Diseases » Shy-Drager Syndrome » Diagnosis

Diagnosis of Shy-Drager Syndrome

Shy-Drager Syndrome Diagnosis: Book Excerpts

• Ask the Following Questions - HYPOTENSION, CHRONIC
• Differential Diagnosis - Hypotension
• Approach to the Diagnosis - HYPOTENSION AND SHOCK
• History and physical examination - Orthostatic hypotension [Postural hypotension]
• History and physical examination - Blood pressure decrease [Hypotension]
• History and physical examination - Decorticate posture
• History and physical examination - Orthostatic hypotension [Postural hypotension]
• History and physical examination - Blood pressure decrease [Hypotension]
• History and physical examination - Decorticate posture [Decorticate rigidity, abnormal flexor response]
• Differential Overview - Orthostatic Hypotension
• History - Hypotension, orthostatic
• History - Decorticate posture [Decorticate rigidity, abnormal flexor response]
• History - Orthostatic hypotension
• History - Decorticate posture
• History and physical examination - Orthostatic hypotension [Postural hypotension]
• History and physical examination - Blood pressure, decreased [Hypotension]
• History and physical examination - Decorticate posture [Decorticate rigidity, abnormal flexor response]
• Approach to the Diagnosis - HYPOTENSION AND SHOCK

Diagnostic Tests for Shy-Drager Syndrome: Online Medical Books

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HYPOTENSION, CHRONIC: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the hypotension found only on standing? The finding of hypotension on standing suggests orthostatic hypotension, which may be due to several causes, including hypopituitarism, diabetic neuropathy, anemia, and various cardiovascular disorders.
2. Is there a history of drug ingestion? Many drugs induce hypotension, including nitroglycerin and its analogues, vasodilators, quinidine, and tricyclic drugs.
3. Is there cardiomegaly or a heart murmur? These findings suggest mitral valvular disease, aortic stenosis, and congestive heart failure.
4. Is there pallor? The finding of pallor suggests anemia.
5. Is there hyperpigmentation? The presence of hyperpigmentation suggests Addison's disease.

DIAGNOSTIC WORKUP

Routine studies include a CBC, sedimentation rate, chemistry panel, urinalysis, thyroid panel, EKG, and chest x-ray. Blood volume and arterial blood gas studies may be useful. If there is cardiomegaly or a murmur, echocardiography and venous pressure and circulation time should be done. A cardiologist should also be consulted.

If there is hyperpigmentation, a serum cortisol and ACTH stimulation test should be done. A skull x-ray can be done to rule out pituitary tumors. A visual field examination by a qualified ophthalmologist may be helpful in this regard also. Twenty-four-hr blood pressure monitoring may be useful in the workup also.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Hypotension: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Orthostatic hypotension
  –Most common in elderly
  –May result in syncope or near-syncope upon standing
  –Decrease of more than 20 mmHg in systolic blood pressure, or a decrease of 10 mmHg in diastolic blood pressure within 2–5 minutes of standing

• Hypotension secondary to medications is common in elderly patients (e.g., antihypertensives; vasodilators, including nitrates, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers; hypoglycemic agents; antidepressants; opiates; alcohol)
• Volume depletion
  –Often due to hyperglycemia, dehydration, hemorrhage, occult bleeding, vomiting, diarrhea, or diuretic use
• Autonomic failure
  –Absence of reflex-induced increase in heart rate as blood pressure is decreased
  –Often due to Parkinson's disease, cerebellar disorders, neuropathies, or Shy-Drager syndrome
• Postprandial hypotension (within 75 minutes of eating)
  –Very common in elderly
• Adrenal insufficiency
  –ACTH stimulation test shows inadequate increase in serum cortisol from baseline
• Diabetic autonomic neuropathy
• Shock
  –Cardiogenic shock
  –Septic shock
  –Neurogenic shock
  –Hemorrhagic shock
• Anaphylaxis
• Splenic rupture
• Ectopic pregnancy
• Hepatitis

Workup and Diagnosis

• History and physical examination
  –Compare blood pressure to patient's usual values
  –The absence of reflex-induced increase in heart rate as blood pressure falls indicates autonomic failure, which may require a workup for suspected underlying neurologic or pharmacologic conditions
  –Cardiogenic shock is often accompanied by cool, clammy extremities

• Laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, calcium, urinalysis, and ECG
• Additional studies (e.g., blood cultures, echocardiogram, blood type and cross) may be indicated based on the underlying disorder
• Swan-Ganz catheterization (right heart catheterization) may be indicated to establish the etiology (e.g., cardiogenic versus noncardiogenic) and determine patient management
• For diagnosis of adrenal insufficiency, obtain baseline cortisol level and then administer 250 µ g of ACTH (Cortrosyn); obtain serum cortisol levels 30 and 60 minutes after ACTH administration; if cortisol level increases by <7, then adrenal insufficiency is highly likely

>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

HYPOTENSION AND SHOCK: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of shock must be vigorous with emergency CBC, blood cultures, blood gases, ECG, electrolytes, blood urea nitrogen (BUN), and type and cross-match of blood at the same time vigorous antishock measures are applied. Checking the GI tract for blood loss with a rectal and nasogastric tube can be both diagnostic and therapeutic. To work up chronic hypotension, one should not forget venous pressure and circulation times (to diagnose decreased cardiac output and CHF), serial electrolytes and cortisol levels (to rule out adrenal insufficiency), and sedimentation rate and cultures of various body fluids to exclude a chronic infectious disease (e.g., tuberculosis).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headaches, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

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

Blood pressure decrease [Hypotension]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Is his gait unsteady? Does he have palpitations? Does he have chest or abdominal pain or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient's blood pressure while he's lying down, sitting, and then standing; compare readings. (See Ensuring accurate blood pressure measurement.) A drop in systolic or diastolic pressure of 10 to 20 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension.

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note paradoxical pulse — an accentuated fall in systolic pressure during inspiration — which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding and palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Also, carefully assess the patient for possible sources of infection such as open wounds.

» READ BOOK EXCERPT ONLINE »

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

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

Test the patient's motor and sensory functions. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask about headache, dizziness, nausea, changes in vision, and numbness or tingling. When did the patient first notice these symptoms? Is his family aware of behavioral changes? Also, ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

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

Blood pressure decrease [Hypotension]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Gait unsteady? Does he have palpitations, chest or abdominal pain, or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient’s blood pressure while he’s lying down, sitting, and then standing and compare readings. A drop in systolic or diastolic pressure of 10 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension. (See Ensuring accurate blood pressure measurement, page 104.)

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note a paradoxical pulse—an accentuated fall in systolic pressure during inspiration—which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding, palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Also, carefully assess the patient for possible sources of infection such as open wounds.

» READ BOOK EXCERPT ONLINE »

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

Decorticate posture [Decorticate rigidity, abnormal flexor response]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Test the patient’s motor and sensory function. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask family members if the patient experienced headache, dizziness, nausea, changes in vision, numbness, or tingling. When did the patient first notice these symptoms? Is his family aware of any behavioral changes? Also, ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic Hypotension: Differential Overview
(Field Guide to Bedside Diagnosis)

Dysautonomia

❑ Diabetes

❑ Drugs

❑ Pernicious anemia

❑ Amyloidosis

❑ Guillain-Barré syndrome

❑ Wernicke syndrome

Other

❑ Dehydration

❑ Prolonged standing

❑ Hemorrhage

❑ Thermodilation

❑ Vasovagal response

❑ Pregnancy

❑ Addison disease

Diagnostic Approach

Dysautonomia is characterized by orthostatic hypotension (postural lightheadedness, fainting, dim vision, weakness, unsteady gait), urinary dysfunction (frequency, urgency, stress incontinence), sexual dysfunction (impotence, retrograde ejaculation), bowel dysfunction (nocturnal diarrhea, incontinence), and/or decreased sweating. It is most easily recognized by the presence of orthostatic hypotension without reflex tachycardia. Within 2 to 5 minutes of quiet standing there will be a 20 mm Hg drop in systolic pressue, a 10 mm Hg drop in diastolic pressure, or symptoms of cerebral hypoperfusion.

With gastrointestinal hemorrhage, an orthostatic blood pressure change of 10 mm Hg suggests a loss of at least 20% of intravascular volume.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Hypotension, orthostatic: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s condition is stable, obtain his history. Ask whether he frequently experiences dizziness, weakness, or fainting when he stands. Ask whether he experienced associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Obtain a complete medication history, including his use of prescription, over-the-counter, herbal preparations, and other supplements. Also ask about his use of illicit drugs.

Physical examination

Begin the physical examination by checking the patient’s skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient’s gait for unsteadiness.

ALERT: Assess the patient for signs and symptoms of hemorrhage and hypovolemic shock. Observe his skin color and check peripheral circulation and capillary refill time. Inspect the skin and mucous membranes for signs of bleeding.

» READ BOOK EXCERPT ONLINE »

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

Decorticate posture [Decorticate rigidity, abnormal flexor response]: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain a history from the patient (if possible) or his family. Did the patient complain about headache, dizziness, nausea, changes in vision, and numbness or tingling? When did he first notice these symptoms? Did the family observe any behavioral changes?

Ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.

Physical examination

Test the patient’s motor and sensory functions. Evaluate pupil size, equality, and response to light. Test cranial nerve function and deep tendon reflexes. Perform a complete neurologic examination and continue to perform frequent neurologic checks. Assess the patient’s respiratory function.

ALERT: Abnormal respirations may indicate a breakdown in the brain’s respiratory center and an impending tentorial herniation — a neurologic emergency.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic hypotension: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headache, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

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

Decorticate posture: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask about headache, dizziness, nausea, changes in vision, and numbness or tingling. When did the patient first notice these symptoms? Is his family aware of any behavioral changes? Also, ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.

» READ BOOK EXCERPT ONLINE »

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

Orthostatic hypotension [Postural hypotension]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient is in no danger, obtain a history. Ask the patient if he frequently experiences dizziness, weakness, or fainting when he stands. Also ask about associated symptoms, particularly fatigue, orthopnea, impotence, nausea, headaches, abdominal or chest discomfort, and GI bleeding. Then obtain a complete drug history.

Begin the physical examination by checking the patient's skin turgor. Palpate peripheral pulses and auscultate the heart and lungs. Finally, test muscle strength and observe the patient's gait for unsteadiness.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Blood pressure, decreased [Hypotension]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient is conscious, ask him about associated symptoms. For example, does he feel unusually weak or fatigued? Has he had nausea, vomiting, or dark or bloody stools? Is his vision blurred? Is his gait unsteady? Does he have palpitations? Does he have chest or abdominal pain or difficulty breathing? Has he had episodes of dizziness or fainting? Do these episodes occur when he stands up suddenly? If so, take the patient's blood pressure while he's lying down, sitting, and then standing; compare readings. (See Ensuring accurate blood pressure measurement.)

A drop in systolic or diastolic pressure of 10 to 20 mm Hg or more and an increase in heart rate of more than 15 beats/minute between position changes suggest orthostatic hypotension.

Next, continue with a physical examination. Inspect the skin for pallor, sweating, and clamminess. Palpate peripheral pulses. Note paradoxical pulse—an accentuated fall in systolic pressure during inspiration—which suggests pericardial tamponade. Then auscultate for abnormal heart sounds (gallops, murmurs), rate (bradycardia, tachycardia), or rhythm. Auscultate the lungs for abnormal breath sounds (diminished sounds, crackles, wheezing), rate (bradypnea, tachypnea), or rhythm (agonal or Cheyne-Stokes respirations). Look for signs of hemorrhage, including visible bleeding and palpable masses, bruising, and tenderness. Assess the patient for abdominal rigidity and rebound tenderness; auscultate for abnormal bowel sounds. Carefully assess the patient for possible sources of infection such as open wounds.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Decorticate posture [Decorticate rigidity, abnormal flexor response]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Test the patient's motor and sensory functions. Evaluate pupil size, equality, and response to light. Then test cranial nerve function and deep tendon reflexes. Ask the patient about headache, dizziness, nausea, changes in vision, and numbness or tingling. When did the patient first notice these symptoms? Is his family aware of behavioral changes? Also ask about a history of cerebrovascular disease, cancer, meningitis, encephalitis, upper respiratory tract infection, bleeding or clotting disorders, or recent trauma.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

HYPOTENSION AND SHOCK: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The workup of shock must be vigorous with emergency CBC, blood cultures, blood gases, ECG, electrolytes, blood urea nitrogen (BUN), and type- and cross-match of blood at the same time that vigorous antishock measures are applied. Checking the GI tract for blood loss with a rectal and nasogastric tube can be both diagnostic and therapeutic. To work up chronic hypotension, one should not forget venous pressure and circulation times (to diagnose decreased cardiac output and CHF), serial electrolytes and cortisol levels (to rule out adrenal insufficiency), and sedimentation rate and cultures of various body fluids (to exclude a chronic infectious disease [e.g., TB]).

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

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