Causes of Restless Legs Syndrome

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

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

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

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

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Source: In a Page: Signs and Symptoms, 2004

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

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

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Source: In a Page: Signs and Symptoms, 2004

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

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

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Source: In a Page: Signs and Symptoms, 2004

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

Acute pain (<6 months)

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

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Source: In a Page: Signs and Symptoms, 2004

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

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

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

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

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Source: In a Page: Signs and Symptoms, 2004

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

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

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Source: In a Page: Signs and Symptoms, 2004

Seizures/Convulsions: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Partial seizure (involve only part of the brain)
  –Simple (no altered consciousness)
  –Complex (with altered consciousness)
• Generalized seizure (involve both hemispheres)
  –Tonic-clonic
  –Atonic
  –Tonic
  –Myoclonic
  –Absence
• Epilepsy
  –Recurrent unprovoked seizures of any or multiple types, which may be idiopathic or symptomatic
  • Secondary seizure
    –Metabolic abnormalities (e.g., electrolyte disturbances, hypoglycemia)
    –Drug effects, intoxication, or withdrawal
    –Head injury/trauma
    –Febrile seizures in children
    –Structural lesions (e.g., tumor, subdural hematoma)
    –Cerebrovascular etiologies (e.g., cerebral infarct, intracerebral hemorrhage, subarachnoid hemorrhage
    –Hypoxic-ischemic encephalopathy
    –Infection (e.g., meningitis, encephalitis)
    –Hypoxia
  • Nonepileptic seizure
    –Not associated with abnormal electrical activity in the brain
    –Patients with loss of consciousness secondary to cerebral hypoperfusion (fainting, syncope) may occasionally exhibit brief periods of twitching or convulsive movements resembling seizure activity
    –Psychological disturbances (pseudoseizure)
  • Inborn errors of metabolism
    –Disorders of amino acid metabolism
    –Organic acidemias
    –Urea cycle disorders
    –Mitochondrial disorders
    –Peroxisomal disorders
    –Glycogen storage disorders
    –Disorders of sugar metabolism
  • Rasmussen's encephalitis
    –Causes seizures and progressive hemispheric dysfunction in infants

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Source: In a Page: Signs and Symptoms, 2004

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

External ear

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

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

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

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

Seizures – Childhood: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Febrile seizure
• Cerebral dysgenesis: Disorders of neuronal migration, heterotopias, lissencephaly
• Epilepsy syndromes
  –Childhood absence
  –Juvenile absence
  –Juvenile myoclonic epilepsy (JME)
  –Benign rolandic epilepsy (BRE)
• Meningitis/encephalitis (e.g., HSV)
• Cerebral abscess
• Postinfectious (e.g., ADEM)
• Hyponatremia
• Hypernatremia
• Hypocalcemia
• Hypoglycemia
• Toxins: Ingestions or sedative withdrawal
• Trauma
• Pyridoxine deficiency
• Neoplasm
• Degenerative
  –Alpers disease
  –Rett syndrome
  –Unterricht-Lundborg disease
  –Lafora disease
  –Neuronal ceroid lipofuscinosis
• Genetic
  –Angelman syndrome
  –Aicardi syndrome
• Metabolic
  –Medium chain acyl-CoA dehydrogenase deficiency (MCAD)
  –Myoclonus epilepsy and ragged-red fibers syndrome (MERRF)
  –Sialidosis
  –Glucose transporter deficiency
  –Urea cycle defects
• Vascular: Stroke, hemorrhage, vasculitis
• Hashimoto encephalitis
• Seizure mimics
  –Breath-holding spells
  –Syncope, convulsive syncope
  –Gastroesophageal reflux
  –Cardiac arrhythmia
  –Movement disorder
  –Migraine
  –Benign paroxysmal vertigo
  –Parasomnia
  –Pseudo-seizure
  –Rage attack

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

Seizures – Neonatal: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Hypoxic ishemic encephalopathy
• Bacterial meningitis/sepsis
• Stroke
• Cerebral dysgenesis
• Electrolyte disturbances
  –Hypoglycemia
  –Hyponatremia
  –Hypomagnesemia
  –Hypocalcemia
• Maternal drug use
  –Drug withdrawal after delivery
  –Direct effect of drugs, such as cocaine
• Congenital infections (TORCH)
  –Toxoplasmosis
  –Syphilis
  –Rubella
  –CMV
  –HSV
• HSV encephalitis
• Intracranial hemorrhage
  –Subdural hemorrhage
  –Intraparenchymal hemorrhage
  –Intraventricular hemorrhage in the premature infant
  –Subarachnoid hemorrhage
• Urea cycle disturbances
• Smith-Lemli-Opitz syndrome
• Nonketotic hyperglycinemia
• Pyridoxine deficiency
• Fructose dysmetabolism
• Amino acidurias
  –Maple syrup urine disease
  –Proprionic acidemia
• Molybdenum cofactor deficiency
• Mitochondrial encephalopathy
• Glucose transporter deficiency
• Benign etiologies
  –Benign idiopathic neonatal seizures (fifth day fits)
  –Benign familial neonatal seizures
• Movements commonly mistaken for seizures
  –Benign neonatal sleep myoclonus
  –Jitteriness (may be secondary to hypoglycemia, drug withdrawal, or idiopathic)
  –Gastroesophageal reflux (arching, writhing)
  –Breath-holding spell

» READ BOOK EXCERPT ONLINE »

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

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

Epigastric pain

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

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

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

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

» READ BOOK EXCERPT ONLINE »

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

Toeing Out: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Femoral retroverson
  –Usually bilateral with excessive external and limited internal range of motion of both hips
• External tibial torsion
  –More common than femoral retroversion
  –May be related to in utero positioning and is sometimes associated with calcaneovalgus foot
• Slipped capital femoral epiphysis (SCFE)
  –Most common in obese adolescent boys
  –Unilateral out-toeing with painful hip
  –Pain and limited range of motion or antalgic externally rotated gait pattern
• Talipes calcaneovalgus
  –Positional deformity in which the foot is extremely dorseflexed and everted
• Everted flat feet
  –Children stand in a toe out position but toe in when walking
• Triceps surae muscle contracture
  –Can be seen with cerebral palsy
• Vertical talus (rocker-bottom foot)
• Congenital absence of the fibula
  –Shortening of the peroneal and triceps surae muscles result in bowing of the tibia and equinovalgus
• Maldirection of the acetabulum
  –If the acetabulum faces posteriorly, leg position is everted

» READ BOOK EXCERPT ONLINE »

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

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

• Femoral anteversion
  –Most common cause of intoeing in children between 2 and 6 years old
  –Incidence in females is twice that of males
  –Femoral shaft internal alignment leads to entire lower limb to be inwardly rotated

• Internal tibial torsion
  –Most common cause of intoeing in children less than 2 years of age
  –Inward rotation of the tibia leads to intoeing

• Metatarsus adductus
  –Forefoot is adducted, with a concave medial foot border with increased space between the first and second toes
  –May be due to in utero packaging problems; thus is associated with a higher incidence of hip dysplasia

• Muscle force imbalance
  –Neuromuscular disorders such as cerebral palsy have a higher incidence of lower extremity rotational abnormalities due to increased muscular tone and dynamic imbalance
• Pronated feet (flatfeet)
  –Children typically stand with feet in valgus position, because this is unstable for walking; children toe in to shift the center of gravity to the center of the foot
• Knock knees
• Maldirection of the acetabulum
  –If the acetabulum is directed anteriorly toeing in will stabilize the hip joint

» READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

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

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

Asymmetric Limbs: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Physiologic: Left leg is often longer than right, and right arm is longer than left, though it is usually not noticeable
• Disturbances of bone
  –Increased blood flow such as occurs in arthritis (infectious, inflammatory), neoplasms, or AVM
  –Premature closure of epiphysis occurs with infection, fracture, radiation therapy, JRA
  –Fracture may also result in malposition or malunion
  –Diaphyseal operations (bone grafts, osteotomy)
  –Developmental dysplasia of the hip
  –Coxa vara, tibia vara (Blount disease)
  –Hypoplastic bones (short femur)
  –Legg-Calvé-Perthes disease
  –SCFE
  –Syndromes such as Albright; Ollier disease; neurofibromatosis
  –Rickets
  • Hemihypertrophy
    –Idiopathic: May be associated with other anomalies involving GU tract, hemangiomas, mental retardation, and pigmented skin lesions
    –Associated with tumors: Wilms, adrenocortical, hepatoblastoma
    –Associated with dysmorphogenic syndromes: Beckwith-Wiedemann, Russell-Silver, Proteus
    –Associated with soft tissue abnormalities: Lymphedema, Klippel-Trenaunay-Weber syndrome
  • Neuromuscular disorders
    –Cerebral palsy
    –Poliomyelitis
    –Myelomeningocele
    –Peripheral neuropathy
    –Focal cerebral lesions (Sturge-Weber syndrome)
    –Stroke (due to coagulopathies, sickle cell disease)
  • Hemophilia (bleeding into a joint)
  • Reflex sympathetic dystrophy (RSD)
  • Congenital syphilis
  • Absence or hypoplasia of thumb and radius (Holt-Oram syndrome, TAR syndrome)

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

Myoclonus: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Alzheimer’s disease

Generalized myoclonus may occur in advanced stages of Alzheimer’s disease, a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

Creutzfeldt-Jakob disease

Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease, a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, usually occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances, or possibly, blindness.

Encephalitis (viral)

With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary, but may include a rapidly decreasing LOC, a fever, a headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

Encephalopathy

Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, a headache, confusion, a gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

Epilepsy

With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

Other causes

Drug withdrawal

Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal or delirium tremens.

Poisoning

Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

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

Breast pain [Mastalgia]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Areolar gland abscess. Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also occur.

❑ Breast abscess (acute). In the affected breast, local pain, tenderness, erythema, peau d'orange, and warmth are associated with a nodule. Malaise, fever, and chills may also occur.

❑ Breast cyst. A breast cyst that enlarges rapidly may cause acute, localized, and usually unilateral pain. A palpable breast nodule may be present.

❑ Fat necrosis. Local pain and tenderness may develop in fat necrosis, a benign disorder. A history of trauma usually is present. Associated findings include ecchymosis; erythema of the overriding skin; a firm, irregular, fixed mass; and skin retraction signs, such as skin dimpling and nipple retraction. Fat necrosis may be hard to differentiate from cancer.

❑ Fibrocystic breast disease. Fibrocystic breast disease is a common cause of breast pain that's associated with the development of cysts that may cause pain before menstruation and are asymptomatic afterward. Later in the course of the disorder, pain and tenderness may persist throughout the cycle. The cysts feel firm, mobile, and well defined. Many are bilateral and found in the upper outer quadrant of the breast, but others are unilateral and generalized. Signs and symptoms of premenstrual syndrome — including headache, irritability, bloating, nausea, vomiting, and abdominal cramping — may also be present.

❑ Mammary duct ectasia. Burning pain and itching around the areola may occur, although ectasia is commonly asymptomatic at first. The history may include one or more episodes of inflammation with pain, tenderness, erythema, and acute fever, or with pain and tenderness alone, which develop and then subside spontaneously within 7 to 10 days. Other findings include a rubbery, subareolar breast nodule; swelling and erythema around the nipple; nipple retraction; a bluish green discoloration or peau d'orange of the skin overlying the nodule; a thick, sticky, multicolored nipple discharge from multiple ducts; and axillary lymphadenopathy. A breast ulcer may occur in late stages.

❑ Mastitis. Unilateral pain may be severe, particularly when the inflammation occurs near the skin surface. Breast skin is typically red and warm at the inflammation site; peau d'orange may be present. Palpation reveals a firm area of induration. Skin retraction signs — such as breast dimpling and nipple deviation, inversion, or flattening — may be pres-ent. Systemic signs and symptoms — such as high fever, chills, malaise, and fatigue — may also occur.

❑ Sebaceous cyst (infected). Breast pain may be reported with sebaceous cyst, a cutaneous cyst. Associated symptoms include a small, well-delineated nodule, localized erythema, and induration.

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

Seizures, absence: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Idiopathic epilepsy

Some forms of absence seizure are accompanied by learning disabilities.

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

Seizures, complex partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include a headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma

Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Herpes simplex encephalitis

The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include a fever, a headache, coma, and generalized seizures.

Temporal lobe tumor

Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include a headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess, site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include a fever, a headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and a headache.

Hepatic encephalopathy

Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, a headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke

Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, a headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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

Seizures, simple partial: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor

Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, a decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma

Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, a headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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

Abdominal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Initially, this life-threatening disorder may produce dull lower abdominal, lower back, or severe chest pain. Usually, abdominal aortic aneurysm produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

❑ Abdominal cancer. Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and abdominal mass and distention.

❑ Abdominal trauma. Generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

❑ Adrenal crisis. Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

❑ Anthrax, GI. An acute infectious disease, GI anthrax is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in any of the following forms: cutaneous, inhaled, or GI.

GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

❑ Appendicitis. With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

❑ Cholecystitis. Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

❑ Cholelithiasis. Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

❑ Cirrhosis. Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

❑ Crohn’s disease. An acute attack in Crohn’s disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

❑ Diverticulitis. Mild cases of diverticulitis usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, a low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

❑ Duodenal ulcer. Localized abdominal pain — described as steady, gnawing, burning, aching, or hunger like — may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it may also produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

❑ Ectopic pregnancy. Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

❑ Endometriosis. Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

❑ Escherichia coli O157:H7. E. coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of normal intestinal flora of healthy humans and animals. However, E. coli O157:H7, one of hundreds of strains of the bacterium, is capable of producing a powerful toxin and can cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop, and this may ultimately lead to acute renal failure.

❑ Gastric ulcer. Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

❑ Gastritis. With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

❑ Gastroenteritis. Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

❑ Heart failure. Right upper quadrant pain commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

❑ Hepatitis. Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

❑ Intestinal obstruction. Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in an intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

❑ Irritable bowel syndrome. Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

❑ Listeriosis. A serious infection, listeriosis is caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in the level of consciousness.

GENDER CUE: Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

❑ Mesenteric artery ischemia. Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

❑ Ovarian cyst. Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

❑ Pancreatitis. Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

❑ Pelvic inflammatory disease. Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

❑ Perforated ulcer. With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

❑ Peritonitis. With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

❑ Prostatitis. Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop with prostatitis. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

❑ Pyelonephritis (acute). Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize this disorder. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

❑ Renal calculi. Depending on the location of calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

❑ Sickle cell crisis. Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

❑ Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites for the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

❑ Splenic infarction. Fulminating pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration. Pain usually radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

❑ Ulcerative colitis. Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Other causes

❑ Drugs. Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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

Arm pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Angina. Angina may cause inner arm pain as well as chest and jaw pain. Typically, the pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators such as nitroglycerin.

❑ Biceps rupture. Rupture of the biceps after excessive weight lifting or osteoarthritic degeneration of bicipital tendon insertion at the shoulder can cause pain in the upper arm. Forearm flexion and supination aggravate the pain. Other signs and symptoms include muscle weakness, deformity, and edema.

❑ Cellulitis. Typically, cellulitis affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or insect bite.

❑ Cervical nerve root compression. Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

❑ Compartment syndrome. Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome. It may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and an absent pulse.

❑ Fractures. In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, felt and heard from bone ends rubbing together (don’t attempt to elicit this sign); deformity, if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

❑ Muscle contusion. Muscle contusion may cause generalized pain in the area of injury. It may also cause local swelling and ecchymosis.

❑ Muscle strain. Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

❑ Myocardial infarction (MI). An MI is a life-threatening disorder in which the patient may complain of left arm pain as well as the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

❑ Neoplasms of the arm. Neoplasms of the arm produce continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

❑ Osteomyelitis. Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

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

Back pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm (dissecting). Life-threatening dissection of this aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, however, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

❑ Ankylosing spondylitis. Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn't relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.

❑ Appendicitis. Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney's point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney's point), and rebound tenderness. Some patients also have painful, urgent urination.

❑ Cholecystitis. Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours, and patients usually have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right upper quadrant tenderness, abdominal rigidity, pallor, and sweating.

❑ Chordoma. A slow-developing malignant tumor, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumor expands, pain may be accompanied by constipation and bowel or bladder incontinence.

❑ Endometriosis. Endometriosis causes deep sacral pain and severe, cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It's accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.

❑ Intervertebral disk rupture. Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It's accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient's spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

❑ Lumbosacral sprain. Lumbosacral sprain causes aching, localized pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine intensifies pain, whereas rest helps relieve it. The pain worsens with movement and is relieved by rest.

❑ Metastatic tumors. Metastatic tumors commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscular pain (usually worse at night), and isn't relieved by rest.

❑ Myeloma. Back pain caused by myeloma, a primary malignant tumor, usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

❑ Pancreatitis (acute). Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about.

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. A late sign may be jaundice. Occurring as inflammation subsides, Turner's sign (ecchymosis of the abdomen or flank) or Cullen's sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

❑ Perforated ulcer. In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, the absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

❑ Prostate cancer. Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also produce hematuria and decrease the urine stream.

❑ Pyelonephritis (acute). Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

❑ Renal calculi.The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. Its intensity varies but may become excruciating if calculi travel down a ureter. If calculi are in the renal pelvis and calyces, dull and constant flank pain may occur. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover the calculi for analysis.

❑ Rift Valley fever. Rift Valley fever is a viral disease generally found in Africa, but recent outbreaks have occurred in Saudi Arabia and Yemen. It's transmitted to humans from the bite of an infected mosquito or from exposure to infected animals. Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

❑ Sacroiliac strain. Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or gluteus medius or abductor lurch.

❑ Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites of the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

❑ Spinal neoplasm (benign).Spinal neoplasm typically causes severe, localized back pain and scoliosis.

❑ Spinal stenosis. Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

❑ Spondylolisthesis. A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may be asymptomatic or may cause low back pain, with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.

❑ Transverse process fracture. Transverse process fracture causes severe localized back pain with muscle spasm and hematoma.

❑ Vertebral compression fracture. Initially, vertebral compression fracture may be painless. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

❑ Vertebral osteomyelitis. Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

❑ Vertebral osteoporosis. Vertebral osteoporosis causes chronic, aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.

Other causes

❑ Neurologic tests. Lumbar puncture and myelography can produce transient back pain.

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

Chest pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angina pectoris.

 With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms — classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.

With Prinzmetal's angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation).

Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in a cutaneous, inhalation, or GI form.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety.

 Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn't related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, a headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).

 The chest pain associated with a dissecting aortic aneurysm usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, a lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma.

 In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Bronchitis.

In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, a sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing.

Cholecystitis.

 Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, a fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy's sign — inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath — may also occur.

Interstitial lung disease.

As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Lung abscess.

Pleuritic chest pain develops insidiously in lung abscess along with a pleural friction rub and a cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull to percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, a fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer.

 The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and a fever.

Mitral valve prolapse.

 Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. Patients may experience cardiac awareness, a migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Myocardial infarction (MI).

 The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain unrelieved by rest or nitroglycerin, it may radiate to the patient's left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

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

Pancreatitis.

In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, a fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer.

 With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis.

Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include a pericardial friction rub, a fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague (Yersinia pestis).

Plague is one of the most virulent bacterial infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to a human when bitten by an infected flea. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy.

 The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea; rapid, shallow breathing; cyanosis; a fever; and fatigue may also occur.

Pneumonia.

Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, a headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax.

Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that's severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain's onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous
crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism.

A pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, a cough (nonproductive or producing blood-tinged sputum), a low-grade fever, restlessness, diaphoresis, crackles, a pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (a weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention.

Q fever.

Q fever is a rickettsial disease caused by Coxiella burnetii. The primary source of human infection results from exposure to infected animals. Cattle, sheep, and goats are most likely to carry the organism. Human infection results from exposure to contaminated milk, urine, feces, or other fluids from infected animals. Infection may also result from inhaling contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Sickle cell crisis.

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, a fever, and jaundice.

Thoracic outlet syndrome.

Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis (TB).

In a patient with TB, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, a fever, malaise, dyspnea, easy fatigability, a mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia.

Also known as rabbit fever, tularemia is an infectious disease that's caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. It's typically a rural disease found in wild animals, water, and moist soil. It's transmitted to humans through a bite by an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It's considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome (CRS).

CRS is a benign condition — a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods — that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; a headache; shortness of breath; and tachycardia.

Drugs.

 The abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease — especially if he has received high doses for a prolonged period.

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

Flank pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of a UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, a low-grade fever, and tenesmus)

Cortical necrosis (acute)

Unilateral flank pain is usually severe. Accompanying findings include gross hematuria, anuria, leukocytosis, and a fever

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, a persistent high fever, chills and, in some patients, a palpable abdominal mass

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of a UTI. Later findings include hematuria and perineal, low back, and suprapubic pain

Pyelonephritis (acute)

Intense, constant, and unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include a persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include a fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, a fever, hypoactive bowel sounds, hematuria, and oliguria or anuria

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin

Renal vein thrombosis

Severe unilateral flank and lower back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include a  fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction

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

Jaw pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain

Angina is less severe than the pain of an MI

It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest

Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion (ROM), and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritiscauses symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited ROM and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and a mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Gender cue

Rheumatoid arthritis usually appears in early middle age, between ages 36 and 50, and most commonly in women.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset

Other findings include a history of leukoplakia; ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, hypocalcemic tetany — a life-threatening disorder — produces paresthesia and carpopedal spasms

The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

Ludwig’s angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling

A fever is a common sign

Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

MI

Initially, MI causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin

The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, a low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include a fever, halitosis, a headache, malaise, a cough, and a sore throat.

Suppurative parotitis

Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene

Besides the abrupt onset of jaw pain, a high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Most common in women older than age 60, temporal arteritis produces sharp jaw pain after chewing or talking

Nonspecific signs and symptoms include a low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss

Vascular lesions produce jaw pain; a throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

TMJ syndrome

TMJ syndrome is a common syndrome that produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement

Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, a headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus

A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth

Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include a headache, irritability, restlessness, a low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trigeminal neuralgia

Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

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

Neck pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Ankylosing spondylitis

Intermittent, moderate to severe neck pain and stiffness with a severely restricted range of motion (ROM) is characteristic of ankylosing spondylitis. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include a low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

Cervical extension injury

Anterior or posterior neck pain may develop within hours or days following a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, an occipital headache, muscle spasms, visual blurring, and unilateral miosis on the affected side.

Cervical spine fracture

Fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, an intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

Cervical spine tumor

Metastatic tumors typically produce persistent neck pain that increases with movement and isn’t relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to atrophy and paralysis, and bladder and bowel incontinence.

Cervical spondylosis

Cervical spondylosis is a degenerative process that produces posterior neck pain that restricts movement and is aggravated by it. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

Esophageal trauma

An esophageal mucosal tear or a pulsion diverticulum may produce mild neck pain, chest pain, edema, hemoptysis, and dysphagia.

Herniated cervical disk

A herniated cervical disk characteristically causes variable neck pain that restricts movement and is aggravated by it. It also causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.

Laryngeal cancer

Neck pain that radiates to the ear develops late in laryngeal cancer. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

Lymphadenitis

With lymphadenitis, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. A fever, chills, and malaise may also occur.

Meningitis

Neck pain may accompany characteristic nuchal rigidity. Related findings include a fever, a headache, photophobia, positive Brudzinski’s and Kernig’s signs, and a decreased level of consciousness (LOC).

Neck sprain

Minor sprains typically produce pain, slight swelling, stiffness, and restricted ROM. Ligament rupture causes pain, marked swelling, ecchymosis, muscle spasms, and nuchal rigidity with head tilt.

Rheumatoid arthritis

Rheumatoid arthritis usually affects peripheral joints, but it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root; increased warmth, swelling, and tenderness in involved joints; stiffness, restricting ROM; paresthesia and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the acute phase.

Spinous process fracture

A fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted ROM, muscle spasms, and deformity.

Subarachnoid hemorrhage

Subarachnoid hemorrhage is a life-threatening condition that may cause moderate to severe neck pain and rigidity, a headache, and a decreased LOC. Kernig’s and Brudzinski’s signs are present. The patient may describe the headache as, “the worst headache of my life.”

Thyroid trauma

Besides mild to moderate neck pain, thyroid trauma may cause local swelling and ecchymosis. If a hematoma forms, it can cause dyspnea.

Torticollis

Torticollis is a neck deformity in which severe neck pain accompanies recurrent unilateral stiffness and muscle spasms that produce a characteristic head tilt.

Tracheal trauma

A fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty.

Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

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

Rectal pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Abscess (perirectal)

A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously, commonly high in the rectum or even in the lower abdomen, and is accompanied by an indurated anal mass. The patient may also develop associated signs and symptoms, such as a fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

Anal fissure

An anal fissure is a longitudinal crack in the anal lining that causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula

Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints include pruritus and drainage of pus, blood, mucus and, occasionally, stool.

Hemorrhoids

Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

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

Complex regional pain syndrome: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The exact cause of CRPS is unknown. Impaired communication between the damaged nerves of the sympathetic nervous system and the brain may cause interference with normal signals for sensations, temperature, and blood flow. This leads to problems in the nerves, blood vessels, skin, bones, and muscles. Infection or injury to an arm or leg may initiate CRPS. It can also occur after heart attacks and strokes. However, the condition can sometimes appear without obvious injury to the affected limb. This condition is more common in people between ages 40 and 60, but has been seen in younger people too. CRPS may also be seen in postoperative patients and in patients with diseases that can cause chronic pain, such as cancer and arthritis. Annual incidence is unknown because CRPS is often misdiagnosed. However, it has been reported in 1% to 2% of patients with various fractures and in 2% to 5% of patients with peripheral nerve injury.

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

Pain disorder: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Pain disorder has no specific cause, but it may be related to severe psychological stress or conflict. The pain provides the patient with a means to cope with upsetting psychological issues. For example, a person with dependency needs may develop this disorder as an acceptable way to receive care and attention. The pain may have special significance such as leg pain in the same leg a parent lost through amputation.

Pain disorder is more common in women than in men and usually has an onset in the 30s and 40s.

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

Myoclonus: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Alzheimer’s disease

Generalized myoclonus may occur in advanced stages of this slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

Creutzfeldt-Jakob disease

Diffuse myoclonic jerks appear early in this rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, often occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and visual disturbance, or possibly, blindness.

Encephalitis (viral)

With this disease, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing level of consciousness, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

Encephalopathy

Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing level of consciousness, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

Epilepsy

With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

Other causes

Drug withdrawal

Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

Poisoning

Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

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

Breast pain [Mastalgia]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Areolar gland abscess

A tender, palpable abscess on the periphery of the areola may result from infection and inflammation of Montgomery’s glands. Fever may also occur.

Breast abscess (acute)

Local pain, tenderness, erythema, peau d’orange, and warmth are associated with a nodule in the affected breast. Malaise, fever, and chills may also occur.

Breast cyst

A breast cyst that enlarges rapidly may cause acute, localized, and usually unilateral pain. A breast nodule may be palpable.

Fat necrosis

Local pain and tenderness may develop in this benign disorder. A history of trauma usually is present. Associated findings include ecchymosis; erythema of the overriding skin; a firm, irregular, fixed mass; and skin retraction signs, such as skin dimpling and nipple retraction. Fat necrosis may be hard to differentiate from breast cancer.

Fibrocystic breast disease

Fibrocystic breast disease is a common cause of breast pain. Initially, the cysts may cause pain only before menstruation. Later in the course of the disorder, pain and tenderness may persist throughout the cycle. The cysts feel firm, mobile, and well defined. Many occur bilaterally in the upper outer quadrant of the breast, but others are unilateral and generalized. A clear, serous nipple discharge may be present in one or both breasts. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.

Intraductal papilloma

Unilateral breast pain or tenderness may accompany intraductal papilloma, although the primary sign is a serous or bloody nipple discharge, usually from only one duct. Intraductal papilloma is the primary cause of nipple discharge in nonpregnant, nonlactating women. Associated signs include a small (usually 1.5- to 3-mm), soft, poorly delineated mass in the ducts beneath the areola.

Mammary duct ectasia

Burning pain and itching around the areola may occur, although ectasia usually produces no symptoms initially. The history may include one or more episodes of inflammation with pain, tenderness, erythema, and acute fever (or with pain and tenderness alone), which subside spontaneously within 7 to 10 days. Other findings include a rubbery, subareolar breast nodule; areolar swelling and erythema; nipple retraction; a bluish green discoloration or peau d’orange of the skin overlying the nodule; a thick, sticky, multicolored nipple discharge from multiple ducts; and axillary lymphadenopathy. A breast ulcer may occur in late stages.

Mastitis

Unilateral pain may be severe, particularly when the inflammation occurs near the skin surface. Breast skin is typically red and warm at the inflammation site; peau d’orange may be present. Palpation reveals a firm area of induration. Skin retraction signs—such as breast dimpling and nipple deviation, inversion, or flattening—may be present. Systemic signs and symptoms—such as high fever, chills, malaise, and fatigue—may also occur.

Sebaceous cyst (infected)

Breast pain may be reported with this cutaneous cyst. Associated findings include a small, well-delineated nodule; localized erythema; and induration.

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

Eye pain [Ophthalmalgia]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acute angle-closure glaucoma

Blurred vision and sudden excruciating pain in and around the eye characterize this disorder; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Astigmatism

Uncorrected astigmatism commonly causes headaches and eye fatigue, aching, and redness. This disorder occurs in both older and younger people.

Blepharitis

Burning pain in both eyelids is accompanied by conjunctival injection and an itching, sticky discharge. Related findings include a foreign-body sensation, eyelid ulcerations, and loss of eyelashes.

Burns

In chemical burns, sudden severe eye pain may occur with erythema and blistering of the face and eyelids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. In ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Some degree of eye pain and excessive tearing occur in four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it typically produces burning, a foreign-body sensation, a purulent discharge, and conjunctival injection.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes; a foreign-body sensation; visible conjunctival follicles; and eyelid edema.

Corneal abrasions

This type of injury typically produces a foreign-body sensation, excessive tearing, photophobia, and conjunctival injection.

Corneal erosion (recurrent)

In this disorder, severe pain occurs on waking and continues throughout the day. Accompanying the pain are conjunctival injection and photophobia.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryoadenitis

Temporal pain may affect both eyes in this disorder. Associated findings include exophthalmos, conjunctival injection, severe eyelid erythema and edema, and a purulent eye discharge.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling around the lacrimal punctum.

Episcleritis

Deep eye pain occurs as tissues over the sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major

This disorder commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva

Sudden severe pain is common in this condition, but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Acute angle-closure glaucoma may cause severe pain and pressure over the eye, blurred vision, halo vision, decreased visual acuity, and nausea and vomiting.

Herpes zoster ophthalmicus

Eye pain occurs with severe unilateral facial pain, usually several days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum (stye)

This lesion usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and eyelid edema, conjunctival injection, and visual impairment may also occur.

Interstitial keratitis

Associated with congenital syphilis, this corneal inflammation produces eye pain with photophobia, blurred vision, prominent conjunctival injection, and grayish pink corneas.

Iritis (acute)

Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Keratoconjunctivitis sicca

This condition—known as dry eye syndrome—causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. A copious mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

This neoplastic lesion usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache

Migraines can produce head pain so severe that the eyes also ache. Nausea, vomiting, blurred vision, and light and noise sensitivity may also occur.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

This disorder causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, a purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

In this disorder, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, this injury causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia.

Orbital pseudotumor

This disorder causes deep, boring eye pain and diplopia in about 50% of patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and limited extraocular movement may also occur.

Pemphigus

In this disorder, bilateral eye pain and irritation may be accompanied by blurred vision and a thick discharge. Blisters may develop on the conjunctiva alone or may extend to the nasal, oral, and vulvar mucous membranes as well as the skin.

Scleritis

This inflammation produces severe eye pain and tenderness, conjunctival injection, bluish purple sclera and, possibly, photophobia and excessive tearing.

Sclerokeratitis

Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma

Following head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma’s location and size.

Trachoma

Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, an eye discharge, eyelid edema and erythema, and visible conjunctival follicles.

Uveitis

Anterior uveitis causes sudden severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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

Seizures, absence: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Idiopathic epilepsy

Some forms of absence seizure are accompanied by learning disabilities.

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

Seizures, complex partial: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain abscess

If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma

Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Herpes simplex encephalitis

The herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

Temporal lobe tumor

Complex partial seizures may be the first sign of this disorder. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Alcohol withdrawal syndrome

i> Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of this disorder. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Seizures are an early sign of this disorder, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Generalized seizures may occur late in this disorder. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypertensive encephalopathy

This life-threatening disorder may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

Hyponatremia

Seizures develop
when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, this disorder may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis

This disorder rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Multiple brain lesions from this disorder cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Porphyria (intermittent acute)

Generalized seizures are a late sign of this disorder, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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

Seizures, simple partial: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Brain abscess

Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor

Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma

Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

Multiple sclerosis

Focal or generalized seizures may occur with this disorder, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

Neurofibromatosis

Multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

Sarcoidosis

Multiple lesions from this disorder affect the brain, producing focal and generalized seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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

Abdominal pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm (dissecting)

Initially, abdominal aortic aneurysm—a life-threatening disorder—may produce dull lower abdominal, lower back, or severe chest pain. In most cases, however, it produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

Abdominal cancer

Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, an abdominal mass, and abdominal distention.

Abdominal trauma

Generalized or localized abdominal pain occurs with ecchymoses on the abdomen; abdominal tenderness; vomiting; and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis

Severe abdominal pain appears early along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness, hypotension, tachycardia, oliguria, cool and clammy skin, and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI

Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhaled, or GI forms.

GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include anorexia, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Appendicitis is a life-threatening disorder in which pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, and vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis

Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity and tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis

Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, and constipation or diarrhea. Subsequent right-upper-quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn’s disease

An acute attack causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right-lower-quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Cystitis

Abdominal pain and tenderness usually occur in the suprapubic region. Associated signs and symptoms include malaise, flank pain, low back pain, nausea, vomiting, urinary frequency and urgency, nocturia, dysuria, fever, and chills.

Diabetic ketoacidosis

Rarely, severe, sharp, shooting, and girdling pain may persist for several days. Fruity breath odor, a weak and rapid pulse, Kussmaul’s respirations, poor skin turgor, polyuria, polydipsia, nocturia, hypotension, decreased bowel sounds, and confusion also occur.

Diverticulitis

Mild cases usually produce intermittent, diffuse left-lower-quadrant pain, which may be relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left-lower-quadrant pain, abdominal rigidity, and possibly signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer

Localized abdominal pain—described as steady, gnawing, burning, aching, or hungerlike—may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy

Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis

Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, abdominal pain may be accompanied by abdominal tenderness, constipation, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7

Gastric ulcer

Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis

With acute gastritis, the patient experiences rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

Gastroenteritis

Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure

Right-upper-quadrant pain commonly accompanies heart failure’s hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatic abscess

Steady, severe abdominal pain in the right upper quadrant or midepigastrium commonly accompanies hepatic abscess—a rare disorder—but right-upper-quadrant tenderness is the most important finding. Other signs and symptoms are anorexia, diarrhea, nausea, fever, diaphoresis, elevated right hemidiaphragm and, rarely, vomiting.

Hepatic amebiasis

Rare in the United States, hepatic amebiasis causes relatively severe right-upper-quadrant pain and tenderness over the liver and possibly the right shoulder. Accompanying signs and symptoms include fever, weakness, weight loss, chills, diaphoresis, and jaundiced or brownish skin.

Hepatitis

Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

Herpes zoster

Herpes zoster of the thoracic, lumbar, or sacral nerves can cause localized abdominal and chest pain in the areas served by these nerves. Pain, tenderness, and fever can precede or accompany erythematous papules, which rapidly evolve into grouped vesicles.

Intestinal obstruction

Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive bowel sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

Irritable bowel syndrome

Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis

Listeriosis is a serious infection that’s caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, it may cause meningitis, characterized by fever, headache, nuchal rigidity, and altered level of consciousness (LOC).

Gender Cue: Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Mesenteric artery ischemia

Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmias, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Myocardial infarction (MI)

In MI—a life-threatening disorder—substernal chest pain may radiate to the abdomen. Associated signs and symptoms include weakness, diaphoresis, nausea, vomiting, anxiety, syncope, jugular vein distention, and dyspnea.

Norovirus infection

Abdominal pain or cramping is a symptom commonly associated with noroviruses. Transmitted by the fecal-oral route and highly contagious, these viruses that cause gastroenteritis may also produce acute-onset vomiting, nausea, and diarrhea. Less common symptoms include low-grade fever, headache, chills, muscle aches, and generalized fatigue. Individuals who are otherwise healthy usually recover in 24 to 60 hours without suffering lasting effects.

Ovarian cyst

Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by a slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass, and possibly amenorrhea. Abdominal distention may occur if the cyst is large. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis

Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move about restlessly. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left-upper-quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

Pelvic inflammatory disease

Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, discomfort on urination, and abnormal vaginal bleeding or a purulent vaginal discharge.

Perforated ulcer

In a life-threatening perforated ulcer, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis

In this life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Pleurisy

Pleurisy may produce upper abdominal or costal margin pain referred from the chest. Characteristic sharp, stabbing chest pain increases with inspiration and movement. Many patients have a pleural friction rub and rapid, shallow breathing; some have a low-grade fever.

Pneumonia

Lower-lobe pneumonia can cause pleuritic chest pain and referred, severe upper abdominal pain, tenderness, and rigidity that diminish with inspiration. It can also cause fever, shaking chills, achiness, headache, blood-tinged or rusty sputum, dyspnea, and a dry, hacking cough. Accompanying signs include crackles, egophony, decreased breath sounds, and dullness on percussion.

Pneumothorax

Pneumothorax is a potentially life-threatening disorder that can cause referred pain from the chest to the upper abdomen and costal margin. Characteristic chest pain arises suddenly and worsens with deep inspiration or movement. Accompanying signs and symptoms include anxiety, dyspnea, cyanosis, decreased or absent breath sounds over the affected area, tachypnea, and tachycardia. Watch for asymmetrical chest movements on inspiration.

Prostatitis

Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute)

Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize pyelonephritis. Pain may radiate to the lower midabdomen or the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi

Depending on their location, calculi may cause severe abdominal or back pain. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant and may be accompanied by agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria.

Sickle cell crisis

Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

Smallpox (variola major)

Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites for the virus, which is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the oral mucosa, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction

Fulminating pain in the left upper quadrant occurs with chest pain that may worsen on inspiration. Pain commonly radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Systemic lupus erythematosus

Generalized abdominal pain is unusual in this disease but may occur after meals. Butterfly rash, photosensitivity, alopecia, mucous membrane ulcers, and nondeforming arthritis are characteristic signs. Other common signs and symptoms include anorexia, vomiting, abdominal tenderness with guarding, abdominal distention after meals, fatigue, fever, and weight loss. Precordial chest pain and a pericardial rub may also occur.

Ulcerative colitis

Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom—recurrent and possibly severe diarrhea with blood, pus, and mucus—may relieve the pain. The abdomen may feel soft and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Uremia

Characterized by generalized or periumbilical pain that shifts and varies in intensity, uremia causes diverse GI signs and symptoms, such as nausea, vomiting, anorexia, and diarrhea. Other findings may include bleeding, abdominal tenderness that changes in location and intensity, visual disturbances, headache, decreased LOC, vertigo, and oliguria or anuria. Chest pain may occur secondary to pericardial effusion. Localized or diffuse pruritus is common.

Other causes

Drugs

Salicylates and nonsteroidal anti-inflammatories commonly cause burning, gnawing pain in the left upper quadrant or epigastric area as well as nausea and vomiting.

Insect toxins

Generalized, cramping abdominal pain usually occurs with low-grade fever, nausea, vomiting, abdominal rigidity, tremors, and burning sensations in the hands or feet.

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

Arm pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina

Angina may cause inner arm pain as well as chest and jaw pain. Typically, the pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators such as nitroglycerin.

Biceps rupture

Rupture of the biceps after excessive weight lifting or osteoarthritic degeneration of bicipital tendon insertion at the shoulder can cause pain in the upper arm. Forearm flexion and supination aggravate the pain. Other signs and symptoms include muscle weakness, deformity, and edema.

Cellulitis

Cellulitis typically affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or insect bite.

Cervical nerve root compression

Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

Compartment syndrome

Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome, which may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and absent pulse.

Fractures

In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, which is felt and heard from bone ends rubbing together (don’t attempt to elicit this sign); deformity if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

Muscle contusion

Muscle contusion may cause generalized pain in the injured area as well as local swelling and ecchymosis.

Muscle strain

Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

Myocardial infarction

In this life-threatening disorder, the patient may complain of left arm pain in addition to the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

Neoplasm of the arm

A neoplasm of the arm produces continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

Osteomyelitis

Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

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

Back pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm (dissecting)

Life-threatening dissection of an abdominal aortic aneurysm may initially cause low back pain or dull abdominal pain, but it usually produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, though, it no longer pulsates. Aneurysm dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, blood pressure that’s lower in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

Ankylosing spondylitis

Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasionally iritis.

Appendicitis

Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney’s point in the right lower quadrant. In retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney’s point), and rebound tenderness. Some patients also have painful urinary urgency.

Cholecystitis

Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours; many patients have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right-upper-quadrant tenderness, abdominal rigidity, pallor, and sweating.

Chordoma

A slowly developing malignant tumor, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumor expands, pain may be accompanied by constipation and bowel or bladder incontinence.

Endometriosis

Endometriosis causes deep sacral pain and severe cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It’s accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.

Intervertebral disk rupture

Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It’s accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient’s spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

Lumbosacral sprain

Lumbosacral sprain causes localized aching pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine and movement intensify the pain, whereas rest helps relieve it.

Metastatic tumors

Metastatic tumors commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscle pain (usually worse at night), and isn’t relieved by rest.

Myeloma

Back pain caused by myeloma—a primary malignant tumor— usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

Pancreatitis (acute)

Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move about restlessly.

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, and tachycardia; some patients experience abdominal guarding and rigidity, rebound tenderness, and hypoactive bowel sounds. Jaundice may be a late sign. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

Perforated ulcer

In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

Prostate cancer

Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also cause hematuria and decreased urine stream.

Pyelonephritis (acute)

Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

Reiter’s syndrome

In some patients, sacroiliac pain is the first sign of Reiter’s syndrome. Pain is accompanied by the classic triad of conjunctivitis, urethritis, and arthritis.

Renal calculi

The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. It varies in intensity but may become excruciating if calculi travel down a ureter. Calculi in the renal pelvis and calyces may cause dull and constant flank pain. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover any expelled calculi for analysis.

Rift Valley fever

Rift Valley fever is a viral disease generally found in Africa, but recent outbreaks have occurred in Saudi Arabia and Yemen. It’s transmitted to humans from the bite of an infected mosquito or from exposure to infected animals. Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Sacroiliac strain

Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or a gluteus medius or abductor lurch.

Smallpox (variola major)

Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites of the virus. The virus is considered a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the oral mucosa, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Spinal neoplasm (benign)

Spinal neoplasm typically causes severe localized back pain and scoliosis.

Spinal stenosis

Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

Spondylolisthesis

A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may produce no symptoms or may cause low back pain with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.

Transverse process fracture

This type of fracture causes severe localized back pain with muscle spasm and hematoma.

Vertebral compression fracture

A vertebral compression fracture may be painless initially. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

Vertebral osteomyelitis

Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

Vertebral osteoporosis

Vertebral osteoporosis causes chronic aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.

Other causes

Neurologic tests

Lumbar puncture and myelography can produce transient back pain.

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

Chest pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina pectoris

A patient with angina pectoris may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound [S ₄]) or a murmur during an anginal episode.

In Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by dyspnea, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation)

This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial flulike signs and symptoms include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Anxiety

Acute anxiety—commonly known as panic attacks—can produce intermittent, sharp, stabbing pain, typically behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting)

The chest pain associated with this life-threatening disorder usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma

In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Blast lung injury

Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.

Blastomycosis

Besides pleuritic chest pain, this disorder initially produces signs and symptoms that mimic those of a viral upper respiratory tract infection: a dry, hacking, or productive cough (and sometimes hemoptysis), fever, chills, anorexia, weight loss, fatigue, night sweats, and malaise.

Bronchitis

In its acute form, this disorder produces burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm with increased coughing and wheezing.

Cardiomyopathy

In hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, a cough, dizziness, syncope, gallops, murmurs, and palpitations.

Cholecystitis

This disorder typically produces abrupt epigastric or right-upper-quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or the right shoulder. Associated findings commonly include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.

Coccidioidomycosis

In this disorder, pleuritic chest pain occurs with a dry or slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional chills, sore throat, backache, headache, malaise, marked weakness, anorexia, and a macular rash.

Costochondritis

Pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint.

Distention of colon’s splenic flexure

Central chest pain may radiate to the left arm in patients with this disorder. The pain may be relieved by defecation or the passage of flatus.

Esophageal spasm

In this disorder, substernal chest pain may last up to an hour and may radiate to the neck, jaw, arms, or back. It commonly mimics the squeezing or dull sensation associated with angina. Other signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.

Herpes zoster (shingles)

The pain of pre-eruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas—usually the thorax, arms, and legs—and the chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.

Hiatal hernia

Typically, this disorder produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially spicy foods and hot drinks.

Interstitial lung disease

As this disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Legionnaires’ disease

This disorder produces pleuritic chest pain in addition to malaise, headache, and possibly diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient suddenly develops a high fever and chills, and an initially nonproductive cough progresses to a productive cough with mucoid and then mucopurulent sputum and possibly hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.

Lung abscess

Pleuritic chest pain develops insidiously in a lung abscess along with a pleural friction rub and a cough that produces copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull on percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer

The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include a cough (sometimes blood-tinged), wheezing, dyspnea, fatigue, anorexia, weight loss, and fever.

Mediastinitis

This disorder produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Accompanying signs and symptoms include chills, fever, and dysphagia.

Mitral valve prolapse

Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or hours and may mimic the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Muscle strain

Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.

Myocardial infarction

The crushing substernal chest pain typically associated with an MI lasts from 15 minutes to hours. Typically unrelieved by rest or nitroglycerin, the pain may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

Gender Cue: An MI may be difficult to diagnose in perimenopausal women because it may produce atypical symptoms, such as fatigue, nausea, dyspnea, and shoulder or neck pain, rather than chest pain.

Nocardiosis

This disorder causes pleuritic chest pain with a cough that produces thick, tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also cause fever, night sweats, anorexia, malaise, weight loss, and diminished or absent breath sounds.

Pancreatitis

Acute pancreatitis usually causes intense epigastric pain that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer

In this disorder, sharp and burning pain usually arises in the epigastric region. This pain characteristically occurs hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis

This disorder produces precordial or retrosternal pain that’s aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague

Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when the plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy

The sharp, even knifelike chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is usually unilateral and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid and shallow breathing, cyanosis, fever, and fatigue may also occur.

Pneumonia

This disorder produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax

Spontaneous pneumothorax, a life-threatening disorder, causes sudden severe, sharp chest pain that increases with chest movement; it’s typically unilateral and rarely localized. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Psittacosis

This disorder may produce pleuritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration.

Pulmonary actinomycosis

This disorder causes pleuritic chest pain with a cough that’s initially dry but later produces purulent sputum. The patient may also display hemoptysis, fever, weight loss, fatigue, weakness, dyspnea, and night sweats. Multiple sinuses may extend through the chest wall and drain externally.

Pulmonary embolism

This disorder produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness on percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less-common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck veins.

Pulmonary hypertension (primary)

Angina-like pain develops late in patients with this disorder, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.

Q fever

Q fever is a rickettsial disease caused by Coxiella burnetii, an organism found in cattle, sheep, and goats. Human infection usually results from exposure to contaminated milk, urine, feces, or other fluids from infected animals, but it may also result from inhalation of contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rib fracture

The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.

Sickle cell crisis

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice.

Thoracic outlet syndrome

Often causing paresthesia along the ulnar distribution of the arm, this syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis

Pleuritic chest pain and fine crackles occur after coughing in a patient with tuberculosis. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia

Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome

This benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.

Drugs

Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary artery disease, especially if he has received high doses for a prolonged period.

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

Facial pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina pectoris

Occasionally, jaw pain may indicate angina pectoris. A more comprehensive history and evaluation is needed to determine cardiac origin.

Dental caries

Caries in the mandibular molars can produce ear, preauricular, and temporal pain; caries in the maxillary teeth can produce maxillary, orbital, retro-orbital, and parietal pain. Other dental causes of facial pain are an abnormal bite and faulty dentures. Facial pain related to chewing or temperature changes may suggest dental problems.

Glaucoma

In glaucoma, an important cause of facial pain, the pain is usually located in the periorbital region.

Glossopharyngeal neuralgia

The pain in this uncommon disorder is similar to that of trigeminal neuralgia. It typically occurs in the throat near the tonsillar fossa and may radiate to the ear and posterior aspect of the tongue. It may be aggravated by swallowing, chewing, talking, or yawning. No underlying structural abnormality is usually present.

Herpes zoster oticus (Ramsay Hunt syndrome)

This disorder causes severe pain around the ear, followed by vesicles in the ear and occasionally on the oral mucosa, tonsils, and posterior tongue. Other findings may include hearing loss, vertigo, and transient ipsilateral facial paralysis.

Multiple sclerosis (MS)

Facial pain in MS may resemble that of trigeminal neuralgia and is accompanied by jaw and facial weakness. Other common findings include visual blurring, diplopia, and nystagmus; sensory impairment such as paresthesia; generalized muscle weakness and gait abnormalities; urinary disturbances; and emotional lability.

Postherpetic neuralgia

Burning, itching, prickly pain persists along any of the three trigeminal nerve divisions and worsens with contact or movement. Mild hypoesthesia or paresthesia and vesicles affect the area before the onset of pain.

Sinus cancer

In ethmoid sinus cancer, facial pain is a late symptom, preceded by exophthalmos. In maxillary sinus cancer, persistent pain along the second division of cranial nerve V is a late symptom.

Sinusitis (acute)

Acute frontal sinusitis commonly produces severe pain above or around the eyes, which worsens when the patient is in a supine position. It also causes nasal obstruction, inflamed nasal mucosa, fever, and tenderness and swelling above the eyes.

Acute ethmoid sinusitis produces pain at or around the inner corner of the eye and sometimes temporal headaches. Other findings include nasal congestion, purulent rhinorrhea, fever, and tenderness at the medial edge of the eye.

In acute sphenoid sinusitis, a deep-seated pain persists behind the eyes or nose or on the top of the head. The pain increases on bending forward and may be accompanied by fever.

Sinusitis (chronic)

Chronic frontal sinusitis produces a persistent low-grade pain above the eyes. The patient usually has a history of trauma or long-standing inflammation.

Chronic ethmoid sinusitis is characterized by nasal congestion, an intermittent purulent nasal discharge, and low-grade discomfort at the medial corners of the eyes. Also common are recurrent sore throat, halitosis, ear fullness, and involvement of the other sinuses.

A low-grade, diffuse headache or retro-orbital discomfort is common in chronic sphenoid sinusitis.

Sphenopalatine neuralgia

In this type of neuralgia, unilateral deep, boring pain occurs below the ear and may radiate to the eye, ear, cheek, nose, palate, maxillary teeth, temple, back of the head, neck, or shoulder. Attacks also cause increased tearing and salivation, rhinorrhea, a sensation of fullness in the ear, tinnitus, vertigo, taste disturbances, pruritus, and shoulder stiffness or weakness.

Temporal arteritis

Unilateral pain occurs behind the eye or in the scalp, jaw, tongue, or neck. A typical episode consists of a severe throbbing or boring temporal headache with redness, swelling, and nodulation of the temporal artery.

Temporomandibular joint syndrome

In this syndrome, intermittent pain, usually unilateral, is described as a severe, dull ache or an intense spasm that radiates to the cheek, temple, lower jaw, ear, or mastoid area. Associated findings include trismus, malocclusion, and clicking, crepitus, and tenderness in the temporomandibular joint.

Trigeminal neuralgia

Paroxysms of intense pain, lasting up to 15 minutes, shoot along any or all of the three branches of the trigeminal nerve. The pain can be triggered by touching the nose, cheek, or mouth; by being exposed to hot or cold weather; by consuming hot or cold foods or beverages; or even by smiling or talking. Between attacks, the pain may diminish to a dull ache or may disappear. This disorder is most common in middle and later life, affecting more women than men.

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

Flank pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Bladder cancer

Dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of bladder cancer is gross, painless, intermittent hematuria, often with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and low back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cortical necrosis (acute)

Unilateral flank pain is usually severe in this disorder. Accompanying findings include gross hematuria, anuria, leukocytosis, and fever.

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI in bacterial cystitis. The patient may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in patients with this disorder is bilateral, constant, and of moderate intensity. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

In an acute obstruction, flank pain may be excruciating; in a gradual obstruction, it’s typically a dull ache. In both types, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings—a palpable abdominal mass, CVA tenderness, and bladder distention—vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

In this disorder, intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms—oliguria or anuria, hematuria, and pyuria—are associated with high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of this renal disorder. The pain can become severe and colicky if cysts rupture and clots migrate or cause an obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs and symptoms of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

Intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain in this disorder. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain, a visible or palpable flank mass, and CVA or abdominal pain (which may be severe and radiate to the groin) are common findings in renal trauma. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea and vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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

Jaw pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion, and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Gender Cue: Rheumatoid arthritis usually appears in early middle age, between ages 36 and 50, and most commonly in women.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, this life-threatening disorder produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

An acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Initially, this life-threatening disorder causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sialolithiasis

With this disorder, stones form in the salivary glands, causing painful swelling that makes chewing uncomfortable. Jaw pain occurs in the lower jaw, floor of the mouth, and TMJ. It may also radiate to the ear or neck.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene. Besides the abrupt onset of jaw pain, high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Most common in women older than age 60, this disorder produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

Temporomandibular joint syndrome

This common syndrome produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus

A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include headache, irritability, restlessness, low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trauma

Injury to the face, head, or neck—particularly fracture of the maxilla or mandible—may produce jaw pain and swelling and decreased jaw mobility. Associated findings include hypotension and tachycardia (indicating shock), lacerations, ecchymoses, and hematomas. Rhinorrhea or otorrhea indicates the leakage of cerebrospinal fluid; blurred vision indicates orbital involvement.

Trigeminal neuralgia

This disorder is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

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

Neck pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ankylosing spondylitis

Intermittent, moderate to severe neck pain and stiffness with severely restricted range of motion is characteristic of this disorder. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

Cervical extension injury

Anterior or posterior neck pain may develop within hours or days following a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, occipital headache, muscle spasms, visual blurring, and unilateral miosis on the affected side.

Cervical fibrositis

This disorder may produce anterior neck pain that radiates to one or both shoulders. Pain is intermittent and variable, often changing with weather patterns. Other findings are nonspecific but commonly include point tenderness over involved muscles.

Cervical spine fracture

Fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

Cervical spine infection (acute)

This infection can cause neck pain that restricts motion. Other findings include fever, possible deformity, muscle spasms, local tenderness, dysphagia, paresthesia, and muscle weakness.

Cervical spine tumor

Metastatic tumors typically produce persistent neck pain that increases with movement and isn’t relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to atrophy and paralysis, and bladder and bowel incontinence.

Cervical spondylosis

This degenerative process produces posterior neck pain that restricts movement and is aggravated by it. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

Cervical stenosis

This progressive disorder, commonly asymptomatic, may cause nonspecific neck and arm pain, paresthesia, muscle weakness or paralysis, and decreased range of motion.

Esophageal trauma

An esophageal mucosal tear or a pulsion diverticulum may produce mild neck pain, chest pain, edema, hemoptysis, and dysphagia.

Herniated cervical disk

This disorder characteristically causes variable neck pain that restricts movement and is aggravated by it. It also causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.

Hodgkin’s lymphoma

This disorder may eventually result in generalized pain that may affect the neck. Lymphadenopathy, the classic sign, may accompany paresthesia, muscle weakness, fever, fatigue, weight loss, malaise, and hepatomegaly.

Laryngeal cancer

Neck pain that radiates to the ear develops late in this disorder. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

Lymphadenitis

With this disorder, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. Fever, chills, and malaise may also occur.

Meningitis

Neck pain may accompany characteristic nuchal rigidity. Related findings include fever, headache, photophobia, positive Brudzinski’s and Kernig’s signs, and decreased level of consciousness.

Neck sprain

Minor sprains typically produce pain, slight swelling, stiffness, and restricted range of motion. Ligament rupture causes pain, marked swelling, ecchymosis, muscle spasms, and nuchal rigidity with head tilt.

Osteoporosis

Neck pain is rare with this disorder, which usually affects the thoracic or lumbar vertebrae. Cervical vertebrae involvement produces tenderness and deformity.

Paget’s disease

This slowly developing disease is commonly asymptomatic in its early stages. As it progresses, cervical vertebrae deformity may produce severe, persistent neck pain, along with paresthesia and arm weakness or paralysis.

Rheumatoid arthritis

This disorder usually affects peripheral joints, but it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root; increased warmth, swelling, and tenderness in involved joints; stiffness, restricting range of motion; paresthesia and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the acute phase.

Spinous process fracture

Fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted range of motion, muscle spasms, and deformity.

Subarachnoid hemorrhage

This life-threatening condition may cause moderate to severe neck pain and rigidity, headache, and a decreased level of consciousness. Kernig’s and Brudzinski’s signs are present. The patient may describe the headache as “the worst headache of my life.”

Thyroid trauma

Besides mild to moderate neck pain, thyroid trauma may cause local swelling and ecchymosis. If a hematoma forms, it can cause dyspnea.

Torticollis

With this neck deformity, severe neck pain accompanies recurrent unilateral stiffness and muscle spasms that produce a characteristic head tilt.

Tracheal trauma

Fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty.

Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

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

Seizures: Differential Overview

(Field Guide to Bedside Diagnosis)

❑ Generalized (grand mal)

❑ Partial (focal)

❑ Complex partial (temporal lobe)

❑ Absence (petit mal)

❑ Vasovagal syncope

❑ Myoclonic

❑ Akinetic (drop attacks)

❑ Psychomotor

❑ Pseudoseizures

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Irritable bowel syndrome

❑ Peptic ulcer disease

❑ Cholecystitis

❑ Chronic pancreatitis

❑ Inflammatory bowel disease

❑ Intermittent mesenteric ischemia

❑ Pancreatic cancer

❑ Gastric cancer

❑ Endometriosis

❑ Recurrent intestinal obstruction

❑ Sickle cell anemia

❑ Radiculopathy

❑ Adrenal insufficiency

❑ Lead poisoning

❑ Porphyria

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Costochondritis

❑ Pneumonia

❑ Rib fracture

❑ Pulmonary embolism

❑ Pleurisy

❑ Pneumothorax

❑ Pericarditis

❑ Lung cancer

❑ Pneumomediastinum

❑ Splenic infarction

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Source: Field Guide to Bedside Diagnosis, 2007

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

Pain Predominant

❑ Epididymitis

❑ Testicular torsion

❑ Prostatitis

❑ Referred pain

❑ Trauma

❑ Orchitis

❑ Torsion of the appendix testis

❑ Inguinal hernia/incarcerated

Swelling Predominant

❑ Varicocele

❑ Inguinal hernia

❑ Hydrocele

❑ Spermatocele

❑ Sebaceous cyst

❑ Testicular cancer

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Chest wall pain

❑ Angina

❑ Unstable angina

❑ Myocardial infarction

❑ Gastroesophageal reflux

❑ Herpes zoster

❑ Thoracic root compression

❑ Panic disorder

❑ Aortic stenosis

❑ Aortic dissection

❑ Mediastinal mass

❑ Biliary disease

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Source: Field Guide to Bedside Diagnosis, 2007

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

Ear Pain

❑ Acute otitis media

❑ Acute otitis externa

❑ Eustachian dysfunction

❑ Temporomandibular joint arthritis

❑ Traumatic tympanic membrane rupture

❑ Foreign body, external auditory canal

❑ Erysipelas

❑ Herpes zoster oticus

❑ Dental abscess

❑ Frostbite

❑ Relapsing polychondritis

❑ Malignant otitis externa

❑ Acute mastoiditis

❑ Nasopharyngeal cancer

Ear Discharge

❑ Otitis externa

❑ Eczematoid dermatitis

❑ Low-viscosity cerumen

❑ Otitis media with perforation

❑ Foreign body

❑ Psoriasis

❑ Herpes zoster oticus

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Maxillary sinusitis

❑ Dental infection

❑ Temporomandibular joint dysfunction

❑ Myofascial masseter pain

❑ Migraine

❑ Trigeminal neuralgia

❑ Frontal sinusitis

❑ Ethmoid sinusitis

❑ Sphenoid sinusitis

❑ Parotitis

❑ Parotid calculus

❑ Orbital fracture

❑ Mandibular fracture

❑ Maxillary fracture

❑ Myocardial infarction

❑ Connective tissue disease

❑ Temporal arteritis

❑ Cavernous sinus thrombosis

❑ Glossopharyngeal neuralgia

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Musculoligamentous strain

❑ Lumbar disc herniation

❑ Osteoarthritis

❑ Compression fracture

❑ Pyelonephritis

❑ Secondary gain

❑ Scoliosis

❑ Spondylolisthesis

❑ Metastatic cancer

❑ Spinal stenosis

❑ Transverse process fracture

❑ Pancreatic cancer

❑ Ankylosing spondylitis

❑ Sacroiliitis

❑ Aortic dissection

❑ Cauda equina syndrome

❑ Vertebral osteomyelitis

❑ Epidural abscess

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Source: Field Guide to Bedside Diagnosis, 2007

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

Generalized/Periumbilical

❑ Gastroenteritis

❑ Obstipation

❑ Small bowel obstruction

❑ Large bowel obstruction

❑ Mesenteric ischemia

❑ Peritonitis

❑ Abdominal aortic dissection

❑ Sickle cell crisis

Right Upper Quadrant/Epigastrium

❑ Hepatitis

❑ Biliary colic

❑ Peptic ulcer disease

❑ Pyelonephritis

❑ Acute cholecystitis

Right Lower Quadrant

❑ Appendicitis

❑ Inflammatory bowel disease

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Ovarian torsion

Left Upper Quadrant

❑ Pancreatitis

❑ Splenic infarction

❑ Pyelonephritis

❑ Myocardial infarction

Left Lower Quadrant

❑ Inflammatory bowel disease

❑ Diverticulitis

❑ Salpingitis

❑ Rectus abdominus muscle strain

❑ Ureteral calculus

❑ Ovarian torsion

❑ Ruptured corpus luteum cyst

❑ Ruptured ectopic pregnancy

❑ Sigmoid volvulus

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Osteoarthritis

❑ Patellofemoral pain

❑ Collateral ligament sprain

❑ Meniscal tear

❑ Anterior cruciate tear

❑ Infrapatellar quadriceps tendinitis

❑ Acute monoarticular arthritis

❑ Prepatellar bursitis

❑ Anserine bursitis

❑ Hamstring injury

❑ Baker cyst

❑ Septic joint

❑ Iliotibial band syndrome

❑ Hemarthrosis

❑ Patellar fracture

❑ Patellar dislocation

❑ Osteochondritis desiccans

❑ Osteonecrosis

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Source: Field Guide to Bedside Diagnosis, 2007

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

Ankle Pain

❑ Ankle sprain

❑ Fibular fracture

❑ Achilles tendinitis

❑ Acute gout

Foot Pain

❑ Plantar fasciitis

❑ Acute gout

❑ Hallux valgus (bunion)

❑ Sciatica

❑ Metatarsalgia

❑ Metatarsal stress fracture

❑ Tibialis anterior tendinitis

❑ Pes planus

❑ Calcaneal fracture

❑ Interdigital neuroma

❑ Posterior tibial nerve entrapment

❑ Compartment syndrome

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑Lateral epicondylitis

❑Olecranon bursitis

❑Medial epicondylitis

❑Bicipitoradialis tendinitis

❑Cubital tunnel syndrome

❑Radial head fracture

❑Septic arthritis

❑Gout

❑Osteoarthritis

❑Elbow dislocation

❑Ruptured distal biceps tendon

❑Epitrochlear lymphadenitis

❑Cervical radiculopathy

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Sinusitis

❑ Migraine

❑ Acute glaucoma

❑ Orbital cellulitis

❑ Zoster prodrome

❑ Orbital fracture

❑ Keratitis

❑ Scleritis

❑ Iritis

❑ Optic neuritis

❑ Temporal arteritis

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑ Ureteral calculus

❑ Acute pyelonephritis

❑ Latissimus strain

❑ Perinephric abscess

❑ Renal infarction

❑ Renal trauma

❑ Renal cancer

❑ Mononeuritis

❑ Papillary necrosis

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Source: Field Guide to Bedside Diagnosis, 2007

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

❑Hip osteoarthritis

❑Trochanteric bursitis

❑Ischial bursitis

❑Iliopectineal bursitis

❑Iliopsoas bursitis

❑Nerve root compression

❑Meralgia paresthetica

❑Obturator inflammation

❑Iliac apophysitis

❑Hip fracture

❑Aortoiliac insufficiency

❑Polymyalgia rheumatica

❑Ankylosing spondylitis

❑Septic arthritis

❑Osteonecrosis

❑Sacroiliitis

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Source: Field Guide to Bedside Diagnosis, 2007

Complex regional pain syndrome: Causes
(Handbook of Diseases)

The exact cause of CRPS is unknown. Impaired communication between the damaged nerves of the sympathetic nervous system and the brain may cause interference with normal signals for sensations, temperature, and blood flow. Infection or injury to an area or leg may initiate CRPS.

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Source: Handbook of Diseases, 2003

Myoclonus: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Alzheimer’s disease

Generalized myoclonus may occur in advanced stages of Alzheimer’s disease, which is a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

Creutzfeldt-Jakob disease

Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease — a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, often occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbance, or possibly, blindness.

Encephalitis (viral)

With encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing level of consciousness, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

Encephalopathy

Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing level of consciousness, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

Epilepsy

With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

Other causes

Drug withdrawal

Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

Poisoning

Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

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

Seizures, generalized tonic-clonic: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Alcohol withdrawal syndrome

Seizures as well as status epilepticus may develop 7 to 48 hours after abrupt cessation of alcohol consumption by the individual with alcohol dependency. Restlessness, hallucinations, profuse diaphoresis, and tachycardia may also occur.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Decreased level of consciousness (LOC) varies from drowsiness to deep stupor according to the size and location of the abscess. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site, but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, decorticate posture.

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysm rupture. Premonitory signs and symptoms may last several days, but the onset is typically abrupt with severe headache, nausea, vomiting, and a decreased LOC. Related signs and symptoms vary according to the site and amount of bleeding, but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma. Other signs and symptoms may include soft-tissue injury of the face, head, or neck as well as facial edema and clear or bloody drainage from the mouth, nose, or ears. The patient may also exhibit Battle’s sign, lack of response to oculocephalic and oculovestibular stimulation, and bony deformity of the face, head, or neck. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypertensive encephalopathy

A life-threatening disorder, hypertensive encephalopathy may cause seizures along with severely increased blood pressure, a decreased LOC, intense headache, vomiting, transient blindness, paralysis and, eventually, Cheyne-Stokes respirations.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis (MS)

MS rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Porphyria (intermittent acute)

Generalized seizures are a late sign of porphyria, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

Seizures (focal more common than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation, paresthesia of the extremities, alopecia, irritated mucous membranes, weakness, muscle aches, peripheral neuropathy, and sharply defined edema of the eyelids, face, and ankles.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, Indocin, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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

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

See Abdominal pain: Causes and associated findings, pages 6 to 11.

Abdominal aortic aneurysm (dissecting)

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

Abdominal cancer

Adrenal crisis

Anthrax, GI

Eating contaminated meat from an infected animal causes GI anthrax. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

Cholecystitis

Cholelithiasis

Cirrhosis

Crohn’s disease

Cystitis

Diabetic ketoacidosis

Diverticulitis

Duodenal ulcer

Ectopic pregnancy

Endometriosis

Escherichia Coli O157:H7

Gastric ulcer

Gastritis

Gastroenteritis

Heart failure

Hepatic abscess

Hepatic amebiasis

Hepatitis

Herpes zoster

Insect toxins

Intestinal obstruction

Irritable bowel syndrome

Listeriosis

Mesenteric artery ischemia

Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmias, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea.

Myocardial infarction (MI)

Ovarian cyst

Pancreatitis

Chronic pancreatitis produces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, poor digestion, and diabetes mellitus are common.

Pelvic inflammatory disease

Perforated ulcer

Peritonitis

Pleurisy

Pneumonia

Pneumothorax

Prostatitis

Pyelonephritis (acute)

Renal calculi

Sickle cell crisis

Smallpox (variola major)

Splenic infarction

Systemic lupus erythematosus

Ulcerative colitis

Uremia

Other causes

Abdominal trauma

Diet

Drugs

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

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

Abdominal aortic aneurysm (dissecting)

Ankylosing spondylitis

Appendicitis

Cholecystitis

Chordoma

Endometriosis

Intervertebral disk rupture

Lumbosacral sprain

Metastatic tumors

Myeloma

Pancreatitis (acute)

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. Jaundice may be a late sign. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

Perforated ulcer

Prostate cancer

Pyelonephritis (acute)

Reiter’s syndrome

Renal calculi

Rift Valley fever

Sacroiliac strain

Smallpox (variola major)

Spinal neoplasm (benign

Spinal stenosis

Spondylolisthesis

Transverse process fracture

Vertebral compression fracture

Vertebral osteomyelitis

Vertebral osteoporosis

Other causes

Neurologic tests

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

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

See Chest pain: Causes and associated findings, pages 78 to 81.

Angina pectoris.

With Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop. Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide, and it may occur in cutaneous, inhalation, and GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening. Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).

Asthma.

Blastomycosis.

Coccidioidomycosis.

Costochondritis.

Legionnaires’ disease.

Lung cancer.

Mediastinitis.

Mitral valve prolapse.

Myocardial infarction (MI).

Peptic ulcer.

Psittacosis.

Other causes

Drugs.

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

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

See Eye pain: causes and associated findings, page 142.

Acute angle-closure glaucoma

Astigmatism

Blepharitis

Burns

Chalazion

Conjunctivitis

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions

Corneal erosion (recurrent)

Corneal ulcers

Dacryoadenitis

Dacryocystitis

Episcleritis

Erythema multiforme major

Foreign bodies in the cornea and conjunctiva

Glaucoma

Herpes zoster ophthalmicus

Hordeolum (stye)

Hyphema

Interstitial keratitis

Iritis (acute)

Keratoconjunctivitis sicca

Lacrimal gland tumor

Migraine headache

Ocular laceration and intraocular foreign bodies

Optic cellulitis

Optic neuritis

Orbital floor fracture

Orbital pseudotumor

Pemphigus

Scleritis

Sclerokeratitis

Subdural hematoma

Trachoma

Uveitis

Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Medical treatments

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

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

See Flank pain: Causes and associated findings, pages 152 and 153.

Bladder cancer

Dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of this cancer is gross, painless, intermittent hematuria, often with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting often accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cortical necrosis (acute)

Unilateral flank pain is usually severe. Accompanying findings include gross hematuria, anuria, leukocytosis, and fever.

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI. The patient may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in patients with glomerulonephritis is bilateral, constant, and of moderate intensity. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease — a renal disorder. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

Intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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

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

Angina pectoris

Arthritis

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Ludwig’s angina

An acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sialolithiasis

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

Temporal arteritis

Temporomandibular joint syndrome

Tetanus

A rare, acute life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include headache, irritability, restlessness, low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trauma

Trigeminal neuralgia

Other causes

Drugs

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

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

Ankylosing spondylitis

Intermittent, moderate to severe neck pain and stiffness with severely restricted ROM is characteristic of ankylosing spondylitis. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

Cervical extension injury

Anterior or posterior neck pain may develop within hours or days after a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, occipital headache, muscle spasms, blurred vision, and unilateral miosis on the affected side.

Cervical fibrositis

Cervical fibrositis may produce anterior neck pain that radiates to one or both shoulders. Pain is intermittent and variable, commonly changing with weather patterns. Other findings are nonspecific but usually include point tenderness over involved muscles.

Cervical spine fracture

A fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

Cervical spine infection (acute)

Cervical spine infection can cause neck pain that restricts motion. Other findings include fever, possible deformity, muscle spasms, local tenderness, dysphagia, paresthesia, and muscle weakness.

Cervical spine tumor

Metastatic tumors typically produce persistent neck pain that increases with movement and isn’t relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to atrophy and paralysis, and bladder and bowel incontinence.

Cervical spondylosis

Cervical spondylosis is a degenerative process that produces posterior neck pain that restricts movement and is aggravated by it. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

Cervical stenosis

Cervical stenosis is a progressive disorder, commonly asymptomatic, that may cause nonspecific neck and arm pain, paresthesia, muscle weakness or paralysis, and decreased ROM.

Esophageal trauma

An esophageal mucosal tear or a pulsion diverticulum may produce mild neck pain, chest pain, edema, hemoptysis, and dysphagia.

Herniated cervical disk

Hodgkin’s lymphoma

Hodgkin’s lymphoma may eventually result in generalized pain that may affect the neck. Lymphadenopathy, the classic sign, may accompany paresthesia, muscle weakness, fever, fatigue, weight loss, malaise, and hepatomegaly.

Laryngeal cancer

Neck pain that radiates to the ear develops late in laryngeal cancer. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

Lymphadenitis

With lymphadenitis, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. Fever, chills, and malaise may also occur.

Meningitis

Neck pain may accompany characteristic nuchal rigidity of meningitis. Related findings include fever, headache, photophobia, positive Brudzinski’s and Kernig’s signs, and a decreased level of consciousness (LOC).

Neck sprain

Osteoporosis

Paget’s disease

Paget’s disease is a slowly developing disease that’s commonly asymptomatic in its early stages. As it progresses, cervical vertebrae deformity may produce severe, persistent neck pain, along with paresthesia and arm weakness or paralysis.

Rheumatoid arthritis (RA)

Although RA typically affects peripheral joints, it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root accompanied by increased warmth, swelling, and tenderness in involved joints. Stiffness may restrict the patient’s ROM. He may also experience paresthesia and muscle weakness, low-grade fever, anorexia, malaise, fatigue and, possibly, neck deformity. Some pain and stiffness remain after the acute phase.

Spinous process fracture

Fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted ROM, muscle spasms, and deformity.

Subarachnoid hemorrhage

In subarachnoid hemorrhage, Kernig’s and Brudzinski’s signs are present. The patient may also develop a headache, possibly describing it as “the worst headache of my life.”

ALERT: Subarachnoid hemorrhage is a life-threatening condition. In addition to Kernig’s and Brudzinski’s signs and a headache, it may also cause moderate to severe neck pain and rigidity and a decreased LOC.

Thyroid trauma

Besides mild to moderate neck pain, thyroid trauma may cause local swelling and ecchymosis. If a hematoma forms, it can cause dyspnea.

Torticollis

With torticollis, severe neck pain accompanies recurrent unilateral stiffness and muscle spasms that produce a characteristic head tilt.

Tracheal trauma

Fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty. Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

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

Myoclonus: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Alzheimer’s disease

Generalized myoclonus may occur in advanced stages of this slowly progressive dementia. Other late findings in Alzheimer’s disease include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

Creutzfeldt-Jakob disease

Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease — a rapidly progressive dementia. Initially random, they gradually become more rhythmic and symmetrical, typically occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances or, possibly, blindness.

Encephalitis (viral)

With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary but may include rapidly decreasing LOC, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

Encephalopathy

Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

Epilepsy

With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It’s usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

Other causes

Drug withdrawal

Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal, or delirium tremens.

Poisoning

Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

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

Seizures, complex partial: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain abscess

If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and a decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma

Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Temporal lobe tumor

Complex partial seizures may be the first sign of a tumor in the temporal lobe. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause a decreased LOC, vomiting and, possibly, papilledema.

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

Seizures, generalized tonic-clonic: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Alcohol withdrawal syndrome

Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit vision deficits, behavioral changes, and headache.

Hepatic encephalopathy

Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypertensive encephalopathy

Hypertensive encephalopathy, a life-threatening disorder, may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability, Chvostek’s sign, dysphagia, tetany, and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Renal failure (chronic)

End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Stroke

Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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

Seizures, simple partial: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain abscess

Seizures can occur in the acute stage of abscess formation or after resolution of the abscess. Decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache, nausea, and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor

Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma

Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and a decreased LOC that may progress to coma.

Multiple sclerosis

Focal or generalized seizures may occur with multiple sclerosis, usually during the late stages. Other findings include visual deficits, paresthesia, constipation, muscle weakness, spasticity, paralysis, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, emotional lability, impotence, and urinary frequency, urgency, and incontinence.

Neurofibromatosis

With neurofibromatosis, multiple brain lesions cause focal seizures and, at times, generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, progressive monocular blindness, nystagmus, and endocrine abnormalities.

Stroke

A major cause of seizures in patients older than age 50, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause vision deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or retention, and vomiting. It may result in generalized seizures.

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

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

Abdominal aortic aneurysm (dissecting)

Dissecting abdominal aortic aneurysm, a life-threatening disorder, may initially produce dull lower abdominal, lower back, or severe chest pain. Typically, it produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

Abdominal trauma

With abdominal trauma, generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis

With adrenal crisis, severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI

GI anthrax is an acute infectious disease that’s caused by eating meat contaminated with the gram-positive, spore-forming bacterium Bacillus anthracis. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis

With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney’s point in the right lower quadrant and is accompanied by abdominal rigidity, increased tenderness (especially over McBurney’s point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis

In cholecystitis, severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy’s sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis

A patient with cholelithiasis may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis

With cirrhosis, dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right-upper-quadrant pain worsens when the patient sits up or leans forward.
Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn’s disease

An acute attack of Crohn’s disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn’s disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding and, possibly, a palpable mass in a lower quadrant. Abdominal pain is usually relieved by defecation. Milder chronic signs and symptoms include right-lower-quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Cystitis

With cystitis, abdominal pain and tenderness are usually suprapubic. Associated signs and symptoms include malaise, flank pain, low back pain, nausea, vomiting, urinary frequency and urgency, nocturia, dysuria, fever, and chills.

Diverticulitis

Mild cases of diverticulitis usually produce intermittent, diffuse left-lower-quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, low-grade fever and, in many cases, a palpable abdominal mass that’s usually tender, firm, and fixed. Rupture causes severe left-lower-quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer

With a duodenal ulcer, localized abdominal pain — described as steady, gnawing, burning, aching, or hungerlike — may occur high in the midepigastrium, slightly off-center, usually on the right. The pain usually doesn’t radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it also may produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy

Lower abdominal pain may be sharp, dull, or cramping, and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- to 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis

With endometriosis, constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7

Escherichia coli O157:H7 is an aerobic, gram-negative bacillus that causes food-borne illness. Most strains of E. coli are harmless and are part of the normal intestinal flora of healthy humans and animals. E. coli O157:H7, one of hundreds of strains of the bacterium, can produce a powerful toxin and cause severe illness. Eating undercooked beef or other foods contaminated with the bacteria causes the disease. Signs and symptoms include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and elderly adults, hemolytic uremic syndrome may develop and may ultimately lead to acute renal failure.

Gastric ulcer

In a patient with a gastric ulcer, diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 to 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis

With acute gastritis, the patient experiences rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. However, significant bleeding is unusual, unless the patient has hemorrhagic gastritis.

Gastroenteritis

With gastroenteritis, cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It’s accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure

Right-upper-quadrant pain commonly accompanies these hallmarks of heart failure: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatitis

Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

Herpes zoster

Herpes zoster of the thoracic, lumbar, or sacral nerves can cause localized abdominal and chest pain in the areas served by these nerves. Pain, tenderness, and fever can precede or accompany erythematous papules, which rapidly evolve into grouped vesicles.

Intestinal obstruction

Short episodes of intense, colicky, cramping pain alternate with pain-free intervals in intestinal obstruction. Accompanying signs and symptoms of this life-threatening disorder may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as hypotension and tachycardia.

Irritable bowel syndrome

With irritable bowel syndrome, lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis

Listeriosis is a serious infection that’s caused by eating food contaminated with the bacterium Listeria monocytogenes. This food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems. Signs and symptoms include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in level of consciousness (LOC).

Mesenteric artery ischemia

Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 to 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Ovarian cyst

Torsion or hemorrhage related to an ovarian cyst causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn’t. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis

Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitis produces severe left-upper-quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and diabetes mellitus are common.

Pelvic inflammatory disease

Pelvic inflammatory disease causes pain in the right or left lower quadrant that ranges from vague discomfort that’s worsened by movement, to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

Perforated ulcer

With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis

With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Pleurisy

Pleurisy may produce upper abdominal or costal margin pain referred from the chest. Characteristic sharp, stabbing chest pain increases with inspiration and movement. Many patients have a pleural friction rub and rapid, shallow breathing; some have a low-grade fever.

Pneumonia

Lower-lobe pneumonia can cause pleuritic chest pain and referred, severe upper abdominal pain, tenderness, and rigidity that diminish with inspiration. It can also cause fever, shaking chills, achiness, headache, blood-tinged or rusty sputum, dyspnea, and a dry, hacking cough. Accompanying signs include crackles, egophony, decreased breath sounds, and dullness on percussion.

Pneumothorax

Pneumothorax is a potentially life-threatening disorder that can cause pain across the upper abdomen and costal margin that’s referred from the chest. Characteristic chest pain arises suddenly and worsens with deep inspiration or movement. Accompanying signs and symptoms include anxiety, dyspnea, cyanosis, decreased or absent breath sounds over the affected area, tachypnea, and tachycardia. Watch for asymmetrical chest movements on inspiration.

Prostatitis

With prostatitis, vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute)

Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize acute pyelonephritis. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi

Depending on the location of renal calculi, severe abdominal or back pain may occur. However, the classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

Sickle cell crisis

Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain in sickle cell crisis. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice. Sickle cell crisis is the hallmark of sickle cell disease and tends to appear periodically after age 5.

Smallpox (variola major)

Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction

Sudden, severe pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration in splenic infarction. Pain commonly radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Ulcerative colitis

Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom — recurrent and possibly severe diarrhea with blood, pus, and mucus — may relieve the pain. The abdomen may feel soft, squashy, and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Uremia

Characterized by generalized or periumbilical pain that shifts and varies in intensity, uremia causes diverse GI signs and symptoms, such as nausea, anorexia, vomiting, and diarrhea. Abdominal tenderness that changes in location and intensity may occur, along with vision disturbances, bleeding, headache, decreased LOC, vertigo, and oliguria or anuria. Chest pain may occur secondary to pericardial effusion. Localized or diffuse pruritus is common.

Other causes

Drugs

Salicylates and nonsteroidal anti-inflammatories commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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

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

Angina

Angina may cause inner arm pain as well as chest and jaw pain. Typically, pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators, such as nitroglycerin.

Cellulitis

Typically, cellulitis affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or an insect bite.

Cervical nerve root compression

Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

Compartment syndrome

Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome. It may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and absent pulse.

Fractures

In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, felt and heard from bone ends rubbing together (don’t attempt to elicit this sign); deformity, if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

Muscle contusion or strain

Muscle contusion may cause generalized pain in the area of injury. It may also cause local swelling and ecchymosis. Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

Myocardial infarction

A patient with myocardial infarction, a life-threatening disorder, may complain of left arm pain as well as the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

Neoplasms of the arm

A neoplasm of the arm produces continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

Osteomyelitis

Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

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

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

Abdominal aortic aneurysm (dissecting)

Life-threatening dissection of abdominal aortic aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, though, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

Ankylosing spondylitis

Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.

Appendicitis

Appendicitis is a life-threatening disorder that causes a vague and dull discomfort in the epigastric or umbilical region, which migrates to McBurney’s point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney’s point), and rebound tenderness. Some patients also have painful, urgent urination.

Cholecystitis

Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours, and patients usually have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right-upper-quadrant tenderness, abdominal rigidity, pallor, and sweating.

Endometriosis

Endometriosis causes deep sacral pain and severe, cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It’s accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.

Intervertebral disk rupture

An intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It’s accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient’s spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

Lumbosacral sprain

A lumbosacral sprain causes aching, localized pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine intensifies pain, whereas rest helps relieve it. The pain worsens with movement and is relieved by rest.

Myeloma

Myeloma, a primary malignant tumor, causes back pain that usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

Pancreatitis (acute)

Acute pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about.

Early associated signs and symptoms of acute pancreatitis include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. A late sign may be jaundice. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

Perforated ulcer

In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, the absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

Prostate cancer

Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also produce hematuria, difficulty initiating a urine stream, dribbling, urine retention, unexplained cystitis as well as decrease in the urine stream. Signs and symptoms of prostate cancer may appear only in the advanced stages.

Pyelonephritis (acute)

Acute pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

Reiter’s syndrome

In some patients, sacroiliac pain is the first sign of Reiter’s syndrome. Pain is accompanied by the classic triad of conjunctivitis, urethritis, and arthritis. In 30% of patients, skin lesions develop 4 to 6 weeks after onset of other symptoms and may last for several weeks.

Renal calculi

The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. Its intensity varies but may become excruciating if calculi travel down a ureter. If calculi are in the renal pelvis and calyces, dull and constant flank pain may occur. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover the calculi for analysis.

Sacroiliac strain

Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or gluteus medius or abductor lurch.

Smallpox

Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Spinal stenosis

Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

Transverse process and vertebral compression fractures

A transverse process fracture causes severe localized back pain with muscle spasm and hematoma. Initially, a vertebral compression fracture may be painless. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

Vertebral osteomyelitis

Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

Vertebral osteoporosis

Vertebral osteoporosis causes chronic, aching back pain that’s aggravated by activity and somewhat relieved by rest. Tenderness may also occur. Vertebral collapse, causing a backache with pain that radiates around the trunk, is the most common presenting feature of osteoporosis.

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

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

Areolar gland abscess

An areolar gland abscess is characterized by a tender, palpable abscess on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever, local swelling, and drainage may also be present, and the patient may complain of malaise.

Breast abscess (acute)

In the abscessed breast, local pain, tenderness, erythema, peau d’orange, and warmth are associated with a nodule. Malaise, fever, and chills may also occur. Axillary nodes may be enlarged.

Fat necrosis

Local pain and tenderness may develop with fat necrosis — a benign disorder. A history of trauma usually is present. Associated findings include ecchymosis; erythema of the overriding skin; a firm, irregular, fixed mass; and skin retraction signs, such as skin dimpling and nipple retraction. Fat necrosis may be hard to differentiate from cancer.

Fibrocystic breast disease

Fibrocystic breast disease, a common cause of breast pain, is associated with the development of cysts that may cause pain before menstruation and produce no symptoms afterward. Later in the course of the disorder, pain and tenderness may persist throughout the cycle. The cysts feel firm, mobile, and well defined. Many are bilateral and found in the upper outer quadrant of the breast, but others are unilateral and generalized. A clear, serous nipple discharge may be present in one or both breasts. Signs and symptoms of premenstrual syndrome — including headache, irritability, bloating, nausea, vomiting, and abdominal cramping — may also be present.

Intraductal papilloma

Unilateral breast pain or tenderness may accompany intraductal papilloma, although the primary sign is a serous or bloody nipple discharge, usually from only one duct. Intraductal papilloma is the primary cause of nipple discharge in nonpregnant, nonlactating women. Associated signs include a small (usually 1.5-mm to 3-mm), soft, poorly delineated mass in the ducts beneath the areola.

Mammary duct ectasia

With mammary duct ectasia, burning pain and itching around the areola may occur, although ectasia commonly produces no symptoms at first. The history may include one or more episodes of inflammation with pain, tenderness, erythema, and acute fever, or with pain and tenderness alone, which develop and then subside spontaneously in 7 to 10 days. Other findings include a rubbery, subareolar breast nodule; swelling and erythema around the nipple; nipple retraction; a bluish green discoloration or peau d’orange of the skin overlying the nodule; a thick, sticky, multicolored nipple discharge from multiple ducts; and axillary lymphadenopathy. A breast ulcer may occur in late stages.

Mastitis

With mastitis, unilateral pain may be severe, particularly when the inflammation occurs near the skin surface. Breast skin is typically red and warm at the inflammation site; peau d’orange may be present. Palpation reveals a firm area of induration. Skin retraction signs — such as breast dimpling and nipple deviation, inversion, or flattening — may be present. Systemic signs and symptoms — such as high fever, chills, malaise, and fatigue — may also occur.

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

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

Angina pectoris

With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region. It may radiate to the neck, jaw, and arms — classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound [S ₄]) or murmur during an anginal episode.

CULTURAL CUE:Not all patients experience angina in the same way. For example, Black and Hispanic patients may not feel chest discomfort. Primary symptoms among these populations may include dyspnea and fatigue.

With Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation)

Inhalation anthrax is caused by inhalation of aerosolized spores of the gram-positive bacterium Bacillus anthracis. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety

Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting)

The chest pain associated with dissecting aortic aneurysm (a life-threatening disorder) usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness; a palpable abdominal mass; tachycardia; murmurs; syncope; blindness; loss of consciousness; weakness or transient paralysis of the arms or legs; a systolic bruit; systemic hypotension; asymmetrical brachial pulses; lower blood pressure in the legs than in the arms; and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma

In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Bronchitis

In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing.

Cardiomyopathy

With hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, a cough, dizziness, syncope, gallops, murmurs, and bradycardia associated with tachycardia. The patient may have a medium-pitched systolic ejection murmur along the left sternal border and apex of the heart. Palpation of peripheral pulses reveals a characteristic double impulse (pulsus biferiens and, with atrial fibrillation, an irregular pulse).

Cholecystitis

Cholecystitis typically produces abrupt epigastric or right-upper-quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or the right shoulder. Common associated findings include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign — inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath — may also occur.

Costochondritis

With costochondritis, pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint. It may be described as a sharp pain in the chest wall that worsens with movement.

Distention of colon’s splenic flexure

Central chest pain may radiate to the left arm in patients with distention of the colon’s splenic flexure. The pain may be relieved by defecation or the passage of flatus. Other signs and symptoms include fever, tachycardia, abdominal pain, and palpable abdominal mass.

Esophageal spasm

With esophageal spasm, substernal chest pain may last up to an hour and can radiate to the neck, jaw, arms, or back. It tends to mimic angina — a squeezing or dull sensation. Associated signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.

Herpes zoster (shingles)

The pain of preeruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas — usually the thorax, arms, and legs — and the chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.

Hiatal hernia

Typically, hiatal hernia produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially hot drinks and spicy foods.

Interstitial lung disease

As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Legionnaires’ disease

Legionnaires’ disease produces pleuritic chest pain in addition to malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient develops a sudden high fever, chills, and a nonproductive cough that progresses to mucoid and then to mucopurulent sputum, possibly with hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.

Mediastinitis

Mediastinitis produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Its accompanying signs and symptoms include chills, fever, and dysphagia.

Mitral valve prolapse

Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours, and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral valve prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Muscle strain

Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.

Myocardial infarction

The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain, unrelieved by rest or nitroglycerin, it may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

Pancreatitis

In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer

With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis

Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague

The pneumonic form of plague, caused by the bacterium Yersinia pestis, is characterized by a sudden onset of chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress and cardiopulmonary insufficiency.

Pleurisy

The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid, shallow breathing, cyanosis, fever, and fatigue may also occur.

Pneumonia

Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax

Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that’s severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism

Pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck veins.

Pulmonary hypertension (primary)

Angina-like pain develops late in patients with primary pulmonary hypertension, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.

Q fever

Signs and symptoms of Q fever, a rickettsial disease caused by Coxiella burnetti, include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rib fracture

The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.

Sickle cell crisis

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice.

Tuberculosis

In a patient with tuberculosis, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia

Following inhalation of the gram-negative, non-spore-forming bacterium Francisella tularensis, patients with tularemia show signs and symptoms that include the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, and empyema. Pneumonia can develop, causing chest pain and hemoptysis.

Other causes

Chinese restaurant syndrome

This benign condition — a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods — mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.

Drugs

Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease — especially if he has received high doses for a prolonged period.

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

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

Blepharitis

With blepharitis, burning pain in both eyelids is accompanied by itching, sticky discharge, and conjunctival injection. Related findings include foreign-body sensation, lid ulcerations, and loss of eyelashes.

Burns

With chemical burns, sudden and severe eye pain may occur with erythema and blistering of the face and lids, photophobia, miosis, conjunctival injection, blurring, and inability to keep the eyelids open. With ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion

A chalazion causes localized pain, tenderness, redness, and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis

Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge.

Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions

With corneal abrasions, eye pain is characterized by a foreign-body sensation. Excessive tearing, photophobia, and conjunctival injection are also common. The patient commonly reports feeling that “something is in” the eye.

Corneal erosion (recurrent)

With recurrent corneal erosion, severe pain occurs on waking and continues throughout the day. Conjunctival injection and photophobia also occur.

Corneal ulcers

Both bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea, unilateral pupil constriction, and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryocystitis

Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling in the lacrimal punctum area.

Foreign body in the cornea or conjunctiva

Sudden severe pain is common but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Glaucoma

Open-angle glaucoma may cause mild aching in the eyes as well as loss of peripheral vision, halo vision, and reduced visual acuity that isn’t corrected by glasses. Angle-closure glaucoma is characterized by blurred vision and sudden, excruciating pain in and around the eye. The pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Herpes zoster ophthalmicus

With herpes zoster ophthalmicus, eye pain occurs with severe unilateral facial pain, usually days before vesicles erupt. Other signs include red, swollen eyelids; excessive tearing; a serous eye discharge; conjunctival injection; and a white, cloudy cornea.

Hordeolum

A hordeolum (stye) usually produces localized eye pain, burning, and discomfort that increases as the stye grows. Eyelid erythema and edema are also common.

Hyphema

Occurring after eye injury or surgery, hyphema accompanies sudden pain in and around the eye. Orbital and lid edema, conjunctival injection, and visual impairment may occur. The patient may report nausea.

Keratoconjunctivitis sicca

Keratoconjunctivitis sicca, also known as dry eye syndrome, causes chronic burning pain in both eyes, itching, a foreign-body sensation, photophobia, dramatic conjunctival injection, and difficulty moving the eyelids. Excessive mucoid discharge and inadequate tearing are typical.

Lacrimal gland tumor

Lacrimal gland tumor is a neoplastic lesion that usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos. The patient may also have ptosis and eye deviation.

Ocular laceration and intraocular foreign bodies

Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic cellulitis

Optic cellulitis causes dull, aching pain in the affected eye, some degree of exophthalmos, eyelid edema and erythema, purulent discharge, impaired extraocular movement and, occasionally, decreased visual acuity and fever.

Optic neuritis

With optic neuritis, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Orbital floor fracture

Sometimes called a blowout fracture, orbital floor fracture causes eye pain, dramatic eyelid edema and, possibly, enophthalmos and diplopia. The patient may report recent eye trauma and reduced vision. Ecchymosis and ptosis may be visible.

Orbital pseudotumor

An orbital pseudotumor causes deep, boring eye pain and diplopia in about 50% of patients. However, prominent exophthalmos and lateral ocular deviation are more characteristic. Eyelid edema and restricted extraocular movement may also occur.

Uveitis

Anterior uveitis causes sudden onset of severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil. Posterior uveitis causes insidious onset of similar features, plus gradual blurring of vision and distorted pupil shape. Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity (the patient usually can perceive only light).

Other causes

Treatments

Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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

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

Angina pectoris

Occasionally, jaw pain may indicate angina pectoris. The pain may be described as burning, squeezing, or tightness and may also radiate to the left arm, neck, and shoulder blade.

Dental caries

Caries in the mandibular molars can produce ear, preauricular, and temporal pain; caries in the maxillary teeth can produce maxillary, orbital, retro-orbital and parietal pain.

Herpes zoster oticus

With herpes zoster oticus, severe pain localizes around the ear, followed by the appearance of vesicles in the ear and occasionally on the oral mucosa, tonsils, and posterior tongue. Eye pain may occur with corneal and scleral damage and impaired vision.

Herpetic neuralgia

With herpetic neuralgia, severe pain localizes around the ear, followed by the appearance of vesicles in the ear and occasionally on the oral mucosa, tonsils, and posterior tongue. Eye pain may occur with corneal and scleral damage and impaired vision.

Multiple sclerosis

Facial pain may resemble that of trigeminal neuralgia and is accompanied by jaw and facial weakness. Other common findings of multiple sclerosis include visual blurring, diplopia, and nystagmus; sensory impairment such as paresthesia; generalized muscle weakness and gait abnormalities; urinary disturbances; and emotional lability.

Ocular glaucoma

The pain of ocular glaucoma is usually located in the periorbital region. Symptoms appear late in the disease and may also include loss of peripheral vision and reduced visual acuity (especially at night) that isn’t correctable with glasses. The patient may also see halos around lights.

Postherpetic neuralgia

With postherpetic neuralgia, burning, itching, prickly pain persists along any of the three trigeminal nerve divisions and worsens with contact or movement. Mild hypoesthesia or paresthesia and vesicles affect the area before the onset of pain.

Sinusitis (acute)

Acute maxillary sinusitis produces unilateral or bilateral pressure, fullness, or burning pain over the cheekbone and upper teeth and around the eyes. Bending over increases the pain. Other findings include nasal congestion and purulent discharge; red, swollen nasal mucosa; tenderness and swelling over the cheekbone; fever; and malaise.

Acute frontal sinusitis commonly produces severe pain above or around the eyes, which worsens when the patient is in a supine position. It also causes nasal obstruction, inflamed nasal mucosa, fever, and tenderness and swelling above the eyes.

Acute ethmoid sinusitis produces pain at or around the inner corner of the eye. Temporal headaches can also occur. Other findings include nasal congestion, purulent rhinorrhea, fever, and tenderness at the medial edge of the eye.

With acute sphenoid sinusitis, a deep-seated pain persists behind the eyes or nose or on the top of the head. Pain increases on bending forward. Fever is common.

Sinusitis (chronic)

Chronic maxillary sinusitis produces a feeling of pressure below the eyes or a chronic toothache. Discomfort typically worsens through the day. Nasal congestion and tenderness over the cheekbone are usually mild.

Chronic ethmoid sinusitis is characterized by nasal congestion, an intermittent and purulent nasal discharge, and low-grade discomfort at the medial corners of the eyes. Also common are recurrent sore throat, halitosis, ear fullness, and involvement of other sinuses.

Chronic frontal sinusitis produces a persistent low-grade pain above the eyes. With chronic sphenoid sinusitis, a low-grade, diffuse headache or retro-orbital discomfort is common.

Sphenopalatine neuralgia

Also called cluster headaches, sphenopalatine neuralgia produces unilateral, deep, boring pain below the ear and may radiate to the eye, ear, cheek, nose, palate, maxillary teeth, temple, back of the head, neck, or shoulder. Attacks bring increased tearing and salivation, rhinorrhea, a sensation of fullness in the ear, tinnitus, vertigo, taste disturbances, pruritus, and shoulder stiffness or weakness.

Temporal arteritis

With temporal arteritis, unilateral pain occurs behind the eye or in the scalp, jaw, tongue, or neck. A typical episode consists of a severe throbbing or boring temporal headache with redness, swelling, and nodulation of the temporal artery.

Temporomandibular joint syndrome

Temporomandibular joint (TMJ) syndrome is characterized by intermittent pain, usually unilateral, that’s described as a severe, dull ache or intense spasm that radiates to the cheek, temple, lower jaw, ear, or mastoid area. Associated findings include trismus, malocclusion, and clicking, crepitus, and tenderness in the temporomandibular joint.

Trigeminal neuralgia

With trigeminal neuralgia, paroxysms of intense pain, lasting up to 15 minutes, shoot along any or all of the three branches of the trigeminal nerve. The pain can be triggered by touching the nose, cheek, or mouth; by being exposed to hot or cold weather; by consuming hot or cold foods or beverages; or even by smiling or talking. Between attacks, the pain may diminish to a dull ache or may disappear. This disorder is most common in middle and later life, affecting more women than men.

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

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

Bladder cancer

With bladder cancer, dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of this cancer is gross, painless, intermittent hematuria, usually with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting usually accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI. The patient with bacterial cystitis may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in acute glomerulonephritis is bilateral, constant, and moderately intense. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop in patients with acute pancreatitis as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms of acute papillary necrosis include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

With a perirenal abscess, intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

With acute pyelonephritis, intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings in acute pyelonephritis include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in patients with renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

With renal infarction, unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom of renal trauma. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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

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

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion, and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints, including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer

Many types of head and neck cancer, especially those of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, this life-threatening disorder produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

Ludwig’s angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Initially, this life-threatening disorder causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings in MI include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

With suppurative parotitis, bacterial infection of the parotid gland by Staphylococcus aureus produces abrupt onset of jaw pain, high fever, and chills. Other findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Temporal arteritis produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

Temporomandibular joint disorders

TMJ disorders produce jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Trauma

Injury to the face, head, or neck — particularly fracture of the maxilla or mandi-
ble — may produce jaw pain and swelling and decreased jaw mobility. Associated findings include hypotension and tachycardia (indicating shock), lacerations, ecchymoses, and hematomas. Rhinorrhea or otorrhea indicates the leakage of cerebrospinal fluid; blurred vision indicates orbital involvement.

Trigeminal neuralgia

Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

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

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

Cervical extension injury

Anterior or posterior neck pain may develop within hours or days following a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, occipital headache, muscle spasms, visual blurring, and unilateral miosis on the affected side.

Cervical spine fracture

Fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

Cervical spine tumor

Metastatic tumors typically produce persistent neck pain that increases with movement and isn’t relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to atrophy and paralysis, and bladder and bowel incontinence.

Cervical spondylosis

Cervical spondylosis, a degenerative process, produces posterior neck pain that’s aggravated by and restricts movement. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

Cervical stenosis

Cervical stenosis is a progressive disorder that commonly produces no symptoms. It may cause nonspecific neck and arm pain, paresthesia, muscle weakness or paralysis, and decreased ROM. The patient may report hand clumsiness and problems with gait and balance.

Herniated cervical disk

A herniated cervical disk characteristically causes variable neck pain that is aggravated by and restricts movement. It also causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.

Hodgkin’s lymphoma

Hodgkin’s lymphoma may eventually result in generalized pain that may affect the neck. Lymphadenopathy, the classic sign, may accompany paresthesia, muscle weakness, fever, fatigue, weight loss, malaise, and hepatomegaly.

Laryngeal cancer

Neck pain that radiates to the ear develops late in laryngeal cancer. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

Lymphadenitis

With lymphadenitis, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. Fever, chills, and malaise may also occur.

Meningitis

With meningitis, neck pain may accompany characteristic nuchal rigidity. Related findings include fever, headache, photophobia, positive Brudzinski’s and Kernig’s signs, and decreased level of consciousness (LOC).

Neck sprain

Minor sprains typically produce pain, slight swelling, stiffness, and restricted ROM. Ligament rupture causes pain, marked swelling, ecchymosis, muscle spasms, and nuchal rigidity with head tilt.

Paget’s disease

Paget’s disease commonly produces no symptoms in its early stages. As it progresses, cervical vertebrae deformity may produce severe, persistent neck pain along with paresthesia and arm weakness or paralysis.

Rheumatoid arthritis

Rheumatoid arthritis usually affects peripheral joints, but it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root; increased warmth, swelling, and tenderness in involved joints; stiffness, restricting ROM; paresthesia and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the acute phase.

Spinous process fracture

Fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted ROM, muscle spasms, and deformity.

Subarachnoid hemorrhage

Subarachnoid hemorrhage is a life-threatening condition that may cause moderate to severe neck pain and rigidity, headache, and a decreased LOC. Kernig’s and Brudzinski’s signs are present. The patient may describe the headache as “the worst headache of my life.”

Torticollis

With torticollis, severe neck pain accompanies recurrent unilateral stiffness and muscle spasms. Stiffness of the neck muscles is followed by a momentary twitching or contraction that pulls the head to the affected side.

Tracheal trauma

Fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty. Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

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

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

Abscess

A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing, local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously high in the rectum or even in the lower abdomen and is accompanied by an indurated anal mass. The patient may also develop such associated signs and symptoms as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

A prostatic abscess occasionally produces rectal pain. Common associated findings include urine retention and frequency, dysuria, and fever. A rectal examination may reveal prostatic tenderness and gas.

Anal fissure

An anal fissure is a longitudinal crack in the anal lining that causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula

Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints of an anorectal fistula include pruritus and drainage of pus, blood, mucus and, occasionally, stool.

Cryptitis

Cryptitis results when particles of stool that are lodged in the anal folds decay and cause infection, which may produce dull anal pain or discomfort and anal pruritus. Intense pain may occur when the anal sphincter contracts.

Hemorrhoids

Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

Proctalgia fugax

With proctalgia fugax, muscle spasms of the rectum and pelvic floor produce sudden, severe episodes of rectal pain that last up to several minutes and then disappear. The patient may report being awakened by the pain, which is sometimes associated with stress or anxiety and relieved by food and drink.

Other causes

Anal intercourse

Shearing forces may cause inflammation or tearing of the mucous membranes and discomfort.

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

Seizures: Principal Causes of Seizures
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Febrileseizures
2. Hypoxic-ischemic encephalopathy
3. Brain disorders
   1. Cerebralmalformations
   2. Intracranial infection
   3. Intracranial hemorrhage
   4. Other
4. Hypertensive encephalopathy
5. Drugs and toxins
6. Metabolic disorders
   1. Hypoglycemia
   2. Hypocalcemia
   3. Hypomagnesemia
   4. Hyponatremia
   5. Hypernatremia
   6. Uremia
   7. Bilirubin encephalopathy (kernicterus)
   8. Pyridoxine dependency
   9. Inborn errors of metabolism
7. Selected epileptic syndromes
   1. Neonatalseizures
   2. Benign neonatal epilepsy
   3. Infantile spasms (West syndrome)
   4. Lennox-Gastaut syndrome
   5. Benign focal epilepsy with centrotemporalspikes
   6. Temporal lobe epilepsy
   7. Juvenile myoclonic epilepsy
   8. Posttraumatic epilepsy
   9. Childhood absence epilepsy
8. Unknown

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

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

1. Neonates
   1. Common
      1. Colic
      2. Necrotizing enterocolitis
   2. Uncommon
      1. Gastrointestinal obstruction or perforationof any viscus
2. Infants
   1. Common
      1. Colic
      2. Gastroenteritis
      3. Viral illness
      4. Incarcerated inguinal hernia
      5. Intussusception
      6. Trauma including child abuse
   2. Uncommon
      1. Appendicitis
      2. Cow milk protein sensitivity
      3. Lactose intolerance
      4. Gastrointestinal obstruction includingvolvulus with malrotation
      5. Sickle cell pain episodes
      6. Lead poisoning
      7. Neoplasm
3. Preschool children
   1. Common
      1. Constipation
      2. Gastroenteritis
      3. Viral illness
      4. Urinary tract infection
      5. Pneumonia
      6. Trauma
      7. Lactose intolerance
      8. Sickle cell pain episodes
   2. Uncommon
      1. Food poisoning
      2. Diabetic ketoacidosis
      3. Gastrointestinal obstruction
      4. Henoch-Schönlein purpura
      5. Neoplasm
      6. Drugs and toxins
      7. Appendicitis
      8. Intussusception
      9. Hepatitis
4. School-aged children and adolescents
   1. Common
      1. Gastroenteritis
      2. Viral illnesses
      3. Constipation
      4. Trauma
      5. Urinary tract infection
      6. Acute appendicitis
      7. Pneumonia
      8. Lactose intolerance
      9. Sickle cell pain episodes
      10. Functional abdominal pain
   2. Uncommon
      1. Peptic ulcer disease
      2. Biliary tract disease
         1. Acutecholecystitis
         2. Biliary colic
      3. Pancreatitis
      4. Obstructive uropathy
      5. Urolithiasis
      6. Intraabdominal abscess
      7. Primary bacterial peritonitis
      8. Inflammatory bowel disease
      9. Lactose intolerance
      10. Hepatitis
      11. Intestinal obstruction
      12. Diabetic ketoacidosis
      13. Neoplasm
      14. Drugs and toxins
5. Adolescent girls
   1. Common
      1. Primarydysmenorrhea
      2. Mittelschmerz
      3. Pelvic inflammatory disease
   2. Uncommon
      1. Ovarian disorders
      2. Endometriosis
      3. Genital tract malformations with obstruction
      4. Complications of pregnancy

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

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

1. Congenital
   1. Spineanomalies
2. Developmental
   1. Scoliosis
   2. Scheuermann disease
3. Trauma
   1. Musculoskeletal
   2. Herniated disc
   3. Spondylolysis
   4. Spondylolisthesis
   5. Slipped vertebral epiphysis
   6. Spinal epidural hematoma
4. Infection/inflammation
   1. Discitis
   2. Disc space calcification
   3. Osteomyelitis
   4. Sacroiliac joint infection
   5. Juvenile rheumatoid arthritis
   6. Ankylosing spondylitis
   7. Spinal epidural abscess
5. Sickle cell disease
6. Neoplasm
   1. Vertebral tumors
   2. Intraspinal tumors
7. Referred pain
8. Psychogenic

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

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

1. Musculoskeletaldisorders
   1. Muscle
      1. Trauma(strain, contusion, laceration)
      2. Stitch
      3. Precordial catch
      4. Sickle cell pain episodes
   2. Bone/cartilage
      1. Trauma(contusion, rib fracture)
      2. Costochondritis
      3. Sickle cell pain episodes
      4. Slipping-rib syndrome
      5. Tietze syndrome
      6. Osteomyelitis
      7. Neoplasm
2. Trachea and proximal bronchi disorders
   1. Infection/inflammation
      1. Bronchitis
      2. Tracheitis
      3. Pneumonia
      4. Cystic fibrosis
   2. Asthma
   3. Foreign body
3. Parietal pleura disorders
   1. Pneumonia
   2. Pleurodynia
   3. Empyema
   4. Pneumothorax
   5. Hemothorax
   6. Pneumomediastinum
   7. Postpericardiotomy syndrome
   8. Pulmonary embolism
   9. Neoplasm
4. Cardiac disorders
   1. Myocardialischemia including infarction
   2. Pericarditis
   3. Mitral valve prolapse
   4. Arrhythmias
5. Diaphragm disorders
   1. Subphrenicabscess
   2. Hepatic abscess
   3. Fitz-Hugh-Curtis syndrome
6. Gastrointestinal disorders
   1. Esophagus
      1. Gastroesophagealreflux
      2. Caustic ingestion
      3. Foreign body
      4. Hiatal hernia
      5. Spasm
      6. Tear
   2. Referred pain
      1. Gastritis
      2. Peptic ulcer disease
      3. Cholesystitis
      4. Pancreatitis
7. Neurologic disorders
   1. Intercostalnerve
      1. Trauma
      2. Herpes zoster neuritis
   2. Dorsal root
      1. Trauma
      2. Radiculitis
8. Psychologic disorders
   1. Anxietywith or without hyperventilation
   2. Depression
   3. School phobia
   4. Hypochondriasis
   5. Conversion reaction
9. Idiopathic chest pain

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

Myoclonus: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Alzheimer's disease.Generalized myoclonus may occur in advanced stages of Alzheimer's disease, a slowly progressive dementia. Other late findings include mild choreoathetoid movements, muscle rigidity, bowel and bladder incontinence, delusions, and hallucinations.

Creutzfeldt-Jakob disease.Diffuse myoclonic jerks appear early in Creutzfeldt-Jakob disease. Initially random, they gradually become more rhythmic and symmetrical, usually occurring in response to sensory stimuli. Associated effects include ataxia, aphasia, hearing loss, muscle rigidity and wasting, fasciculations, hemiplegia, and vision disturbances, or possibly, blindness.

Encephalitis (viral).With viral encephalitis, myoclonus is usually intermittent and either localized or generalized. Associated findings vary, but may include rapidlydecreasing LOC, fever, headache, irritability, nuchal rigidity, vomiting, seizures, aphasia, ataxia, hemiparesis, facial muscle weakness, nystagmus, ocular palsies, and dysphagia.

Encephalopathy.Hepatic encephalopathy occasionally produces myoclonic jerks in association with asterixis and focal or generalized seizures.

Hypoxic encephalopathy may produce generalized myoclonus or seizures almost immediately after restoration of cardiopulmonary function. The patient may also have a residual intention myoclonus.

Uremic encephalopathy commonly produces myoclonic jerks and seizures. Other signs and symptoms include apathy, fatigue, irritability, headache, confusion, gradually decreasing LOC, nausea, vomiting, oliguria, edema, and papilledema. The patient may also exhibit elevated blood pressure, dyspnea, arrhythmias, and abnormal respirations.

Epilepsy.With idiopathic epilepsy, localized myoclonus is usually confined to an arm or leg and occurs singly or in short bursts, usually upon awakening. It's usually more frequent and severe during the prodromal stage of a major generalized seizure, after which it diminishes in frequency and intensity.

Myoclonic jerks are usually the first signs of myoclonic epilepsy, the most common cause of progressive myoclonus. At first, myoclonus is infrequent and localized, but over a period of months, it becomes more frequent and involves the entire body, disrupting voluntary movement (intention myoclonus). As the disease progresses, myoclonus is accompanied by generalized seizures and dementia.

Other causes

Drug withdrawal.Myoclonus may be seen in patients with alcohol, opioid, or sedative withdrawal or delirium tremens.

Poisoning.Acute intoxication with methyl bromide, bismuth, or strychnine may produce an acute onset of myoclonus and confusion.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Breast pain [Mastalgia]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Areolar gland abscess.Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also occur.

Breast abscess (acute).In the affected breast, local pain, tenderness, erythema, peau d'orange, and warmth are associated with a nodule. Malaise, fever, and chills may also occur.

Breast cyst.A breast cyst that enlarges rapidly may cause acute, localized, and usually unilateral pain. A palpable breast nodule may be present.

Fat necrosis.Local pain and tenderness may develop in fat necrosis, a benign disorder. A history of trauma usually is present. Associated findings include ecchymosis; erythema of the overriding skin; a firm, irregular, fixed mass; and skin retraction signs, such as skin dimpling and nipple retraction. Fat necrosis may be hard to differentiate from cancer.

Fibrocystic breast disease.Fibrocystic breast disease is a common cause of breast pain that's associated with the development of cysts that may cause pain before menstruation and are asymptomatic afterward. Later in the course of the disorder, pain and tenderness may persist throughout the cycle. The cysts feel firm, mobile, and well defined. Many are bilateral and found in the upper outer quadrant of the breast, but others are unilateral and generalized. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.

Mammary duct ectasia.Burning pain and itching around the areola may occur, although ectasia is commonly asymptomatic at first. The history may include one or more episodes of inflammation with pain, tenderness, erythema, and acute fever, or with pain and tenderness alone, which develop and then subside spontaneously within 7 to 10 days. Other findings include a rubbery, subareolar breast nodule; swelling and erythema around the nipple; nipple retraction; a bluish green discoloration or peau d'orange of the skin overlying the nodule; a thick, sticky, multicolored nipple discharge from multiple ducts; and axillary lymphadenopathy. A breast ulcer may occur in late stages.

Mastitis.Unilateral pain may be severe, particularly when the inflammation occurs near the skin surface. Breast skin is typically red and warm at the inflammation site; peau d'orange may be present. Palpation reveals a firm area of induration. Skin retraction signs—such as breast dimpling and nipple deviation, inversion, or flattening—may be present. Systemic signs and symptoms—such as high fever, chills, malaise, and fatigue—may also occur.

Sebaceous cyst (infected).Breast pain may be reported with sebaceous cyst, a cutaneous cyst. Associated symptoms include a small, well-delineated nodule, localized erythema, and induration.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Eye pain [Ophthalmalgia]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute angle-closure glaucoma.Blurred vision and sudden, excruciating pain in and around the eye characterize acute angle-closure glaucoma; the pain may be so severe that it causes nausea, vomiting, and abdominal pain. Other findings are halo vision, rapidly decreasing visual acuity, and a fixed, nonreactive, moderately dilated pupil.

Blepharitis.Burning pain in both eyelids is accompanied by itching, sticky discharge, and conjunctival injection. Related findings include a foreign-body sensation, lid ulcerations, and loss of eyelashes.

Burns.With chemical burns, sudden and severe eye pain may occur with erythema and blistering of the face and lids, photophobia, miosis, conjunctival injection, blurring, and an inability to keep the eyelids open. With ultraviolet radiation burns, moderate to severe pain occurs about 12 hours after exposure along with photophobia and vision changes.

Chalazion.A chalazion causes localized tenderness and swelling on the upper or lower eyelid. Eversion of the lid reveals conjunctival injection and a small red lump.

Conjunctivitis.Some degree of eye pain and excessive tearing occurs with four types of conjunctivitis. Allergic conjunctivitis causes mild, burning, bilateral pain accompanied by itching, conjunctival injection, and a characteristic ropey discharge. Bacterial conjunctivitis causes pain only when it affects the cornea. Otherwise, it produces burning and a foreign-body sensation. A purulent discharge and conjunctival injection are also typical.

If the cornea is affected, fungal conjunctivitis may cause pain and photophobia. Even without corneal involvement, it produces itching, burning eyes; a thick, purulent discharge; and conjunctival injection.

Viral conjunctivitis produces itching, red eyes, a foreign-body sensation, visible conjunctival follicles, and eyelid edema.

Corneal abrasions.With this type of injury, eye pain is characterized by a foreign-body sensation. Excessive tearing, photophobia, and conjunctival injection are also common.

Corneal ulcers.Bacterial and fungal corneal ulcers cause severe eye pain. They may also cause a purulent eye discharge, sticky eyelids, photophobia, and impaired visual acuity. In addition, bacterial corneal ulcers produce a grayish white, irregularly shaped ulcer on the cornea; unilateral pupil constriction; and conjunctival injection. Fungal corneal ulcers produce conjunctival injection, eyelid edema and erythema, and a dense, cloudy, central ulcer surrounded by progressively clearer rings.

Dacryocystitis.Pain and tenderness near the tear sac characterize acute dacryocystitis. Additional signs include excessive tearing, a purulent discharge, eyelid erythema, and swelling in the lacrimal punctum area.

Episcleritis.Deep eye pain occurs as tissues over the sclera become inflamed. Related effects include photophobia, excessive tearing, conjunctival edema, and a red or purplish sclera.

Erythema multiforme major.Erythema multiforme major commonly produces severe eye pain, entropion, trichiasis, purulent conjunctivitis, photophobia, and decreased tear formation.

Foreign bodies in the cornea and conjunctiva.Sudden severe pain is common, but vision usually remains intact. Other findings include excessive tearing, photophobia, miosis, a foreign-body sensation, a dark speck on the cornea, and dramatic conjunctival injection.

Hordeolum (stye).Hordeolum usually produces localized eye pain that increases as the stye grows. Eyelid erythema and edema are also common.

Iritis (acute).Moderate to severe eye pain occurs with severe photophobia, dramatic conjunctival injection, and blurred vision. The constricted pupil may respond poorly to light.

Lacrimal gland tumor.A lacrimal gland tumor is a neoplastic lesion that usually produces unilateral eye pain, impaired visual acuity, and some degree of exophthalmos.

Migraine headache.Migraines can produce pain so severe that the eyes also ache. Additionally, nausea, vomiting, blurred vision, and light and noise sensitivity may occur.

Ocular laceration and intraocular foreign bodies.Penetrating eye injuries usually cause mild to severe unilateral eye pain and impaired visual acuity. Eyelid edema, conjunctival injection, and an abnormal pupillary response may also occur.

Optic neuritis.With optic neuritis, pain in and around the eye occurs with eye movement. Severe vision loss and tunnel vision develop but improve in 2 to 3 weeks. Pupils respond sluggishly to direct light but normally to consensual light.

Scleritis.Scleritis produces severe eye pain and tenderness, along with conjunctival injection, a bluish purple sclera and, possibly, photophobia and excessive tearing.

Sclerokeratitis.Inflammation of the sclera and cornea causes pain, burning, irritation, and photophobia.

Subdural hematoma.Following head trauma, a subdural hematoma commonly causes severe eye ache and headache. Related neurologic signs depend on the hematoma's location and size.

Trachoma.Along with pain in the affected eye, trachoma causes excessive tearing, photophobia, eye discharge, eyelid edema and redness, and visible conjunctival follicles.

Uveitis.Anterior uveitis causes the sudden onset of severe pain, dramatic conjunctival injection, photophobia, and a small, nonreactive pupil.

Posterior uveitis causes an insidious onset of similar features as well as gradual blurring of vision and distorted pupil shape.

Lens-induced uveitis causes moderate eye pain, conjunctival injection, pupil constriction, and severely impaired visual acuity. In fact, the patient usually can perceive only light.

Other causes

Treatments and surgery.Contact lenses may cause eye pain and a foreign-body sensation. Ocular surgery may also produce eye pain, ranging from a mild ache to a severe pounding or stabbing sensation.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, absence: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Idiopathic epilepsy.Some forms of absence seizure are accompanied by learning disabilities.

Other causes

Drugs.Drugs that lower the threshold for seizures, such as alcohol, cocaine, penicillin in high doses, isoniazid, and phenothiazines may trigger seizures in patients with preexisting epilepsy.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, complex partial: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.If the brain abscess is in the temporal lobe, complex partial seizures commonly occur after the abscess disappears. Related problems may include headache, nausea, vomiting, generalized seizures, and decreased level of consciousness (LOC). The patient may also develop central facial weakness, auditory receptive aphasia, hemiparesis, and ocular disturbances.

Head trauma.Severe trauma to the temporal lobe (especially from a penetrating injury) can produce complex partial seizures months or years later. The seizures may decrease in frequency and eventually stop. Head trauma also causes generalized seizures and behavior and personality changes.

Herpes simplex encephalitis.Herpes simplex virus commonly attacks the temporal lobe, resulting in complex partial seizures. Other features include fever, headache, coma, and generalized seizures.

Temporal lobe tumor.Complex partial seizures may be the first sign of a temporal lobe tumor. Other signs and symptoms include headache, pupillary changes, and mental dullness. Increased intracranial pressure may cause decreased LOC, vomiting and, possibly, papilledema.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, generalized tonic-clonic: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.Generalized seizures may occur in the acute stage of a brain abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor.Generalized seizures may occur with a brain tumor, depending on it's location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure.End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul's respirations.

Eclampsia.Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis.Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic).In most cases, the cause of recurrent seizures is unknown.

Head trauma.With severe head trauma, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle's sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy.Generalized seizures may occur latein hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski's sign.

Hypoglycemia.Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

Hyponatremia.Seizures may develop when the serum sodium level falls below 125 mEq/L, especially if the sodium loss is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism.Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs. Worsening tetany causes generalized seizures.

Hypoxic encephalopathy.Besidesgeneralized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis.Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke.Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning.Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal.In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests.Contrast agents used in radiologic tests may cause generalized seizures.

Drugs.Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, simple partial: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.Seizures can occur in the acute stage of a brain abscess formation or after resolution of the abscess. A decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure and include a constant, intractable headache; nausea; and vomiting. Later signs and symptoms include ocular disturbances, such as nystagmus, decreased visual acuity, and unequal pupils. Other findings vary according to the abscess site and may include aphasia, hemiparesis, and personality changes.

Brain tumor.Focal seizures are commonly the earliest indicators of a brain tumor. The patient may report a morning headache, dizziness, confusion, vision loss, and motor and sensory disturbances. He may also develop aphasia, generalized seizures, ataxia, decreased LOC, papilledema, vomiting, increased systolic blood pressure, and widening pulse pressure. Eventually, he may assume a decorticate posture.

Head trauma.Any head injury can cause seizures, but penetrating wounds are characteristically associated with focal seizures. The seizures usually begin 3 to 15 months after injury, decrease in frequency after several years, and eventually stop. The patient may develop generalized seizures and decreased LOC that may progress to coma.

Stroke.A major cause of seizures, a stroke may induce focal seizures up to 6 months after its onset. Related effects depend on the type and extent of the stroke, but may include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. A stroke may also cause visual deficits, memory loss, poor judgment, personality changes, emotional lability, headache, urinary incontinence or urine retention, and vomiting. It may result in generalized seizures.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Abdominal pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm
(dissecting).Initially, this life-threatening disorder may produce dull lower abdominal, lower back, or severe chest pain. Usually, a dissecting abdominal aortic aneurysm produces constant upper abdominal pain, which may worsen when the patient lies down and may abate when he leans forward or sits up. Palpation may reveal an epigastric mass that pulsates before rupture but not after it.

Other findings may include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate abdominal tenderness with guarding, and abdominal rigidity. Signs of shock, such as tachycardia and tachypnea, may appear.

Abdominal cancer.Abdominal pain usually occurs late in abdominal cancer. It may be accompanied by anorexia, weight loss, weakness, depression, and abdominal mass and distention.

Abdominal trauma.Generalized or localized abdominal pain occurs with ecchymoses on the abdomen, abdominal tenderness, vomiting and, with hemorrhage into the peritoneal cavity, abdominal rigidity. Bowel sounds are decreased or absent. The patient may have signs of hypovolemic shock, such as hypotension and a rapid, thready pulse.

Adrenal crisis.Severe abdominal pain appears early, along with nausea, vomiting, dehydration, profound weakness, anorexia, and fever. Later signs are progressive loss of consciousness; hypotension; tachycardia; oliguria; cool, clammy skin; and increased motor activity, which may progress to delirium or seizures.

Anthrax, GI.GI anthrax is caused by eating contaminated meat from an infected animal. Initial signs and symptoms include loss of appetite, nausea, vomiting, and fever. Late signs and symptoms include abdominal pain, severe bloody diarrhea, and hematemesis.

Appendicitis.With appendicitis, a life-threatening disorder, pain initially occurs in the epigastric or umbilical region. Anorexia, nausea, or vomiting may occur after the onset of pain. Pain localizes at McBurney's point in the right lower quadrant and is accompanied by abdominal rigidity, increasing tenderness (especially over McBurney's point), rebound tenderness, and retractive respirations. Later signs and symptoms include malaise, constipation (or diarrhea), low-grade fever, and tachycardia.

Cholecystitis.Severe pain in the right upper quadrant may arise suddenly or increase gradually over several hours, usually after meals. It may radiate to the right shoulder, chest, or back. Accompanying the pain are anorexia, nausea, vomiting, fever, abdominal rigidity, tenderness, pallor, and diaphoresis. Murphy's sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.

Cholelithiasis.Patients may suffer sudden, severe, and paroxysmal pain in the right upper quadrant lasting several minutes to several hours. The pain may radiate to the epigastrium, back, or shoulder blades. The pain is accompanied by anorexia, nausea, vomiting (sometimes bilious), diaphoresis, restlessness, and abdominal tenderness with guarding over the gallbladder or biliary duct. The patient may also experience fatty food intolerance and frequent indigestion.

Cirrhosis.Dull abdominal aching occurs early and is usually accompanied by anorexia, indigestion, nausea, vomiting, constipation, or diarrhea. Subsequent right upper quadrant pain worsens when the patient sits up or leans forward. Associated signs include fever, ascites, leg edema, weight gain, hepatomegaly, jaundice, severe pruritus, bleeding tendencies, palmar erythema, and spider angiomas. Gynecomastia and testicular atrophy may also be present.

Crohn's disease.An acute attack in Crohn's disease causes severe cramping pain in the lower abdomen, typically preceded by weeks or months of milder cramping pain. Crohn's disease may also cause diarrhea, hyperactive bowel sounds, dehydration, weight loss, fever, abdominal tenderness with guarding, and possibly a palpable mass in a lower quadrant. Abdominal pain is commonly relieved by defecation. Milder chronic signs and symptoms include right lower quadrant pain with diarrhea, steatorrhea, and weight loss. Complications include perirectal or vaginal fistulas.

Diverticulitis.Mild cases of diverticulitis usually produce intermittent, diffuse left lower quadrant pain, which is sometimes relieved by defecation or passage of flatus and worsened by eating. Other signs and symptoms include nausea, constipation or diarrhea, a low-grade fever and, in many cases, a palpable abdominal mass that's usually tender, firm, and fixed. Rupture causes severe left lower quadrant pain, abdominal rigidity and, possibly, signs and symptoms of sepsis and shock (high fever, chills, and hypotension).

Duodenal ulcer.Localized abdominal pain—described as steady, gnawing, burning, aching, or hunger like—may occur high in the midepigastrium, slightly off center, usually on the right. The pain usually doesn't radiate unless pancreatic penetration occurs. It typically begins 2 to 4 hours after a meal and may cause nocturnal awakening. Ingestion of food or antacids brings relief until the cycle starts again, but it may also produce weight gain. Other symptoms include changes in bowel habits and heartburn or retrosternal burning.

Ectopic pregnancy.Lower abdominal pain may be sharp, dull, or cramping and constant or intermittent in ectopic pregnancy, a potentially life-threatening disorder. Vaginal bleeding, nausea, and vomiting may occur, along with urinary frequency, a tender adnexal mass, and a 1- or 2-month history of amenorrhea. Rupture of the fallopian tube produces sharp lower abdominal pain, which may radiate to the shoulders and neck and become extreme with cervical or adnexal palpation. Signs of shock (such as pallor, tachycardia, and hypotension) may also appear.

Endometriosis.Constant, severe pain in the lower abdomen usually begins 5 to 7 days before the start of menses and may be aggravated by defecation. Depending on the location of the ectopic tissue, the pain may be accompanied by constipation, abdominal tenderness, dysmenorrhea, dyspareunia, and deep sacral pain.

Escherichia coli O157:H7 infection.Signs and symptoms of E. coli O157:H7 infection include watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in elderly patients, hemolytic uremic syndrome may develop, and this may ultimately lead to acute renal failure.

Gastric ulcer.Diffuse, gnawing, burning pain in the left upper quadrant or epigastric area commonly occurs 1 or 2 hours after meals and may be relieved by ingestion of food or antacids. Vague bloating and nausea after eating are common. Indigestion, weight change, anorexia, and episodes of GI bleeding also occur.

Gastritis.With acute gastritis, the patient experiences a rapid onset of abdominal pain that can range from mild epigastric discomfort to burning pain in the left upper quadrant. Other typical features include belching, fever, malaise, anorexia, nausea, bloody or coffee-ground vomitus, and melena. Significant bleeding is unusual unless the patient has hemorrhagic gastritis.

Gastroenteritis.Cramping or colicky abdominal pain, which can be diffuse, originates in the left upper quadrant and radiates or migrates to the other quadrants, usually in a peristaltic manner. It's accompanied by diarrhea, hyperactive bowel sounds, headache, myalgia, nausea, and vomiting.

Heart failure.Right upper quadrant pain caused by liver congestion or enlargement commonly accompanies heart failure's hallmarks: jugular vein distention, dyspnea, tachycardia, and peripheral edema. Other findings include nausea, vomiting, ascites, productive cough, crackles, cool extremities, and cyanotic nail beds. Clinical signs are numerous and vary according to the stage of the disease and amount of cardiovascular impairment.

Hepatitis.Liver enlargement from any type of hepatitis causes discomfort or dull pain and tenderness in the right upper quadrant. Associated signs and symptoms may include dark urine, clay-colored stools, nausea, vomiting, anorexia, jaundice, malaise, and pruritus.

Intestinal obstruction.Short episodes of intense, colicky, cramping pain alternate with pain-free intervals with an intestinal obstruction, a life-threatening disorder. Accompanying signs and symptoms may include abdominal distention, tenderness, and guarding; visible peristaltic waves; high-pitched, tinkling, or hyperactive sounds proximal to the obstruction and hypoactive or absent sounds distally; obstipation; and pain-induced agitation. In jejunal and duodenal obstruction, nausea and bilious vomiting occur early. In distal small- or large-bowel obstruction, nausea and vomiting are commonly feculent. Complete obstruction produces absent bowel sounds. Late-stage obstruction produces signs of hypovolemic shock, such as altered mental status, tachycardia, and hypotension.

Irritable bowel syndrome.Lower abdominal cramping or pain is aggravated by ingestion of coarse or raw foods and may be alleviated by defecation or passage of flatus. Related findings include abdominal tenderness, diurnal diarrhea alternating with constipation or normal bowel function, and small stools with visible mucus. Dyspepsia, nausea, and abdominal distention with a feeling of incomplete evacuation may also occur. Stress, anxiety, and emotional lability intensify the symptoms.

Listeriosis.Signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop; signs and symptoms include fever, headache, nuchal rigidity, and change in the level of consciousness.

Mesenteric artery ischemia.Always suspect mesenteric artery ischemia in patients older than age 50 with chronic heart failure, cardiac arrhythmia, cardiovascular infarct, or hypotension who develop sudden, severe abdominal pain after 2 or 3 days of colicky periumbilical pain and diarrhea. Initially, the abdomen is soft and tender with decreased bowel sounds. Associated findings include vomiting, anorexia, alternating periods of diarrhea and constipation and, in late stages, extreme abdominal tenderness with rigidity, tachycardia, tachypnea, absent bowel sounds, and cool, clammy skin.

Norovirus infection.Abdominal pain or cramping is a symptom commonly associated with noroviruses. Transmitted by the fecal-oral route and highly contagious, these viruses that cause gastroenteritis may also produce acute-onset vomiting, nausea, and diarrhea. Less common symptoms include low-grade fever, headache, chills, muscle aches, and generalized fatigue. Individuals who are otherwise healthy usually recover in 24 to 60 hours without suffering lasting effects.

Ovarian cyst.Torsion or hemorrhage causes pain and tenderness in the right or left lower quadrant. Sharp and severe if the patient suddenly stands or stoops, the pain becomes brief and intermittent if the torsion self-corrects or dull and diffuse after several hours if it doesn't. Pain is accompanied by slight fever, mild nausea and vomiting, abdominal tenderness, a palpable abdominal mass and, possibly, amenorrhea. Abdominal distention may occur if the patient has a large cyst. Peritoneal irritation, or rupture and ensuing peritonitis, causes high fever and severe nausea and vomiting.

Pancreatitis.Life-threatening acute pancreatitis produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about. Early findings include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal rigidity, rebound tenderness, and hypoactive bowel sounds. Turner's sign (ecchymosis of the abdomen or flank) or Cullen's sign (a bluish tinge around the umbilicus) signals hemorrhagic pancreatitis. Jaundice may occur as inflammation subsides.

Chronic pancreatitisproduces severe left upper quadrant or epigastric pain that radiates to the back. Abdominal tenderness, a midepigastric mass, jaundice, fever, and splenomegaly may occur. Steatorrhea, weight loss, maldigestion, and hyperglycemia are common.

Pelvic inflammatory disease.Pain in the right or left lower quadrant ranges from vague discomfort worsened by movement to deep, severe, and progressive pain. Sometimes, metrorrhagia precedes or accompanies the onset of pain. Extreme pain accompanies cervical or adnexal palpation. Associated findings include abdominal tenderness, a palpable abdominal or pelvic mass, fever, occasional chills, nausea, vomiting, urinary discomfort, and abnormal vaginal bleeding or purulent vaginal discharge.

Perforated ulcer.With perforated ulcer, a life-threatening disorder, sudden, severe, and prostrating epigastric pain may radiate through the abdomen to the back or right shoulder. Other signs and symptoms include boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, absent bowel sounds, grunting and shallow respirations and, in many cases, fever, tachycardia, hypotension, and syncope.

Peritonitis.With peritonitis, a life-threatening disorder, sudden and severe pain can be diffuse or localized in the area of the underlying disorder; movement worsens the pain. The degree of abdominal tenderness usually varies according to the extent of disease. Typical findings include fever; chills; nausea; vomiting; hypoactive or absent bowel sounds; abdominal tenderness, distention, and rigidity; rebound tenderness and guarding; hyperalgesia; tachycardia; hypotension; tachypnea; and positive psoas and obturator signs.

Prostatitis.Vague abdominal pain or discomfort in the lower abdomen, groin, perineum, or rectum may develop with prostatitis. Other findings include dysuria, urinary frequency and urgency, fever, chills, low back pain, myalgia, arthralgia, and nocturia. Scrotal pain, penile pain, and pain on ejaculation may occur in chronic cases.

Pyelonephritis (acute).Progressive lower quadrant pain in one or both sides, flank pain, and CVA tenderness characterize this disorder. Pain may radiate to the lower midabdomen or to the groin. Additional signs and symptoms include abdominal and back tenderness, high fever, shaking chills, nausea, vomiting, and urinary frequency and urgency.

Renal calculi.Depending on the location of calculi, severe abdominal or back pain may occur. The classic symptom is severe, colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia. The pain may be excruciating or dull and constant. Pain-induced agitation, nausea, vomiting, abdominal distention, fever, chills, hypertension, and urinary urgency with hematuria and dysuria may occur.

Sickle cell crisis.Sudden, severe abdominal pain may accompany chest, back, hand, or foot pain. Associated signs and symptoms include weakness, aching joints, dyspnea, and scleral jaundice.

Smallpox (variola major).Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Splenic infarction.Fulminating pain in the left upper quadrant occurs along with chest pain that may worsen on inspiration. Pain usually radiates to the left shoulder with splinting of the left diaphragm, abdominal guarding and, occasionally, a splenic friction rub.

Ulcerative colitis.Ulcerative colitis may begin with vague abdominal discomfort that leads to cramping lower abdominal pain. As the disorder progresses, pain may become steady and diffuse, increasing with movement and coughing. The most common symptom—recurrent and possibly severe diarrhea with blood, pus, and mucus—may relieve the pain. The abdomen may feel soft and extremely tender. High-pitched, infrequent bowel sounds may accompany nausea, vomiting, anorexia, weight loss, and mild, intermittent fever.

Other causes

Drugs.Salicylates and nonsteroidal anti-inflammatory drugs commonly cause burning, gnawing pain in the left upper quadrant or epigastric area, along with nausea and vomiting.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Arm pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Angina.Angina may cause inner arm pain as well as chest and jaw pain. Typically, the pain follows exertion and persists for a few minutes. Accompanied by dyspnea, diaphoresis, and apprehension, the pain is relieved by rest or vasodilators such as nitroglycerin.

Biceps rupture.Rupture of the biceps after excessive weight lifting or osteoarthritic degeneration of bicipital tendon insertion at the shoulder can cause pain in the upper arm. Forearm flexion and supination aggravate the pain. Other signs and symptoms include muscle weakness, deformity, and edema.

Carpal tunnel syndrome.Median nerve compression in the carpal tendon of the wrist may cause numbness and tingling in the fingers, along with increasing arm pain. Symptoms usually occur at night, but may increase over time with continued repetitive movement of the hand.

Cellulitis.Typically, cellulitis affects the legs, but it can also affect the arms. It produces pain as well as redness, tenderness, edema and, at times, fever, chills, tachycardia, headache, and hypotension. Cellulitis usually follows an injury or insect bite.

Cervical nerve root compression.Compression of the cervical nerves supplying the upper arm produces chronic arm and neck pain, which may worsen with movement or prolonged sitting. The patient may also experience muscle weakness, paresthesia, and decreased reflex response.

Compartment syndrome.Severe pain with passive muscle stretching is the cardinal symptom of compartment syndrome. It may also impair distal circulation and cause muscle weakness, decreased reflex response, paresthesia, and edema. Ominous signs include paralysis and an absent pulse.

Fractures.In fractures of the cervical vertebrae, humerus, scapula, clavicle, radius, or ulna, pain can occur at the injury site and radiate throughout the entire arm. Pain at a fresh fracture site is intense and worsens with movement. Associated signs and symptoms include crepitus, felt and heard from bone ends rubbing together (don't attempt to elicit this sign); deformity, if bones are misaligned; local ecchymosis and edema; impaired distal circulation; paresthesia; and decreased sensation distal to the injury site. Fractures of the small wrist bones can manifest with pain and swelling several days after the trauma.

Muscle contusion.Muscle contusion may cause generalized pain in the area of injury. It may also cause local swelling and ecchymosis.

Muscle strain.Acute or chronic muscle strain causes mild to severe pain with movement. The resultant reduction in arm movement may cause muscle weakness and atrophy.

Myocardial infarction (MI).MI is a life-threatening disorder in which the patient may complain of left arm pain as well as the characteristic deep and crushing chest pain. He may display weakness, pallor, nausea, vomiting, diaphoresis, altered blood pressure, tachycardia, dyspnea, and feelings of apprehension or impending doom.

Neoplasms of the arm.Neoplasms of the arm produce continuous, deep, and penetrating arm pain that worsens at night. Occasionally, redness and swelling accompany arm pain; later, skin breakdown, impaired circulation, and paresthesia may occur.

Osteomyelitis.Osteomyelitis typically begins with vague and evanescent localized arm pain and fever and is accompanied by local tenderness, painful and restricted movement and, later, swelling. Associated findings include malaise and tachycardia.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Back pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm
(dissecting).Life-threatening dissection of this type of aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, however, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.

Ankylosing spondylitis.Ankylosing spondylitis causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn't relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.

Appendicitis.Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney's point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney's point), and rebound tenderness. Some patients also have painful, urgent urination.

Cholecystitis.Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours, and patients usually have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right upper quadrant tenderness, abdominal rigidity, pallor, and sweating.

Chordoma.A slow-developing malignant tumor, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumor expands, pain may be accompanied by constipation and bowel or bladder incontinence.

Endometriosis.Endometriosis causes deep sacral pain and severe, cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It's accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.

Intervertebral disk rupture.Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It's accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient's spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.

Lumbosacral sprain.Lumbosacral sprain causes aching, localized pain and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine intensifies pain, whereas rest helps relieve it. The pain worsens with movement and is relieved by rest.

Metastatic tumors.Metastatic tumors commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscular pain (usually worse at night), and isn't relieved by rest.

Myeloma.Back pain caused by myeloma, a primary malignant tumor, usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.

Pancreatitis (acute).Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about.

Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. A late sign may be jaundice. Occurring as inflammation subsides, Turner's sign (ecchymosis of the abdomen or flank) or Cullen's sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.

Perforated ulcer.In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This life-threatening disorder also causes boardlike abdominal rigidity, tenderness with guarding, generalized rebound tenderness, the absence of bowel sounds, and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.

Prostate cancer.Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also produce hematuria and decrease the urine stream.

Pyelonephritis (acute).Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.

Renal calculi.The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. Its intensity varies but may become excruciating if calculi travel down a ureter. If calculi are in the renal pelvis and calyces, dull and constant flank pain may occur. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover the calculi for analysis.

Rift Valley fever.Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Sacroiliac strain.Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or gluteus medius or abductor lurch.

Smallpox (variola major).Initial signs and symptoms of smallpox include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Spinal neoplasm (benign).Spinal neoplasm typically causes severe, localized back pain and scoliosis.

Spinal stenosis.Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.

Spondylolisthesis.A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may be asymptomatic or may cause low back pain, with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.

Transverse process fracture.Transverse process fracture causes severe localized back pain with muscle spasm and hematoma.

Vertebral compression fracture.Initially, vertebral compression fracture may be painless. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.

Vertebral osteomyelitis.Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.

Vertebral osteoporosis.Vertebral osteoporosis causes chronic, aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.

Other causes

Neurologic tests.Lumbar puncture and myelography can produce transient back pain.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Chest pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Angina pectoris.With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.

With Prinzmetal's angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation).Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety.Acute anxiety—or, more commonly, panic attacks—can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn't related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, a headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).The chest pain associated with a dissecting aortic aneurysm usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, a lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma.In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Blast lung injury.Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.

Bronchitis.In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, a sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101º to 102º F (38.3º to 38.9º C) and possible bronchospasm with worsening wheezing and increased coughing.

Cholecystitis.Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, a fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy's sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.

Interstitial lung disease.As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Lung abscess.Pleuritic chest pain develops insidiously with a lung abscess along with a pleural friction rub and a cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull to percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, a fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer.The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and a fever.

Mitral valve prolapse.Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. Patients may experience cardiac awareness, a migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Myocardial infarction (MI).The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain unrelieved by rest or nitroglycerin, it may radiate to the patient's left arm, jaw, neck, or shoulder blades. Women are less likely to experience chest pain with an MI, but may complain of pain in the shoulder blade, jaw, and upper back. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles. Women also complain of fatigue, palpitations, and indigestion.

Pancreatitis.In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, a fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer.With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis.Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include a pericardial friction rub, a fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague(Yersinia pestis).Signs and symptoms of the plague include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy.The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea; rapid, shallow breathing; cyanosis; a fever; and fatigue may also occur.

Pneumonia.Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, a headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax.Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that's severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain's onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism.A pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, decreased pulse oximetry, a cough (nonproductive or producing blood-tinged sputum), a low-grade fever, restlessness, diaphoresis, crackles, a pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (a weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention.

Q fever.Signs and symptoms of Q fever include a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Sickle cell crisis.Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, a fever, and jaundice.

Thoracic outlet syndrome.Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis (TB).In a patient with TB, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, a fever, malaise, dyspnea, easy fatigability, a mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome (CRS).CRS is a benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; a headache; shortness of breath; and tachycardia.

Drugs.The abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease—especially if he has received high doses for a prolonged period.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Flank pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Calculi.Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of a UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, a low-grade fever, and tenesmus).

Cortical necrosis (acute).Unilateral flank pain is usually severe with corticol necrosis. Accompanying findings include gross hematuria, anuria, leukocytosis, and a fever.

Obstructive uropathy.With acute obstruction, flank pain may be excruciating; with gradual obstruction, it's typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings—a palpable abdominal mass, CVA tenderness, and bladder distention—vary with the site and cause of the obstruction.

Papillary necrosis (acute).Intense bilateral flank pain occurs with papillary necrosis along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess.With perirenal abscess, intense unilateral flank pain and CVA tenderness accompany dysuria, a persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease.Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of a UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute).Intense, constant, and unilateral or bilateral flank pain develops over a few hours or days with acute pyelonephritis along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include a persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer.Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include a fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction.Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain with renal infarction. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, a fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma.Variable bilateral or unilateral flank pain is a common symptom of renal trauma. A visible or palpable flank mass may also exist, along with CVA or abdominal pain—which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner's sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis.Severe unilateral flank and lower back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include a fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Jaw pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Angina pectoris.Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It's commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis.With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion (ROM), and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited ROM and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and a mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer.Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia; ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany.Besides painful muscle contractions of the jaw and mouth, hypocalcemic tetany—a life-threatening disorder—produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek's and Trousseau's signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig's angina.Ludwig's angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. A fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

MI.Initially, MI causes intense, crushing substernal pain that's unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, a low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Sinusitis.Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include a fever, halitosis, a headache, malaise, a cough, and a sore throat.

Suppurative parotitis.Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene. Besides the abrupt onset of jaw pain, a high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen's ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis.Most common in women older than age 60, temporal arteritis produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include a low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; a throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

TMJ syndrome.TMJ syndrome is a common syndrome that produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, a headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus.A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include a headache, irritability, restlessness, a low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trigeminal neuralgia.Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs.Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Neck pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Ankylosing spondylitis.Intermittent, moderate to severe neck pain and stiffness with severely restricted ROM is characteristic of ankylosing spondylitis. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include a low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

Cervical extension injury.Anterior or posterior neck pain may develop within hours or days following a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, an occipital headache, muscle spasms, visual blurring, and unilateral miosis on the affected side.

Cervical spine fracture.Fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, an intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

Cervical spine tumor.Metastatic cervical spine tumors typically produce persistent neck pain that increases with movement and isn't relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to atrophy and paralysis, and bladder and bowel incontinence.

Cervical spondylosis.Cervical spondylosis produces posterior neck pain that restricts movement and is aggravated by it. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

Esophageal trauma.An esophageal mucosal tear or a pulsion diverticulum may produce mild neck pain, chest pain, edema, hemoptysis, and dysphagia.

Herniated cervical disk.A herniated cervical disk characteristically causes variable neck pain that restricts movement and is aggravated by it. It also causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.

Laryngeal cancer.Neck pain that radiates to the ear develops late in laryngeal cancer. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

Lymphadenitis.With lymphadenitis, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. Fever, chills, and malaise may also occur.

Meningitis.With meningitis, neck pain may accompany characteristic nuchal rigidity. Related findings include fever, headache, photophobia, positive Brudzinski's and Kernig's signs, and decreased level of consciousness (LOC).

Neck sprain.Minor neck sprains typically produce pain, slight swelling, stiffness, and restricted ROM. Ligament rupture causes pain, marked swelling, ecchymosis, muscle spasms, and nuchal rigidity with head tilt.

Rheumatoid arthritis.Rheumatoid arthritis usually affects peripheral joints, but it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root; increased warmth, swelling, and tenderness in involved joints; stiffness, restricting ROM; paresthesia and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the acute phase.

Spinous process fracture.A fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted ROM, muscle spasms, and deformity.

Subarachnoid hemorrhage.Subarachnoid hemorrhage isalife-threatening condition that may cause moderate to severe neck pain and rigidity, headache, and decreased LOC. Kernig's and Brudzinski's signs are present.

Thyroid trauma.Besides mild to moderate neck pain, thyroid trauma may cause local swelling and ecchymosis. If a hematoma forms, it can cause dyspnea.

Torticollis.Torticollis is a neck deformity in which severe neck pain accompanies recurrent unilateral stiffness and muscle spasms that produce a characteristic head tilt.

Tracheal trauma.A fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty.

Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Rectal pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abscess (perirectal).A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing local pain that's exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously, commonly high in the rectum or even in the lower abdomen, and is accompanied by an indurated anal mass. The patient may also develop associated signs and symptoms, such as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.

Anal fissure.An anal fissure causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.

Anorectal fistula.Anorectal fistula causes rectal pain to develop when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints include pruritus and drainage of pus, blood, mucus and, occasionally, stools.

Hemorrhoids.Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient's fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

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