Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
.pdf
signs and symptoms may be absent. However, dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals a TIA and may herald a stroke.
Carotid cavernous fistula. Continuous bruits heard over the eyeballs and temples are characteristic, as are vision disturbances and protruding, pulsating eyeballs.
Peripheral arteriovenous fistula. A rough, continuous bruit with systolic accentuation may be heard over the fistula; a palpable thrill is also common.
Peripheral vascular disease. Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower-extremity ulcers that heal with difficulty.
Renal artery stenosis. Systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear. Subclavian steal syndrome. With subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of arterial lumen narrowing. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.
Thyrotoxicosis. A systolic bruit is commonly heard over the thyroid gland. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.
Special Considerations
Because bruits can signal a life-threatening vascular disorder, frequently check the patient’s vital signs, auscultate over the affected arteries, and monitor peripheral pulses. Be especially alert for bruits that become louder or develop a diastolic component.
As needed, administer prescribed drugs, such as a vasodilator, an anticoagulant, an antiplatelet drug, or an antihypertensive. Prepare the patient for diagnostic tests, such as blood studies, radiographs, an electrocardiogram, cardiac catheterization, and ultrasonography.
Patient Counseling
Teach the patient the symptoms of stroke, and tell him to report them immediately. Discuss lifestyle changes, such as quitting smoking, exercising regularly, and eating a balanced diet.
Pediatric Pointers
Bruits are common in young children but are usually of little significance — for example, cranial bruits are normal until age 4. However, certain bruits may be significant. Because birthmarks commonly accompany congenital arteriovenous fistulas, carefully auscultate for bruits in children with port-wine spots or cavernous or diffuse hemangiomas.
Geriatric Pointers
Elderly people with atherosclerosis may experience bruits over several arteries. Those related to carotid artery stenosis are particularly important because of the high incidence of associated stroke. Close follow-up is mandatory as well as prompt surgical referral when indicated.
REFERENCES
Amarenco, P., Labreuche, J., & Mazighi, M. (2010). Lessons from carotid endarterectomy and stenting trials. Lancet, 376, 1028–1031. Brott, T. G., Hobson, R. W., II , Howard, G. , Roubin, G. S., Clark, W. M. , Brooks, W., … Meschia, J. F. (2010) . Stenting versus
endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine, 363, 11–23.
Butterfly Rash
The presence of a butterfly rash is typically a sign of systemic lupus erythematosus (SLE), but it can also signal dermatologic disorders. Typically, butterfly rash appears in a malar distribution across the nose and cheeks. (See Recognizing Butterfly Rash.) Similar rashes may appear on the neck, scalp, and other areas. Butterfly rash is sometimes mistaken for sunburn because it can be provoked or aggravated by ultraviolet rays, but it has more substance, is more sharply demarcated, and has a thicker feel in relation to surrounding skin.
History and Physical Examination
Ask the patient when he first noticed the butterfly rash and if he has recently been exposed to the sun. Has he noticed a rash elsewhere on his body? Also, ask about recent weight or hair loss. Does he have a family history of lupus? Is he taking hydralazine or procainamide (common causes of druginduced lupus erythematosus [LE])?
Inspect the rash, noting any macules, papules, pustules, or scaling. Is the rash edematous? Are areas of hypopigmentation or hyperpigmentation present? Look for blisters or ulcers in the mouth, and note any inflamed lesions. Check for rashes elsewhere on the body.
Medical Causes
Discoid lupus erythematosus. With discoid lupus erythematosus, a localized form of LE, the patient may come into your facility with a unilateral or butterfly rash that consists of erythematous, raised, sharply demarcated plaques with follicular plugging and central atrophy. The rash may also involve the scalp, ears, chest, or any part of the body exposed to the sun. Telangiectasia, scarring alopecia, and hypopigmentation or hyperpigmentation may occur later. Other accompanying signs include conjunctival redness, dilated capillaries of the nail fold, bilateral parotid gland enlargement, oral lesions, and mottled, reddish blue skin on the legs.
Recognizing Butterfly Rash
With classic butterfly rash, lesions appear on the cheeks and the bridge of the nose, creating a characteristic butterfly pattern. The rash may vary in severity from malar erythema to discoid lesions (plaques).
Erysipelas. Erysipelas causes rosy or crimson swollen lesions, mainly on the neck and head and commonly along the nasolabial fold. It may cause hemorrhagic pus-filled blisters. Other signs and symptoms include fever, chills, cervical lymphadenopathy, and malaise.
Polymorphous light eruption. Butterfly rash appears as erythema, vesicles, plaques, and multiple small papules that may later become eczematized, lichenified, and excoriated. Provoked by ultraviolet rays, the rash appears on the cheeks and bridge of the nose, the hands and arms, and other areas, beginning a few hours to several days after exposure. It may be accompanied by pruritus.
Rosacea. Initially, butterfly rash may appear as a prominent, nonscaling, intermittent erythema limited to the lower half of the nose or including the chin, cheeks, and central forehead. As rosacea develops, the duration of the rash increases; instead of disappearing after each episode, the rash varies in intensity and is commonly accompanied by telangiectasia. With advanced rosacea, the skin is oily, with papules, pustules, nodules, and telangiectasis restricted to the central oval of the face. In men with severe rosacea, butterfly rash may be accompanied by rhinophyma — a thickened, lobulated overgrowth of sebaceous glands and epithelial connective tissue on the lower half of the nose and, possibly, the adjacent cheeks. This is more common in elderly patients.
Seborrheic dermatitis. Butterfly rash appears as greasy, scaling, slightly yellow macules and papules of varying size on the cheeks and the bridge of the nose, in a “butterfly” pattern. The scalp, beard, eyebrows, portions of the forehead above the bridge of the nose, nasolabial fold, or trunk may also be involved. Associated signs and symptoms include crusts and fissures (particularly when the external ear and scalp are involved), pruritus, redness, blepharitis, styes, severe acne, and oily skin. Severe seborrheic dermatitis of the face occurs in acquired immunodeficiency syndrome.
Systemic lupus erythematosus. Occurring in about 40% of patients with this connective tissue disorder, butterfly rash appears as a red, usually scaly, sharply demarcated macular eruption. The rash may be transient in patients with acute SLE or may progress slowly to include the forehead, the chin, the area around the ears, and other exposed areas. Common associated skin findings include scaling, patchy alopecia, mucous membrane lesions, mottled erythema of the palms and fingers, periungual erythema with edema, reddish purple macular lesions on the volar surfaces of the fingers, telangiectasia of the base of the nails or eyelids, purpura, petechiae, and
ecchymoses.
Butterfly rash may also be accompanied by joint pain, stiffness, and deformities, particularly ulnar deviation of the fingers and subluxation of the proximal interphalangeal joints. Related findings include periorbital and facial edema, dyspnea, a low-grade fever, malaise, weakness, fatigue, weight loss, anorexia, nausea, vomiting, lymphadenopathy, photosensitivity, and hepatosplenomegaly.
Other Causes
Drugs. Hydralazine and procainamide can cause a lupus-like syndrome.
Special Considerations
Prepare the patient for immunologic studies, complete blood count, and, possibly, liver studies. Obtain a urine specimen, if needed. Withhold photosensitizing drugs, such as phenothiazines, sulfonamides, sulfonylureas, and thiazide diuretics. Instruct the patient to avoid exposure to the sun or to use sunscreen. Suggest that he use hypoallergenic makeup to help conceal facial lesions.
Patient Counseling
Urge the use of sunscreen, and stress the avoidance of sun exposure. Encourage the use of hypoallergenic makeup to conceal facial lesions. Inform the patient about sources of support such as the Lupus Foundation of America.
Pediatric Pointers
Rare in pediatric patients, a butterfly rash may occur as part of an infectious disease such as erythema infectiosum, or “slapped cheek syndrome.”
REFERENCES
Croxtall, J. D. (2011) . Ustekinumab: A review of its use in the management of moderate to severe plaque psoriasis . Drugs, 71, 1733–1753.
Nograles, K. E., Davidovici, B., & Krueger, J. G. (2010). New insights in the immunologic basis of psoriasis. Seminars in Cutaneous Medicine and Surgery, 29, 3–9.
C
Capillary Refill Time, Increased
Capillary refill time is the duration required for color to return to the nail bed of a finger or toe after application of slight pressure, which causes blanching. This duration reflects the quality of peripheral vasomotor function. Normal capillary refill time is less than 3 seconds.
Increased refill time isn’t diagnostic of a disorder, but must be evaluated along with other signs and symptoms. However, this sign usually signals obstructive peripheral arterial disease, especially in the lower limbs, or decreased cardiac output.
Capillary refill time is typically tested during a routine cardiovascular assessment. It isn’t tested with suspected life-threatening disorders because other, more characteristic signs and symptoms appear earlier.
History and Physical Examination
If you detect increased capillary refill time, take the patient’s vital signs and check pulses in the affected limb. Does the limb feel cold or look cyanotic? Does the patient report pain or unusual or decreased sensations in his fingers or toes, especially after exposure to cold?
Take a brief medical history, especially noting previous peripheral vascular disease. Find out which medications the patient is taking. Ask the patient if he smokes.
Medical Causes
Aortic aneurysm (dissecting). Capillary refill time is increased in the fingers and toes with a dissecting aneurysm in the thoracic aorta and is prolonged in just the toes with a dissecting aneurysm in the abdominal aorta. Accompanying signs and symptoms include a pulsating abdominal mass, a systolic bruit, and substernal back or abdominal pain.
Aortic arch syndrome. Increased capillary refill time in the fingers occurs early in the patient with this syndrome. He displays absent carotid pulses and possibly unequal radial pulses. Other signs and symptoms usually precede loss of pulses and include fever, night sweats, arthralgia, weight loss, anorexia, nausea, malaise, a skin rash, splenomegaly, and pallor.
Arterial occlusion (acute). Increased capillary refill time occurs early in the affected limb. Arterial pulses are usually absent distal to the obstruction; the affected limb appears cool and pale or cyanotic. Intermittent claudication, moderate to severe pain, numbness, and paresthesia or paralysis of the affected limb may occur.
Buerger’s disease. Capillary refill time is increased in the toes. Exposure to low temperatures turns the feet cold, cyanotic, and numb; later, they redden, become hot, and tingle. Other findings include intermittent claudication of the instep and weak peripheral pulses; in later stages, the patient may experience ulceration, muscle atrophy, and gangrene. If the disease affects the hands, increased capillary refill time may accompany painful fingertip ulcerations.
Cardiac tamponade. Increased capillary refill time represents a late sign of decreased cardiac output. Associated signs include paradoxical pulse, tachycardia, cyanosis, dyspnea, jugular vein distention, and hypotension.
Hypothermia. Increased capillary refill time may appear early as a compensatory response. Associated signs and symptoms depend on the degree of hypothermia and may include shivering, fatigue, weakness, a decreased level of consciousness (LOC), slurred speech, ataxia, muscle stiffness or rigidity, tachycardia or bradycardia, hyporeflexia or areflexia, diuresis, oliguria, bradypnea, decreased blood pressure, and cool, pale skin.
Peripheral arterial trauma. Trauma to a peripheral artery that reduces distal blood flow also increases capillary refill time in the affected extremity. Related findings in that extremity include bruising or pulsating bleeding, a weakened pulse, cyanosis, paresthesia, sensory loss, and cool, pale skin.
Peripheral vascular disease. Increased capillary refill time in the affected extremities is a late sign. Peripheral pulses gradually weaken and then disappear. Intermittent claudication, coolness, pallor, and decreased hair growth are associated signs. Impotence may accompany arterial occlusion in the descending aorta or femoral areas.
Raynaud’s disease . Capillary refill time is prolonged in the fingers, the usual site of this disease’s characteristic episodic arterial vasospasm. Exposure to cold or stress produces blanching in the fingers, then cyanosis, and then erythema before the fingers return to normal temperature. Warmth relieves the symptoms, which may include paresthesia. Chronic disease may produce trophic changes, such as sclerodactyly, ulcerations, or chronic paronychia.
Volkmann’s contracture . Increased capillary refill time results from this contracture’s characteristic vasospasm. Associated signs include the loss of mobility and loss of strength in the affected extremity.
Other Causes
Diagnostic tests. Cardiac catheterization can cause arterial hematoma or clot formation and increased capillary refill time.
Drugs. Drugs that cause vasoconstriction (particularly alpha-adrenergic blockers) increase capillary refill time.
Treatments. Increased capillary refill time can result from an arterial or umbilical line (which can cause arterial hematoma and obstructed distal blood flow) or from an improperly fitting cast (which constricts circulation).
Special Considerations
Frequently assess the patient’s vital signs, LOC, and affected extremity, and report any changes, such as progressive cyanosis or loss of an existing pulse. Also, examine the dorsalis pedis and posterior arteries in the lower limbs. Prepare the patient for diagnostic tests, which may include arteriography or Doppler ultrasonography, to help confirm or rule out arterial occlusion.
Patient Counseling
Explain the signs and symptoms the patient needs to report, and instruct in ways to promote
circulation. Discuss ways to reduce the risk of aggravating or reintroducing the underlying disorder. Stress the importance of quitting smoking.
Pediatric Pointers
Capillary refill time may be increased in neonates with acrocyanosis; however, this is a normal finding. Typically, increased capillary refill time is associated with the same disorders in children as in adults. However, its most common pediatric cause is cardiac surgery such as the repair of congenital heart defects.
REFERENCES
Akre, M., Finkelstein, M., Erickson, M., Liu, M., Vanderbilt, L., & Billman, G. (2010). Sensitivity of the pediatric early warning score to identify patient deterioration. Pediatrics, 125(4), e763–e769.
Al Salloum, A. A. , El Mouzan, M. I., Al Herbish, A. S., Al Omar, A. A. , & Qurashi, M. M. (2009). Blood pressure standards for Saudi children and adolescents. Annals of Saudi Medicine, 29(3), 173–178.
Archbold, K. H., Johnson, N. L., Goodwin, J. L., Rosen, C. L., & Quan, S. F. (2010). Normative heart rate parameters during sleep for children aged 6 to 11 years. Journal of Clinical Sleep Medicine, 6(1), 47–50.
Carpopedal Spasm
Carpopedal spasm is the violent, painful contraction of the muscles in the hands and feet. (See
Recognizing Carpopedal Spasm, page 146.) It’s an important sign of tetany, a potentially lifethreatening condition characterized by increased neuromuscular excitation and sustained muscle contraction. Tetany, not to be confused with tetanus, may be caused by hypocalcemia or alkalosis.
Carpopedal spasm requires prompt evaluation and intervention. If the primary event isn’t treated promptly, the patient can also develop laryngospasm, seizures, cardiac arrhythmias, and cardiac and respiratory arrest.
EMERGENCY INTERVENTIONS
If you detect carpopedal spasm, quickly examine the patient for signs of respiratory distress (laryngospasm, stridor, loud crowing noises, cyanosis) or cardiac arrhythmias, which indicate hypocalcemia. Obtain blood specimens for electrolyte analysis (especially calcium and bicarbonate), and perform an electrocardiogram. Connect the patient to a cardiac monitor to watch for the appearance of arrhythmias. Administer an I.V. calcium preparation, and provide emergency respiratory and cardiac support. If calcium infusion doesn’t control seizures, administer a sedative, such as chloral hydrate or phenobarbital.
History and Physical Examination
If the patient isn’t in distress, obtain a detailed history. Ask about the onset and duration of the spasms and ask for a description of pain they produce. Also, ask about related signs and symptoms of hypocalcemia, such as numbness and tingling of the fingertips and feet, other muscle cramps or spasms, and nausea, vomiting, and abdominal pain. Check for previous neck surgery, calcium or magnesium deficiency, tetanus exposure, and hypoparathyroidism.
During the history, form a general impression of the patient’s mental status and behavior. If possible, ask family members or friends if they’ve noticed changes in the patient’s behavior. Mental confusion or even personality changes may occur with hypocalcemia.
EXAMINATION TIP Recognizing Carpopedal Spasm
In the hand, carpopedal spasm involves adduction of the thumb over the palm, followed by flexion of the metacarpophalangeal joints, extension of the interphalangeal joints (fingers together), adduction of the hyperextended fingers, and flexion of the wrist and elbow joints. Similar effects occur in the joints of the feet.
Inspect the patient’s skin and fingernails, noting dryness or scaling and ridged, brittle nails.
Medical Causes
Hypocalcemia. Carpopedal spasm is an early sign of hypocalcemia. It’s usually accompanied by paresthesia of the fingers, toes, and perioral area; muscle weakness, twitching, and cramping; hyperreflexia; chorea; fatigue; and palpitations. Positive Chvostek’s and Trousseau’s signs can be elicited. Laryngospasm, stridor, and seizures may appear in severe hypocalcemia.
Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows.
Tetanus. Tetanus develops when Clostridium tetani enters a wound in a nonimmunized individual. The patient develops muscle spasms and painful seizures. Difficulty swallowing and a low-grade fever are also present. If the patient isn’t treated or treatment is delayed, the mortality rate is very high.
Other Causes
Treatments. Multiple blood transfusions and parathyroidectomy may cause hypocalcemia, resulting in carpopedal spasm. Surgical procedures that impair calcium absorption, such as ileostomy formation and gastric resection with gastrojejunostomy, may also cause hypocalcemia.
Special Considerations
Carpopedal spasm can cause severe pain and anxiety, leading to hyperventilation. If this occurs, help the patient slow his breathing through your relaxing touch, reassuring attitude, and instructing him to breathe through pursed lips. Provide a quiet, dark environment to reduce his anxiety.
Prepare the patient for laboratory tests, such as complete blood count and serum calcium, phosphorus, and parathyroid hormone studies.
Patient Counseling
Explain the importance of tetanus immunization and keeping an immunization record and schedule.
Pediatric Pointers
Idiopathic hypoparathyroidism is a common cause of hypocalcemia in children. Carefully monitor children with this condition because carpopedal spasm may herald the onset of epileptiform seizures or generalized tetany followed by prolonged tonic spasms.
Geriatric Pointers
Always ask elderly patients about their immunization record. Suspect tetanus in anyone who comes to your facility with carpopedal spasm, difficulty swallowing, and seizures. Such patients may have incomplete immunizations or may not have had a recent booster shot. Always ask about any recent wound, no matter how inconsequential it may seem.
REFERENCES
McCormick, B. B., Davis, J. , Burns, K. D. (2012) . Severe hypocalcemia following denosumab injection in a hemodialysis patient.
American Journal of Kidney Diseases, 60(4), 626–628.
Recker, R. R., Lewiecki, E. M., Miller, P. D. , Reiffel, J. (2009). Safety of bisphosphonates in the treatment of osteoporosis. American Journal of Medicine, 122, S22–S32.
Cat’s Cry
Occurring during infancy, a mewing, kitten-like sound is the primary indicator of cat’s cry syndrome (also known as cri-du-chat). This syndrome affects about 1 in 50,000 neonates and causes profound mental retardation and failure to thrive. Most of those affected can have a normal life span; however, a few have serious organ defects and other life-threatening medical conditions.
GENDER CUE
Cat’s cry syndrome affects females more commonly than males.
The chromosomal defect responsible (deletion of the short arm of chromosome 5) usually appears spontaneously, but may be inherited from a carrier parent. The characteristic cry is thought to result from abnormal laryngeal development. Associated features include microcephaly, low birth weight, distinctive facial features, and hypotonia.
EMERGENCY INTERVENTIONS
Suspect cat’s cry syndrome if you detect a kitten-like cry in a neonate. Be alert for signs of respiratory distress, such as nasal flaring; irregular, shallow respirations; cyanosis; and a respiratory rate over 60 breaths/minute. Be prepared to suction the neonate and to administer warmed oxygen. Keep emergency resuscitation equipment nearby because bradycardia may develop.
History and Physical Examination
Perform a physical examination, and note abnormalities. If you detect cat’s cry in an older infant, ask the parents when it developed. The sudden onset of an abnormal cry in an infant with a previously normal, vigorous cry suggests other disorders. (See “Cry, High-pitched”, pages 209 and 210.)
Medical Causes
Cat’s cry syndrome. A kitten-like cry begins at birth or shortly thereafter. It’s accompanied by profound mental retardation, microcephaly, low birth weight, hypotonia, failure to thrive, and feeding difficulties. Typically, the neonate has a round face with wide-set eyes; strabismus; a broad-based nose with oblique or downsloping epicanthal folds; abnormally shaped, low-set ears; and an unusually small jaw. She may also have a short neck, webbed fingers, and a simian crease. Other abnormalities may include heart defects and GI abnormalities.
Special Considerations
Connect the neonate to an apnea monitor, and check for signs of respiratory distress. Keep suction equipment and warmed oxygen available. Obtain a blood sample for chromosomal analysis. Prepare the neonate for a computed tomography scan to rule out other causes of microcephaly and for an ear, nose, and throat examination to evaluate vocal cords.
Because the neonate with cat’s cry syndrome is usually a poor eater, monitor her intake, output, and weight.
Patient Counseling
Teach the parents about their child’s disorder and treatment options. Instruct the parents to offer the neonate small, frequent feedings. Prepare the parents to work long term with a team of specialists, such as those in genetics, neurology, cardiology, and speech and language. Discuss counselors or support groups that are available.
REFERENCES
Torun, D., Bahce, M., Alanbay, I., Guran, S., & Baser, I. (2009). Prenatal diagnosis of Cri-du chat syndrome following high maternal serum human chorionic gonadotropin and choroid plexus cysts. Prenatal Diagnosis, 29(5), 536–537.
Ye, Y . , Luo, Y. , Qian, Y. , Xu, C., & Jin F. (2011) . Cri du chat syndrome after preimplantation genetic diagnosis for reciprocal translocation. Fertility and Sterility, 96(1), e71–e75.