Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015

ectodermal dysplasia, are the most common causes of anhidrosis.

Because delayed development of the thermoregulatory center renders an infant — especially a premature one — anhidrotic for several weeks after birth, caution parents against overdressing their infant.

REFERENCES

Barclay, L. (2009). Autonomic testing may help differentiate multiple system atrophy from Parkinson disease. Medscape, July 17, 2009. Jindal, G. , Parmar V. R. , & Gupta V. K. (2009) . Isolated ptosis as acute ophthalmoplegia without ataxia, positive for anti-GQ1b

immunoglobulin G. Pediatric Neurology, 41, 451–452.

Anorexia

Anorexia, a lack of appetite in the presence of a physiologic need for food, is a common symptom of GI and endocrine disorders and is characteristic of certain severe psychological disturbances such as anorexia nervosa. It can also result from such factors as anxiety, chronic pain, poor oral hygiene, increased blood temperature due to hot weather or fever, and changes in taste or smell that normally accompany aging. Anorexia also can result from drug therapy or abuse. Short-term anorexia rarely jeopardizes health, but chronic anorexia can lead to life-threatening malnutrition.

History and Physical Examination

Take the patient’s vital signs and weight. Find out previous minimum and maximum weights. Ask about involuntary weight loss greater than 10 lb (4.5 kg) in the past month. Explore dietary habits such as when and what the patient eats. Ask what foods he likes and dislikes and why. The patient may identify tastes and smells that nauseate him and cause loss of appetite. Ask about dental problems that interfere with chewing, including poor-fitting dentures. Ask if he has difficulty or pain when swallowing or if he vomits or has diarrhea after meals. Ask the patient how frequently and intensely he exercises.

Check for a history of stomach or bowel disorders, which can interfere with the ability to digest, absorb, or metabolize nutrients. Find out about changes in bowel habits. Ask about alcohol use and drug use and dosage.

If the medical history doesn’t reveal an organic basis for anorexia, consider psychological factors. Ask the patient if he knows what’s causing his decreased appetite. Situational factors — such as a death in the family or problems at school or at work — can lead to depression and a subsequent loss of appetite. Be alert for signs of malnutrition, consistent refusal of food, and a 7% to 10% loss of body weight in the preceding month. (See Is Your Patient Malnourished?, page 50.)

Medical Causes

Acquired immunodeficiency syndrome. An infection or Kaposi’s sarcoma affecting the GI or respiratory tract may lead to anorexia. Other findings include fatigue, afternoon fevers, night sweats, diarrhea, cough, lymphadenopathy, bleeding, oral thrush, gingivitis, and skin disorders, including persistent herpes zoster and recurrent herpes simplex, herpes labialis, or herpes genitalis.

EXAMINATION TIP Is Your Patient Malnourished?

Hair. Dull, dry, thin, fine, straight, and easily plucked; areas of lighter or darker spots and hair loss

Face. Generalized swelling, dark areas on cheeks and under eyes, lumpy or flaky skin around the nose and mouth, enlarged parotid glands

Eyes. Dull appearance; dry and either pale or red membranes; triangular, shiny gray spots on conjunctivae; red and fissured eyelid corners; bloodshot ring around cornea

Lips. Red and swollen, especially at corners

Tongue. Swollen, purple, and raw looking, with sores or abnormal papillae

Teeth. Missing, or emerging abnormally; visible cavities or dark spots; spongy, bleeding gums

Neck. Swollen thyroid gland

Skin. Dry, flaky, swollen, and dark, with lighter or darker spots, some resembling bruises; tight and drawn, with poor skin turgor

Nails. Spoon shaped, brittle, and ridged

Musculoskeletal system. Muscle wasting, knock-knee or bowlegs, bumps on ribs, swollen joints, musculoskeletal hemorrhages

Cardiovascular system. Heart rate above 100 beats/minute, arrhythmias, elevated blood pressure

Abdomen. Enlarged liver and spleen

Reproductive system. Decreased libido, amenorrhea

Nervous system. Irritability, confusion, paresthesia in hands and feet, loss of proprioception, decreased ankle and knee reflexes

When assessing a patient with anorexia, make sure to check for these common signs of malnutrition.

Adrenocortical hypofunction. With adrenocortical hypofunction, anorexia may begin slowly and subtly, causing gradual weight loss. Other common signs and symptoms include nausea and vomiting, abdominal pain, diarrhea, weakness, fatigue, malaise, vitiligo, bronze-colored skin, and purple striae on the breasts, abdomen, shoulders, and hips.

Alcoholism. Chronic anorexia commonly accompanies alcoholism, eventually leading to malnutrition. Other findings include signs of liver damage (jaundice, spider angiomas, ascites, edema), paresthesia, tremors, increased blood pressure, bruising, GI bleeding, and abdominal pain.

Anorexia nervosa. Chronic anorexia begins insidiously and eventually leads to life-threatening malnutrition, as evidenced by skeletal muscle atrophy, loss of fatty tissue, constipation, amenorrhea, dry and blotchy or sallow skin, alopecia, sleep disturbances, distorted self-image, anhedonia, and decreased libido. Paradoxically, the patient typically exhibits extreme restlessness and vigor and may exercise avidly. He also may have complicated food preparation and eating rituals.

Appendicitis. Anorexia closely follows the abrupt onset of generalized or localized epigastric pain, nausea, and vomiting. It can continue as pain localizes in the right lower quadrant

(McBurney’s point), and other signs and symptoms appear: abdominal rigidity, rebound tenderness, constipation (or diarrhea), a slight fever, and tachycardia.

Cancer. Chronic anorexia occurs along with possible weight loss, weakness, apathy, and cachexia.

Chronic renal failure. Chronic anorexia is common and insidious. It’s accompanied by changes in all body systems, such as nausea, vomiting, mouth ulcers, ammonia breath odor, metallic taste in the mouth, GI bleeding, constipation or diarrhea, drowsiness, confusion, tremors, pallor, dry and scaly skin, pruritus, alopecia, purpuric lesions, and edema.

Cirrhosis. Anorexia occurs early in cirrhosis and may be accompanied by weakness, nausea, vomiting, constipation or diarrhea, and dull abdominal pain. It continues after these early signs and symptoms subside and is accompanied by lethargy, slurred speech, bleeding tendencies, ascites, severe pruritus, dry skin, poor skin turgor, hepatomegaly, fetor hepaticus, jaundice, leg edema, gynecomastia, and right upper quadrant pain.

Crohn’s disease. Chronic anorexia causes marked weight loss. Associated signs vary according to the site and extent of the lesion, but may include diarrhea, abdominal pain, fever, an abdominal mass, weakness, perianal or vaginal fistulas and, rarely, clubbing of the fingers. Acute inflammatory signs and symptoms — right lower quadrant pain, cramping, tenderness, flatulence, fever, nausea, diarrhea (including nocturnal), and bloody stools — mimic those of appendicitis.

Gastritis. With acute gastritis, the onset of anorexia may be sudden. The patient may experience postprandial epigastric distress after a meal, accompanied by nausea, vomiting (commonly with hematemesis), fever, belching, hiccups, and malaise.

Hepatitis. With viral hepatitis (hepatitis A, B, C, or D), anorexia begins in the preicteric phase, accompanied by fatigue, malaise, headache, arthralgia, myalgia, photophobia, nausea and vomiting, a mild fever, hepatomegaly, and lymphadenopathy. It may continue throughout the icteric phase, along with mild weight loss, dark urine, clay-colored stools, jaundice, right upper quadrant pain and, possibly, irritability and severe pruritus.

Signs and symptoms of nonviral hepatitis usually resemble those of viral hepatitis but may vary, depending on the cause and extent of liver damage.

Hypothyroidism. Anorexia is common and usually insidious in patients with a thyroid hormone deficiency. Typically, vague early findings include fatigue, forgetfulness, cold intolerance, unexplained weight gain, and constipation. Subsequent findings include decreased mental stability; dry, flaky, and inelastic skin; edema of the face, hands, and feet; ptosis; hoarseness; thick, brittle nails; coarse, broken hair; and signs of decreased cardiac output such as bradycardia. Other common findings include abdominal distention, menstrual irregularities, decreased libido, ataxia, intention tremor, nystagmus, a dull facial expression, and slow reflex relaxation time.

Ketoacidosis. Anorexia usually arises gradually and is accompanied by dry, flushed skin; a fruity breath odor; polydipsia; polyuria and nocturia; hypotension; a weak, rapid pulse; a dry mouth; abdominal pain; and vomiting.

Pernicious anemia. With pernicious anemia, insidious anorexia may cause considerable weight loss. Related findings include the classic triad of a burning tongue, general weakness, and numbness and tingling in the extremities; alternating constipation and diarrhea; abdominal pain; nausea and vomiting; bleeding gums; ataxia; positive Babinski’s and Romberg’s signs; diplopia and blurred vision; irritability; headache; malaise; and fatigue.

Failure.) Fortunately, anuria is rare; even with renal failure, the kidneys usually produce at least 75 mL of urine daily.

Because urine output is easily measured, anuria rarely goes undetected. However, without immediate treatment, it can rapidly cause uremia and other complications of urine retention.

EMERGENCY INTERVENTIONS

After detecting anuria, your priorities are to determine if urine formation is occurring and to intervene appropriately. Prepare to catheterize the patient to relieve any lower urinary tract obstruction and to check for residual urine. You may find that an obstruction hinders catheter insertion and that urine return is cloudy and foul smelling. If you collect more than 75 mL of urine, suspect lower urinary tract obstruction; if you collect less than 75 mL, suspect renal dysfunction or obstruction higher in the urinary tract.

History and Physical Examination

Take the patient’s vital signs, and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.

Major Causes of Acute Renal Failure

Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.

Medical Causes

Acute tubular necrosis. Oliguria (occasionally anuria) is a common finding with acute tubular necrosis. It precedes the onset of diuresis, which is heralded by polyuria. Associated findings reflect the underlying cause and may include signs and symptoms of hyperkalemia (muscle weakness, cardiac arrhythmias), uremia (anorexia, nausea, vomiting, confusion, lethargy, twitching, seizures, pruritus, uremic frost, and Kussmaul’s respirations), and heart failure (edema, jugular vein distention, crackles, and dyspnea).

Cortical necrosis (bilateral). Cortical necrosis is characterized by a sudden change from oliguria to anuria, along with gross hematuria, flank pain, and fever.

Glomerulonephritis (acute). Acute glomerulonephritis produces anuria or oliguria. Related effects include a mild fever, malaise, flank pain, gross hematuria, facial and generalized edema, elevated blood pressure, headache, nausea, vomiting, abdominal pain, and signs and symptoms

of pulmonary congestion (crackles, dyspnea).

Hemolytic-uremic syndrome. Anuria commonly occurs in the initial stages of hemolytic-uremic syndrome and may last from 1 to 10 days. The patient may experience vomiting, diarrhea, abdominal pain, hematemesis, melena, purpura, fever, elevated blood pressure, hepatomegaly, ecchymoses, edema, hematuria, and pallor. He may also show signs of upper respiratory tract infection.

Renal artery occlusion (bilateral). Renal artery occlusion produces anuria or severe oliguria, commonly accompanied by severe, continuous upper abdominal and flank pain; nausea and vomiting; decreased bowel sounds; a fever up to 102°F (38.9°C); and diastolic hypertension.

Renal vein occlusion (bilateral). Renal vein occlusion occasionally causes anuria; more typical signs and symptoms include acute low back pain, fever, flank tenderness, and hematuria. Development of pulmonary emboli — a common complication — produces sudden dyspnea, pleuritic pain, tachypnea, tachycardia, crackles, pleural friction rub and, possibly, hemoptysis.

Urinary tract obstruction. Severe urinary tract obstruction can produce acute and sometimes total anuria, alternating with or preceded by burning and pain on urination, overflow incontinence or dribbling, increased urinary frequency and nocturia, voiding of small amounts, or an altered urine stream. Associated findings include bladder distention, pain and a sensation of fullness in the lower abdomen and groin, upper abdominal and flank pain, nausea and vomiting, and signs of secondary infection, such as fever, chills, malaise, and cloudy, foulsmelling urine.

Vasculitis. Vasculitis occasionally produces anuria. More typical findings include malaise, myalgia, polyarthralgia, fever, elevated blood pressure, hematuria, proteinuria, arrhythmia, pallor and, possibly, skin lesions, urticaria, and purpura.

Other Causes

Diagnostic tests. Contrast media used in radiographic studies can cause nephrotoxicity, producing oliguria and, rarely, anuria.

Drugs. Many classes of drugs can cause anuria or, more commonly, oliguria through their nephrotoxic effects. Antibiotics, especially the aminoglycosides, are the most commonly seen nephrotoxins. Anesthetics, heavy metals, ethyl alcohol, and organic solvents can also be nephrotoxic. Adrenergics and anticholinergics can cause anuria by affecting the nerves and muscles of micturition to produce urine retention.

Special Considerations

If catheterization fails to initiate urine flow, prepare the patient for diagnostic studies — such as ultrasonography, cystoscopy, retrograde pyelography, and renal scan — to detect any obstruction higher in the urinary tract. If these tests reveal an obstruction, prepare him for immediate surgery to remove the obstruction, and insert a nephrostomy or ureterostomy tube to drain the urine. If these tests fail to reveal an obstruction, prepare the patient for further kidney function studies.

Carefully monitor the patient’s vital signs and intake and output, initially saving any urine for inspection. Restrict daily fluid allowance to 600 mL more than the previous day’s total urine output. Restrict foods and juices high in potassium and sodium, and make sure that the patient maintains a balanced diet with controlled protein levels. Provide low-sodium hard candy to help decrease thirst.

Record fluid intake and output, and weigh the patient daily.

Patient Counseling

Discuss fluids and foods the patient should avoid. Instruct the patient on nephrostomy tube or ureterostomy tube care, if needed.

Pediatric Pointers

In neonates, anuria is defined as the absence of urine output for 24 hours. It can be classified as primary or secondary. Primary anuria results from bilateral renal agenesis, aplasia, or multicystic dysplasia. Secondary anuria, associated with edema or dehydration, results from renal ischemia, renal vein thrombosis, or congenital anomalies of the genitourinary tract. Anuria in children commonly results from loss of renal function.

Geriatric Pointers

In elderly patients, anuria is a gradually occurring sign of underlying pathology. Hospitalized or bedridden elderly patients may be unable to generate the necessary pressure to void if they remain in a supine position.

REFERENCES

Briggs, S., Goettler, C. E., Schenarts, P. J. , Newell, M. A., Sagraves, S. G., Bard, M. R., … Rotondo, M. F. (2009) . High-frequency oscillatory ventilation as a rescue therapy for adult trauma patients, American Journal of Critical Care, 18, 144–148.

Ferguson, N. D., Cook, D. J., Guyatt, G. H., Mehta, S., Hand, L., Austin, P., … Meade, M. O. (2013). High-frequency oscillation in early acute respiratory distress syndrome. New England Journal of Medicine, 368(9), 795–805.

Anxiety

Anxiety is the most common psychiatric symptom and can result in significant impairment. A subjective reaction to a real or imagined threat, anxiety is a nonspecific feeling of uneasiness or dread. It may be mild, moderate, or severe. Mild anxiety may cause slight physical or psychological discomfort. Severe anxiety may be incapacitating or even life threatening.

Everyone experiences anxiety from time to time — it’s a normal response to actual danger, prompting the body (through stimulation of the sympathetic and parasympathetic nervous systems) to purposeful action. It’s also a normal response to physical and emotional stress, which can be produced by virtually any illness. In addition, anxiety can be precipitated or exacerbated by many nonpathologic factors, including lack of sleep, poor diet, and excessive intake of caffeine or other stimulants. However, excessive, unwarranted anxiety may indicate an underlying psychological problem.

History and Physical Examination

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a

reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake and alleviated by rest, tranquilizers, or exercise.

Obtain a complete medical history, especially noting drug use. Then, perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.

If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological basis. Determine the patient’s level of consciousness (LOC), and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.

Medical Causes

Acute respiratory distress syndrome. Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.

Anaphylactic shock. Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

Angina pectoris. Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.

Asthma. With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Autonomic hyperreflexia. The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

Cardiogenic shock. Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

Chronic obstructive pulmonary disease (COPD). Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.

Heart failure. With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.

Hyperthyroidism. Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.

Mitral valve prolapse. Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an