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Diseases » Urticaria » Tests
 

Diagnostic Tests for Urticaria

Contents
  1. Urticaria: Introduction
  2. Symptoms of Urticaria
  3. Diagnosis
  4. Home Diagnostic Testing
  5. Alternative Diagnoses
  6. Misdiagnosis
  7. Complications

Urticaria Tests: Book Excerpts

Home Diagnostic Testing

These home medical tests may be relevant to Urticaria:

Urticaria Diagnosis: Book Excerpts

Diagnostic Tests for Urticaria: Online Medical Books

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

EDEMA, GENERALIZED: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

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: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

This can be found under Rash--Distribution.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

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

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

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.

» READ BOOK EXCERPT ONLINE »

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.

» READ BOOK EXCERPT ONLINE »

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

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

 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.

Testing

 A. Laboratory tests. Routine tests include (a) complete blood count to look for eosinophilia, neoplastic disorders, and occult infection; (b) thyroid studies (thyroxine and thyroid-stimulating hormone; (c) erythrocyte sedimentation rate to help rule out connective tissue disorders and occult infection, urine analysis with urine culture, chemical profile, stool cultures for parasites, liver function tests, and an antinuclear antibody test. Other tests can include immunoglobulins, prick testing, rheumatoid factor, cryoglobulins, serum complement, and skin biopsy. However, laboratory tests often do not provide answers beyond those obtained in the history (3).

 B. Diagnostic imaging. Chest x-ray, sinus, and dental films may help to rule out cancer and infection.

Diagnostic assessment

It is important to rule out underlying conditions such as neoplastic disorders, endocrine disorders, connective tissue diseases, infections, and other disorders. The most significant factors in diagnosing acute urticaria are the history and physical examination. Facts must be obtained concerning food or drug ingestion, insect stings, current infections, or physical triggers such as cold or heat. Most acute urticarial reactions resolve spontaneously, but some continue and become chronic in nature. Of the chronic urticaria, a cause is found in only a few of these patients, with more than 75% of them having an idiopathic disorder (4).


References

1. Beltrani VS. Allergic dermatoses. Med Clin North Am 1998;82(5):1105–1133.

2. Greaves MW, Sabroe RA. ABC of allergies. Allergy and the skin. I—Urticaria. BMJ 1998;316(7138):1147–1150.

3. Kozel MM. The effectiveness of a history-based diagnostic approach in chronic urticaria and angioedema. Arch Dermatol 1998;134(12):1575–1580.

4. Greaves MW. Chronic urticaria [published erratum appears in N Engl J Med 1995;
333(16):1091]. N Engl J Med 1995;332(26):1767–1772.

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

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

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

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

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

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

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

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

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

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

Testing

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

Diagnostic assessment

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


References

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

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

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

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

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

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

 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.

Testing

Routine studies can include complete blood count (CBC), urinalysis, chest films, electrocardiogram (ECG), and biochemical screening to include albumin, total protein, total cholesterol, liver function tests, and thyroid function tests (4). Specific tests or imaging studies are indicated in clinical situations listed below.

Diagnostic assessment

A. Edema affecting the arms only

1. Edema exclusively of the upper extremities, caused by increased venous pressure, points to superior vena cava syndrome. A venogram will be useful.

2. If venous obstruction is suspected, obtain a venogram and Doppler or ultrasound studies.

3. If a thoracic outlet syndrome is suggested, computed tomography (CT), magnetic resonance imaging (MRI), or plain films may be helpful.

B. Edema of the arms and legs

1. Cardiac causes include CHF and constrictive pericarditis (Chapter 7.5). Diagnostic studies include a chest x-ray (CXR) study and ECG.

2. A leading hepatic cause is cirrhosis. Liver function tests are indicated.

3. Renal causes

a. Nephrotic syndrome: order 24-hour urine protein and lipids.

b. Glomerulonephritis or acute tubular necrosis: obtain urinalysis with sediment evaluation.

c. Preeclampsia: laboratory tests include urine protein, urate, blood urea nitrogen (BUN), creatinine, and serum bilirubin (5).

4. Other causes of generalized edema and tests that may be useful include hypothyroidism [thyroid-stimulating hormone, (TSH)], aldosteronism (serum potassium), Cushing’s disease (cortisol or dexamethasone test), malnutrition (prealbumin), beriberi (thiamine), malabsorption (total protein), angioedema, inflammatory bowel disease (sigmoidoscopy), serum sickness, malignancies (CT or MRI), and idiopathic edema (6).

C. Unilateral edema of the legs only points to a local peripheral cause such as trauma, venous obstruction, mass, or inflammation.

D. Bilateral chronic edema of the legs only

1. If tenderness is present, consider lipedema if no foot involvement, or varicose veins if the foot is involved.

2. Consider the possibility of a medication-related cause: see above.

3. An elevated TSH may point to a diagnosis of hypothyroidism or Grave’s disease.

4. Unilateral left-sided edema could be caused by iliac compression or pelvic mass obstructing venous outflow. A venogram, CT, or MRI may be helpful.


References

1. Braunwald E. Edema. In: Fauci AS, ed. Harrison’s principles of internal medicine, 14th ed. New York: McGraw Hill, 1998:210–214.

2. Powel AA, Armstrong MA. Peripheral edema. Am Fam Physician 1997;55:1721–1726.

3. Weber R. Leg edema. In: Rakel RE, ed. Saunders manual of medical practice. Philadelphia: WB Saunders, 1996:207–209.

4. Friedman HH. Edema. In: Friedman HH, ed. Problem oriented medical diagnosis, 6th ed. Boston: Little, Brown and Company, 1996:1–4.

5. Taylor RB. Manual of family practice. Boston: Little, Brown and Company, 1997:
497–499.

6. MacGregor GA, deWardner HE. Idiopathic edema. In: Schrier RW, Gottschalk CW, eds. Diseases of the kidney, 5th ed. Boston: Little, Brown and Company, 1993:
2493–2501.>

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

Urticaria/Angioedema: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

Edema: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

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.

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Source: Field Guide to Bedside Diagnosis, 2007

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

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

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

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

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

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

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

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

Determine the edema’s severity by comparing the size and symmetry of the 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 Differentiating between pitting and nonpitting edema, page 245.) Next, examine and compare the color and temperature of the 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.

» READ BOOK EXCERPT ONLINE »

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

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

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 Differentiating between pitting and nonpitting edema, page 245.) Next, take the patient’s 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 soft-tissue swelling.

» READ BOOK EXCERPT ONLINE »

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

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

Begin the physical examination by examining each leg for pitting edema. (See Differentiating between pitting and nonpitting edema, page 245.) Because leg edema may compromise arterial blood flow, palpate or use Doppler ultrasonography 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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

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

Fully evaluate the papular rash: note its color, configuration, and location on the patient’s body. Then complete a whole-body examination of the patient’s skin, hair, and nails.

» READ BOOK EXCERPT ONLINE »

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

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

Age of onset is important in determiningcause of edema. Other distinguishing features are presence of hypoalbuminemia ± proteinuria.

Fetal and Neonatal Onset

  • Hydropsfetalis should be suspected in either second or third trimesterof pregnancy, when discrepancy exists between size of fetus andpresumed gestational age.
  • Polyhydramnios occurs in ≥50% ofcases, and this can be confirmed by U/S.
  • First step in diagnosis of fetal hydropsis to perform prenatal antibody screen to exclude any kind of isoimmunization.
  • Other tests include CBC and RBC indicesin both parents to screen for alpha-thalassemia; hemoglobin electrophoresis;Kleihauer-Betke test for fetomaternal transfusion; and maternalrapid plasma reagin, appropriate serology, and cultures for congenitalinfection.
  • U/S can detect multiple pregnancies(twin-twin transfusion), chondrodysplasias (limb length measurements),and many congenital anomalies.
  • Fetal movement studies also can bedone using real-time U/S.
  • Fetal echocardiography may detect cardiacstructural defects and fetal arrhythmias.
  • If these tests fail to reveal causeof fetal hydrops, amniocentesis can be performed. Several testsare commonly performed on amniotic fluid: fetal karyotype, culturesand polymerase chain reaction for infection, specific metabolictests for storage diseases, and alpha-fetoprotein (congenital nephrosis).
  • Fetal blood can be obtained by cordocentesisfor other tests: CBC, blood type, hemoglobin electrophoresis, serumalbumin, cultures and polymerase chain reaction, karyotype, andspecific tests for metabolic disorders.
  • After infant's birth, physicalexam as well as exam of umbilical cord and placenta narrow diagnosticpossibilities and suggest most appropriate investigations.

  • Several testsshould be considered depending on clinical circumstances: infant's bloodgroup and Rh type; CBC; hemoglobin electrophoresis; UA; chest, longbone, abdominal, and spine radiography; ECG; 2-D echocardiography;maternal and infant rapid plasma reagin; urine culture for cytomegalovirus;serology for toxoplasmosis; serum electrolytes, creatinine, glucose,and liver function tests; blood urea nitrogen; analysis of fluidfrom effusion or ascites for chyle, protein, or culture; chromosomalkaryotype; metabolic studies; and exam of placenta including histology.
  • Other investigations depend on resultsof these tests and suspected diagnosis.

    • Postneonatal Onset

  • UA screensfor proteinuria and renal disease.
  • In absence of significant proteinuriaor cardiac failure, serum albumin should be measured. Fluid overloadand allergic reactions are common causes of edema with normal serumalbumin. Decreased serum albumin without proteinuria suggests liverdisease, protein-losing enteropathy, or protein-caloric malnutrition.
  • Jaundice, hepatomegaly, and abnormalliver function tests are manifestations of liver disease.
  • Elevated fecal alpha1-antitrypsinlevel indicates increased protein loss in stool and is seen withvarious causes of protein-losing enteropathy.
  • Protein-calorie malnutrition can beassessed by plotting weight and height on growth charts developedby CDC (2001).
  • U/S or MRI may help diagnosecauses of lymphedema.

    • » 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

    Rash - Case 9-2: 7-Week-Old Girl: III. Physical Examination
    (Pediatric Complaints and Diagnostic Dilemmas)

    T, 37.0°C; RR, 43/min; HR, 180 bpm; BP, 113/53 mm Hg
    Height, 50th percentile; weight, 50th percentile
    The physical examination was remarkable for a hemangioma of the left occiput, a hematoma of the tip of the tongue, and two ecchymotic areas on the right mandible, each about 1 cm in diameter. She had three 3- to 4-cm ecchymotic areas on the left back. A caf é-au-lait macule (1 cm) was seen on the left thigh. Lungs were clear. Cardiac examination revealed tachycardia but no murmurs, rubs, or gallops. There was no hepatosplenomegaly and no prominent adenopathy. Neurologically she was alert, crying, and moving all extremities. Funduscopic examination revealed right retinal hemorrhages. The rest of her examination was normal.

    VI. Diagnostic Studies

    Laboratory analysis revealed 18,800 WBCs/mm3, with 39% segmented neutrophils, 49% lymphocytes, and 11% monocytes. The hemoglobin was 11.4 g/dL, and there were 406, 000 platelets/mm 3. PT and PTT were normal. Electrolytes, BUN, and creatinine were normal. Alkaline phosphatase was 270 mU/mL. Other liver function studies were as follows: alanine aminotransferase, 100 IU/L; aspartate aminotransferase, 220 IU/L; and γ-glutamyltransferase, 46 IU/L. Examination of the cerebrospinal fluid revealed 8 WBCs/mm 3and 5,250 red blood cells/mm3. The glucose concentration was 60 mg/dL, and the protein concentration was 36 mg/dL. There were no organisms on Gram staining of the CSF.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Diagnosis of Urticaria

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