperature.)

» READ BOOK EXCERPT ONLINE »

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

Cough, nonproductive: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE:Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB — those born in another country, those in contact with acute TB, and those with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, and signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

» READ BOOK EXCERPT ONLINE »

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

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

  • In manycases history and physical exam are diagnostic.
  • Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities.

    • Age of Child and Duration of Cough

  • In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.
  • In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).
  • Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.
  • Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.
  • In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.
  • Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems.

    • Periodicity and Quality of Cough

  • Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.
  • Recurrent viral URIs and asthma causeepisodic coughing.
  • Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.
  • Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.
  • Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.
  • Neuromuscular disorders produce a weakand feeble cough.
  • Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease.

    • Timing of Cough

  • If coughdisappears while asleep, it usually has psychologic basis.
  • Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.
  • Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis.

    • Nature of Sputum Production

    Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.

    Associated Findings

  • Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.
  • Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.
  • Cough associated with stridor indicatesairway obstruction.

    • Evaluation

  • Etiologyof cough can usually be determined or at least suspected from historyand physical exam.
  • Chest radiography shows pattern andextent of disease and is confirmatory in many instances.
  • With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.
  • If TB is suspected, intermediate-strengthPPD should be placed.
  • Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.
  • With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.
  • Another useful test is sweat test inchildren with recurrent or chronic cough.
  • With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step.

    • » READ BOOK EXCERPT ONLINE »

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

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

  • Most acutefevers are caused by infection, usually viral or bacterial.
  • Common infections should be consideredbefore less common ones, unless clinical findings suggest otherwise.
  • Best guide to accurate diagnosis ishistory and physical exam.

    • Clinical Findings

  • Age of child,height of fever, compromised host defenses, and associated findings (e.g.,rash, painful extremity, abdominal pain, jaundice, generalized lymphadenopathy,hepatomegaly, or splenomegaly) are important factors in diagnosisof any child who presents with fever.
  • Important historical information includesany history of contact with other ill individuals, foreign travel,previous immunizations, drug exposure, history of pica, and exposureto animals or birds.

  • History of pica suggests toxoplasmosis or toxocariasis(visceral larva migrans).
  • History of tick exposure suggests RockyMountain spotted fever, relapsing fever, or Lyme disease.
  • History of exposure to animals or birdssuggests diseases caused by rats (plague, rat-bite fever, leptospirosis);hamsters (lymphocytic choriomeningitis encephalitis); rabbits (tularemia);cattle, goats, and dogs (brucellosis); cats (cat scratch disease,toxoplasmosis); and birds (psittacosis).

    • Age

  • Risk ofserious bacterial illness (e.g., septicemia and meningitis) varieswith age and is greatest during immediate neonatal period, especiallyin premature infants.
  • Clinical findings may be nonspecific,including poor feeding, decreased activity, fever, or hypothermia.
  • In such infants, CBC with differentialand blood, urine, and spinal fluid cultures should be performed.
  • Gram-stained smear of spinal fluidshould be performed and antigen studies considered.
  • Chest radiograph should be performedwith history of respiratory symptoms.
  • Stool culture should be performed withhistory of diarrhea.

    • Height of Fever

  • In infants,incidence of serious bacterial infection is higher in those withrectal temperature >41°C compared with those withlower temperature.
  • Preschool and school-aged childrenoften have high fever that persists for several days and is notassociated with localizing findings. Such children do not appearvery ill and usually have self-limited viral infections.
  • Continued observation with close follow-upusually clarifies many of these problems.
  • Whatever the height of fever, assessmentof toxicity and level of functioning is crucial in diagnosis andmanagement.

    • Compromised Host Defenses

    Children with impaired host defenses dueto primary or secondary immunodeficiency disorders are at risk fordevelopment of serious infection caused by wide range of infectiveagents, including bacteria (S. aureus, gram-negative enteric organisms),viruses (cytomegalovirus, VZV), protozoa (P. carinii), and fungi(Candida and Aspergillus species).

    Associated Physical Findings

    Fever and Rash

  • Macularor papular rashes occur with viral infection (enteroviruses, herpesvirus6, measles virus, rubella virus, parvovirus B19, Epstein-Barr virus),bacterial infection (scarlet fever, meningococcemia, toxic shocksyndrome, typhoid fever, rat bite fever, leptospirosis), rickettsialinfection (Rocky Mountain spotted fever), Kawasaki disease, anddrug reactions (most commonly penicillins and sulfonamides).
  • Erythematous rashes occur with viralinfection (parvovirus B19), bacterial infection (scarlet fever,toxic shock syndrome, staphylococcal scalded skin syndrome), Kawasakidisease, and reactions to same drugs causing macular or papularrashes.
  • Petechial and purpuric rashes occurwith congenital viral infection (rubella virus, cytomegalovirus),other viral infection (enteroviruses, Epstein-Barr virus, arboviruses),bacterial infection (group A Streptococcus, N. meningitidis, S.pneumoniae, N. gonorrhoeae, S. aureus, H. influenzae type b, P. aeruginosaand other gram-negative enteric bacteria), rickettsial infection(Rocky Mountain spotted fever), and parasitic infection (toxoplasmosis).
  • Vesicular rashes occur with viral infection(herpes simplex virus, varicella-virus infection, enteroviruses)and bacterial infection (bullous impetigo, staphylococcal scaldedskin syndrome).
  • See Chap.60, Skin Lesions and Rashes.

    • Fever and Painful Extremity

  • Infectiousor inflammatory causes

  • Cellulitis
  • Septic arthritis
  • Osteomyelitis
  • Transient synovitis
  • Skin/soft tissue abscess
  • Thrombophlebitis
  • Acute rheumatic fever
  • Vaccine immunization
  • Other causes

  • Neoplasia (leukemia, osteogenic sarcoma,Ewing sarcoma, metastatic neuroblastoma)
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • Kawasaki disease
  • Serum sickness
  • Arthritis associated with inflammatorybowel disease
  • See Chap.37, Limp.

    • Fever and Abdominal Pain

  • Infectiousand inflammatory causes

  • Nonspecific viral illness
  • Gastroenteritis
  • Urinary tract infection
  • Pneumonia
  • Appendicitis
  • Intraabdominal abscess
  • Hepatitis
  • Peritonitis
  • Cholecystitis
  • Cholangitis
  • IBD
  • Pelvic inflammatory disease
  • Pancreatitis
  • Generalized vasculitis
  • Other causes

  • Neoplasia (leukemia, Hodgkin disease,non-Hodgkin lymphoma, neuroblastoma, hepatic malignancies)
  • Diabetic ketoacidosis
  • Black widow spider bite
  • See Chap.2, Abdominal Pain.

    • Fever and Jaundice

  • Most commoncause of fever and unconjugated hyperbilirubinemia in neonates is septicemia.Causes of fever and conjugated hyperbilirubinemia in neonates include

  • Viral infection(rubella virus, cytomegalovirus, herpes simplex virus, VZV, enteroviruses,hepatitis B virus)
  • Bacterial infection (septicemia, syphilis)
  • In infancy and childhood, fever andconjugated hyperbilirubinemia may be due to

  • Viral infection (hepatitis A, B, C,D, E; enteroviruses; herpes simplex virus; Epstein-Barr virus; cytomegalovirus
  • Bacterial infection (septicemia, cholecystitis,cholangitis, liver abscess, leptospirosis, brucellosis)
  • Rickettsial infection (Q fever)
  • Fungal infection (histoplasmosis)
  • Parasitic infection (amebiasis, malaria,visceral larval migrans)
  • Drug reactions
  • Neoplasia (hepatic malignancies, non-Hodgkinlymphoma)
  • See Chap.36, Jaundice.

    • Fever and Generalized Lymphadenopathy

  • Infectiouscauses

  • Viralinfection (rubella virus, measles virus, Epstein-Barr virus, cytomegalovirus, VZV,hepatitis A virus, HIV)
  • Bacterial infection (pyogenic infectionfrom S. aureus, group A Streptococcus, H. influenzae type b, S.pneumoniae; tuberculosis; brucellosis; tularemia; salmonellosis;leptospirosis; syphilis)
  • Fungal infection (histoplasmosis)
  • Parasitic infection (toxoplasmosis,malaria)
  • Noninfectious causes

  • Neoplasia(leukemia, non-Hodgkin lymphoma, metastatic neuroblastoma)
  • Langerhans histiocytosis
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • Drug reactions
  • Serum sickness
  • Chronic granulomatous disease
  • Sarcoidosis
  • See Chap.38, Lymphadenopathy.

    • Fever with Hepatomegaly, Splenomegaly, or Hepatosplenomegaly

  • Causes offever and hepatomegaly

  • Hepatitis (A, B, C, D, E)
  • Primary liver abscess
  • Amebiasis
  • Primary liver malignancies
  • Causes of fever and splenomegaly

  • Viral infection(rubella virus, cytomegalovirus, herpes simplex virus, enteroviruses, Epstein-Barrvirus)
  • Bacterial infection (septicemia, endocarditis,tularemia, plague, salmonellosis, splenic abscess)
  • Rickettsial infection (Rocky Mountainspotted fever)
  • Parasitic infection (malaria, toxoplasmosis)
  • Infectious causes of fever and hepatosplenomegaly

  • Viral infection(rubella virus; herpes simplex virus; cytomegalovirus; VZV; enteroviruses;Epstein-Barr virus; hepatitis A, B, C, D, E)
  • Bacterial infection (septicemia, endocarditis,brucellosis, tuberculosis, syphilis, leptospirosis, relapsing fever)
  • Fungal infection (histoplasmosis, coccidioidomycosis)
  • Parasitic infection (visceral larvalmigrans, toxoplasmosis, Chagas disease)
  • Other causes of fever and hepatosplenomegaly

  • Neoplasia(leukemia, Hodgkin disease, non-Hodgkin lymphoma, neuroblastoma)
  • Langerhans histiocytosis
  • Collagen vascular disease (juvenilerheumatoid arthritis, systemic lupus erythematosus)
  • See Chap.30, Hepatomegaly and Chap. 62, Splenomegaly.

    • Fever without Localizing Signs

  • Most childrenwith fever and no apparent focus of infection have self-limitedviral infection that resolves without treatment and has no sequelae.
  • Small percentage of children with acuteonset of fever ≥39°C and no localizing signs, especiallyat 3–36 mos, may have urinary tract infection, bacteremia,or meningitis.
  • In infants <1 mo of age, commoncauses of septicemia and meningitis are group B Streptococcus andgram-negative enteric bacteria, commonly E. coli. Much less commonis infection with L. monocytogenes.
  • At 1–3 mos of age, most commoncauses of septicemia and meningitis are S. pneumoniae, group B Streptococcus,and N. meningitidis.
  • In children >3 mos of age,S. pneumoniae, N. meningitidis, and Salmonella species (usually occurringwith gastroenteritis) cause most bacterial infections that occurwithout a focus.
  • Diagnostic and management approachto child with fever without apparent focus of infection dependson age, exposure history, usual pathogens, and severity of illness.
  • See references at end of chapter forfurther information.

    • Lab Findings

  • Lab tests(cultures and radiographs most commonly) are used to confirm diagnostic impressionof infection.
  • WBC and differential may suggest bacterialor viral infection, but they are not diagnostic. WBC count >20,000/mm3 withpredominance of neutrophils (>70%) or <5,000/mm3 withlarge number of band forms (>5%–10%)suggests bacterial infection. Although similar WBC counts sometimeoccur with viral infections, in such cases there is usually predominanceof lymphocytes and few band forms.
    • >>

    » READ BOOK EXCERPT ONLINE »

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

    Sore Throat: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Historyand physical exam provide important clues for proper diagnosis ofsore throat.
  • Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.
  • Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.
  • Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.

    • » READ BOOK EXCERPT ONLINE »

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

    Respiratory Distress and Apnea: Diagnostic Approach: Respiratory Distress
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • In preterminfants, most common cause of respiratory distress is respiratorydistress syndrome. In term infants, transient tachypnea, meconiumaspiration, pneumonia, and pneumothorax are most common lower respiratorytract disorders causing respiratory distress. Other nonpulmonarycauses of respiratory distress in neonates are congenital heartdisease, persistent fetal circulation, and septicemia. In infancyand childhood, most common causes of respiratory distress are bronchiolitis,croup, asthma, pneumonia, foreign body aspiration, and congenitalor acquired heart disease with cardiac failure.
  • History and physical exam suggest mostlikely cause for respiratory distress. Oxygen saturation in roomair indicates degree of hypoxemia. Certain tests should be considereddepending on clinical circumstances:

  • Airway radiography or endoscopy for upperairway obstruction
  • Chest radiography for lower respiratorydisorders or cardiac disease
  • CBC for anemia
  • Serum electrolytes and creatinine;blood urea nitrogen; and venous/capillary pH for metabolicacidosis
  • ECG and 2-D echocardiography for cardiacfailure
  • Chest CT for any airway, lung, or mediastinal mass

    • » READ BOOK EXCERPT ONLINE »

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

    Stertor, Stridor, and Airway Obstruction: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Stertorand stridor are signs of upper airway obstruction. With seriousairway obstruction, establishing control of the airway and maintainingventilation are the most important immediate priorities. In absenceof life-threatening airway obstruction, prompt but thorough investigationis essential.
  • Age of onset is useful in diagnosis.Onset of stridor at birth or during neonatal period suggests laryngomalacia,laryngeal web, vocal cord paralysis, or vascular ring. In infancyand childhood, onset of acute stridor suggests croup, supraglottitis,or foreign body. Most common cause of persistent stertor in children2–8 yrs of age is adenoid or tonsillar hypertrophy.
  • Phase of respiration in which stridoroccurs, pitch of the sound, character of voice or cry, and changein position help in assessing degree of obstruction and its localization.

  • The phaseof respiration associated with different levels of airway obstructionhas already been described.
  • Variation in pitch depends on leveland degree of obstruction. Coarse low-pitched snoring sounds (stertor)localize lesion to nose, nasopharynx, or oropharynx. Harsh inspiratorystridor may occur with supraglottic, glottic, or subglottic lesions.Stridor associated with deep barking cough signifies subglotticor tracheal obstruction, whereas stridor associated with hoarsenessor change in character of voice or cry signifies glottic lesion.
  • When infants with laryngomalacia orinnominate artery compression are placed in prone position withneck extended, stridor decreases.
  • After history and physical exam, othertests may be useful depending on suspected diagnosis. These includeneck and chest radiography and flexible laryngoscopy. If resultsof these tests are normal, upper GI radiographic series with attentionto the pharynx and esophagus should be considered. With suspectedobstruction below glottis, bronchoscopy is necessary. Usefulnessof esophagoscopy, CT, and MRI depends on suspected diagnosis.
  • Histologic diagnosis is necessary forany suspected neoplasm except perhaps hemangioma, which can usuallybe recognized clinically.

    • » READ BOOK EXCERPT ONLINE »

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

    Cough, barking: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

    Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, productive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

    How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

    Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

    Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds—rhonchi, crackles, or wheezes.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Cough, nonproductive: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

    Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

    As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

    Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

    Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Fever [Pyrexia]: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's fever is only mild to moderate, ask him when it began and how high his temperature reached. Did the fever disappear, only to reappear later? Did he experience other symptoms, such as chills, fatigue, or pain?

    Obtain a complete medical history, noting especially immunosuppressive treatments or disorders, infection, trauma, surgery, diagnostic testing, and the use of anesthesia or other medications. Ask about recent travel because certain diseases are endemic.

    Let the history findings direct your physical examination. Because a fever can accompany diverse disorders, the examination may range from a brief evaluation of one body system to a comprehensive review of all systems. (See How fever develops.)

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Respiratory infections

    Rate This Website

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

    Website User Survey

    Medical Tools & Articles:

    Next articles:

    Tools & Services:

    Medical Articles:

    Forums & Message Boards
     
    HONcode We subscribe to the HONcode principles

    By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

    Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

    Copyright © 2009 Health Grades Inc. All rights reserved.