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Diseases » Throat cancer » Diagnosis
 

Diagnosis of Throat cancer

Throat cancer Diagnosis: Book Excerpts

Diagnostic Tests for Throat cancer: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Throat cancer.


DYSPHAGIA: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there abnormalities on oropharyngeal examination? If so, then of course the cause may be local. This is particularly true if there are painful ulcerations of the mouth, glossitis, or tonsillitis. There may be neoplasms in the oropharynx or larynx that may be either obstructing swallowing or causing pain on swallowing.
  2. Is the dysphagia constant or intermittent? Intermittent dysphagia would make one think of myasthenia gravis, and if there are other neurologic findings to suggest that, it would be the most likely working diagnosis. Without neurologic findings, a Schatzki ring may be present.
  3. Does the patient have difficulty swallowing both liquids and solids or only solids? If the patient has difficulty with both liquids and solids, a diagnosis of achalasia, scleroderma, or diffuse esophageal spasm should be entertained. Patients who have difficulty swallowing solids only usually should be considered to have esophageal carcinoma until proven otherwise.
  4. Is heartburn present? If there is heartburn as well as dysphagia, a diagnosis of reflux esophagitis with or without hiatal hernia should be entertained. Many conditions, including achalasia, diffuse esophageal spasm, and even advanced esophageal carcinoma, may be associated with pain on swallowing or chest pain.
  5. Is the patient male or female? Dysphagia in a male is suggestive of esophageal carcinoma; this would be especially true with a history of significant smoking and drinking. Dysphagia in a female would suggest esophageal web, as in Plummer-Vinson syndrome.
  6. Is there significant weight loss? Significant weight loss is very often associated with esophageal carcinoma, but not until it is advanced to a significant degree. One often forgets that weight loss is also associated with achalasia.
  7. Is there a history of syphilis? Obviously, this would suggest an aortic aneurysm, and in considering aortic aneurysm, one should also consider other mediastinal masses that might be associated with this condition.
  8. Are there dermatologic signs and symptoms? This would bring up the possibility of scleroderma.

DIAGNOSTIC WORKUP

In a patient with definite dysphagia, it is wise to consult a gastroenterologist at the outset! The most useful diagnostic test (and most inexpensive) is the barium swallow, and an upper GI series might be done as well. The barium swallow will often display fairly definitive features of carcinoma of the esophagus, esophageal diverticulum, achalasia, hiatal hernia, and esophagitis. The barium swallow, however, must be frequently followed by esophagoscopy to obtain a more definitive diagnosis and a tissue biopsy, particularly in the case of carcinoma of the esophagus. If both of these tests are negative, the possibility of myasthenia gravis should be considered, and a Tensilon test should be done. Esophageal manometry may detect achalasia or diffuse esophageal spasm. When a mediastinal mass is suspected, a CT scan of the mediastinum should be done. When all testing is negative, hysteria should be considered. Ultrasonography can be used to diagnose abnormal movements of the tongue and larynx. Videofluoroscopy is also useful in diagnosing oropharyngeal causes. Reflux esophagitis can be diagnosed with ambulatory pH monitoring. A therapeutic trial of a proton pump inhibitor may be useful.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SORE THROAT: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Are there exudates? This is a key question when evaluating a sore throat. Most cases of sore throat with exudates will be found to have streptococcal pharyngitis. Without exudates, one could still have a streptococcal sore throat, but it is less likely.
  2. Is there a temperature elevation? A significant elevation of the temperature, with or without exudates, is also characteristic of streptococcal pharyngitis.
  3. Are there enlarged lymph nodes? If the lymph nodes are enlarged in the peritonsillar area, this is often a sign of streptococcal sore throat, but it certainly is not diagnostic. Interestingly enough, 90% of patients with infectious mononucleosis have posterior cervical adenopathy.
  4. Are there systemic symptoms and signs? Patients who present with exudative tonsillitis and splenomegaly certainly should be considered to have infectious mononucleosis until proven otherwise. Also, an exudative tonsillitis along with a fever and heart murmur should make one consider rheumatic fever. Systemic symptoms such as dry cough, runny nose, and generalized malaise or fatigue should make one think of a viral URI.

DIAGNOSTIC WORKUP

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

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

  • Intrinsic esophageal lesions
    –Gastric acid reflux
    –Esophageal webs and rings
    –Radiation-induced inflammation and stricture formation
    –Trauma
    –Esophageal perforation
    –Diverticula
    –Malignancy
    –Postsurgical
    –Foreign body retention
  • Extrinsic lesions
    –Anterior cervical osteophyte
    –Mediastinal mass (e.g., thymoma, teratoma, lymphoma, carotid/aortic aneurysm)
    –Post-thoracic surgery or anterior cervical discectomy
    –Enlarged thyroid
    –Thyroglossal duct cyst
  • Aberrant motility
    –Hypertensive lower esophageal sphincter
    –Nutcracker esophagus
    –Scleroderma
    –Achalasia
    –Diffuse esophageal spasm (DES)
  • Neurological causes
    –Myopathies (e.g., polymyositis, inherited)
    –Neuromuscular junction disorders (e.g., myasthenia gravis, botulism)
    –Polyneuropathies (e.g., diabetic, Guillain-Barré syndrome, toxin-related)
    –Brainstem stroke
    –ALS
  • Less common etiologies (“zebras”) include globus hystericus (psychogenic dysphagia), anxiety disorders, hypothyroidism, amyloidosis, dysphagia lusoria (extrinsic esophageal compression due to aortic arch anomalies), left atrial enlargement, and Chagas’ disease

Workup and Diagnosis

  • History and physical examination
    –History should include onset, duration, and severity; dysphagia with liquid versus solids; past medical history, including anxiety and other psychiatric illnesses; prior dysphagia or caustic substance exposure; and other head and neck problems
    –Exam should include a thorough head, nose, mouth, neck/thyroid, and abdominal examination, and observation of the patient swallowing
  • Oropharyngeal dysphagia: Difficulty initiating swallowing
    –Barium swallow will identify area of swallowing lesion (usually done by speech therapist)
    –EMG/nerve conduction tests to rule out neurologic causes (e.g., myasthenia gravis, ALS)
    –Elevated CPK level suggests muscle disease
    –Brain MRI if CVA is suspected
  • Esophageal dysphagia: Sensation of food sticking seconds after initiating swallowing
    –Solids: Barium swallow is less invasive than endoscopy and is frequently sufficient for diagnosis
    –Liquids and/or solids: Esophageal manometry and barium swallow visualization (scleroderma, DES)
  • In general, endoscopy and biopsy by a trained gastroenterologist (or surgeon) is necessary for suspected cancer and various therapeutic interventions

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Sore Throat: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Viral pharyngitis/laryngitis
    –Most common cause of sore throat
    –Associated with cough, low-grade fever, nasal congestion, and sneezing
    –Influenza occasionally causes sore throat with high fever, cough, severe myalgias
    –Rhino-, adeno-, coxsackie-, and herpesvirus
    –Acute HIV infection
  • Mononucleosis
    –Associated with fever, headache, and excessive fatigue
    –Most common in teen and college ages
    –May have associated lymphadenopathy, splenomegaly, hepatitis, or encephalitis
  • Streptococcal pharyngitis
    –May be associated with scarlatiniform rash, fever >101°F (>38.3°C), exudative pharyngitis, tender cervical lymphadenopathy, and absence of cough
    –More common in winter months, ages 5–10, and with history of group A Streptococcus exposure
  • Allergic pharyngitis
  • Gonococcal pharyngitis
  • Fungal pharyngitis (e.g., Candida)
    • Foreign body in throat
      –Most often occurs in smaller children
      –Associated with sudden onset of audible wheezing, stridor, drooling
    • GERD
    • Sore throat secondary to postnasal drip
    • Irritation secondary to inhalants (e.g., cigarette smoke), chemicals (e.g., alcohol), hot foods
    • Voice abuse (e.g., excessive screaming)
    • Deep neck space infections (e.g., retropharyngeal abscess, peritonsillar abscess, Ludwig's angina)
      • Epiglottitis/bacterial tracheitis
        –Occurs in children ages 2–7 and increasingly in adults
      • Diphtheria
      • Trauma
      • Lymphadenitis (cervical)
      • Cancer (e.g., tonsillar, tongue, laryngeal, esophageal)
      • Caustic ingestions
      • Thyroiditis
      • Angina/acute coronary syndrome

      Workup and Diagnosis

      • History and physical exam often make the diagnosis
        –Consider exposure history, age, associated symptoms, past medical history (e.g. immunocompromise), use of inhaled steroids (e.g. with Candida pharyngitis), allergy history)
        –Focus on head and neck, lung, and abdominal examinations
      • Streptococcal pharyngitis is often a clinical diagnosis
        –Presence of three out of four of the following criteria suggests the diagnosis: Exudative pharyngitis (not just a red throat); tender anterior lymphadenopathy; presence or history of fever; and absence of a cough; whereas if none or one of the criteria exists, group A β-hemolytic streptococcus is unlikely
        –Streptococcal culture is the gold standard (inexpensive; identifies group A and others; 1–2 days for results)
        –Rapid strep testing is more expensive and identifies only group A strep, but gives immediate results; very specific (95%) but less sensitive (60–70%), so consider culture if negative
      • Monospot or CBC showing atypical lymphocytes is diagnostic for mononucleosis
      • X-ray for foreign body; laryngoscopy if unable to verify
      • Lateral neck X-ray may diagnose epiglottitis and retropharyngeal abscess
      • Gonococcal and diphtheria cultures if necessary
      • Barium swallow, upper GI series, or EGD for GERD

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

    • A problem with any phase of swallowing may cause dysphagia

    Oral preparatory phase
  • Decreased salivation
  • Nasal obstruction: Inability to breathe through nose may cause problems with swallowing in neonates and young infants

Oral phase
  • Cleft palate and velopharyngeal insufficiency: Inability to separate the nose/nasopharynx from the mouth may lead to nasal regurgitation during swallowing
    –Hypertrophic tonsils: Mechanical obstruction to swallowing
    –Neuromuscular problems: Prematurity, cerebral palsy, Duchenne muscular dystrophy, Guillain-Barré syndrome, Riley-Day syndrome all lead to poor coordination of swallow
    Pharyngeal phase
    • Congenital defects such as vallecular cysts or laryngeal cleft
      –Inflammatory response; e.g., GERD
      –Infectious processes
      –Viral and bacterial pharyngitis
      –Mass effect from deep neck space abscess
    • Tumors: lymphangiomas, hemangiomas, respiratory papillomas, ranulas
      –Trauma caused by foreign body or caustic ingestion

    Esophageal phase
  • Congenital lesions such as vascular lesions, webs, or rings
    • Inflammatory/infectious
      –Esophagitis (may be from GERD, allergy, Candida, or HSV)
      –Chagas disease
    • Esophageal dysmotility
      –Cricopharyngeal or lower esophageal sphincter achalasia
      –Esophageal spasm
  • Systemic
    –Diabetes mellitus, thyroid disease
    –Scleroderma, polymyositis, dermatomyositis
  • Psychological: Globus hystericus

Workup and Diagnosis

  • History
    –Fever, duration, onset, severity, frequency, odynophagia, drooling; vomiting of solids, liquids, or secretions
    –Voice changes, aspiration, weight loss or failure to thrive, foreign body ingestion, trauma, caustic ingestion
    –Liquids are least affected by obstructive lesions and first affected by neurologic disorders
    –Prenatal history: Polyhydramnios, esophageal anomalies
  • Physical exam
    –Craniofacial anomalies/defects in facial anatomy
    –Nasal exam: Mass or obstruction (6 Fr catheter should pass through in healthy newborn)
    –Mouth: Pooled secretions, mass, tonsil size, palatal motion
    –Neck: Neck mass, thyromegaly
  • Workup
    –Modified barium swallow evaluates all phases of swallowing and esophageal function
    –Flexible fiberoptic exam assesses dynamic problems
    –Rigid endoscopy: Allows for controlled airway, better optics, and removal of foreign body
    –Functional endoscopic evaluation of swallow (FEES): Evaluates pharyngeal phase, limited in children because of poor patient cooperation

» READ BOOK EXCERPT ONLINE »

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

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

  • Infectious
    –Viral
         –Adenovirus
         –Rhinovirus
         –Parainfluenza
         –Influenza
         –Coronavirus
         –Others: EBV RSV, CMV, HSV
    –Bacterial
         –Streptococcus
         –Haemophilus
         –Moraxella
         –Staphylococcus
         –Corynebacterium
    –Fungal
         –Candida
    • Inflammatory
      –Allergy
      –Gastroesophageal reflux disease
      –Sinusitis resulting in postnasal drainage
      • Tumors
        –Leukemia
        –Rhabdosarcomas
        –Squamous cell carcinoma secondary to oral ulcerations
      • Trauma
        –Foreign body ingestion
        –Caustic ingestion
        –Soft tissue injury from accidental and nonaccidental trauma
    • Systemic/rheumatologic disorders
      –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
      –Behçet syndrome
      –Reiter syndrome
      • Others
        –Cigarette smoke
        –Environmental pollutants
        –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

    Workup and Diagnosis

  • History
    –Duration, onset, severity, frequency, odynophagia, dysphagia, daycare, sick contacts, fever, malaise, headache
    –Foreign body and caustic ingestion
    –Days of school or work missed
    –Immunization history
    –Medical history: Systemic disease, connective tissue disorder
      • Physical exam
        –Nasal exam: Evidence of rhinosinusitis
        –Mouth: Ulcerations, masses, tonsil size, erythema, exudates
        –Neck: Lymphadenopathy
        –Skin: Rash
        –Chest: Wheezes, asymmetry
    • Studies
      –For pharyngitis: A major goal is to differentiate streptococcal pharyngitis from viral etiologies
      –Throat culture: 92% sensitive; 100% specific; requires 24–48 hours
      –Rapid strep test: 72–85% sensitive; 88–100% specific
      –CBC with differential for suspected mononucleosis
      –Chest X-ray (inspiratory and expiratory) for suspected foreign body
      –CT neck: When complication of infection is suspected such as abscess

    » READ BOOK EXCERPT ONLINE »

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

    ORAL OR LINGUAL MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    DIFFICULTY SWALLOWING (DYSPHAGIA): Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The age of onset is significant because carcinoma of the esophagus is rare before age 50, whereas achalasia and reflux esophagitis are more common in young and middle-aged adults. The onset is gradual in carcinoma and aortic aneurysms but more acute in reflux esophagitis and foreign bodies. Patients with achalasia have trouble swallowing both food and water, but those with carcinoma suffer the most, and often the only difficulty is swallowing food.

    Association of other symptoms and signs is important. Neurologic findings will focus on the diagnosis of bulbar and pseudobulbar palsy whereas hematemesis and heartburn will suggest esophageal carcinoma or reflux esophagitis.

    The barium swallow is still the most useful initial study to order. However, esophagoscopy and biopsy will lead to a definitive diagnosis in most cases of mechanical obstruction. If esophagoscopy is negative, one may resort to a mecholyl test to diagnose achalasia, a Tensilon test to exclude myasthenia gravis, and esophageal manometry to diagnose reflux esophagitis, scleroderma, and diffuse esophageal spasm.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

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

    If the patient's dysphagia doesn't suggest an airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

    To evaluate the patient's swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you're sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient's mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.

    » READ BOOK EXCERPT ONLINE »

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

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

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

    Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

    Introduction: Malignant Neoplasms: Diagnostic methods
    (Professional Guide to Diseases (Eighth Edition))

    A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).

    An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:

    ❑as a baseline during chemotherapy to evaluate the extent of tumor spread

    ❑to regulate drug dosage

    ❑to prognosticate after surgery or radiation

    ❑to detect tumor recurrence.

    Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.

    » READ BOOK EXCERPT ONLINE »

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

    Malignant spinal neoplasms: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    ❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.

    ❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.

    ❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)

    ❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.

    ❑ Computed tomography scan shows cord compression and tumor location.

    ❑ Frozen section biopsy at surgery identifies the tissue type.

    ❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.

    » READ BOOK EXCERPT ONLINE »

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

    Throat abscesses: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis of peritonsillar abscess usually begins with a patient history of bacterial pharyngitis. Examination of the throat shows swelling of the soft palate on the abscessed side, with displacement of the uvula to the opposite side; red, edematous mucous membranes; and tonsil displacement toward the midline. Culture may reveal streptococcal or staphylococcal infection.

    Diagnosis of retropharyngeal abscess is based on patient history of nasopharyngitis or pharyngitis and on physical examination revealing a soft, red bulging of the posterior pharyngeal wall. X-rays show the larynx pushed forward and a widened space between the posterior pharyngeal wall and vertebrae. If neck pain or stiffness occurs, look for extension to the epidural space or the cervical vertebrae. Culture and sensitivity tests isolate the causative organism and reveal the appropriate antibiotic.

    » READ BOOK EXCERPT ONLINE »

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

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

    If the patient’s dysphagia doesn’t suggest an airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

    To evaluate the patient’s swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you’re sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient’s mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.

    » READ BOOK EXCERPT ONLINE »

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

    Mouth lesions: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient’s lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially any painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.

    Palpate the neck for adenopathy, especially in patients who smoke tobacco or use alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

     More than 80% of the causes of dysphagia can be identified by history alone. Is there difficulty initiating the swallow or a sensation of the food bolus getting stuck in the chest? Oropharyngeal dysphagias cause difficulty initiating a swallow and have associated coughing, choking, or nasal regurgitation. The patient’s speech quality may have a nasal tone. Esophageal dysphagias cause patients to complain of food sticking in their throat or chest.

     A. Chronology and progression of the dysphagia. Has the dysphagia acutely progressed or has it gradually worsened over a long time? A progressively rapid course can represent mechanical obstruction secondary to tumors, other mediastinal masses, and esophageal webs or rings. Gradual dysphagias requiring progressive, forceful swallows and the Valsalva maneuver are indicative of neuromuscular motor disease. Acute dysphagia suggests infection, irritation, or food bolus impaction.

     B. Solid or liquid dysphagia. Does the patient have dysphagia for solids, liquids, or both? Solid food dysphagia and weight loss indicate mechanical obstruction; difficulty with both liquids and solids suggests neuromuscular disease. Cold foods and beverages can exacerbate neuromuscular dysphagia.

     C. Social history. Does the patient use tobacco, alcohol, or any over-the-counter (OTC) or prescription medications? Smoking causes chest malignancies, including esophageal carcinoma. Alcohol and many OTC and prescription medications decrease esophageal motility, relax the lower esophageal sphincter, or induce esophagitis directly (4).

     D. Associated symptoms. Pain with swallowing can be associated with achalasia or spasm. Pain on swallowing saliva alone suggests mucosal inflammation from infection. Heartburn and dysphagia for solids indicate distal esophageal stricture from reflux. Are there associated neurologic symptoms consistent with a stroke (Chapter 4.8)?

     E. Evidence of aspiration. Does the patient cough when swallowing? Does the cough occur in the oropharyngeal stage or esophageal stage of swallowing? Pneumonia or other chest infection without a cough can indicate silent aspiration.

    Physical examination

    A general physical examination and focused organ- or symptom-specific examinations based on the history often confirm the cause of the patient’s dysphagia.

     A. Focused examination. Assess mental status, motor and sensory functioning, deep tendon reflexes, cerebellar function, and cranial nerves. Focus special attention on the cranial nerves (CN) associated with swallowing (CN IX, X). A decreased gag reflex is associated with an increased risk of aspiration. Inspect the oropharynx and note the patients’speech. A widened anteroposterior chest diameter and distant breath sounds are signs of chronic obstructive lung disease and may indicate chronic aspiration.

     B. The swallow. Observe the patient swallowing a variety of liquids and solids. Can the patient chew, mix, and propel a food bolus to the posterior pharynx without choking or coughing? When in the swallowing sequence does the patient complain of difficulty?

    » READ BOOK EXCERPT ONLINE »

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

    Sore Throat: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Rhinovirus

    ❑ Group A streptococci

    ❑ Ebstein-Barr virus

    ❑ Adenovirus

    ❑ Influenza

    ❑ Candida/thrush

    ❑ Herpes simplex virus

    ❑ Peritonsillar abscess

    ❑ Mycoplasma pneumoniae

    ❑ Coxsackievirus

    ❑ Primary HIV

    ❑ Neisseria gonorrhea

    ❑ Epiglottitis

    ❑ Corynebacterium diphtheriae

    ❑ Leukemia

    Diagnostic Approach

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    dysphagia/Heartburn: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Dysphagia

    ❑ Infectious esophagitis

    ❑ Reflux stricture

    ❑ Zenker diverticulum

    ❑ Transfer dysphagia

    ❑ Diffuse esophageal spasm

    ❑ Foreign body

    ❑ Esophageal cancer

    ❑ Achalasia

    ❑ External compression

    ❑ Scleroderma

    ❑ Myasthenia gravis

    ❑ Radiation injury

    ❑ Globus hystericus

    ❑ Esophageal web

    ❑ Botulism

    Heartburn

    ❑ Reflux esophagitis

    ❑ Drugs

    ❑ Gastritis

    ❑ Pregnancy

    ❑ Aerophagia

    ❑ Infectious esophagitis

    ❑ Scleroderma

    Diagnostic Approach

    Dysphagia, a sensation of sticking usually occurs at the level of the obstruction, although distal esophageal obstruction may be referred to the suprasternal notch. Odynophagia (painful swallowing) is usually caused by infectious esophagitis (Candida, HSV, CMV), severe reflux, or pill-induced esophagitis. Phagophobia (fear of swallowing) can occur in patients with hysteria, rabies, tetanus, or pharyngeal paralysis.

    Weight loss may occur with dysphagia of any cause, but a major loss disproportionate to the dysphagia suggests cancer. Hoarseness occurring before dysphagia is consistent with a laryngeal lesion. Hoarseness occurring after the onset of dysphagia suggests recurrent laryngeal involvement with esophageal or bronchogenic cancer or laryngitis due to reflux or neuromuscular disease. Hiccups signal a problem in the terminal esophagus (cancer, achalasia, hiatal hernia). Progressive dysphagia is usually caused by cancer or a peptic stricture, while intermittent dysphagia is most often due to a lower esophageal ring. Unilateral wheezing with dysphagia indicates a mediastinal mass involving both the esophagus and bronchus.

    History differentiates mechanical obstruction from motor disorders with 80% accuracy.

    Heartburn is typically a retrosternal burning, occurring after meals or awakening the patient from sleep. Patients may regurgitate acid and small amounts of undigested food without nausea or retching. Less common symptoms include water brash, a foamy reflex hypersalivation, and globus, the constant sensation of a lump in the throat. The correlation between severity of heartburn and endoscopic grade of esophagitis is poor.

    Early evaluation is indicated by coincident symptoms such as dysphagia, severe nausea, vomiting, weight loss or bleeding, lack of response to empiric therapy, or increase in symptoms with exertion (suggesting angina). Heartburn can mimic angina, with chest pressure radiating to the jaw or shoulder. Pain
    or difficulty swallowing suggests active inflammation, malignancy, achalasia, or stricture. Nocturnal pain relieved by intake of food, milk, or antacids favors
    peptic ulcer disease. Pain increased by meals and not interfering with daily
    activities favors nonulcer dyspepsia.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

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

    If the patient’s dysphagia doesn’t suggest airway obstruction, begin a health history. Ask whether swallowing is painful and if so, is the pain constant or intermittent? Have the patient point to the location of the most intense dysphagia. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

    Physical examination

    To evaluate the patient’s swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you’re sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient’s mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.

    » READ BOOK EXCERPT ONLINE »

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

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

    If the patient’s dysphagia doesn’t suggest airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

    » READ BOOK EXCERPT ONLINE »

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

    Mouth lesions: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed any pain, odor, or drainage. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, frequency of dental examinations, and the date of his most recent dental visit.

    » READ BOOK EXCERPT ONLINE »

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

    Infection

    Pharyngitis/Tonsillitis

    Viral

  • Severalviruses may cause pharyngitis/tonsillitis, including parainfluenzaviruses, influenza viruses, rhinoviruses, coronaviruses, and respiratorysyncytial virus. Coryza and cough predominate, whereas fever isvariable finding. Nasal wash cultures are diagnostic but usuallyunnecessary for management.
  • Enteroviruses also may cause sore throatand fever, especially in summer months, but tonsillar exudate isunusual.

  • Herpanginais characterized by fever and painful vesicular lesions on pharynxand tonsils.
  • Coxsackie A16 is major cause of hand-foot-mouthdisease, which is characterized by vesicular lesions in the mouthand on hands and feet.
  • Herpes simplex virus produces acutegingivostomatitis with fever and painful vesicles usually confinedto anterior mouth. However, lesions may extend to anterior tonsillarpillars.
  • Epstein-Barr virus is common causeof sore throat in adolescents. Other characteristic findings ofinfectious mononucleosis include fever, malaise, fatigue, cervicalor generalized lymphadenopathy, and hepatosplenomegaly. >10% atypicallymphocytes are usually seen on blood smear. Positive mono spottest, which identifies immunoglobulin M (IgM) heterophile antibody,is diagnostic. When this test is negative, IgG and IgM antibodyagainst viral capsid antigen (VCA) should be determined. Presenceof IgM-VCA is associated with recent or current illness and confirmsdiagnosis, whereas IgG-VCA is present continuously after acute infection.
  • Adenovirus may cause pharyngoconjunctivalfever. Follicular hyperplasia of tonsils and exudate may be seen.

    • Bacterial

    Group A Streptococcus

  • Most commonbacterial cause of pharyngitis/tonsillitis is group A Streptococcus.
  • Classic clinical presentation is school-agedchild with acute onset of fever and sore throat. Headache, abdominalpain, and vomiting also may occur. Rhinorrhea, cough, conjunctivitis,hoarseness, and diarrhea are unusual. Tonsils are enlarged and inflamed,with patches of exudate. Petechiae may sometimes be seen on palate.
  • Anterior cervical lymph nodes may beenlarged on 1 or both sides and are often tender.
  • Usual clinical dilemma is to distinguishbetween viral infection or group A streptococcal infection. Difficultto distinguish them clinically, except when typical erythematoussandpaper-like rash of scarlet fever occurs, which signifies infectionwith group A Streptococcus.
  • Rapid techniques are now availablefor detection of streptococcal antigen. Either rapid antigen testor throat culture should be performed if streptococcal pharyngitisis suspected. If antigen assay is negative, throat culture shouldbe obtained.

    • Other Bacteria

  • Pharyngitiscaused by group C or G Streptococcus is indistinguishable from that causedby group A Streptococcus.
  • A. hemolyticum produces illness similarto group A Streptococcus. Scarlet fever–like rash occursmost often in adolescents, but strawberry tongue and palatal petechiaehave not been described.
  • N. gonorrhoeae pharyngitis can occurin sexually active adolescents as consequence of oral-genital contact.Ulceration of pharynx and tonsils along with exudate may be seen.Its presence in younger children suggests sexual abuse.
  • M. pneumoniae is uncommon cause ofpharyngitis, whereas C. diphtheriae is rare cause of pharyngitis.With the latter infection, acute onset of fever and sore throatis followed in 1–2 days by grayish membrane over pharynxand tonsils, which may extend into larynx and trachea.
  • Positive throat culture confirms diagnosisof these pathogens.

    • Peritonsillar, Retropharyngeal, and Lateral Pharyngeal Abscesses

  • Generallydue to spread of infection from local sites.
  • Most common pathogens are aerobes (groupA Streptococcus, S. aureus, H. influenzae) and anaerobes (Peptostreptococcus,Fusobacterium, Prevotella, Porphyromonas species), although manyinfections are polymicrobial.
  • Peritonsillar abscess generally occursas complication of acute bacterial tonsillitis in older childrenand adolescents. Sore throat, fever, pain on swallowing, drooling,and trismus characterize this infection. Ipsilateral otalgia alsomay occur. Swollen inflamed tonsil has fluctuant quality and oftenpushes uvula across midline of oral cavity. Diagnosis is clinical,although specific pathogen can be cultured from infected tonsilor abscess drainage.
  • Although retropharyngeal abscess/cellulitisis uncommon cause of sore throat, it usually occurs in children <4yrs. Most children appear toxic and are in respiratory distress,but some complain of sore throat and painful swallowing early incourse. Often direct visualization is impossible and lateral neck radiographyshows bulge of posterior pharyngeal wall. If diagnosis is uncertain,CT can be performed.
  • Lateral pharyngeal abscess usuallypresents with fever and trismus as well as swelling and tendernessbelow mandible. CT is helpful in determining extent of abscess.

    • Irritants

  • Upon awakeningin morning, otherwise well child may have scratchy sore throat, whichusually improves over several hours. This sensation is usually dueto dryness of pharynx and frequently occurs with rhinitis, especiallyduring winter months when humidity is low and mouth breathing islikely because of nasal congestion.
  • Exposure to dust or smoke also maycause irritation of pharynx.
  • Postnasal drip secondary to allergicrhinitis or sinusitis also may cause pharyngeal irritation and mildsore throat.

    • Trauma

  • Excessiveuse of voice due to prolonged shouting or singing may cause sore throat.
  • Burn secondary to exposure of hot gasesor liquid also may cause pharyngeal pain.

    • Foreign Body

  • Foreignbody lodged in pharynx causes acute onset of choking, dysphagia,and sometimes upper airway obstruction.
  • Commonly, fish bone or chicken bonecan be seen in pharynx. Otherwise, neck radiography may be diagnostic.
  • Only symptom of retained foreign bodyin upper airway may be persistent stridor. In this circumstance,laryngoscopy is usually diagnostic.

    • Caustic Substances

  • Ingestionof caustic substances may cause inflammation of pharynx.
  • History and physical exam are diagnostic.
  • For suspected esophageal injury, esophagoscopyshould be performed.

    • Psychogenic

    Sometimes there does not seem to be explanationfor sore throat after history, physical exam, negative throat culture,and normal neck radiographs. In this case, psychosocial historyis most valuable clinical tool.

    Diagnostic Approach

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

    » READ BOOK EXCERPT ONLINE »

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

    Dysphagia: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient's dysphagia doesn't suggest an airway obstruction, begin a health history. Ask the patient if swallowing is painful. If so, is the pain constant or intermittent? Have the patient point to where dysphagia feels most intense. Does eating alleviate or aggravate the symptom? Are solids or liquids more difficult to swallow? If the answer is liquids, ask if hot, cold, and lukewarm fluids affect him differently. Does the symptom disappear after he tries to swallow a few times? Is swallowing easier if he changes position? Ask if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.

    To evaluate the patient's swallowing reflex, place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise, the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if you're sure he has a good swallow or cough reflex. Listen closely to his speech for signs of muscle weakness. Does he have aphasia or dysarthria? Is his voice nasal, hoarse, or breathy? Assess the patient's mouth carefully. Check for dry mucous membranes and thick, sticky secretions. Observe for tongue and facial weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to swallow.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Mouth lesions: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin your evaluation with a thorough history. Ask the patient when the lesions appeared and whether he has noticed odor or drainage or experienced pain. Also ask about associated complaints, particularly skin lesions. Obtain a complete drug history, including drug allergies and antibiotic use, and a complete medical history. Note especially malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma. Ask about his dental history, including oral hygiene habits, the frequency of dental examinations, and the date of his most recent dental visit.

    Next, perform a complete oral examination, noting lesion sites and character. Examine the patient's lips for color and texture. Inspect and palpate the buccal mucosa and tongue for color, texture, and contour; note especially painless ulcers on the sides or base of the tongue. Hold the tongue with a piece of gauze, lift it, and examine its underside and the floor of the mouth. Depress the tongue with a tongue blade, and examine the oropharynx. Inspect the teeth and gums, noting missing, broken, or discolored teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums. Note any odor.

    Palpate the neck for adenopathy, especially in patients who use tobacco or ingest alcohol excessively.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    ORAL OR LINGUAL MASS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Most of these lesions are referred to the oral surgeon for diagnosis and treatment, so an elaborate discussion of the workup is unnecessary in a text of this scope. Obviously, cultures should be made in cases of suspected infectious granulomas, whereas biopsy or excision is the main diagnostic tool for neoplasms.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and to start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    DIFFICULTY SWALLOWING (DYSPHAGIA): Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The age of onset is significant because carcinoma of the esophagus is rare before age 50, whereas achalasia and reflux esophagitis are more common in young and middle-aged adults. The onset is gradual in carcinoma and aortic aneurysms but more acute in reflux esophagitis and foreign bodies. Patients with achalasia have trouble swallowing both food and water, but those with carcinoma suffer the most, and often the only difficulty is swallowing food. Association of other symptoms and signs is important. Neurologic findings will focus on the diagnosis of bulbar and pseudobulbar palsy whereas hematemesis and heartburn will suggest esophageal carcinoma or reflux esophagitis. The barium swallow is still the most useful initial study to order. However, esophagoscopy and biopsy will lead to a definitive diagnosis in most cases of mechanical obstruction. If esophagoscopy is negative, one may resort to a mecholyl test to diagnose achalasia, a Tensilon test to exclude myasthenia gravis, and esophageal manometry to diagnose reflux esophagitis, scleroderma, and diffuse esophageal spasm.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Throat cancer

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