Diseases » Urticaria » Diagnosis

Diagnosis of Urticaria

Urticaria Diagnosis: Book Excerpts

• Ask the following questions - EDEMA, GENERALIZED
• Ask the Following Questions - PERIORBITAL EDEMA
• Ask the following questions - EDEMA, LOCALIZED
• Ask the Following Questions - RASH--DISTRIBUTION
• Ask the Following Questions - RASH--MORPHOLOGY
• Differential Diagnosis - Urticaria
• Differential Diagnosis - Periorbital Edema
• Differential Diagnosis - Pruritis without Rash
• Differential Diagnosis - Pruritis with Rash
• Differential Diagnosis - Rash with Fever
• Differential Diagnosis - Peripheral Edema
• Differential Diagnosis - Scalp Rash
• Differential Diagnosis - Urticaria
• Differential Diagnosis - Periorbital Edema
• Differential Diagnosis - Edema
• Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
• Approach to the Diagnosis - RASH, GENERAL
• Approach to the Diagnosis - RASH, LOCAL
• History and physical examination - Pustular rash
• History - Urticaria [Hives]
• History and physical examination - Edema, generalized
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the leg
• History and physical examination - Papular rash
• Diagnosis - Urticaria and angioedema
• Diagnosis - Pulmonary edema
• History and physical examination - Pustular rash
• History - Urticaria [Hives]
• History and physical examination - Edema, generalized
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the face
• History and physical examination - Edema of the leg
• History and physical examination - Papular rash
• History - Urticaria
• History - Rash Accompanied by Fever
• History - Edema
• Differential Overview - Urticaria/Angioedema
• Differential Overview - Edema
• Differential Overview - Scaling Rash
• Diagnosis - Urticaria and angioedema
• Diagnosis - Pulmonary edema
• History - Urticaria
• History - Edema, facial
• History - Edema, generalized
• History - Pustular rash
• History - Urticaria
• History - Edema, generalized
• History - Edema of the arm
• History - Edema of the face
• History - Edema of the leg
• History - Papular rash
• Clinical Features and Diagnosis - Edema
• History and physical examination - Pustular rash
• History and physical examination - Urticaria [Hives]
• History and physical examination - Edema, generalized
• History and physical examination - Edema of the arm
• History and physical examination - Edema of the face
• History and physical examination - Edema of the leg
• History and physical examination - Papular rash
• Approach to the Diagnosis - EDEMA OF THE EXTREMITIES
• Approach to the Diagnosis - RASH, GENERAL
• Approach to the Diagnosis - RASH, LOCAL
• I. History of Present Illness - Rash - Case 9-2 7-Week-Old Girl

Diagnostic Tests for Urticaria: Online Medical Books

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EDEMA, GENERALIZED: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Does the edema pit on pressure? Edema that pits on pressure is more likely to be due to heart, liver, or kidney disease. Edema that does not pit on pressure is more likely due to myxedema or lymphedema.
2. Is there hepatomegaly? If there is hepatomegaly, one should consider liver disease such as cirrhosis or cardiac disease.
3. Is there ascites? If there is ascites along with hepatomegaly, cirrhosis of the liver is the most likely cause of the edema. However, one should not forget constrictive pericarditis. If there is no ascites along with the hepatomegaly, then congestive heart failure should be considered.
4. Is there jugular vein distention? Jugular vein distention certainly would be most suggestive of congestive heart failure, but other causes of jugular vein distention include superior vena cava syndrome due to a mediastinal mass such as carcinoma of the lung and constrictive pericarditis. Right heart failure secondary to pulmonary emphysema and fibrosis can also cause jugular vein distention.
5. Is there an abnormal urinary sediment? If there is an abnormal urinary sediment, consider nephritis, whether it might be due to chronic glomerulonephritis or whether it is secondary to diabetes mellitus or a collagen disease.
6. Is the patient taking any drugs that could cause the edema? Among the drugs that should be considered are corticosteroids, progesterone, estrogen, anti-inflammatory drugs such as naproxen (Naprosyn®) and ibuprofen (Motrin®), antihypertensive drugs such as methyldopa (Aldomet®) and clonidine hydrochloride, calcium channel blockers, beta-adrenergic blockers, and antidepressants.

DIAGNOSTIC WORKUP

A CBC should be done to rule out significant anemia that may be the cause of the edema. If there is anemia, we need to determine its source. Liver function tests are done to rule out liver disease, and serum protein electrophoresis and tests for BUN and creatinine should be done to exclude renal disease. The urinalysis is very important both for the routine studies and also to examine the urinary sediment for diseases such as chronic glomerulonephritis and collagen disease. If there is significant loss of protein in the urine, one should be considering nephrosis. An EKG, chest x-ray, and venous pressure and circulation time will be extremely helpful in diagnosing congestive heart failure, but pulmonary function tests can be done as the vital capacity is significantly reduced in this disease. When there is a strong suspicion of congestive heart failure, echocardiography or radionuclide-gated blood pool scintigraphy should be done to determine the left ventricular ejection fraction (LVEF). A value of less than 45% is considered abnormal. A thyroid profile should be done to diagnose myxedema. A CT scan of the chest will help diagnose constrictive pericarditis. Occasionally, the edema is due to an abdominal tumor. A CT scan of the abdomen and pelvis will be helpful in those cases. Contrast lymphangiography may be necessary to diagnose lymphedema.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PERIORBITAL EDEMA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there a periorbital or facial rash? The presence of a periorbital or facial rash should suggest contact dermatitis, angioneurotic edema, trichinosis, and herpes zoster. Remember, herpes zoster is usually unilateral.
2. Is there a generalized edema? The presence of generalized edema suggests myxedema, cirrhosis, acute and chronic glomerulonephritis, congestive heart failure, and other disorders.
3. Is there fever? The presence of fever suggests acute sinusitis, cavernous sinus thrombosis, orbital cellulitis, meningitis, and neurosyphilis.

DIAGNOSTIC WORKUP

Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, thyroid profile, chest x-ray, VDRL test, and x-ray of the sinuses and orbits. If there is fever, a nose and throat culture and blood culture should be done and antibiotics begun without delay. A CT scan of the brain and sinuses probably ought to be done in these cases, but why not get an ear, nose, and throat or neurologic consultation first?

If there is generalized edema, the workup should proceed as outlined on page 138 .

Trichinosis can be diagnosed by the skin test, serologic studies, or a muscle biopsy. Superior vena cava syndrome may be diagnosed by a chest x-ray in many cases, but a CT scan of the mediastinum may be necessary.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

EDEMA, LOCALIZED: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the edema acute or chronic? Acute edema, if it is localized, should always bring to mind a deep vein thrombophlebitis. It also should bring to mind acute lymphangitis, particularly if there is erythema in the area. Finally, it should also make one think of trauma or a focal infection such as cellulitis. Chronic localized edema, on the other hand, is more likely related to varicose veins or lymphedema.
2. Is the edema pitting or nonpitting? If the edema pits, it is more likely related to inflammation or venous incompetence. If it is nonpitting, it is more likely due to obstruction of the lymphatics, i.e., lymphedema.
3. Is there erythema, a rash, or focal tenderness, or all three? Erythema and focal tenderness would suggest cellulitis, lymphangitis, thrombophlebitis, angioneurotic edema, insect bite, or snake bite. It also would suggest a sprain or contusion. Focal tenderness alone with pitting edema and no significant erythema or rash would suggest a deep vein thrombophlebitis. When there is no erythema or tenderness in a case of pitting edema of a localized nature, one should consider varicose veins or, in the lower extremities, a popliteal cyst that might be obstructing the veins on a chronic basis.
4. If the edema is of the lower extremities, is there a positive Homans' sign? A positive Homans' sign should always be looked for because this would suggest a deep vein thrombophlebitis. Action must be taken immediately in such cases.

DIAGNOSTIC WORKUP

A venous ultrasound study, impedance plethysmography, and contrast venography are very useful in the diagnosis of deep vein thrombophlebitis. d -dimer testing is also a sensitive indicator of active deep vein thrombophlebitis and the need for anticoagulants. Patients with suspected cellulitis or osteomyelitis should have a CBC, sedimentation rate, and cultures of the blood or any fluid that is available from the site of the lesion, either direct or by aspiration. X-rays and CT scans of the involved area are useful as well. Bone scans are often of value in diagnosing osteomyelitis and fractures. Lymphangiography will be helpful in the diagnosis of carcinomatosis or lymphedema from other causes. A CT scan of the abdomen or pelvis may also demonstrate the malignant lymph nodes. A thyroid profile will diagnose cases of pretibial myxedema due to thyrotoxicosis. Patients with upper extremity edema should have a chest x-ray and CT scan of the mediastinum to determine the causes of superior vena cava syndrome.

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RASH--DISTRIBUTION: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is it focal or diffuse? Focal rashes suggest the dermatophytoses, scabies, actinic dermatitis, herpes zoster, warts, contact dermatitis, erythema nodosum, actinic dermatosis, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, pyoderma, acne vulgaris, herpes simplex, impetigo, and tuberous sclerosis. Diffuse rashes suggest xanthoma, erythema multiforme, psoriasis, lichen planus, eczema, drug eruptions, dermatitis herpetiformis, secondary syphilis, exfoliative dermatitis, and pemphigus. A diffuse rash also may be due to pityriasis rosea and tinea versicolor.
2. If diffuse, is it primarily the extremities that are involved? A diffuse rash that involves primarily the extremities would suggest smallpox and erythema multiforme, eczema, milium, lichen planus, and psoriasis.
3. If diffuse, does it involve primarily the face and trunk? A diffuse rash that involves primarily the face and trunk suggests chickenpox, typhoid fever, German measles, pityriasis rosea, tinea versicolor, and pemphigus.
4. If focal, does it primarily involve the extremities? A focal rash that involves primarily the extremities suggests dermatophytosis, erythema nodosum, contact dermatitis, warts, discoid lupus, actinic dermatosis, scabies, dyshidrosis, skin tumors, nummular eczema, stasis dermatitis, and pyoderma.
5. If focal, is it primarily involving the face and head? A rash that involves primarily the face and head should suggest acne vulgaris, acne rosacea, seborrheic dermatitis, herpes simplex, actinic dermatosis, carcinoma, impetigo, contact dermatitis, Sturge-Weber syndrome, tuberous sclerosis, and tinea capitis.
6. Is it equally distributed to the trunk and extremities? A rash that is equally distributed to the trunk and extremities would suggest herpes zoster, neurofibromatosis, scarlet fever, drug eruptions, dermatitis herpetiformis, secondary syphilis, measles, and exfoliative dermatitis.

DIAGNOSTIC WORKUP

If there are any exudates, a smear and culture for fungi and routine bacteria should be done. Skin scrapings may be examined microscopically with a saline or potassium hydroxide preparation to rule out scabies and fungi. A Wood's lamp examination is very useful in diagnosing various fungi. All isolated lesions should be biopsied.

Diffuse rashes require routine CBC, sedimentation rate, urinalysis, chemistry panel, ANA test, and VDRL test. If there is fever, blood cultures should probably be done. Skin biopsies in consultation with a dermatologist should be done in a timely fashion. Patch testing and intradermal skin testing should be done when appropriate. A dark field examination may be necessary. GI series and barium enemas may be necessary to look for GI neoplasms, Crohn's disease, and ulcerative colitis.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

RASH--MORPHOLOGY: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the rash macular or papular? A macular or papular rash would suggest scarlet fever, measles, erythema multiforme, exfoliative dermatitis, pityriasis rosea, eczema, contact dermatitis, secondary syphilis, drug eruption, and actinic dermatoses.
2. Is the rash pustular? A pustular rash suggests staphylococcus, scabies, secondary syphilis, acne, folliculitis, and dermatophytosis.
3. Is the rash vesicular or bullous? A bullous or vesicular rash would suggest chickenpox, smallpox, dermatitis herpetiformis, contact dermatitis, pemphigus, herpes zoster, bullous impetigo, herpes simplex, dyshidrosis, and nummular eczema.
4. Is the rash scaly? A scaly rash suggests ichthyosis, psoriasis, lichen planus, neurodermatitis, dermatophytosis, exfoliative dermatitis, and drug eruptions.
5. Are there ulcers? The presence of ulcers in the lesions would suggest basal cell carcinoma, syphilis, lupus erythematosus, diabetic ulcers, ischemic ulcers, pyoderma gangrenosum, and ecthyma.
6. Is there fever? The presence of fever suggests scarlet fever, measles, erythema multiforme, exfoliative dermatitis, serum sickness, chickenpox, and smallpox.

DIAGNOSTIC WORKUP

This can be found under Rash--Distribution.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

• Idiopathic urticaria without angioedema
  –Most common diagnosis in patients with hives
  –Often related to food or drug allergies, bites, or stings
  –25% of patients with one episode will progress to chronic urticaria

• Chronic urticaria
  –Idiopathic in 50% of cases
  –Chronic idiopathic urticaria spontaneously resolves within 2 years in 80% of patients
  –Criterion for chronic urticaria is duration of more than 6 weeks
• Occult infection (e.g., sinusitis, oral infection, cholecystitis, vaginitis, prostatitis, hepatitis, HIV, tinea manus or pedis)
• Malignancy
• Thyroid disease
• Drugs (e.g., radiocontrast media, penicillin, salicylates, benzoates, azo dyes)
  –May result in life-threatening episodes of urticaria and acute angioedema that can lead to anaphylaxis
• Urticaria secondary to physical stimuli [e.g., exercise (cholinergic), vibratory pressure, sun exposure (solar urticaria), cold exposure]
  –Dermographism occurs in 5% of the population; manifests as a physical urticaria that arises in the distribution line of a scratch or rubbed skin area
• Hereditary or acquired deficiency of complement factor C1
  –Generally appears as episodic angioedema in the absence of urticaria
  –Only in the absence of urticaria should hereditary or acquired complement deficiency be considered

• Angioedema-urticaria-eosinophilia syndrome
  –Associated with elevated serum IgE, fever, and fluid retention during an acute attack
• Urticarial vasculitis
  –Presents as urticaria that lasts longer than 12–24 hours
  –Associated with autoimmune disease (e.g., systemic lupus erythematosus)
• Cutaneous mastocytosis/urticaria pigmentosa

Workup and Diagnosis

• Complete history and physical examination
  –Family history of angioedema, anaphylaxis, etc.
  –Seasonal or activity-related (work/home) symptoms
  –Note whether urticaria occurs after ingestion of certain foods or with physical stimuli (e.g., exercise, pressure)
  –Physical exam should evaluate for underlying occult infections (e.g., UTI, vaginal yeast infection, tinea)
  –Firmly trace the blunt tip of a cotton applicator across the patient's back; patients with dermographism will develop a pruritic urticarial wheal within 5 minutes

• Determine whether the patient has isolated urticaria, urticaria with angioedema, or isolated angioedema
• Consider sinus X-rays, T₄, TSH, and thyroid antibodies
• In isolated angioedema without urticaria, check C2, C4, and/or C1 esterase inhibitor serum levels
• IgE level measurement is indicated if angioedema-urticariaeosinophilia syndrome is suspected
• If urticarial lesions last longer than 12–24 hours, a punch biopsy of the involved skin is indicated to confirm the presence of vasculitis
• Perform age-appropriate malignancy screening
• If a cause cannot be found, consider referral to a dermatologist to rule out an occult etiology, although many cases will ultimately be deemed idiopathic

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Source: In a Page: Signs and Symptoms, 2004

Periorbital Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Conjunctivitis
• Allergy
  –Systemic (e.g., reaction to medication, urticaria/angioedema)
  –Local (e.g., insect bite)
• Contact dermatitis/dermatitis medicamentosa
• Chalazion
  –Zeis or Meibomian gland obstruction of eyelid
• Orbital disease (see “Proptosis/Exophthalmos” entry)
• Preseptal/periorbital cellulitis
• Acute dacryocystitis (infection of the lacrimal ducts)
• Orbital fat herniation through attenuated or dehiscent orbital septum and/or orbicularis oculi muscle (aging changes)
• Herpes simplex/zoster
• Blepharitis/dermatitis
• Trauma/postsurgical (e.g., orbital fracture)
• Dermatomyositis/polymyositis
  –Associated with a heliotropic (violet colored) rash on the upper eyelids
• Chemical, ultraviolet, or thermal burn
• Cardiac failure (generalized edema)
• Renal failure
• Nephrotic syndrome
• Blepharitis/rosacea
• Dacryoadenitis
• Hypothyroidism
  –Associated with fatigue, pretibial edema, and delayed relaxation of reflexes
• Superior vena cava syndrome
• Sebaceous gland carcinoma
• Squamous or basal cell carcinoma
• Discoid lupus
• Ocular cicatricial pemphigoid (symblepharon)

Workup and Diagnosis

• History should include symptom course, exposure history (allergens, irritants, chemicals, ultraviolet, or thermal injury), associated symptoms, past medical and family history, and medication history
• Physical exam, including a full ophthalmologic exam for erythema, tenderness, cutaneous vesicles, discharge, proptosis, vision changes, and conjunctival injection or chemosis
• Initial laboratory evaluation may include CBC with differential, electrolytes, BUN, creatinine, TSH, ESR, ANA, albumin, and urinalysis
• Culture and Gram stain of eye discharge if infection is considered
• Consider CT/MRI of orbits, neck, and/or chest as appropriate
• Consider biopsy of suspicious or persistent lesions
• Consider echocardiogram if heart failure is being considered
• Consider ophthalmology consultation

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Source: In a Page: Signs and Symptoms, 2004

Pruritis without Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Hepatobiliary disorders
  –Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
  –Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
  –Biliary obstruction: Pruritus not a presenting symptom
• Endocrine disorders
  –Hypo- and hyperthyroidism

• Hematopoietic disorders
  –Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
  –Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
  –Iron deficiency anemia
• Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
• Malignancies: Adenocarcinoma, squamous cell carcinomas
• HIV: Increasing frequency with disease progression
• Psychogenic states: May have underlying personality disorder such as OCD
• Senescence: Elderly pruritus very common
• Drug reactions
• Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)

Workup and Diagnosis

• History and physical examination
  –A focused history including past medical history, social history, family history, and sexual history is important
  –A complete review of systems may identify underlying disease (e.g., change in bowel habits with colon cancer, cold intolerance with hypothyroidism, right upper quadrant pain with hepatic disease)
  –Complete physical examination is necessary including stool exam for occult blood, and Pap smear and pelvic examination
  –Include a full body skin exam to confirm that there are no cutaneous rashes or lesions
• Initial lab tests may include CBC with differential (look for eosinophilia associated with parasites), LFTs (alkaline phosphatase is the best screening test for hepatobiliary disorders), renal function tests, thyroid function tests
• Rule out internal malignancies (e.g., chest X-ray, mammogram, stool for occult blood)
• Other labs to consider: HIV test, hepatitis B and C panel, serum iron and ferritin, serum and urine protein electrophoresis, stool for ova and parasites, blind skin biopsy with or without immunofluorescence

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Source: In a Page: Signs and Symptoms, 2004

Pruritis with Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Infectious causes
  –Fungal infections: Dermatophyte infections (tinea), candidiasis (beefy red color with satellite papules), seborrheic dermatitis (from Pityrosporum, common in hair-bearing areas, with scale)
  –Bacterial infections: Erythrasma (from Corynebacterium), frequently in axilla
  –Viral infections: Chicken pox (Varicella)
  –Insect vectors: Scabies, pediculosis or lice (also present on spouse and other family members), flea bites (typically on legs), mosquito bites (central punctum)
  –Mixed infections: Intertrigo (present at skin folds or area of friction)
• Noninfectious causes
  –Contact dermatitis (e.g. rhus dermatitis): May be revealed in contact history, linear vesicular lesions with sharp margins
  –Atopic dermatitis: Erythematous rash in flexural areas, patient with seasonal allergies and/or asthma
  –Eczematous dermatitis: Stasis dermatitis (hyperpigmented legs of patients with vascular disease), lichen simplex chronicus (anxious patient who chronically scratches), dyshidrotic eczema (on hands and feet with scaling, erythema, and minute vesicles and painful fissures), nummular eczema (round scaly lesions on dry skin, common in the winter)
  –Pityriasis rosea: Mostly on trunk in “Christmas tree” pattern, begins as single, larger “herald” patch
  –Lichen planus: Koebner reaction (lesions occur with trauma, such as linear lesions from scratching), purple, polygonal, pruritic papules
  –Psoriasis: Koebner reaction, pink, silvery scaling plaques, extensor surfaces, nail pits
• Less common etiologies (“zebras”) include mycoses fungoides (referred to as Sézary syndrome if erythroderma, lymphadenopathy, and atypical circulating white blood cells are present), dermatitis herpetiformis, miliaria (heat rash)

Workup and Diagnosis

• History and physical examination
  –Past medical and family history (e.g., asthma, psoriasis) and exposure history (e.g., poison ivy, oak, or sumac) are important, including whether the lesions are occurring for the first time or are recurrent
  –Perform a total body skin exam to evaluate distribution of rash; evaluate especially for rashes on the extensor or flexor surfaces of skin folds, and interdigital spaces
  –Note the morphology of the lesion (e.g., macule, papule, pustule, plaque, crust, vesicle, bulla, wheal)
  –Note the configuration of the lesion [e.g., linear (Koebner reaction or contact), grouped, annular, geographic]
• Scrape lesions and perform KOH test if fungal infection is suspected (hyphae visible in dermatophyte infections, and pseudohyphae visible in Candida infections)
• Wood's lamp test: Erythrasma turns coral red
• Scrape possible burrow site to identify a mite in scabies
• Patch testing may be done if allergic contact dermatitis is suspected
• Punch biopsy may be done to establish a histologic diagnosis (e.g., mycosis fungoides)
• Anti-gliadin antibodies and/or anti-endomysial antibodies may be found in the serum of patients with dermatitis herpetiformis
• Consider referral to a dermatologist if diagnosis remains unclear

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Source: In a Page: Signs and Symptoms, 2004

Rash with Fever: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Viral exanthems
  –Leading cause of fever and rash in childhood
  –Most children present with low-grade fevers, viral prodromal symptoms, and a secondary diffuse exanthem that is usually nonspecific and morbilliform
  –Often last only a few days and requires only supportive management
• Drug reactions
  –Account for a large portion of rashes with associated fever
  –Immune complex disease or serum sickness has been reported with many medications
• Meningococcemia
  –Most common under age 1
  –After a brief prodrome; onset is abrupt with spiking fevers, diffuse purpuric lesions, delirium, and death
  –DIC and purpura fulminans with secondary necrosis of digits and limbs can occur

• Rocky Mountain Spotted Fever
  –A fulminant and deadly rickettsial disease transmitted by a tick bite
  –Only 60% of patients are aware of tick bite
  –Characteristic rash starts acrally on wrists and ankles and spreads toward the trunk
  –Initially, pink macules evolve over 10–24 hours into red papules, then purpuric macules and violaceous patches involving most of the body surface area
  –Necrosis and DIC may occur
• Toxic shock syndrome, Staphylococcus aureus, and streptococcal diseases
  –Most cases due to toxin production
  –Rapid onset of fever, hypotension with generalized skin (palms and soles common) and mucous membrane erythema (“erythroderma” in case definition), and subsequent multiorgan failure
  –Palmar/solar desquamation in 1–3 weeks
  –A morbilliform rash and skin “pain” or hyperesthesia is common
  –Nonsurgical and surgical wounds are often the source of infection in the more common nonmenstrual variant of TSS

• Fifth disease
• Measles
• Rubella
• Parvovirus
• Varicella

Workup and Diagnosis

• Because of a seemingly endless list of possible etiologies for fever and rash, a focused history and physical exam are essential to a quick, accurate diagnosis
• Determine whether the patient appears toxic; age and presence of co-morbid conditions aid diagnosis
• If there is any evidence of purpura;
  –Quickly consider the diagnosis of RMSF, meningococcemia, or systemic vasculitis
  –In the cases of meningococcemia and RMSF, the diagnosis must be made empirically, then later confirmed so that therapy is immediately initiated

Obtain bacterial cultures from any wounds, culture the pharynx if indicated, and consider skin biopsy and culture; blood cultures are indicated in toxic patients; consider immediate lumbar puncture for CSF culture and Gram stain if meningococcemia is suspected

Acute and convalescent antibody titers can confirm RMSF; skin biopsy with immunofluorescnce may demonstrate a vasculitis with visible rickettsial organisms within the endothelium

TSS is often diagnosed by history and examination alone; recent cutaneous injury and nonspecific morbilliform rash in a hypotensive patient in association with the presence of epidermal necrosis on skin biopsy can confirm the diagnosis; wound cultures with growth of staph or strep

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Source: In a Page: Signs and Symptoms, 2004

Peripheral Edema: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Venous insufficiency
  –Caused by incompetent venous valves
  –Skin characteristically has superficial varicose veins associated with a reddish-brown pretibial discoloration (“venous stasis skin changes”)
  –Swelling is typically worse after legs are held in a dependent position and is least noticeable after a night's sleep
• Congestive heart failure
  –Associated with pitting peripheral edema
  –Other signs of heart failure include a third heart sound, cardiomegaly, and hepatomegaly
• Cellulitis
  –Usually unilateral
  –Edematous legs are typically red, warm, and inflamed
  –The patient may exhibit signs of systemic toxicity with fever and leukocytosis
  • Deep venous thrombosis
    –Typically unilateral swelling
    –May exhibit a palpable cord representing a thrombosed vein
    –Homan's sign (pain in the calf with passive dorsiflexion of the foot)
    –Virchow's triad (hypercoagulable states, venous stasis, and vessel injury) are risk factors
  • Cirrhosis
    –Advanced liver disease results in hypoalbuminemia and poor venous return through cirrhotic liver tissue
    –Other stigmata of chronic liver disease include caput medusae, ascites, and spider angiomata
  • Nephrotic syndrome
    –Glomerular damage results in protein loss and decreased oncotic pressure
  • Less common etiologies (“zebras”) include filariasis (lymphatic infection by Wuchereria bancrofti worm), myxedema (seen in patients with severe hypothyroidism), Milroy's disease (congenital lymphedema), chronic lymphedema (e.g., lymphatic damage due to surgery, such as vein harvesting for CABG), and gout

  Workup and Diagnosis

  • History and physical examination should focus on time course, associated symptoms (e.g., dyspnea, urinary changes, fever), unilateral versus bilateral involvement, pitting versus nonpitting edema, and risk factors for DVT
  • Initial labs may include CBC, electrolytes, BUN/creatinine, urinalysis, coagulation studies, LFTs, serum albumin, and thyroid function tests
  • Chest X-ray may reveal signs of pulmonary edema or cardiomegaly
  • Duplex ultrasound of the legs is useful in diagnosing deep venous thrombosis
  • Echocardiography may reveal a depressed ejection fraction in cases of congestive heart failure
  • Blood cultures are often indicated in immunocompromised or systemically ill patients
  • Renal or liver biopsy may be necessary to diagnose cirrhosis or renal pathology leading to nephrotic syndrome

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Source: In a Page: Signs and Symptoms, 2004

Scalp Rash: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Seborrheic dermatitis (“cradle cap,” “dandruff”)
  –The most common scalp condition, it occurs across all age ranges
  –May be caused by Pityrosporum ovale
  –An inflammatory condition that causes itching and loose, silvery-white scale on scalp, and occasionally blepharitis
  –May also affect the eyebrows, nasolabial folds, external auditory canals, chin, anterior chest, upper back, and groin
  –Does not cause hair loss
  –The scalp is not usually erythematous, but other affected skin areas may be red, greasy, or oily

• Tinea capitis
  –Most commonly caused by Trichophyton tonsurans or rarely Microsporum canis
  –Presents as patches of scale and/or pruritus with broken hairs, patchy hair loss (i.e., “black dot alopecia”)
  –May progress to a kerion (see below)

• Kerion
  –A boggy, tender, subcutaneous fungal infection (dermatophyte)
  –Often has associated drainage and hair loss

Scalp folliculitis
–Presents as recurrent, itchy, crusted papules or pustules
–An overgrowth of Staphylococcus aureus

• Psoriasis
  –Usually presents with plaques of thick, silvery, adherent scalp scale that overlies well-demarcated patches of erythema
  –Often occurs at the ears and occipital area
  –May be limited to the scalp, but often has skin disease, nail pitting, or nail dystrophy
• Dissecting cellulitis of the scalp
  –Chronic, tender, boggy, often suppurative subcutaneous fluctuant masses
  –Occurs in black patients
  –May be associated with acne keloidalis, which can cause a scarring hair loss at the occiput

• Discoid lupus
  –Presents initially as well-demarcated erythematous plaques of patchy, scarring scalp hair loss, then spreads centrifugally

Contact dermatitis

Workup and Diagnosis

• History and physical examination
  –If the scalp scale is diffuse, white, and nonadherent, seborrheic dermatitis is the likely diagnosis

Bacterial culture from any intact scalp pustule or suppurating area may be helpful to confirm bacterial folliculitis or dissecting cellulitis

KOH prep of scalp scale or scalp hair can be assessed under a microscope in the office to confirm the presence of endothrix (spores within the hair shaft) in the hair or branching hyphae in the scalp scale

Fungal cultures can be obtained from the drainage of a kerion or from scalp scale scraped by a tongue depressor or sterile toothbrush
–Hairs from the affected area can also be sent for fungal culture to rule out tinea capitus; the hairs must be plucked so that the root of the hair is available
–Cultures may take several weeks and sensitivity varies widely based on clinician technique and lab handling

• A punch or shave biopsy is usually unnecessary, but can aid in the diagnosis of seborrheic dermatitis
• In cases of tinea capitis, only M. canis, which is uncommon in the U.S., fluoresces with a Wood's lamp

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Source: In a Page: Signs and Symptoms, 2004

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

• Urticaria
  –Epidemiology: Lifetime incidence 20%; most cases resolve within 48 hours; chronic >6 weeks
  –Pathophysiology: Hypersensitivity reaction: allergens (IgE-mediated, prior sensitization), complement, and other cytokines activate mast cells and basophils to release histamine (also kinins, prostaglandins, serotonin) with plasma extravasation; wheals/hives: dermis edema
  –Triggers: Most cases are idiopathic
  –IgE-mediated: Insects (bees, wasps, scorpions, spiders, jellyfish), foods (eggs, shellfish, tree nuts, peanuts, tomatoes), drugs (penicillins, cephalosporins, NSAIDs, barbiturates, amphetamines, insulin, blood products), pollen, danders, food additives
  –Non-IgE-mediated: Infections (strep, EBV; hepatitis A, B, and C; adenovirus, enterovirus; fleas, mites), drugs (opiates, acetylsalicylic acid, local anesthetics), physical (exercise, cold/heat, UV light, water, pressure), contrast dyes, latex

• Chronic urticaria: Associated with collagen vascular diseases (SLE, cryoglobulinemia), inflammatory bowel disease, malignancy, thyroiditis, hyperthyroidism, Behçet disease, vasculitis
• Angioedema: 50% of urticaria cases; subcutaneous and mucous membrane edema
• Anaphylaxis (IgE-mediated)
  –Most potent foods: Peanuts, fish
  –Mortality: 100–500 deaths/year in U.S.
  –Associated shock has a poor prognosis
• Hereditary angioedema
  –High mortality
  –Most cases are autosomal dominant
  –C1 esterase inhibitor deficiency
  –Recurrent episodes of edema (face, upper airway, extremities)
  –Triggers: Trauma, surgery
  –Unresponsive to epinephrine, antihistamines
• Others: Erythema multiforme, mastocytosis, guttate psoriasis, flushing, cellulitis

Workup and Diagnosis

• History: Exposure to triggers, associated symptoms, symptoms of hypo-/hyperthyroidism, “feeling of impending doom” (anaphylaxis), history of atopy, family history of systemic diseases

• Physical exam
  –Wheals/hives: Transient, elevated, erythematous, severely pruritic plaques, sudden onset; each wheal lasts 30 minutes to 3 hours, reappearing in other areas
  –Papular uritcaria: 2–3 mm red papules surrounded by 10–20 mm wheals, most common in toddlers, due to fleas and mites (e.g., scabies)
  –Physical urticaria: 10–20 mm erythematous macules with central wheal
  –Angioedema: Edema of face, hands, feet, genitalia
  –Anaphylaxis: Irritability, wheals, broncho- or laryngospasm (wheezing/stridor), angioedema, hypotension (late finding in children), vomiting, bloody diarrhea, mental status change; develops over minutes to hours; may develop DIC
  –Hereditary angioedema: Nonpruritic edema

• Labs/studies
  –Urticaria/anaphylaxis: IgE antibody skin test or radioallergosorbent test for IgE-mediated causes; culture, microscopy (ova and parasites)
  –Angioedema: C1 esterase inhibitor, C3, C4
  –Chronic urticaria: ANA, urinalysis, CBC, CRP, ESR, thyroid antibodies

» READ BOOK EXCERPT ONLINE »

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

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

• Periorbital cellulitis
  –Also described as preseptal cellulitis (infection is anterior to the orbital septum and thus does not affect the orbit or globe)
  –Usual pathogens are streptococcal species, Staphylococcus aureus, and Haemophilus influenzae

• Orbital cellulitis
  –Also described as postseptal and affects the preseptal structures as well as the extraocular muscles and the optic nerve
  –Bacterial pathogens are the same as periorbital cellulitis and may reflect direct spread
  –May be accompanied by orbital abscess and may spread via the sinuses to the brain

• Other infections
  –Conjunctivitis
  –Sinusitis
  –Dental abscess
• Allergic reaction
  –Conjunctivitis
  –Urticaria/angioedema
  –Drug reaction
• Local ocular causes
  –Insect bites
  –Contact dermatitis
  –Trauma
  –Foreign body
• Systemic disorders with generalized edema
  –Hypoproteinemia
  –Renal disease
  –Congestive heart failure
• Malignancy
  –Neuroblastomas: Associated with ecchymoses, “raccoon eyes,” and proptosis
  –Leukemia: Associated with fever, fatigue, anemia, bone pain, lymphadenopathy, splenomegaly

Workup and Diagnosis

• History
  –Onset, duration, progression of symptoms
  –Presence of pain or pruritus
  –History of trauma
  –Systemic symptoms such as fever
• Physical exam
  –Temperature, vital signs, growth parameters
  –Proptosis
  –Ocular range of motion
  –Full physical exam including heart, lung, and extremities
• Labs
  –Electrolytes, BUN, creatinine
  –Serum protein and albumin
  –CBC and blood culture if infection is suspected
  –ESR, LDH if malignancy is suspected
• Studies
  –CT to distinguish periorbital cellulitis from orbital cellulitis
  –CT or MRI to discover orbital or cranial tumors
  –CXR if CHF is suspected
  –Renal ultrasound to evaluate the architecture of the kidneys, Doppler to evaluate renal flow, DMSA to evaluate renal parenchyma if edema is generalized

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

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

• Kidney disease (nephrotic syndrome)
  –Insidious onset, periorbital and lower extremity edema, abdominal distension
  –Various types include minimal change disease (MCNS), focal segmental glomerulosclerosis, acute and chronic glomerulonephritis
• Chronic renal failure from any cause may result in impaired fluid excretion
• Liver disease from any cause resulting in impaired production of albumin
• Congestive heart failure (CHF)
• Protein losing enteropathy
  –Menetrier disease (typically CMV), inflammatory bowel disease, neuroblastoma, intestinal lymphangiectasia, trypsinogen deficiency
• Celiac disease
• Sepsis, with capillary leak (movement of fluid out of the blood vessels into the interstitium)
• Hereditary angioneurotic edema
  –Intermittent swelling of extremities
  –Often preceded by trauma
  –Decreased C4 and C1 esterase inhibitor
• Rocky Mountain spotted fever
• Stevens-Johnson syndrome
• Vitamin E deficiency
• Hypothyroidism
• Severe malnutrition
  –Marasmus (calorie deficiency)
  –Kwashiorkor (protein deficiency)
• Zinc deficiency
• Hydrops fetalis
• Impaired lymphatic drainage
  –Milroy disease
  –Meigs syndrome
  –Yellow nail syndrome
  –Lymphedema praecox
• Filariasis (nematode infection resulting in elephantiasis)
• Immobility including placement of body casts and paralysis

Workup and Diagnosis

• History
  –Onset, duration, severity
  –History of heart, kidney, or liver disease; GI bleeding, hypertension, weight gain, feeding intolerance
  –Chest pain, shortness of breath, orthopnea (cardiac disease), jaundice, acholic stools, abdominal distension, GI bleeding (liver disease), oliguria, facial edema, headache or vision changes (hypertension), diarrhea, fever

• Physical exam
  –Blood pressure (hypo- or hypertension), cardiac exam (JVD, murmur)
  –Hepatomegaly, splenomegaly, ascites, scleral icterus
  –Periorbital, lower extremity or presacral edema, abdominal distension, poor peripheral perfusion

• Labs
  –Urinalysis (no proteinuria excludes renal protein loss)
  –Serum chemistries: Albumin, triglycerides, liver transaminases
  –Stool for α-1 antitrypsin for protein-losing enteropathy
  –Prothrombin time (impaired hepatic function)

• Abdominal ultrasound (for liver or kidney disease)
• Studies depending on clinical situation
  –Echocardiogram/ECG for cardiac failure
  –Renal biopsy (if kidney disease other than MCNS is suspected)
  –GI imaging or endoscopy

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

EDEMA OF THE EXTREMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Bilateral pitting edema of the lower extremities is usually due to congestive heart failure, nephrosis, or cirrhosis of the liver. Venous pressure and circulation time will rule out congestive heart failure but echocardiography can be more definitive. Serum and urine osmolality can be helpful also. If there is nephrosis, there will be significant lowering of the serum albumin level and proteinuria. Liver function studies will usually confirm cirrhosis or liver disease but ultrasonography can reveal ascites to assist in the diagnosis. Nonpitting edema of the lower extremities will usually be due to lymphatic obstruction but hypothyroidism can be ruled out with a free T4 assay or TSH. Unilateral edema of the lower extremities suggest deep vein thrombosis, which can be confirm by Doppler ultrasound studies, plethysomography, or contrast venography. A CT scan of the chest will help diagnose constrictive pericarditis, which is rarely found today. Spirometry and arterial blood gas analysis will diagnose pulmonary emphysema with cor pulmonale.

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Source: Differential Diagnosis in Primary Care, 2007

RASH, GENERAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or the if symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

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Source: Differential Diagnosis in Primary Care, 2007

RASH, LOCAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis is similar to that of the general rash (see page 446).

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Source: Differential Diagnosis in Primary Care, 2007

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

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

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

Urticaria [Hives]: History
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products or detergents? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

» READ BOOK EXCERPT ONLINE »

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

Edema, generalized: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the
day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

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

Edema of the arm: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema Pitting or nonpitting? page 240.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

» READ BOOK EXCERPT ONLINE »

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

Edema of the leg: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 240.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans' sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

» READ BOOK EXCERPT ONLINE »

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

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

Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

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

Urticaria and angioedema: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

An accurate patient history can help determine the cause of urticaria. Such a history should include:

❑ drug history, including over-the-counter preparations (vitamins, aspirin, and antacids)

❑ frequently ingested foods (strawberries, milk products, fish)

❑ environmental influences (pets, carpet, clothing, soap, inhalants, cosmetics, hair dye, and insect bites and stings).

Diagnosis also requires physical assessment to rule out similar conditions as well as a complete blood count, urinalysis, erythrocyte sedimentation rate, and a chest X-ray to rule out inflammatory infections. Skin testing, an elimination diet, and a food diary (recording time and amount of food eaten and circumstances) can pinpoint provoking allergens. The food diary may also suggest other allergies. For instance, a patient allergic to fish may also be allergic to iodine contrast materials.

Recurrent angioedema without urticaria, along with a familial history, points to hereditary angioedema. (See Hereditary angioedema.) Decreased serum levels of complement 4 and complement 1 esterase inhibitors confirm this diagnosis.

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

Pulmonary edema: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Clinical features of pulmonary edema permit a working diagnosis. Arterial blood gas (ABG) analysis usually shows hypoxia; the partial pressure of arterial carbon dioxide is variable. Profound respiratory alkalosis and acidosis may occur. Chest X-ray shows diffuse haziness of the lung fields and, commonly, cardiomegaly and pleural effusions. Ultrasound (echocardiogram) may show weak heart muscle, leaking or narrow heart valves, and fluid surrounding the heart. Pulmonary artery catheterization helps identify left-sided heart failure by showing elevated pulmonary wedge pressures. This helps to rule out acute respiratory distress syndrome — in which pulmonary wedge pressure is usually normal.

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

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

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

Examine the entire skin surface, noting if it’s dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

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

Urticaria [Hives]: History
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is it related to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has he recently used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

» READ BOOK EXCERPT ONLINE »

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

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

When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

» READ BOOK EXCERPT ONLINE »

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

Edema of the arm: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema’s severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth. Be sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting? page 292.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare the radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

» READ BOOK EXCERPT ONLINE »

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

Edema of the face: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 292.) Next, take vital signs and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.

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

Edema of the leg: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or any recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting? page 292.) Because leg edema may compromise arterial blood flow, palpate or use a handheld Doppler device to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.

» READ BOOK EXCERPT ONLINE »

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

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

Your first step is to fully evaluate the papular rash: Note its color, configuration, and location on the patient’s body. Find out when it erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have him describe associated signs and symptoms, such as fever, headache, and GI distress.

Next, obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, including any sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

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

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

A. Characteristics. Is the rash localized or systemic? Is it pruritic? What is the duration of symptoms? Does anything relieve the symptoms? Are there any specific triggers (2)?

1. Food and drugs are common causes of urticaria.

2. Certain systemic diseases can cause urticaria. Infections, connective tissue disorders, endocrine disorders, and neoplastic disorders are some examples.

3. Insect stings and bites are another common cause of urticaria.

B. Symptom chronology. When does it occur? How long does it last? Is it in association with physical trauma? Has the patient been on any medication that has helped relieve symptoms (e.g., antihistamines)?

C. Family history. Are there any members of the family who suffer from a connective tissue disorder? Do any complement disorders occur in the family, such as hereditary angioedema, which can be associated with urticaria? Also, is there a family history of atopy?

Physical examination

 A complete physical is required to rule out infection or other systemic diseases. An urticarial wheal is usually well demarcated. It begins as an erythematous area, which then develops a white center. The size of the wheal can vary from 2 mm to well over 30 cm. The rash is usually pruritic, especially when it occurs on the palms of the hand and the soles of the feet. Most often, the wheal will disappear within 3 to 4 hours of onset. The accompanying angioedema can last for a couple of days. The skin will return to normal once the wheal is gone.

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

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

History is quite important and should include standard items, such as onset, duration, aggravating factors, relieving factors, and associated symptoms. Additionally, other factors to consider, include:

 A. Exposure history. Are any other family members or close contacts ill? Is there a history of exposure to brackish water, mosquitoes, foreign travel, and so forth?

B. Are there any underlying illnesses or a significant possibility of immunologic compromise (e.g., undiagnosed HIV infection)?

Physical examination

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

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

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

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

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

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

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

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

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

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

A. Onset. When the onset of edema is sudden, consider the following possible causes: cellulitis, deep venous thrombosis (DVT), compartment syndrome, trauma, and exacerbation of chronic problems (systemic disease, medications, venous insufficiency, lymphedema).

When the onset is gradual, consider the causes listed below.

B. Clinical course. Is the edema intermittent or recurrent, or is it chronic?

C. Painful edema most likely results from (3):

1. Cellulitis

2. Trauma

3. Ruptured Baker’s cyst

4. Compartment syndrome

5. DVT

D. Painless edema or bilateral edema usually results from a systemic cause.

E. Associated systemic symptoms

1. Fever and chills can be caused by cellulitis, lymphangitis, or venous thrombosis.

2. Dyspnea and orthopnea suggest that the edema is of cardiac origin.

3. Either a history of streptococcal throat infection or recurrent urinary tract infection (UTI) points to renal causes.

F. Medications that can be associated with edema include the following: diazoxide, minoxidil, hydralazine, calcium channel blockers, alpha- and beta-blockers, reserpine, guanethidine, nonsteroidal antiinflammatory drugs (NSAIDs), carbenicillin, amantadine, lithium, phenothiazines, thioridazine, monoamine oxidase (MAO) inhibitors, corticosteroids, testosterone, estrogen, progesterone, or interleukin-2 (2, 3).

G. Endocrine diseases

1. Hypothyroidism can present with pretibial myxedema (Chapter 14.4).

2. Cushing’s syndrome can cause edema.

H. Miscellaneous causes of edema. These include:

1. Pregnancy

2. Sodium overload

3. Malnutrition

4. Stopping laxatives

5. Prolonged dependent position

6. Cyclic edema in women

7. Lymphatic obstruction (neoplastic, parasitic, iatrogenic)

8. Idiopathic

Physical examination

 A. Generalized edema manifests in the most dependent area (e.g., pedal edema in ambulatory patients, presacral edema in bedbound patients).

B. Peripheral edema (3)

1. Sparing of the feet suggests lipedema.

2. Pitting edema present for more than 3 months usually indicates a low serum protein level. Chronic edema can have fibrosis as well.

3. Assessment of color

a. Redness suggests infection or phlebitis.

b. A red-blue color suggests DVT.

c. A slightly cyanotic color bilaterally suggests CHF (Chapter 7.5).

d. The presence of ecchymosis suggests trauma.

» READ BOOK EXCERPT ONLINE »

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

Urticaria/Angioedema: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ingestants

❑ Drugs

❑ Inhalants

❑ Hymenoptera venom

❑ Latex sensitivity

❑ Dermatographism

❑ Pressure urticaria

❑ Cholinergic urticaria

❑ Cold urticaria

❑ Solar urticaria

❑ Infection

❑ Urticarial vasculitis

❑ Hereditary angioedema

❑ Mastocytosis

Diagnostic Approach

Urticaria appears as transient, mutable wheals with red raised serpiginous borders and clear centers, which often coalesce. Urticaria is experienced by 10% to 20% of the population at some time. Angioedema is well-demarcated localized edema.

The appearance may be helpful. Gyrate hives (erythema gyratum) are associated with internal malignancy. Hives without pseudopods suggest allergy. Small lesions with erythematous flares suggest cholinergic urticaria. Urticarial lesions unchanged for 24 hours suggest vasculitis, especially if associated with scaling or purpura.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Edema: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Congestive heart failure

❑ Venous insufficiency

❑ Hypoalbuminemia

❑ Drugs

❑ Cirrhosis

❑ Deep vein thrombosis

❑ Inferior vena cava obstruction

❑ Lymphatic obstruction

❑ Glomerular injury

❑ Idiopathic edema

❑ Myxedema

❑ Lipedema

❑ Toxemia

❑ Cyclical edema

❑ Refeeding

❑ Filariasis

❑ Milroy

Diagnostic Approach

The degree of edema is influenced by membrane permeability, hydrostatic pressure, and/or oncotic pressure. Edema implies an increase in interstitial volume of several liters. Low protein fluids (hypoalbuminemia, cardiac, and venous edema) pit easily and recover quickly on release. High protein fluids (cellulitis, lymphedema) resist pitting and recover slowly.

The distribution of the edema combined with an estimation of the jugular venous pressure (JVP) can help differentiate heart failure, cirrhosis, renal sodium retention and nephrotic syndrome. Anasarca suggests cardiac, renal, or hepatic disease. Splenomegaly is found more often in patients with cirrhosis than those with congestive heart failure.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Scaling Rash: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Eczema

❑ Atopic dermatitis

❑ Seborrheic dermatitis

❑ Tinea versicolor

❑ Pityriasis rosea

❑ Psoriasis

❑ Contact dermatitis

❑ Tinea corporis

❑ Tinea manuum

❑ Stasis dermatitis

❑ Drugs

❑ Lichen planus

❑ Secondary syphilis

❑ Reiter

❑ Bowen disease

❑ Cutaneous T-cell lymphoma

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Urticaria and angioedema: Diagnosis
(Handbook of Diseases)

An accurate patient history can help determine the cause of urticaria. Such a history should include:

❑  drug history, including over-the-counter preparations (vitamins, aspirin, and antacids)

❑  frequently ingested foods (strawberries, milk products, fish)

❑  environmental influences (pets, carpet, clothing, soap, inhalants, cosmetics, hair dye, and insect bites and stings).

Diagnosis also requires physical assessment to rule out similar conditions, as well as a complete blood count, urinalysis, erythrocyte sedimentation rate, and a chest X-ray to rule out inflammatory infections. Skin testing, an elimination diet, and a food diary (recording time and amount of food eaten and circumstances) can pinpoint provoking allergens. The food diary may also suggest other allergies. For instance, a patient allergic to fish may also be allergic to iodine contrast materials.

Recurrent angioedema without urticaria, along with a familial history, points to hereditary angioedema. Decreased serum levels of complement 4 and complement 1 esterase inhibitors confirm this diagnosis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Pulmonary edema: Diagnosis
(Handbook of Diseases)

Clinical features of pulmonary edema permit a working diagnosis. The following tests are also helpful:

❑ Arterial blood gas (ABG) analysis usually shows hypoxia; partial pressure of arterial carbon dioxide varies. Profound respiratory alkalosis and acidosis may occur. Metabolic acidosis occurs when cardiac output is low.

❑ Chest X-ray films show diffuse haziness of the lung fields and, often, cardiomegaly and pleural effusions.

❑ Pulmonary artery catheterization helps identify left-sided heart failure by showing an elevated pulmonary artery wedge pressure (PAWP). This helps to rule out adult respiratory distress syndrome — in which PAWP is usually normal.

❑ An echocardiogram may reveal weak heart muscle, leaking or narrow heart valves, or fluid surrounding the heart.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

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

If the patient isn’t in distress, obtain his medical history. Does he have known allergies? Does urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note a history of chronic or parasitic infection, skin disease, or GI disorder.

Physical examination

Obtain the patient’s vital signs. Perform a complete cardiopulmonary assessment, noting signs and symptoms of shock or respiratory distress. Assess for urticaria in other areas because new crops may continue to appear.

» READ BOOK EXCERPT ONLINE »

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

Edema, facial: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma and dental procedures.

Physical examination

Begin the physical examination by characterizing the edema. Is it localized and distributed over one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting? page 128.) Next, take vital signs, and assess neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for any soft-tissue swelling.

» READ BOOK EXCERPT ONLINE »

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

Edema, generalized: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

When the patient’s condition permits, obtain a complete medical history. First, note when and where the edema began. Does it move throughout the course of the day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality? 

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Physical examination

Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether his hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment. Also, obtain a baseline weight for this patient.

» READ BOOK EXCERPT ONLINE »

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

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

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied any topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

» READ BOOK EXCERPT ONLINE »

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

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

If the patient isn’t in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

» READ BOOK EXCERPT ONLINE »

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

Edema, generalized: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Ask the patient to describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

» READ BOOK EXCERPT ONLINE »

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

Edema of the arm: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When taking the patient’s history, one of the first questions to ask is “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

» READ BOOK EXCERPT ONLINE »

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

Edema of the face: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient isn’t in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

» READ BOOK EXCERPT ONLINE »

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

Edema of the leg: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury, surgery, or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

» READ BOOK EXCERPT ONLINE »

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

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

Find out when the rash erupted. Has the patient noticed any changes in the rash since then? Is it itchy or burning, or painful or tender? Have the patient describe associated signs and symptoms, such as fever, headache, and GI distress.

Obtain a medical history, including allergies, previous rashes or skin disorders, infections, childhood diseases, sexual history, sexually transmitted diseases (STDs), and cancers. Has the patient recently been bitten by an insect or a rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

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

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

Disorders with Normal Serum Albumin

Increased Capillary Permeability

Skin Disorders

Cellulitis,exfoliative dermatitis, and burns can cause increase in capillarypermeability and edema.

History and physical exam are diagnostic.

Allergic Reaction

Releaseof histamine and other vasoactive mediators can produce localizedor generalized edema.

Drugs, chemical exposure by inhalation,foods (especially milk, eggs, chocolate, nuts), and bee stings arecommon causes of allergic reactions.

Lips, eyelids, and face are frequentlyinvolved, and urticaria also may occur.

Wheezing, laryngospasm, and hypotensionmay be seen with anaphylactic reactions.

History and physical exam are usuallydiagnostic.

Vasculitis

Common causes of vasculitis causing edemainclude Kawasaki disease and collagen vascular disease.

Septicemia

Severe bacterial or rickettsial infectionscan cause increase in capillary permeability and edema.

Vitamin E Deficiency

Uncommonsince addition of vitamin E to infant formulas.

Preterm infants 4–6 wks ofage without normal intake of vitamin E may develop generalized edema,hemolytic anemia, and thrombocytosis.

Serum concentration of vitamin E islow.

Hereditary Angioedema

Deficiencyor functional defect of C1 inhibitor is responsible for this disorder,which is transmitted as autosomal-dominant trait. Gene locus hasbeen mapped to chromosome 11q11-q13.1.

In most common form (type I), serumlevels are 5–30% of normal and functional activityis diminished, whereas in type II, serum levels are normal or increased,but functional activity is decreased.

The 2 types are clinically indistinguishable.Episodic edema may involve face, trunk, and extremities. Most worrisomefeature is edema of larynx and upper airway. Episodes last severaldays, and interval between attacks can be days, months, or years.

Low serum C4 concentration is mostuseful screening test for this disease. Serum C3 concentration isnormal.

Diagnosis is confirmed by measurementof C1 inhibitor and assay of its activity.

Increased Hydrostatic Pressure

Increased Blood Volume

Administrationof excessive amounts of sodium or fluid can produce volume overloadand edema.

In cardiac failure, diminished renalblood flow leads to decrease in glomerular filtration rate (GFR)and edema.

Renal disease (e.g., glomerulonephritis)or any cause of renal failure also may lead to decrease in GFR andedema.

Increased Venous Pressure

Increasedvenous pressure from deep venous thrombosis, constrictive pericarditis, portalhypertension, or impaired venous drainage from tumor may produceedema.

Deep venous thrombosis in thigh orcalf produces pain and swelling of leg distal to thrombus. U/Sis usually diagnostic.

See Chap.30, Hepatomegaly, and Chap. 62, Splenomegaly,for discussion of constrictive pericarditis and portal hypertension.

Increased Lymph Pressure

Lymphedemais excessive accumulation of lymph in interstitial space and isprincipal cause of increased lymph pressure.

Can be congenital or acquired, sporadicor familial, and may appear at birth or in childhood or adolescence.

Abnormal development or dysfunctionof lymphatic vessels, lymph node obstruction, and venous stasisare common mechanisms producing lymphedema.

Common presentation is unilateral,painless edema of leg; however, pain may occur with massive edemaor cellulitis.

U/S and MRI are useful indetection of lymphatic malformations and obstructive lesions.

Disorders with Decreased Serum Albumin (Decreased OncoticPressure)

Disorders with Proteinuria

Any renaldisorder causing severe proteinuria may produce edema. Nephroticsyndrome and acute glomerulonephritis are common examples.

UA confirms presence of proteinuria.

See Chap.50, Proteinuria.

Disorders without Proteinuria

Acute and Chronic Liver Disease

Decreasein synthesis of albumin in liver produces hypoalbuminemia.

Serum albumin of <2.5 g/dLcauses decrease in plasma oncotic pressure and edema.

See Chap.30, Hepatomegaly, and Chap. 36, Jaundice, fordiscussion of causes of acute and chronic liver disease.

Gastrointestinal Disease

Loss ofserum albumin in GI tract leads to decreased plasma oncotic pressureand edema.

Causes of protein-losing enteropathyinclude cow milk protein sensitivity, cystic fibrosis, celiac disease,inflammatory bowel disease, and intestinal lymphangiectasia.

Screening test for protein loss instool is measurement of alpha₁-antitrypsinin spot stool sample.

See Chap.14, Diarrhea.

Protein-Calorie Malnutrition

Severe protein-caloriemalnutrition can produce edema because of decrease in serum albumin.

Growth failure, decreased muscle mass,diarrhea, hepatomegaly, anemia, pigment changes of hair and skin,fatigue, and apathy are other findings.

Edema resolves with adequate calorieand protein intake.

Congenital Albumin Deficiency

Severe edemaoccurs with congenital albumin deficiency, which is rare.

Very low or undetectable serum albuminconcentration in absence of other causes of hypoalbuminemia confirmsdiagnosis.

Hydrops Fetalis: Immune and Nonimmune

Hydrops fetalis is term used to describesevere generalized edema in fetus or newborn.Because of use of anti-D immune globulinfor Rh isoimmunization, most cases of hydrops are nonimmune type(Table 17.1 ). >

» READ BOOK EXCERPT ONLINE »

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

Pustular rash: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Have the patient describe the appearance, location, and onset of the first pustular lesion. Did another type of skin lesion precede the pustule? Find out how the lesions spread. Ask what medications the patient takes and if he has applied topical medication to his rash. If so, what type and when did he last apply it? Find out if he has a family history of a skin disorder.

Examine the entire skin surface, noting if it's dry, oily, moist, or greasy. Record the exact location and distribution of the skin lesions and their color, shape, and size.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Urticaria [Hives]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in distress, obtain a complete history. Does he have any known allergies? Does the urticaria follow a seasonal pattern? Do certain foods or drugs seem to aggravate it? Is there a relationship to physical exertion? Is the patient routinely exposed to chemicals on the job or at home? Has the patient recently changed or used new skin products or detergents? Obtain a detailed drug history, including prescription and over-the-counter drugs. Note any history of chronic or parasitic infection, skin disease, or a GI disorder.

Next, assess respiratory status. Inspect the chest for sternal retractions and accessory muscle use. Auscultate and percuss the chest. Assess cardiac status. Obtain vital signs and pulse oximetry and begin cardiac monitoring. Assess all skin surfaces.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema, generalized: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When the patient's condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day—for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?

Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.

Begin the physical examination by comparing the patient's arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the arm: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.

Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema: Pitting or nonpitting?page 226.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the face: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.

Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema: Pitting or nonpitting?page 226.) Next, take the patient's vital signs, and assess his neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Edema of the leg: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury or recent surgery or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.

Begin the physical examination by examining each leg for pitting edema. (See Edema: Pitting or nonpitting?page 226.) Because leg edema may compromise arterial blood flow, palpate or use a Doppler to auscultate peripheral pulses to detect an insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans'sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in edematous areas.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Papular rash: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Your first step is to fully evaluate the papular rash: note its color, configuration, and location on the patient's body. Find out when it erupted. Has the patient noticed changes in the rash since then? Is it itchy or burning, or painful or tender? Has there ever been discharge or drainage from the rash? If so, have the patient describe it. Also, have him describe associated signs and symptoms, such as fevers, headaches, and GI distress.

Next, obtain a medical history, including allergies; previous rashes or skin disorders; infections; childhood diseases; sexual history, including sexually transmitted diseases; and cancers. Has the patient recently been bitten by an insect or rodent or been exposed to anyone with an infectious disease? Finally, obtain a complete drug history.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

EDEMA OF THE EXTREMITIES: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Bilateral pitting edema of the lower extremities is usually due to CHF, nephrosis, or cirrhosis of the liver. Venous pressure and circulation time will rule out CHF, but echocardiography can be more definitive. Serum and urine osmolality can be helpful also. If there is nephrosis, there will be significant lowering of the serum albumin level and proteinuria. Liver function studies will usually confirm cirrhosis or liver disease, but ultrasonography can reveal ascites to assist in the diagnosis. Nonpitting edema of the lower extremities will usually be due to lymphatic obstruction, but hypothyroidism can be ruled out with a free thyroxine (T₄) or thyroid-stimulating hormone (TSH) assay. Unilateral edema of the lower extremities suggests deep vein thrombosis, which can be confirmed by Doppler ultrasound studies, plethysomography, or contrast venography. A CT scan of the chest will help diagnose constrictive pericarditis, which is rarely found today. Spirometry and arterial blood gas analysis will diagnose pulmonary emphysema with cor pulmonale.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RASH, GENERAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or if the symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RASH, LOCAL: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis is similar to that of the general rash .

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Rash - Case 9-2: 7-Week-Old Girl: I. History of Present Illness
(Pediatric Complaints and Diagnostic Dilemmas)

II. Past Medical History

III. Physical Examination

VI. Diagnostic Studies

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

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Choose ... Alzheimers & Dementia Asthma Child ADHD ADHD in Adults Allergy Hypertension Bipolar Breast Cancer Celiac Disease Crohns Disease Colon Cancer Contraception Diabetes Cancer Depression Erectile Disorder Cholesterol COPD GERD Heartburn/Reflux Metabolic Syndrome Migraine/Headache Multiple Sclerosis Obesity Osteoporosis Overactive Bladder Psoriasis Sexual Disorder Sleep Disorders Smoking The Pill Ulcerative Colitis All Common Mistakes

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