Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
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Abdominal aortic aneurysm (dissecting). Life-threatening dissection of this aneurysm may initially cause low back pain or dull abdominal pain. More commonly, it produces constant upper abdominal pain. A pulsating abdominal mass may be palpated in the epigastrium; after rupture, however, it no longer pulses. Aneurysmal dissection can also cause mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock (such as cool, clammy skin) appear if blood loss is significant.
Ankylosing spondylitis. Ankylosing spondylitis is a chronic, progressive disorder that causes sacroiliac pain, which radiates up the spine and is aggravated by lateral pressure on the pelvis. The pain is usually most severe in the morning or after a period of inactivity and isn’t relieved by rest. Abnormal rigidity of the lumbar spine with forward flexion is also characteristic. This disorder can cause local tenderness, fatigue, fever, anorexia, weight loss, and occasional iritis.
Appendicitis. Appendicitis is a life-threatening disorder in which a vague and dull discomfort in the epigastric or umbilical region migrates to McBurney’s point in the right lower quadrant. With retrocecal appendicitis, pain may also radiate to the back. The shift in pain is preceded by anorexia and nausea and is accompanied by fever, occasional vomiting, abdominal tenderness (especially over McBurney’s point), and rebound tenderness. Some patients also have painful, urgent urination.
Cholecystitis. Cholecystitis produces severe pain in the right upper quadrant of the abdomen that may radiate to the right shoulder, chest, or back. The pain may arise suddenly or may increase gradually over several hours, and patients usually have a history of similar pain after a high-fat meal. Accompanying signs and symptoms include anorexia, fever, nausea, vomiting, right upper quadrant tenderness, abdominal rigidity, pallor, and sweating.
Chordoma. A slow-developing malignant tumor, chordoma causes persistent pain in the lower back, sacrum, and coccyx. As the tumor expands, pain may be accompanied by constipation and bowel or bladder incontinence.
Endometriosis. Endometriosis causes deep sacral pain and severe, cramping pain in the lower abdomen. The pain worsens just before or during menstruation and may be aggravated by defecation. It’s accompanied by constipation, abdominal tenderness, dysmenorrhea, and dyspareunia.
Intervertebral disk rupture. Intervertebral disk rupture produces gradual or sudden low back pain with or without leg pain (sciatica). It rarely produces leg pain alone. Pain usually begins in the back and radiates to the buttocks and leg. The pain is exacerbated by activity, coughing, and sneezing and is eased by rest. It’s accompanied by paresthesia (most commonly, numbness or tingling in the lower leg and foot), paravertebral muscle spasm, and decreased reflexes on the affected side. This disorder also affects posture and gait. The patient’s spine is slightly flexed and he leans toward the painful side. He walks slowly and rises from a sitting to a standing position with extreme difficulty.
Lumbosacral sprain. Lumbosacral sprain causes aching, localized pain, and tenderness associated with muscle spasm on lateral motion. The recumbent patient typically flexes his knees and hips to help ease pain. Flexion of the spine intensifies pain, whereas rest helps relieve it. The pain worsens with movement and is relieved by rest.
Metastatic tumors. Metastatic tumors commonly spread to the spine, causing low back pain in at least 25% of patients. Typically, the pain begins abruptly, is accompanied by cramping muscular pain (usually worse at night), and isn’t relieved by rest.
Myeloma. Back pain caused by myeloma, a primary malignant tumor, usually begins abruptly and worsens with exercise. It may be accompanied by arthritic signs and symptoms, such as achiness, joint swelling, and tenderness. Other signs and symptoms include fever, malaise, peripheral paresthesia, and weight loss.
Pancreatitis (acute). Pancreatitis is a life-threatening disorder that usually produces fulminating, continuous upper abdominal pain that may radiate to both flanks and to the back. To relieve this pain, the patient may bend forward, draw his knees to his chest, or move restlessly about.
Early associated signs and symptoms include abdominal tenderness, nausea, vomiting, fever, pallor, tachycardia and, in some patients, abdominal guarding, rigidity, rebound tenderness, and hypoactive bowel sounds. A late sign may be jaundice. Occurring as inflammation subsides, Turner’s sign (ecchymosis of the abdomen or flank) or Cullen’s sign (bluish discoloration of skin around the umbilicus and in both flanks) signals hemorrhagic pancreatitis.
Perforated ulcer. In some patients, perforation of a duodenal or gastric ulcer causes sudden, prostrating epigastric pain that may radiate throughout the abdomen and to the back. This lifethreatening disorder also causes boardlike abdominal rigidity; tenderness with guarding; generalized rebound tenderness; the absence of bowel sounds; and grunting, shallow respirations. Associated signs include fever, tachycardia, and hypotension.
Prostate cancer. Chronic aching back pain may be the only symptom of prostate cancer. This disorder may also produce hematuria and decrease the urine stream.
Pyelonephritis (acute). Pyelonephritis produces progressive flank and lower abdominal pain accompanied by back pain or tenderness (especially over the costovertebral angle). Other signs and symptoms include high fever and chills, nausea and vomiting, flank and abdominal tenderness, and urinary frequency and urgency.
Renal calculi. The colicky pain of renal calculi usually results from irritation of the ureteral lining, which increases the frequency and force of peristaltic contractions. The pain travels from the costovertebral angle to the flank, suprapubic region, and external genitalia. Its intensity varies but may become excruciating if calculi travel down a ureter. If calculi are in the renal pelvis and calyces, dull and constant flank pain may occur. Renal calculi also cause nausea, vomiting, urinary urgency (if a calculus lodges near the bladder), hematuria, and agitation due to pain. Pain resolves or significantly decreases after calculi move to the bladder. Encourage the patient to recover the calculi for analysis.
Rift Valley fever. Rift Valley fever is a viral disease generally found in Africa, but in 2000, outbreaks occurred in Saudi Arabia and Yemen. It’s transmitted to humans from the bite of an infected mosquito or from exposure to infected animals. Rift Valley fever may present as several different clinical syndromes. Typical signs and symptoms include fever, myalgia, weakness, dizziness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.
Sacroiliac strain. Sacroiliac strain causes sacroiliac pain that may radiate to the buttock, hip, and lateral aspect of the thigh. The pain is aggravated by weight bearing on the affected extremity and by abduction with resistance of the leg. Associated signs and symptoms include tenderness of the symphysis pubis and a limp or gluteus medius or abductor lurch.
Smallpox (variola major). Worldwide eradication of smallpox was achieved in 1977; the United States and Russia have the only known storage sites of the virus. The virus is considered
a potential agent for biological warfare. Initial signs and symptoms include high fever, malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular rash develops on the mucosa of the mouth, pharynx, face, and forearms and then spreads to the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions develop at the same time, appear identical, and are more prominent on the face and extremities. The pustules are round, firm, and deeply embedded in the skin. After 8 to 9 days, the pustules form a crust, and later, the scab separates from the skin, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.
Spinal neoplasm (benign). Spinal neoplasm typically causes severe, localized back pain and scoliosis.
Spinal stenosis. Resembling a ruptured intervertebral disk, spinal stenosis produces back pain with or without sciatica, which commonly affects both legs. The pain may radiate to the toes and may progress to numbness or weakness unless the patient rests.
Spondylolisthesis. A major structural disorder characterized by forward slippage of one vertebra onto another, spondylolisthesis may be asymptomatic or may cause low back pain, with or without nerve root involvement. Associated symptoms of nerve root involvement include paresthesia, buttock pain, and pain radiating down the leg. Palpation of the lumbar spine may reveal a “step-off” of the spinous process. Flexion of the spine may be limited.
Transverse process fracture. Transverse process fracture causes severe localized back pain with muscle spasm and hematoma.
Vertebral compression fracture. Initially, vertebral compression fracture may be painless. Several weeks later, it causes back pain aggravated by weight bearing and local tenderness. Fracture of a thoracic vertebra may cause referred pain in the lumbar area.
Vertebral osteomyelitis. Initially, vertebral osteomyelitis causes insidious back pain. As it progresses, the pain may become constant, more pronounced at night, and aggravated by spinal movement. Accompanying signs and symptoms include vertebral and hamstring spasms, tenderness of the spinous processes, fever, and malaise.
Vertebral osteoporosis. Vertebral osteoporosis causes chronic, aching back pain that is aggravated by activity and somewhat relieved by rest. Tenderness may also occur.
Other Causes
Neurologic tests. Lumbar puncture and myelography can produce transient back pain.
Special Considerations
Monitor the patient closely if the back pain suggests a life-threatening cause. Be alert for increasing pain, altered neurovascular status in the legs, loss of bowel or bladder control, altered vital signs, sweating, and cyanosis.
Until a tentative diagnosis is made, withhold analgesics, which may mask the symptoms of a lifethreatening cause. Also, withhold food and fluids in case surgery is necessary. Make the patient as comfortable as possible by elevating the head of the bed and placing a pillow under his knees. Encourage relaxation techniques such as deep breathing. Prepare the patient for a rectal or pelvic examination. He may also require routine blood tests, urinalysis, a computed tomography scan, appropriate biopsies, and X-rays of the chest, abdomen, and spine.
Fit the patient for a corset or lumbosacral support. Instruct him not to wear this in bed. He may also require heat or cold therapy, a backboard, a convoluted foam mattress, or pelvic traction. Explain these pain-relief measures to the patient. Teach him about alternatives to analgesic drug therapy, such as biofeedback and transcutaneous electrical nerve stimulation.
Be aware that back pain is notoriously associated with malingering. Refer the patient to other professionals, such as a physical therapist, an occupational therapist, or a psychologist, if indicated.
Patient Counseling
Provide information about the use of anti-inflammatories, analgesics, and alternatives to drug therapy, such as biofeedback and transcutaneous electric nerve stimulation. Teach relaxation techniques such as deep breathing, and instruct the patient on correct use of corset or lumbosacral support. Discuss lifestyle changes, such as losing weight or correcting posture.
Pediatric Pointers
Because a child may have difficulty describing back pain, be alert for nonverbal clues, such as wincing or a refusal to walk. Closely observe family dynamics during history taking for clues that suggest child abuse.
Back pain in the child may stem from intervertebral disk inflammation (diskitis), neoplasms, idiopathic juvenile osteoporosis, and spondylolisthesis. Disk herniation typically doesn’t cause back pain. Scoliosis, a common disorder in adolescents, rarely causes back pain.
Geriatric Pointers
Suspect metastatic cancer — especially of the prostate, colon, or breast — in older patients with a recent onset of back pain that usually isn’t relieved by rest and worsens at night.
REFERENCES
Costa, L. C., Maher, C. G., McAuley, J. H., Hancock, M. J., Herbert, R. D., Refshauge K. M., & Henschke, N. (2009). Prognosis for patients with chronic low back pain: Inception cohort study. British Medical Journal, 339, b3829.
Hay, E. M., & Dunn, K. M. (2009). Prognosis of low back pain in primary care. British Medical Journal, 339, 816–817.
Battle’s Sign
Battle’s sign — ecchymosis over the mastoid process of the temporal bone — is commonly the only outward sign of a basilar skull fracture. In fact, this type of fracture may go undetected even by skull X-rays. If left untreated, it can be fatal because of associated injury to the nearby cranial nerves and brain stem as well as to blood vessels and the meninges.
Appearing behind one or both ears, Battle’s sign is easily overlooked or hidden by the patient’s hair. During emergency care of a trauma victim, it may be overshadowed by imminently lifethreatening or more apparent injuries.
A force that’s strong enough to fracture the base of the skull causes Battle’s sign by damaging supporting tissues of the mastoid area and causing seepage of blood from the fracture site to the mastoid. Battle’s sign usually develops 24 to 36 hours after the fracture and may persist for several days to weeks.
History and Physical Examination
Perform a complete neurologic examination. Begin with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient’s level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
Check the patient’s vital signs; be alert for widening pulse pressure and bradycardia and signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Also, note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn’t. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with basilar skull fracture.
Medical Causes
Basilar skull fracture. Battle’s sign may be the only outward sign of basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.
Special Considerations
Expect a patient with a basilar skull fracture to be on bed rest for several days to weeks. Keep him flat to decrease pressure on dural tears and to minimize CSF leakage. Monitor his neurologic status closely. Avoid nasogastric intubation and nasopharyngeal suction, which may cause cerebral infection. Also, caution the patient against blowing his nose, which may worsen a dural tear.
The patient may need skull X-rays and a computed tomography scan to help confirm basilar skull fracture and to evaluate the severity of head injury. Typically, a basilar skull fracture and associated dural tears heal spontaneously within several days to weeks. However, if the patient has a large dural tear, a craniotomy may be necessary to repair the tear with a graft patch.
Patient Counseling
Explain what diagnostic tests the patient may need along with what activities he should avoid, and emphasize the importance of bed rest. Explain to the patient (or caregivers) what signs and symptoms to look for and report, such as changes in mental status, loss of consciousness (LOC), or breathing. Tell the patient to take acetaminophen for headaches, discuss the prospect of surgery with the patient, and answer his questions and concerns.
Pediatric Pointers
Children who are victims of abuse frequently sustain basilar skull fractures from severe blows to the head. As in adults, Battle’s sign may be the only outward sign of fracture and, perhaps, the only clue
to child abuse. If you suspect child abuse, follow facility protocol for reporting the incident.
REFERENCES
Fugate, J. E., Wijdicks, E. F. , Mandrekar, J., Claassen, D. O., Manno, E. M., White, R. D., …, Rabinstein, A. A. (2010). Predictors of neurologic outcome in hypothermia after cardiac arrest. Annals of Neurology, 68(6), 907–914.
Perry, J. J., Stiell, I. G., Sivilotti, M. L., Bullard, M. J., Emond, M. , Symington, C., …, Wells, G. A. (2011) . Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: Prospective cohort study.
British Medical Journal, 343, d4277.
Biot’s Respirations[Ataxic respirations]
A late and ominous sign of neurologic deterioration, Biot’s respirations are characterized by an irregular and unpredictable rate, rhythm, and depth. This rare breathing pattern may appear abruptly and may reflect increased pressure on the medulla coinciding with brain stem compression.
EMERGENCY INTERVENTIONS
Observe the patient’s breathing pattern for several minutes to avoid confusing Biot’s respirations with other respiratory patterns. (See Identifying Biot’s Respirations.) Assess the patient’s respiratory status and prepare to intubate him and provide mechanical ventilation. Next, take his vital signs, noting especially increased systolic pressure.
Medical Causes
Brain stem compression. Biot’s respirations are characteristic in brain stem compression, a neurologic emergency. Rapidly enlarging lesions may cause ataxic respirations and lead to complete respiratory arrest.
Special Considerations
Monitor the patient’s vital signs frequently, including oxygen saturation. Elevate the head of the patient’s bed 30 degrees to help reduce intracranial pressure. Prepare the patient for emergency surgery to relieve pressure on the brain stem. Computed tomography scans or magnetic resonance imaging may confirm the cause of brain stem compression.
Identifying Biot’s Respirations
Biot’s respirations, also known as ataxic respirations, have a completely irregular pattern. Shallow and deep breaths occur randomly, with haphazard, irregular pauses. The respiratory rate tends to be slow and may progressively decelerate to apnea.
Patient Counseling
Because Biot’s respirations typically reflect a grave prognosis, give the patient’s family information and emotional support.
Pediatric Pointers
Biot’s respirations are rarely seen in children.
REFERENCES
Schefold, J. C., Storm, C., Krüger, A., Ploner, C. J., & Hasper, D. (2009). The Glasgow Coma Score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia. Resuscitation, 80(6), 658–661.
Wijdicks, E. F. (2010). The bare essentials: Coma. Practical Neurology, 10(1), 51–60.
Bladder Distention
Bladder distention — abnormal enlargement of the bladder — results from an inability to excrete urine, which results in its accumulation. Distention can be caused by a mechanical or anatomic obstruction, neuromuscular disorder, or the use of certain drugs. Relatively common in all ages and both sexes, it’s most common in older men with prostate disorders that cause urine retention.
Distention usually develops gradually, but it occasionally has a sudden onset. Gradual distention usually remains asymptomatic until stretching of the bladder produces discomfort. Acute distention produces suprapubic fullness, pressure, and pain. If severe distention isn’t corrected promptly by catheterization or massage, the bladder rises within the abdomen, its walls become thin, and renal function can be impaired.
Bladder distention is aggravated by the intake of caffeine, alcohol, large quantities of fluid, and diuretics. (See Bladder Distention: Common Causes and Associated Findings, pages 92 and 93.)
EMERGENCY INTERVENTIONS
If the patient has severe distention, insert an indwelling urinary catheter to help relieve discomfort and prevent bladder rupture. If more than 700 mL is emptied from the bladder, compressed blood vessels dilate and may make the patient feel faint. Typically, the indwelling urinary catheter is clamped for 30 to 60 minutes to permit vessel compensation.
History and Physical Examination
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
Medical Causes
Benign prostatic hyperplasia (BPH). With BPH, bladder distention gradually develops as the prostate enlarges. Occasionally, its onset is acute. Initially, the patient experiences urinary hesitancy, straining, and frequency; reduced force of and the inability to stop the urine stream; nocturia; and postvoiding dribbling. As the disorder progresses, it produces prostate enlargement, sensations of suprapubic fullness and incomplete bladder emptying, perineal pain, constipation, and hematuria.
Bladder calculi. Bladder calculi may produce bladder distention but more commonly produce pain as the only symptom. The pain is usually referred to the tip of the penis, the vulvar area, the lower back, or the heel. It worsens during walking or exercise and abates when the patient lies down. It can be accompanied by urinary frequency and urgency, terminal hematuria, and dysuria. Pain is usually most severe when micturition ceases.
Bladder cancer. By blocking the urethral orifice, neoplasms can cause bladder distention. Associated signs and symptoms include hematuria (most common sign); urinary frequency and urgency; nocturia; dysuria; pyuria; pain in the bladder, rectum, pelvis, flank, back, or legs; vomiting; diarrhea; and sleeplessness. A mass may be palpable on bimanual examination.
CULTURAL CUE
Bladder cancer is twice as common in Whites as in Blacks. It’s relatively uncommon among Asians, Hispanics, and Native Americans.
Multiple sclerosis. With multiple sclerosis, a neuromuscular disorder, urine retention, and bladder distention result from the interruption of upper motor neuron control of the bladder. Associated signs and symptoms include optic neuritis, paresthesia, impaired position and vibratory senses, diplopia, nystagmus, dizziness, abnormal reflexes, dysarthria, muscle weakness, emotional lability, Lhermitte’s sign (transient, electric-like shocks that spread down the body when the head is flexed), Babinski’s sign, and ataxia.
Prostate cancer. Prostate cancer eventually causes bladder distention in about 25% of patients.
Usual signs and symptoms include dysuria, urinary frequency and urgency, nocturia, weight loss, fatigue, perineal pain, constipation, and induration of the prostate or a rigid, irregular prostate on digital rectal examination. For some patients, urine retention and bladder distention are the only signs.
CULTURAL CUE
Prostate cancer is more common in blacks than in other racial or ethnic groups.
Prostatitis. With acute prostatitis, bladder distention occurs rapidly along with perineal discomfort and suprapubic fullness. Other signs and symptoms include perineal pain; a tense, boggy, tender, and warm enlarged prostate; decreased libido; impotence; decreased force of the urine stream; dysuria; hematuria; and urinary frequency and urgency. Additional signs and symptoms include fatigue, malaise, myalgia, fever, chills, nausea, and vomiting.
With chronic prostatitis, bladder distention is rare. However, it may be accompanied by sensations of perineal discomfort and suprapubic fullness, prostatic tenderness, decreased libido, urinary frequency and urgency, dysuria, pyuria, hematuria, persistent urethral discharge, ejaculatory pain, and a dull pain radiating to the lower back, buttocks, penis, or perineum.
Bladder Distention: Common Causes and Associated Findings
