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the presence of cerumen. With cerumen impaction, no
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structures can be visualized. A foreign body is easily
visualized. Vesicles on the external ear canal and
auricle may indicate herpes zoster (Ramsay Hunt
syndrome).
Visualize any discharge, noting color, consistency,
and odor. Discharge is usually indicative of an active
infection. However, cranial trauma with cerebrospinal uid leakage must be kept in mind. Cheesy,
green-blue, or gray discharge can be seen with otitis
externa.
Inspect Tympanic Membranes
Visualize the TM, noting light reex and anatomical
structures. A normal TM is translucent and pearly gray
in color. Mild diffuse redness can occur from crying or
coughing. Mild vascularity is sometimes seen in the
normal eardrum, especially on the handle of the malleus.
Localized redness is a sign of inammation. Scarring
and effusion can cause whitening and opacication of
the TM.
The contour of the normal TM is somewhat concave. Fullness or bulging indicates either increased
air pressure, or more commonly, increased hydrostatic pressure within the middle ear. Fullness of
the eardrum is seen rst around the periphery of the
TM. As pressure increases, central fullness becomes
visible. Concavity or retraction of the eardrum is associated with negative middle ear pressure or postinammatory adhesions. As the eardrum retracts, the
handle of the malleus short process becomes more
visible.
Myringitis is a red, inamed eardrum without effusion. Bullous myringitis describes an extremely painful condition of small blisters on the TM caused by
bacterial otitis media. Figure 15-2 illustrates the usual
landmarks of a normal right TM. Chronic otitis media
can lead to cholesteatoma, or a cyst-like mass behind
the eardrum, caused by the proliferation of squamous
epithelium. The mass can grow to cause necrosis of the
ossicles. Examination will reveal a collection of white
granulation tissue with perforation of the TM. A series
of videos that show the examination of the TM when
otitis media with effusion is present is available at
www2.aap.org/sections/infectdis/video.cfm.
Perform Pneumatic Otoscopy (Insufflation)
The normal eardrum is suspended from its margins and
responds to slight pressure changes. Insufation tests
the mobility of the TM. It can be an insensitive test for
otitis media if poor technique fails to create a seal.
Chapter 15 • Earache
Pars flaccida
Incus
9
Pars tensa
6
FIGURE 15-2 Usual landmarks of the right tympanic membrane
with a “clock” superimposed. (From Barkauskas VH, Baumann
L, Darling-Fisher C: Health and physical assessment, ed. 3,
St Louis, 2002, Mosby.)
Short process
of malleus
3
Manubrium of
malleus
Umbo
Light reflex
179
Properly performed, however, it is more reliable than
visualization alone.
To perform insufation, a large speculum is needed
to create a seal. A normal nding elicits a slight motion
of the TM when air is insufated. This movement is
compared with the opposite ear. A TM that has been
retracted as a result of negative middle ear pressure or
adhesions does not move with ination, but rebound
mobility is seen when the bulb is released. Any accumulation of liquid in the middle ear (e.g., effusion)
or scarring of the TM inhibits movement when air is
insufated.
Test Hearing Acuity
Hearing acuity is tested using the whisper test and the
tuning fork for the Rinne and Weber tests. The sensory
function of the acoustic nerve (cranial nerve VIII)
should be tested to determine whether air or bone conduction loss is present with ear pain.
The Weber test is performed with a 512-hertz (Hz)
or higher frequency tuning fork. To perform the test,
rmly place the vibrating tuning fork on a midline
point of the skull. If there is unilateral conductive
hearing loss, sound will lateralize to the ear with the
loss because the better ear will be distracted by ambient noise. Alternately, if the patient has unilateral
sensorineural loss, the sound will lateralize to the better ear because the neural pathway will be interrupted
on the affected side. Equal perception of vibration
can indicate normal hearing or bilateral hearing loss.
The Rinne test compares air conduction (AC) with
bone conduction (BC); the ratio should be 2:1 AC
greater than BC. A 20- to 30-decibel (dB) conductive
loss would result in better sound transmission through
bone than through air. Conductive hearing loss results
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Chapter 15 • Earache
when sound transmission is impaired through the external or middle ear. Sensorineural hearing loss results from a defect in the inner ear. Findings of both
the Weber and Rinne tests must be considered for
optimal diagnosis. Sensorineural loss in the right ear
lateralizes to the left with both the Weber and Rinne,
and AC is greater than BC in both ears. With a conduction loss in the right ear, the Weber lateralizes
to the right and BC is greater than AC on the right; if
BC is greater than AC in both ears, there is a mixed
defect.
Examine Related Body Systems
Examine other regional body systems of the head and
neck, including inspection of the conjunctiva; examination of the mucosa and patency of the nose; percussion and palpation of the frontal and maxillary sinuses
for tenderness; and inspection of the posterior pharynx
for lymphedema, color, and presence of exudate. Inspection of the condition of the oral mucosa (teeth and
gums) will provide information about possible causes
of referred pain. A focused physical examination for
head and neck symptoms should include palpation of
cervicofacial lymph nodes, especially the preauricular
and postauricular nodes.
Perform an Intraotic Manipulation
If referred pain is suspected, conduct a more extensive
neurological examination and assess for TMJ disorder.
TMJ pain can be replicated by instructing the patient to
open the mouth wide. Face the patient, insert a single
ngertip in each ear, and pull the patient toward you
as the patient is instructed to open and close the mouth.
Pain will be elicited in 90% of patients with TMJ
disorder.
Evaluate Cranial Nerves V, VII, and IX
To evaluate the trigeminal nerve (cranial nerve V),
observe jaw and facial muscle movement for symmetry and strength by palpating over the masseter muscles, and ask the patient to bite and clench the teeth.
Assess intactness of sensation to pain and light touch
using a sharp/dull stimulus over the three branches of
cranial nerve V. Both cranial nerve VII (anterior two
thirds) and cranial nerve IX (posterior one third) innervate taste sensation to the tongue as well as sensation to the external ear. Have the patient protrude
the tongue and apply sweet and salty substances separately to each half of the tongue to test cranial nerve
VII, and apply bitter and sour substances to test
cranial nerve IX.
LABORATORY AND DIAGNOSTIC STUDIES
Tympanometry
Tympanometry involves inserting a probe into the external ear canal while continually changing pressure
against the eardrum to assess the mobility of the TM.
The tympanogram provides an indirect measure of
pressure in the middle ear. Under normal middle ear
pressure, the TM absorbs the sound energy waves and
produces a bell-shaped pattern that peaks when sound
pressure is introduced. With positive or negative
middle ear pressure, the tympanogram results in a at
pattern or an early peak pressure. Figure 15-3 illustrates examples of various tympanogram results.
Audiometry
Audiometry assesses both the frequency and the
intensity of sound that can be perceived. An air conduction audiometer tests each ear separately via earphones and transmits a pure tone that has variable
frequency and intensity settings. The goal of audiometry is to test the lowest decibel intensity that can be
heard for each frequency tested. An individual trained
in the proper technique will produce reliable, reproducible, and valid test results. A threshold of up to
20 dB is considered normal. At a higher level, hearing
loss is graded as mild, moderate, moderately severe,
severe, or profound.
Mastoid Process Radiography
Radiographs of the mastoid bone show clouding of the
air cells when otitis media is present. Chronic mastoiditis may reveal decalcication of the bony wall between
the mastoid air cells.
Computed Tomography Scanning
A computed tomography (CT) scan of the temporal
bone is helpful in diagnosing cholesteatoma and congenital syndromes.
DIFFERENTIAL DIAGNOSIS
External Otitis
External otitis is more common in adults than in children and often presents as bilateral pain that worsens
with manipulation of the pinna. The patient reports a
stuffed ear, and occasionally conductive hearing loss
occurs. Discharge and itching that occur 1 to 2 days
after swimming may be associated with otitis externa.
The affected canal may be swollen shut. Palpation will
often disclose enlarged preauricular or postauricular
Chapter 15 • Earache
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181
Pneumatic otoscopy
Tympanic
membrane position
1. Neutral
2. Neutral
monometric
3. Neutral
4. Retracted
slightly
5. Retracted
markedly
6. Retracted
7. Full
Ext.
canal
Middle
ear
Air
External canal
pressure
2+
3+
3+
4+
1+
2+
1+
3+
0
2+
0
2+
0
1+
0
0
1+
0
Middle ear
status Tympanograms
ContentPos Neg Pressure
Air
Air
Air and
liquid
Air
Air and
liquid
Air
Air and
liquid
Liquid
Liquid
and air
Normal
Normal
Normal
Low
negative
High
negative
Indeterminate
Positive or
indeterminate
Jerger's
classification
Peaked
Gradual
Peaked
Gradual
Type A
Type A
Type A
Type C
Type C
Type B
Type C
Type A+
Type B
8. Bulging
FIGURE 15-3 Middle ear evaluation with pneumatic otoscopy and impedance tympanograms. (From
Daeschner CW Jr: Pediatrics: An approach to independent learning, New York, 1983, John Wiley
& Sons.)
nodes. Malignant otitis externa is a rare complication
and involves infection and damage of the bones of the
ear canal and at the base of the skull.
Acute Otitis Media
AOM most often occurs in children younger than 6 years
and is associated with an upper respiratory tract infection. It is an acute infection associated with ear pain and
a bulging, red eardrum. The pain of otitis media is severe
enough to interfere with sleep and may be suddenly relieved if the eardrum perforates. Swelling of the preauricular node is sometimes seen in children with AOM.
Otitis Media With Effusion
Otitis media with effusion commonly occurs in children and is by denition painless. It is caused by a
Liquid
0
Liquid
0
Indeterminate
400 0 +200200
Type B
mechanical process or eustachian tube blockage that
leads to inadequate ventilation of the middle ear. On
examination, a collection of uid that resembles mucus, air bubbles, or a uid level is seen. Associated
conductive hearing loss is usually present. The TM
may be injected and immobile, either bulging or retracted, as noted by the shape of the cone of light reex
and pneumatic otoscopy. Associated recent upper respiratory tract infection is a common nding in adults.
Cholesteatoma
Cholesteatoma is an epidermal inclusion cyst formation
in the middle ear and mastoid cavity. It is often the sequelae of chronic otitis media. The formation occurs
with chronic negative middle ear pressure, causing the
migration of skin cells from the external ear canal
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Chapter 15 • Earache
through a perforation in the TM. Once established in
the middle ear, the cells desquamate and form the cholesteatoma. This condition is life threatening if left untreated because it will continue to erode away medially
to impinge on intracranial structures. A cholesteatoma
can also occur congenitally. A cholesteatoma appears as
a cyst or collection of granulation tissue on the TM,
commonly located in the pars accida area in the superior anterior quadrant of the TM.
Mastoiditis
Mastoiditis is an infection of the soft tissue surrounding the air spaces in the mastoid bone and is connected
to the middle ear space. Mastoiditis usually occurs
with bacterial otitis media and is associated with fever.
More advanced mastoiditis is manifested by swelling,
erythema, and tenderness over the mastoid bone.
Swelling can displace the position of the auricle. The
swelling can extend to the facial nerve, causing paralysis, or to the labyrinth or cerebrospinal uid, causing
meningitis or brain abscess. Advanced mastoiditis requires immediate referral and surgical management.
Foreign Bodies
Foreign bodies are easily visualized on examination of
the ear canal and can produce foul-smelling ear drainage secondary to infection or abscess.
Cerumen Impaction
Impaction of cerumen is likely if the patient reports a
stuffed-up ear or decreased hearing acuity. An impaction may also produce pain if cerumen is pressed
against the TM. Examination will reveal cerumen that
occludes the external canal.
Barotrauma
Barotrauma produces an acute serous otitis that is caused
by pressure changes (e.g., in divers or airplane travelers)
and is often aggravated by a recent upper respiratory tract
infection or nasal congestion. Serosanguineous uid collects in the middle ear; during descent this may be felt as
ear pressure, pain, tinnitus, or temporary deafness. Swallowing, chewing, or blowing out the nose with the mouth
and nose occluded can relieve symptoms.
Trauma
Blunt or penetrating trauma can perforate the TM. A
hole in the TM is visible on examination, or the examiner may notice an absence of normal landmarks. A
perforated eardrum does not signicantly impair hearing or result in vertigo, and it usually heals within 4 to
6 weeks without sequelae. Assess the extent of other
damage to the ear when perforation is identied.
Cervical Lymphadenitis
Anterior cervical lymphadenitis is a common cause of
referred ear pain in children. This may be seen with strep
throat, as well as in cases of mononucleosis with extensive cervical node swelling in adolescents or young
adults.
Referred Pain From Cervical and Cranial Nerves
Cervical nerves II and III innervate the skin and muscles of the neck and include the great auricular nerve,
which supplies the external canals and posterior auricular area. Pain is perceived in these areas. The ear
examination will be normal.
Cranial nerves associated with referred ear pain in-
clude V, VII, IX, and X. The trigeminal nerve (cranial
nerve V) supplies the anterior portion of the auricle
and tragus, the anterior and superior auditory canal,
and the anterior TM. The facial (cranial nerve VII),
vagus (cranial nerve X), and glossopharyngeal (cranial
nerve IX) nerves innervate the posterior portion of the
TM and the external auditory canal. Inammation of
cranial nerve X is associated with lesions of the larynx,
esophagus, trachea, and thyroid. With referred pain,
the structures of the ear will appear normal.
Temporomandibular Joint Disorder
TMJ disorder is a common secondary cause of ear pain.
Diagnosis of the disorder is likely if palpation over the
TMJ elicits tenderness and movement of the joint creates a clicking sound. Results of examination of the ear
are normal. Pain also increases with intraotic manipulation. TMJ pain is often worse in the morning. The pain
can be acute (related to trauma or overextension of the
mouth) or chronic (related to dental malocclusion or
rheumatoid arthritis).
Chapter 15 • Earache
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183
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Ear Pain
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
AOM, Acute otitis media; CT, computed tomography; TM, tympanic membrane; URI, upper respiratory tract infection.
References and Readings
Harmes K, Blackwood A, Burrows H, et al: Otitis media: Diagnosis
and treatment, Amer Fam Physic 88:7, 2013.
Ishiyama A: Why does air travel cause earache? West J Med 171:106,
1999.
Li J, Brunk J: Otalgia: Emedicine. 2010. Retrieved from emedicine.
medscape.com/article/845173-overview.
Lieberthal A, Carroll AE, Chonmaitree T, et al: American Academy
of Pediatrics Clinical Practice Guideline: The diagnosis and management of acute otitis media, Pediatrics 131:964, 2013
Majumdar S, Wu K, Bateman ND, Ray J: Diagnosis and management
of otalgia in children, Arch Dis Child Educ Pract Ed 94:33, 2009.
Pelton SI: Otitis media: Re-evaluation of diagnosis and treatment in the
era of antimicrobial resistance, pneumococcal conjugate vaccine,
and evolving morbidity, Pediatr Clin North Am 52:711, 2005.
CHAPTER
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16
atigue, also called asthenia, is a constitutional
F
symptom that can be the result of normal physiological consequences of exertion or a symptom of illness. It is a sensation of profound tiredness that is not
relieved by rest or sleep and does not have an objective
nding of muscle weakness. Fatigue can result from
any disruption of energy production. Anemia, decreased oxygenation of blood, or reduced blood ow
limits the amount of oxygen available to cells. Other
factors that contribute to fatigue interfere with restorative mechanisms provided by sleep and rest, nutritional state, and mechanisms to remove or regulate
wastes of metabolism. When fatigue is associated with
cardiovascular or respiratory symptoms, clues are
present that may point to the cause. However, most
patients who have the symptom of fatigue have a normal physical examination and psychological factors
are often a contributing cause.
Fatigue is classied as physiological, psychological, and acute or chronic. Physiological fatigue is the
result of normal activities that lead to overwork or
exhaustion. Psychological fatigue is often related to a
stressful event. Organic causes can produce acute or
chronic fatigue. Acute fatigue lasts less than 6 months
and is often a prodrome to other illnesses, most often
infections such as endocarditis, hepatitis, or other acute
bacterial or viral illnesses. However, fatigue can also
indicate a disease state, most often related to hyperthyroidism, hypothyroidism, heart failure, anemia, chronic
obstructive pulmonary disease (COPD), sleep apnea,
autoimmune disorder, or cancer.
Chronic fatigue lasts longer than 6 months, and its
onset is usually slow and progressive. Chronic fatigue
may be an indication of depression, chronic infection,
or systemic disease, or it may be secondary to alcohol
or medication use. Chronic fatigue syndrome is a
distinct clinical entity characterized by fatigue that is
persistent or relapses, is not alleviated with rest, and
affects the patient’s ability to function.
Fatigue is uncommon in very young children; the
younger the child, the more likely the cause is organic.
Fatigue
Most cases of fatigue in school-age children are related
to acute infection. Fatigue is common in adolescents
and in older adults because of lifestyle factors.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
Is this really fatigue?
Key Question
l
Can you tell me what you mean by fatigue?
Fatigue versus Weakness
It is important to discriminate between weakness and
fatigue. Often, patients describe muscle weakness
when speaking about fatigue such as, “I am tired all the
time and I feel weak.” In children with weakness, parents will say the child is oppy or “doesn’t run in gym
like the other children.” An individual tends to tire
easily with metabolic or neuromuscular diseases such
as hypothyroidism or myasthenia gravis.
Young children tend not to vocalize fatigue; often it
is the parent who brings the child to seek treatment.
The parent may state that “the child is lying around,”
“I can’t get the child to do anything,” or “she just
doesn’t have any energy.” Adolescents will say they
are “always” tired.
Is the fatigue physiologic?
Key Questions
l
Tell me about your lifestyle habits (e.g., exercise and
diet)
l
What is your sleep pattern?
l
Do you require naps? How often?
l
Do you feel rested when you wake up in the morning?
l
When was your last menstrual period?
Lifestyle Habits
A history of the patient’s daily living and working habits may reveal a physiological cause for exhaustion.
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Chapter 16 • Fatigue
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185
Erratic eating patterns, dieting, and missed meals may
result in undernutrition or overnutrition. High levels
of caffeine can affect the amount of energy a person
has as well as the sleep cycle, causing fatigue. Academic stress, athletic participation, and employment
further contribute to fatigue in adolescents.
Sleep Pattern
Lack of adequate amounts of sleep is often the cause
of fatigue (see Chapter 31). Adults need at least 6 to
8 hours of sleep for adequate rest; adolescents, 8 to
9 hours; and children, 10 hours. Patients with sleep
apnea, which is more common in men older than
45 years, may report waking up and not feeling refreshed. Heart failure causes postural nocturnal dyspnea,
leading to difculty breathing at night and disturbed
sleep. Early morning wakening is a symptom of depression, as is excessive sleeping during the day.
Last Normal Menstrual Period
Fatigue is a common symptom in women. Fatigue is an
early sign of pregnancy, a symptom post childbirth,
and a symptom associated with menopause. Perimenopausal women may have fatigue as a result of disrupted
sleep because of night sweats or hot ashes.
Do I need to consider an organic cause?
Key Questions
l
Do you practice safe sex (if sexually active)?
l
Have you ever had hepatitis?
l
What medications do you take?
l
Do you drink alcohol or use recreational drugs?
antihypertensive drugs, cardiovascular medications,
psychotropic medications, and opiates. Side effects also
occur with drugs such as sedatives and antihistamines.
Many drugs that cause fatigue are over-the-counter
preparations.
Alcohol and Drug Use
Alcohol abuse and use of recreational drugs may be
overlooked as a cause of chronic fatigue in adolescents
and school-age children. This fatigue is due directly to
the substance, usually alcohol or marijuana, and to
secondary factors such as associated poor lifestyle
habits related to sleep, rest, and nutrition. Family and
friends may express the greatest concerns about fatigue
that affects the patient’s ability to function. The CAGE
questionnaire is a useful screening tool to assess for
alcohol abuse (see Box 4-3).
What other clues can help me rule out an organic
cause?
Key Questions
l
Have you noticed a change in appetite? Increased
thirst?
l
Do you have any joint tenderness or pain?
l
Have you noticed increased urination?
l
Any change in your bowel movements?
l
What other symptoms have you experienced?
Appetite
An increased appetite may indicate hypoglycemia; in-
creased thirst may indicate hyperglycemia. A decreased
appetite may indicate an infectious process.
Exposure to Body Fluids
Fatigue may be the initial and most prominent symptom of hepatitis, human immunodeciency virus
(HIV) infection, or acquired immunodeciency syndrome (AIDS). Hepatitis B can be sexually transmitted through semen or contracted from exposure to
contaminated blood. Sexual practices that traumatize
mucous membranes, such as anal intercourse, increase the risk of transmission of organisms. The
person with HIV/AIDS experiences cognitive impairment that includes difculty processing complex information. These impairments are correlated with the
severity of fatigue.
Medications
Almost any drug may have fatigue as a side effect.
The most common drugs that cause fatigue are
Weight Loss
Weight loss may indicate malignancy, infection, or poor
nutrition related to depression or lack of information
about a healthy and balanced diet.
Increased Urination
Diabetes mellitus, especially type 2, often presents
with fatigue along with polydipsia, polyphagia, and
polyuria.
Joint Tenderness
In children with juvenile rheumatoid arthritis (JRA),
severe fatigue that seems to be more than expected
with the degree of joint involvement is seen. In young
and middle-aged patients, chronic fatigue syndrome
can involve multiple tender points on the body that are
over joints.
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Chapter 16 • Fatigue
Associated Symptoms
Psychological fatigue is often associated with nonspecic and multiple symptoms, such as muscle aching,
abdominal pain, and general lethargy. Organic causes
of fatigue are associated with a few specic symptoms
that worsen over time, such as dry skin and nails with
hypothyroidism, or shortness of breath with exertion or
when lying at, as seen in congestive heart failure.
Could this have an environmental cause?
Key Questions
l
Where do you work?
l
Have you been exposed to any toxins?
l
Have you been camping?
Occupational Exposure
Heavy metals and pesticides may cause fatigue and
other neurological symptoms. Soldiers returning from
combat zones may develop unrelenting fatigue from an
unknown cause.
Camping
Lyme disease is carried by the deer tick, and the patient may present with a history of weeks of malaise
and chronic fatigue before any skin manifestations
appear.
What else do I need to know about the fatigue?
Key Questions
l
Describe the onset and pattern of your fatigue.
l
When did you rst notice this?
l
How severe is the fatigue?
l
What makes the fatigue better or worse?
l
Have you had a fever?
l
Have you had any bleeding?
Onset and Pattern
The onset of psychological fatigue is often related
to a stressful event and may have a sudden onset.
Fatigue associated with metabolic causes may have a
slow and progressive onset. Signicant fatigue is considered to last longer than 2 weeks and is experienced
by about 25% of adults. Fatigue may be an early sign
of pregnancy.
Severity
Clinically signicant fatigue may vary throughout
the day but never completely disappears. Children with
Lyme disease and JRA experience severe fatigue that is
in excess of the degree of disease involvement. The
patient may need to limit social functioning and recreational activities as a result of fatigue, which may then
exacerbate mood disturbances and, in turn, contribute
to fatigue.
Aggravating/Alleviating Factors
Psychological fatigue is usually worse in the morning
and physical activity may relieve the fatigue. Organic
fatigue is not associated with intensity or duration of
activity and is not relieved with rest or sleep.
Fever
Fever generally accompanies infectious diseases, which
are common causes of fatigue (see Chapter 17). Prolonged fever may indicate chronic infection, inammatory disease, or malignancy.
Bleeding
Heavy menstrual ow may lead to anemia (see
Chapter 36). Other sources of bleeding, such as gastrointestinal ulcers, polyps, or cancer of the bowel,
may result in occult blood loss and fatigue.
If I suspect a psychological cause, what else do
I need to know?
Key Questions
l
What is your stress level and how do you cope with
stress in your life?
l
Have you recently had a stressful event in your life?
l
Do you or does anyone in your family have a prob-
lem with anxiety or depression?
l
How are you doing in school?
Stress
Stressful life events increase the risk of depression in
some adolescents and adults. In the presence of organic
disease, stress may be secondary to pain or discomfort
that may disrupt sleep and rest patterns. Deconditioning secondary to muscle atrophy with inactivity or bed
rest can lead to fatigue (see Chapter 4).
Anxiety and Depression
Children who have family members with depression
are at a greater risk for depression. Generally, the rst
episode of major depression occurs between the ages
of 20 and 30 years and affects women more often than
men. Major depressive disorder may have a genetic
component. Diagnostic criteria will point to depression
or anxiety as a cause.
Chapter 16 • Fatigue
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187
School Performance
Decreased academic performance and decreased productivity may be an early sign of low self-esteem
and early depression. Children also may overachieve
academically to compensate for their lower self-esteem
and to hide their depression.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
A general physical examination, including psychological screening for depression and anxiety, is needed to
make a differential diagnosis of fatigue. The majority
of patients will have a normal physical examination,
but clues can be found for the presence of systemic
disease.
Note General Appearance
Observe the patient entering the examination room to
note any abnormality of gait that may indicate neurological involvement or generalized weakness. Observe
the patient’s demeanor and appearance for signs of neglect or a facial expression that might indicate depression or generalized anxiety. In the presence of organic
disease, the patient will appear ill; with psychological
stress, the patient may appear depressed or anxious.
Children may appear sad or irritable.
Take Vital Signs
The presence of fever suggests inammation or infection. Blood pressure reading, pulse rate, and respiratory rate reect the function of the cardiorespiratory
system. An elevated pulse rate may be associated with
anxiety, anemia, dehydration, and hyperthyroidism.
Evaluate the patient for orthostatic hypotension or
neutrally-mediated hypotension. Weigh and measure
the patient to obtain the body mass index (BMI); a
BMI outside the normal range can indicate poor nutritional status as well as cardiovascular risk.
Inspect Skin, Hair, and Nails
Observe for signs of thyroid dysfunction. Hypothyroidism is associated with coarse, dry hair and skin and
thickening of nails. Hyperthyroidism is characterized
by ne, limp hair and warm skin. Look for skin lesions
or rashes that may indicate infection or inammation.
A faint maculopapular rash is sometimes associated
with mononucleosis. Lyme disease is associated with a
macular lesion with a clear center. Atrophic skin of the
lower extremities is an indication of arterial insufciency and underlying arteriovascular disease. Venous
stasis can lead to swelling of the ankles, varicose veins,
and skin ulcers. Patients with anxiety disorders may
bite their nails or self-inict excoriation lesions, usu-
ally over the face and extremities.
Examine the Nose, Eyes, Mouth, and Throat
Inspect for any signs of infection or inammation sec-
ondary to an allergic response. Petechiae on the palate
may be seen with mononucleosis. Palpate for cervico-
facial nodes. Lymphadenopathy is seen with HIV,
malignancy, and mononucleosis. Inspect mucous
membranes for lesions and moisture. Dry, cracked, and
ulcerated mucosa can indicate a nutritional deciency
or dehydration.
Conduct a Cardiovascular Examination
Palpate the anterior thorax for the location of the point
of maximal impulse (PMI) and for lifts or heaves.
Listen for carotid and thyroid bruits. Auscultate the
heart, listening carefully for rate, rhythm, and mur-
murs, especially a late systolic murmur heard loudest
over the mitral area, which may indicate mitral pro-
lapse. Audible third or fourth heart sounds (S3 or S4) in
an adult may indicate heart failure.
Examine the Lungs
First, observe the patient for ease of breathing and
respiratory rate. Note the anteroposterior (AP)/lateral
diameter of the thorax. An increased AP diameter
indicates chronic obstructive pulmonary disease
(COPD). Test for egophony, and palpate and percuss
the anterior and posterior thorax to listen for reso-
nance (normal) or consolidation. Tactile fremitus
will increase over areas of consolidated lung. Listen
for rales and wheezes. Bilateral basilar rales may
indicate congestive heart failure; most pneumonia is
unilateral. Barely audible breath sounds are associ-
ated with COPD.
Examine the Abdomen
Begin the examination by observing the abdomen (see
Chapter 3). Observe the intactness and condition of the
skin. A rigid abdomen suggests peritoneal irritation.
Generalized symmetrical distention may occur with
obesity, enlarged organs, uid or ascites, and gas. De-
hydration or malnutrition may present as a concave
contour of the abdomen.
Listen for bowel sounds. Anxiety, gastrointestinal
irritation, and hunger can increase the frequency and
loudness of bowel sounds. Depression can decrease
bowel sounds.
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Chapter 16 • Fatigue
Perform general light palpation to assess the skin
and abdominal musculature. Note the patient’s response to the examination. Perform deep palpation
over the liver, spleen, and right kidney. Fist palpation over the posterior thorax tests for kidney tenderness associated with pyelonephritis, renal calculi,
or stenosis.
Perform a Musculoskeletal Examination
Observe and palpate joints for inammation and swelling. Bilateral tenderness of at least 11 of 18 tender
points is diagnostic of bromyalgia. An informative
example of how to examine for tender points can be
found at www.youtube.com/watch?v508qtNhsTXHQ.
Test stamina by asking the patient to perform certain
musculoskeletal movements or to walk a certain distance to evaluate changes in fatigue level.
Conduct a Neurological Examination
Assess both cognitive and physical function to evaluate attention span, judgment, memory, and affect. Abnormalities may suggest a psychiatric disorder or brain
pathology. Dementia is also seen in patients with HIV/
AIDS. Test cranial nerves. A change in deep tendon
reexes (DTRs) may indicate thyroid dysfunction.
Cerebellar and motor testing will rule out weakness or
any associated neurological pathology.
LABORATORY AND DIAGNOSTIC STUDIES
Complete Blood Count With Indices and
Differential
A complete blood count (CBC) with indices will provide information about the degree and cause of anemia.
Hematocrit and hemoglobin levels reect the degree of
anemia, and the indices point to a cause. Microcytic
hypochromic anemia reects chronic blood loss,
whereas normocytic normochromic anemia suggests
an acute blood loss.
A white blood cell (WBC) count of greater than
12,000/mL indicates inammation or infection. Normally the circulating neutrophils are in a mature form,
called segs because the cell nuclei are segmented. Immature neutrophils are called bands. Infection will increase the total number of neutrophils, with an increase
in the number of immature cells or bands.
Ferritin
Ferritin is a protein that stores iron in bone marrow,
and the ferritin level most accurately reects total
body iron stores. The ferritin level is low in a patient
with iron deciency anemia. In contrast, the ferritin
level may be elevated or normal in a patient
with anemia caused by chronic disease or a patient
with a thalassemia caused by a reduced life cycle
of red blood cells (RBCs). The bone marrow fails
to compensate for the loss by increasing RBC
production.
Total Iron-Binding Capacity
Iron is transported in plasma bound with transferrin, a
serum protein synthesized in the liver. Total ironbinding capacity (TIBC) of serum is an indirect measure of transferrin. This capacity may be increased in
iron deciency anemia because although the capacity
to bind with iron is high, hemoglobin is decreased, and
both mean corpuscular volume (MCV) and mean corpuscular hemoglobin concentration (MCHC) are decreased (e.g., hypochromic microcytic anemia). TIBC
is normal or low in patients with a chronic disease,
often because of the shorter life cycle of an RBC and
the body’s inability to compensate.
Urinalysis
Dipstick urinalysis can rule out or point to infection
or systemic disease if incontinence is present. Hematuria, pyuria, bacteriuria, and the presence of leukocyte esterase or nitrites indicate urinary tract infection. Glycosuria or proteinuria is suggestive of
infection, cardiovascular disease, diabetes mellitus,
or renal disease. The presence of bacteria or WBCs
on microscopic examination indicates urinary tract
infection; RBC casts may indicate nephropathy (see
Chapter 35).
Erythrocyte Sedimentation Rate
An increased ESR is a general indication of an inammatory process and does not identify the source. The
ESR is often elevated as a result of acute or chronic
infection and inammatory conditions such as rheumatoid arthritis, temporal arteritis, or any other injury
causing an inammatory response.
Fasting Blood Glucose
A fasting blood glucose level of 126 mg/dL or higher
points to a diagnosis of diabetes mellitus. Prediabetes
is indicated when the fasting blood glucose level is
between 100 to 125 mg/dL. Unless changes in lifestyle
behaviors and weight occur, the person will most likely
develop diabetes.
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