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228 DYSMENORRHEA
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rehabilitation and training. Other findings include facial weakness, diplopia, hemiparesis,
spasticity, drooling, dyspnea, and decreased LOC.
◆ Stroke (cerebral). A massive bilateral stroke
causes pseudobulbar palsy. Bilateral weakness
produces dysarthria that’s most severe at the
stroke’s onset. This sign is accompanied by dysphagia, drooling, dysphonia, bilateral hemianopsia, and aphasia. Sensory loss, spasticity,
and hyperreflexia may also occur.
O
THER CAUSES
◆ Drugs. Dysarthria can occur when anticon-
vulsant dosage is too high. Ingestion of large
doses of barbiturates may also cause dysarthria.
◆ Manganese poisoning. Chronic manganese
poisoning causes progressive dysarthria accompanied by weakness, fatigue, confusion, hallucinations, drooling, hand tremors, limb stiffness,
spasticity, gross rhythmic movements of the
trunk and head, and a propulsive gait.
◆ Mercury poisoning. Chronic mercury poi-
soning causes progressive dysarthria accompanied by weakness, fatigue, depression, lethargy,
irritability, confusion, ataxia, and tremors.
S
PECIAL CONSIDERATIONS
Encourage the patient with dysarthria to speak
slowly so that he can be understood. Give him
time to express himself, and encourage him to
use gestures. Dysarthria usually requires consultation with a speech pathologist.
P
EDIATRIC POINTERS
Dysarthria in children usually results from brain
stem glioma, a slow-growing tumor that primarily affects children. It may also result from
cerebral palsy.
Dysarthria may be difficult to detect, especially
in an infant or a young child who hasn’t perfected speech. Be sure to look for other neurologic deficits, too. Encourage a child with
dysarthria to speak; a child’s potential for rehabilitation is typically greater than an adult’s.
Dysmenorrhea
in the pelvis or lower abdomen that may radiate
to the thighs and lower sacrum. This pain may
precede menstruation by several days or may
accompany it. The pain gradually subsides as
bleeding tapers off.
Dysmenorrhea may be idiopathic, as in premenstrual syndrome (PMS) and primary dysmenorrhea. It commonly results from endometriosis and other pelvic disorders. It may
also result from structural abnormalities such as
an imperforate hymen. Stress and poor health
may aggravate dysmenorrhea; rest and mild
exercise may relieve it.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient complains of dysmenorrhea,
have her describe it fully. Is it intermittent or
continuous? Sharp, cramping, or aching? Ask
where the pain is located and whether it’s bilateral. How long has she been experiencing
it? When does the pain begin and end, and
when is it severe? Does it radiate to the back?
Explore associated signs and symptoms, such
as nausea and vomiting, altered elimination
habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability,
or depression.
Then obtain a menstrual and sexual history.
Ask the patient if her menstrual flow is heavy or
scant. Have her describe any vaginal discharge
between menses. Does she experience pain
during sexual intercourse? Does it occur with
menses? Find out what relieves her cramps.
Does she take pain medication? Is it effective?
Note her method of contraception, and ask
about a history of pelvic infection. Does she
have any signs and symptoms of urinary system
obstruction, such as pyuria, urine retention, or
incontinence? Determine how she copes with
stress. Determine her risk for sexually transmitted diseases.
Next, perform a focused physical examination. Take vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses.
Note costovertebral angle tenderness.
Dysmenorrhea—painful menstruation—affects
more than 50% of menstruating women; in fact,
it’s the leading cause of lost time from school
and work among women of childbearing age.
Dysmenorrhea may involve sharp, intermittent
pain or dull, aching pain. It’s usually characterized by mild to severe cramping or colicky pain
M
EDICAL CAUSES
◆ Adenomyosis. In this disorder, endometrial
tissue invades the myometrium, resulting in severe dysmenorrhea with pain radiating to the
back or rectum, menorrhagia, and a symmetrically enlarged, globular uterus that’s usually
softer on palpation than a uterine myoma.
◆ Cervical stenosis. This structural disorder
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causes dysmenorrhea and scant or absent menstrual flow.
◆ Endometriosis. In this disorder, steady,
aching pain typically begins before menses and
peaks at the height of menstrual flow, but it may
also occur between menstrual periods. The pain
may arise at the endometrial deposit site or may
radiate to the perineum or rectum. Associated
signs and symptoms include premenstrual spotting, dyspareunia, infertility, nausea and vomiting, painful defecation, and rectal bleeding and
hematuria during menses. A tender, fixed adnexal mass is usually palpable on bimanual examination.
◆ Pelvic inflammatory disease. Chronic in-
fection produces dysmenorrhea accompanied
by fever; malaise; a foul-smelling, purulent
vaginal discharge; menorrhagia; dyspareunia;
severe abdominal pain; nausea and vomiting;
and diarrhea. A pelvic examination may reveal
cervical motion tenderness and bilateral adnexal tenderness.
◆ PMS. The cramping pain of PMS usually
begins with menstrual flow and persists for
several hours or days, diminishing as flow
decreases. Abdominal bloating, breast tenderness, palpitations, diaphoresis, flushing,
depression, and irritability commonly precede
menses by several days to 2 weeks. Other
findings include nausea, vomiting, diarrhea,
and headache. Because PMS usually follows
an ovulatory cycle, it rarely occurs during the
first 12 months of menses, which may be
anovulatory.
◆ Primary (idiopathic) dysmenorrhea. In-
creased prostaglandin secretion intensifies uterine contractions, apparently causing mild to severe spasmodic cramping pain in the lower
abdomen, which radiates to the sacrum and inner thighs. The cramping abdominal pain peaks
a few hours before menses. Patients may also
experience nausea and vomiting, fatigue, diarrhea, and headache.
◆ Uterine leiomyomas. If these tumors twist
or degenerate after circulatory occlusion or infection or if the uterus contracts in an attempt
to expel them, they may cause constant or intermittent lower abdominal pain that worsens
with menses. Associated signs and symptoms
include backache, constipation, menorrhagia,
and urinary frequency or retention. Palpation
may reveal the tumor mass and an enlarged
uterus. The tumors are almost always nontender.
DYSMENORRHEA
229
Relief for dysmenorrhea
To relieve cramping and other symptoms
caused by primary dysmenorrhea or an intrauterine device, the patient may receive a
prostaglandin inhibitor, such as aspirin,
ibuprofen, indomethacin, or naproxen.
These nonsteroidal anti-inflammatory drugs
block prostaglandin synthesis early in the
inflammatory reaction, thereby inhibiting
prostaglandin action at receptor sites. They
also have analgesic and antipyretic effects.
Make sure you and your patient are informed about the adverse effects and cautions associated with these drugs.
Adverse effects
Alert the patient to the possible adverse
effects of prostaglandin inhibitors. Central
nervous system effects include dizziness,
headache, and vision disturbances. GI effects include nausea, vomiting, heartburn,
and diarrhea. Advise the patient to take the
drug with milk or after meals to reduce
gastric irritation.
Contraindications
Because prostaglandin inhibitors are potentially teratogenic, be sure to rule out the
possibility of pregnancy before starting the
patient on this therapy. Advise any patient
who suspects she’s pregnant to delay therapy until menses begins.
Other cautions
If the patient has cardiac decompensation,
hypertension, renal dysfunction, an ulcer, or
a coagulation defect (and is receiving ongoing anticoagulant therapy), use caution
when administering a prostaglandin inhibitor. Because a patient who is hypersensitive to aspirin may also be hypersensitive
to other prostaglandin inhibitors, watch for
signs of gastric ulceration and bleeding.
O
THER CAUSES
◆ Intrauterine devices. These devices may
cause severe cramping and heavy menstrual
flow.
S
PECIAL CONSIDERATIONS
In the past, women with dysmenorrhea were
considered neurotic. Although current research
suggests that prostaglandins contribute to this
symptom, old attitudes persist. Encourage the
230 DYSPAREUNIA
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patient to view dysmenorrhea as a medical
problem, not as a sign of maladjustment.
P
EDIATRIC POINTERS
Dysmenorrhea is rare during the first year of
menstruation, before the menstrual cycle becomes ovulatory. However, the incidence of
dysmenorrhea is generally higher among adolescents than older women. Teach the adolescent about dysmenorrhea. Dispel myths about
it, and inform her that it’s a common medical
problem. Encourage good hygiene, nutrition,
and exercise.
P
ATIENT COUNSELING
If dysmenorrhea is idiopathic, advise the patient
to place a heating pad on her abdomen to relieve the pain. This therapy reduces abdominal
muscle tension and increases blood flow.
Effleurage, a light circular massage with the
fingertips, may also provide relief. Other comfort measures include drinking warm beverages,
taking a warm shower, performing waistbending and pelvic-rocking exercises, and
walking. Inform the patient that increasing aerobic exercise and dietary intake of vitamin B
and fish oil capsules have also proved effective
in relieving dysmenorrhea.
Inform the patient that taking a nonsteroidal
anti-inflammatory drug (NSAID) 1 to 2 days before the onset of menses is usually helpful. If
she isn’t trying to get pregnant, taking
monophasic birth control pills is also beneficial.
Warn the patient that both of these treatments
may reduce menstrual flow and duration. Be
sure to rule out the possibility of pregnancy before starting contraceptive or NSAID therapy.
Explain the actions and adverse effects of these
drugs. (See Relief for dysmenorrhea, page 229.)
1
Dyspareunia
A major obstacle to sexual enjoyment, dyspareunia is painful or difficult coitus. Although most
sexually active women occasionally experience
mild dyspareunia, persistent or severe dyspareunia is cause for concern. Dyspareunia may occur with attempted penetration or during or after coitus. It may stem from friction of the penis
against perineal tissue or from jarring of deeper
adnexal structures. The location of pain helps
determine its cause.
Dyspareunia commonly accompanies pelvic
disorders. However, it may also result from di-
minished vaginal lubrication associated with
aging, the effects of drugs, and psychological
factors—most notably, fear of pain or injury. A
cycle of fear, pain, and tension may become
established, in which repeated episodes of
painful coitus condition the patient to anticipate pain, causing fear, which prevents sexual
arousal and adequate vaginal lubrication. Contraction of the pubococcygeal muscle also occurs, making penetration still more difficult
and traumatic.
Psychological factors include guilty feelings
about sex, fear of pregnancy or of injury to the
fetus during pregnancy, and anxiety caused by a
disrupted sexual relationship or by a new sexual
partner. Inadequate vaginal lubrication associated with insufficient foreplay and mental or
physical fatigue may also cause dyspareunia.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by asking the patient to describe the pain.
Does it occur with attempted penetration or deep
thrusting? How long does it last? Is the pain intermittent or does it always accompany intercourse? Ask whether changing coital position or
using a vaginal lubricant relieves the pain.
Next, ask about a history of pelvic, vaginal, or
urinary tract infection. Does the patient have
signs and symptoms of a current infection?
Have her describe any discharge. Also, ask
about malaise, headache, fatigue, abdominal or
back pain, nausea and vomiting, and diarrhea
or constipation.
Obtain a sexual and menstrual history. Determine whether dyspareunia is related to the patient’s menstrual cycle. Are her cycles regular?
Ask about dysmenorrhea and metrorrhagia. Has
the patient had a baby? If so, did she have an
episiotomy? Note whether she’s breast-feeding.
Ask about previous abortion, sexual abuse, or
pelvic surgery. Also, find out what contraceptive
method the patient uses. Does her partner use
condoms? Does he or could he have a latex allergy? Then try to determine her attitude toward
sexual intimacy. Does she feel tense during
coitus? Is she satisfied with the length of foreplay? Does she usually achieve orgasm? Ask
about a history of rape, incest, or sexual abuse
as a child.
Next, perform a physical examination, starting with vital signs. Palpate the abdomen for
tenderness, pain, or masses and for inguinal
lymphadenopathy. Finally, inspect the genitalia
for lesions and vaginal discharge.
M
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EDICAL CAUSES
◆ Allergies. Allergic reactions to diaphragms
or condoms may result in dyspareunia.
◆ Atrophic vaginitis. In postmenopausal and
breast-feeding women, decreased estrogen secretion may lead to inadequate vaginal lubrication and dyspareunia, which intensifies as intercourse continues. Accompanying signs and
symptoms include pruritus, burning, bleeding,
and vaginal tenderness. Patients may complain
of a watery discharge at the same time that
they’re feeling “dry.”
◆ Bartholinitis. This inflammatory disorder
may produce throbbing pain accompanied by
vulvar tenderness during intercourse. The patient may also complain of pain with walking or
sitting. Chronic inflammation causes a purulent
discharge from the infected cyst.
◆ Cervicitis. This inflammatory disorder causes
pain with deep penetration. It may also cause
dull lower abdominal pain, a purulent vaginal
discharge, backache, and metrorrhagia.
◆ Condylomata acuminata. These papular,
mosaic, warty growths occur on the vulva, vaginal and cervical walls, and perianal area. They
may bleed, itch, cause burning or paresthesia in
the vaginal introitus, and become tender during
and after intercourse. A profuse, odorless vaginal discharge may also occur.
◆ Cystitis. Dyspareunia may occur if the pa-
tient has inflammation or infection of the bladder. Associated findings include dysuria; urinary
urgency, frequency, or incontinence; pyuria;
and, after coitus, hematuria.
◆ Endometriosis. This disorder causes in-
tense pain during deep coital penetration. In
addition, aching pain may occur during gentle
thrusting or during a pelvic examination. The
pain is usually in the lower abdomen or behind
the uterus and may be worse on one side. It
may be relieved by changing coital positions.
Other signs and symptoms include dysmenorrhea, irregular menses, infertility, painful urination or defecation, and rectal bleeding and
hematuria during menses. Typically, a tender,
fixed adnexal mass is palpable on bimanual
examination.
◆ Herpes genitalis. During intercourse, friction
against lesions on the labia, vulva, vagina, or
perianal skin causes pain and itching. The lesions are fluid-filled and usually painless at first,
but may rupture and form shallow, painful ulcers
with erythema and edema. Related findings include leukorrhea, fever, malaise, headache, inguinal lymphadenopathy, myalgia, and dysuria.
DYSPAREUNIA 231
◆ Occlusive or rigid hymen. Dyspareunia
may prevent penetration in this condition.
◆ Ovarian cyst or tumor. In this disorder,
lower abdominal pain accompanies deep penetration during intercourse. Other signs and
symptoms include chronic lower back pain; a
tender, palpable abdominal mass; constipation;
urinary frequency; menstrual irregularities; and
hirsutism.
◆ Pelvic inflammatory disease. Deep pene-
tration causes severe pain that’s unrelieved by
changing coital positions. Uterine tenderness
may also occur with gentle thrusting or during a
pelvic examination. This disorder also causes
fever; malaise; a foul-smelling, purulent vaginal
discharge; menorrhagia; dysmenorrhea; a soft,
enlarged uterus; severe abdominal pain; nausea
and vomiting; cervical motion tenderness; and
diarrhea.
◆ Uterine prolapse. Sharp or aching pain oc-
curs when the penis strikes the descended
cervix of a patient with uterine prolapse. Other
effects are dysmenorrhea, pelvic pressure, leukorrhea, urine retention and urinary incontinence, and chronic lower back pain.
◆ Vaginitis. This infection produces dyspareu-
nia along with vulvar pain, burning, and itching
during and for several hours after coitus. These
symptoms may be aggravated by sexual arousal
aside from intercourse. Vaginal discharge is typical; the type varies with the causative organism. Candida albicans produces a curdlike, odorless to musty-smelling discharge; Trichomonas
vaginalis produces a yellow-green, frothy, fishsmelling discharge; bacterial vaginosis and
Neisseria gonorrhoeae produce a profuse whitish
yellow, foul-smelling discharge. Pruritus and dysuria may also occur.
O
THER CAUSES
◆ Contraceptive and hygienic products.
Some spermicidal jellies, douches, and vaginal
creams and deodorants cause irritation and
edema, resulting in dyspareunia.
◆ Diaphragms and intrauterine devices. An
ill-fitting diaphragm may produce cramps with
intercourse. An incorrectly placed intrauterine
device may cause dyspareunia during orgasm.
◆ Drugs. Antihistamines, decongestants, and
nonsteroidal anti-inflammatory drugs decrease
lubrication, resulting in dyspareunia.
◆ Episiotomy. If the episiotomy scar constricts
the vaginal introitus or narrows the vaginal barrel, the patient may experience perineal pain
with coitus.
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PATIENT-TEACHING AID
How to do Kegel
exercises
Dear Patient:
Repeated painful intercourse may cause involuntary contraction of the pubococcygeal
(PC) muscle, which encircles your urinary
opening and vagina. When this happens, intercourse becomes even more difficult.
Below are some isometric exercises—called
Kegel exercises—that can strengthen the PC
muscle and help you gain voluntary control
of it.
◆ Begin by sitting on the toilet with your
legs spread. Then, without moving your
legs, start and stop the flow of urine. The PC
muscle is the one that contracts to help
control urine flow.
◆ Now that you’ve identified the PC muscle,
you can exercise it regularly. Like most
isometric exercises, Kegel exercises can be
performed almost anywhere—while sitting
at your desk, lying in bed, standing in line,
and especially while urinating. As you perform these exercises, remember to breathe
naturally—don’t hold your breath.
Now, periodically contract the PC muscle
as you did to stop the urine flow. Count
slowly to three and then relax the muscle.
◆ Next, contract and relax the PC muscle as
quickly as possible, without using your
stomach or buttock muscles.
◆ Finally, slowly contract the entire vaginal
area. Then bear down, using your abdominal muscles and your PC muscle.
For the first week, repeat each exercise
10 times (1 set) for 5 sets daily. Then each
week, add 5 repetitions of each exercise
(15, 20, and so forth). Keep doing 5 sets daily.
After about 2 weeks of practice, you’ll
notice improvement.
This patient-teaching aid may be reproduced by office
copier for distribution to patients. © 2007, Lippincott
Williams & Wilkins.
◆ Pelvic irradiation. Radiation therapy for
pelvic cancer may cause pelvic and vaginal
scarring, resulting in dyspareunia.
S
PECIAL CONSIDERATIONS
Prepare the patient for a pelvic examination.
Explain that it involves inspection of the vagina
and cervix and bimanual palpation of the
uterus, fallopian tubes, and ovaries. Remind her
to breathe deeply and evenly during the examination. If an antimicrobial or anti-inflammatory
drug is prescribed, teach her how to apply the
cream or insert the vaginal suppository.
P
EDIATRIC POINTERS
Dyspareunia can also be an adolescent problem. Although about 40% of adolescents are
sexually active by age 19, most are reluctant to
initiate a frank sexual discussion. Obtain a thorough sexual history by asking the patient direct
but nonjudgmental questions.
G
ERIATRIC POINTERS
In postmenopausal women, the absence of estrogen reduces vaginal diameter and elasticity,
which causes tearing of the vaginal mucosa
during intercourse. These tears as well as inflammatory reactions to bacterial invasion
cause fibrous adhesions that occlude the
vagina. Dyspareunia can result from any of
these conditions.
P
ATIENT COUNSELING
Encourage the patient to discuss dyspareunia
openly. A woman may hesitate to report dyspareunia because of embarrassment and modesty.
To minimize dyspareunia, advise the patient
to apply a vaginal lubricant before intercourse,
to attempt different coital positions, and to increase foreplay time. Teach her Kegel exercises
to reduce muscle tension. (See How to do Kegel
exercises.)
Dyspepsia
Dyspepsia refers to an uncomfortable fullness
after meals that’s associated with nausea,
belching, heartburn and, possibly, cramping
and abdominal distention. Frequently aggravated by spicy, fatty, or high-fiber foods and by
excessive caffeine intake, dyspepsia without
other pathology indicates impaired digestive
function.
Dyspepsia is primarily caused by GI disorders and, to a lesser extent, by cardiac, pulmonary, and renal disorders and by the effects
of drugs. It apparently results when altered
gastric secretions lead to excessive stomach
acidity. This symptom may also result from
emotional upset and overly rapid eating or improper chewing. It usually occurs a few hours
after eating and lasts for a variable period of
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time. Its severity depends on the amount and
type of food eaten and on GI motility. Additional food or an antacid may relieve the discomfort. (See Dyspepsia: Causes and associated
findings, page 234.)
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient complains of dyspepsia, begin by
asking him to describe it in detail. How often
and when does it occur, specifically in relation
to meals? Do any drugs or activities relieve or
aggravate it? Has the patient had nausea, vomiting, melena, hematemesis, cough, or chest
pain? Ask if he’s taking any prescription drugs
and if he has recently had surgery. Does he have
a history of renal, cardiovascular, or pulmonary
disease? Has he noticed any change in the
amount or color of his urine?
Ask the patient if he’s experiencing an unusual or overwhelming amount of emotional
stress. Determine the patient’s coping mechanisms and their effectiveness.
Focus the physical examination on the abdomen. Inspect it for distention, ascites, scars,
obvious hernias, jaundice, uremic frost, and
bruising. Then auscultate it for bowel sounds
and characterize their motility. Palpate and percuss the abdomen, noting any tenderness, pain,
organ enlargement, or tympany.
Finally, examine other body systems. Ask
about behavior changes, and evaluate level of
consciousness. Auscultate for gallops and
crackles. Percuss the lungs to detect consolidation. Note peripheral edema and any swelling of
lymph nodes.
M
EDICAL CAUSES
◆ Cholelithiasis. Dyspepsia may occur with
gallstones, commonly after intake of fatty foods.
Biliary colic, a more common symptom of gallstones, causes acute pain that may radiate to
the back, shoulders, and chest. The patient may
also have diaphoresis, tachycardia, chills, lowgrade fever, petechiae, bleeding tendencies,
jaundice with pruritus, dark urine, and claycolored stools.
◆ Cirrhosis. In this chronic disorder, dyspepsia
varies in intensity and duration and is relieved
by ingestion of an antacid. Other GI effects are
anorexia, nausea, vomiting, flatulence, diarrhea,
constipation, abdominal distention, and epigastric or right-upper-quadrant pain. Weight loss,
jaundice, hepatomegaly, ascites, dependent
edema, fever, bleeding tendencies, and muscle
weakness are also common. Skin changes include severe pruritus, extreme dryness, easy
bruising, and lesions, such as telangiectasis and
palmar erythema. Gynecomastia or testicular
atrophy may also occur.
◆ Duodenal ulcer. A primary symptom of duo-
denal ulcer, dyspepsia ranges from a vague feeling of fullness or pressure to a boring or aching
sensation in the middle or right epigastrium. It
usually occurs 1
relieved by food or an antacid. The pain may
awaken the patient at night with heartburn and
fluid regurgitation. Abdominal tenderness and
weight gain may occur; vomiting and anorexia
are rare.
1
⁄2 to 3 hours after eating and is
◆ Gastric dilation (acute). Epigastric fullness
is an early symptom of this life-threatening
disorder. Accompanying dyspepsia are nausea
and vomiting, upper abdominal distention, a
succussion splash, and apathy. The patient
may display signs and symptoms of dehydration, such as poor skin turgor and dry mucous
membranes, and of electrolyte imbalance, such
as irregular pulse and muscle weakness. Gastric bleeding may produce hematemesis and
melena.
◆ Gastric ulcer. Dyspepsia and heartburn after
eating may occur in the early stages of a gastric
ulcer. The cardinal symptom, however, is epigastric pain that may occur with vomiting, fullness, and abdominal distention and may not be
relieved by food. Weight loss and GI bleeding
are also characteristic.
◆ Gastritis (chronic). In this disorder, dyspep-
sia is relieved by antacids; lessened by smaller,
more frequent meals; and aggravated by spicy
foods or excessive caffeine. It occurs with
anorexia, a feeling of fullness, vague epigastric
pain, belching, nausea, and vomiting.
◆ GI cancer. This type of cancer usually pro-
duces chronic dyspepsia. Other features include
anorexia, fatigue, jaundice, melena, hematemesis, constipation, and abdominal pain.
◆ Heart failure. Common in right-sided heart
failure, transient dyspepsia may occur with
chest tightness and a constant ache or sharp
pain in the right upper quadrant. Heart failure
also typically causes hepatomegaly, anorexia,
nausea, vomiting, bloating, ascites, tachycardia,
jugular vein distention, tachypnea, dyspnea,
and orthopnea. Other findings include dependent edema, anxiety, fatigue, diaphoresis, hypotension, cough, crackles, ventricular and atrial gallops, nocturia, elevated diastolic blood
pressure, and cool, pale skin.
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SIGNS & SYMPTOMS
Dyspepsia: Causes and associated findings
Common
causes
Major associated signs and symptoms
Abdominal
distention
Abdominal pain
Anorexia
Bruising, easy
Chest pain
Cough
Edema
Hepatomegaly
Jaundice
Nausea/vomiting
Oliguria
Tachycardia
Weight loss
Cholelithiasis
Cirrhosis
Duodenal ulcer
Gastric dilation
(acute)
Gastric ulcer
Gastritis (chronic)
GI cancer
Heart failure
Hepatitis
Hiatal hernia
Pancreatitis
(chronic)
Pulmonary
embolism
Pulmonary
tuberculosis
Uremia
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◆ Hepatitis. Dyspepsia occurs in two of the three
stages of hepatitis. The preicteric phase produces
moderate to severe dyspepsia, fever, malaise,
arthralgia, coryza, myalgia, nausea, vomiting, an
altered sense of taste or smell, and hepatomegaly.
Jaundice marks the onset of the icteric phase,
which also includes continued dyspepsia, anorexia, irritability, and severe pruritus. As jaundice
clears, dyspepsia and other GI effects also diminish. In the recovery phase, only fatigue remains.
◆ Hiatal hernia. In this disorder, dyspepsia
results when the lower portion of the esophagus and the upper portion of the stomach
rise into the chest as abdominal pressure
increases.
◆ Pancreatitis (chronic). Dyspepsia is usually
accompanied by severe continuous or intermittent epigastric pain that radiates to the back or
through the abdomen. Anorexia, nausea,
vomiting, jaundice, dramatic weight loss,
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hyperglycemia, and steatorrhea may also occur.
The patient may have Turner’s or Cullen’s sign.
◆ Pulmonary embolism. Sudden dyspnea
characterizes this potentially fatal disorder;
however, dyspepsia may occur as an oppressive, severe, substernal discomfort. Other findings include anxiety, tachycardia, tachypnea,
cough, pleuritic chest pain, hemoptysis, syncope, cyanosis, jugular vein distention, and
hypotension.
◆ Pulmonary tuberculosis. Vague dyspepsia
may occur along with anorexia, malaise, and
weight loss. Common associated findings include high fever, night sweats, palpitations on
mild exertion, a productive cough, dyspnea,
adenopathy, and occasional hemoptysis.
◆ Uremia. Of the many GI complaints associated
with uremia, dyspepsia may be the earliest and
most important. Others include anorexia, nausea,
vomiting, bloating, diarrhea, abdominal cramps,
epigastric pain, and weight gain. As the renal system deteriorates, the patient may experience edema, pruritus, pallor, hyperpigmentation, uremic
frost, ecchymoses, sexual dysfunction, poor
memory, irritability, headache, drowsiness,
muscle twitching, seizures, and oliguria.
O
THER CAUSES
◆ Drugs. Nonsteroidal anti-inflammatory
drugs, especially aspirin, commonly cause dyspepsia. Diuretics, antibiotics, antihypertensives,
corticosteroids, and many other drugs can also
cause dyspepsia, depending on the patient’s
tolerance of the dosage.
◆ Surgery. After GI or other surgery, postoper-
ative gastritis can cause dyspepsia, which usually disappears in a few weeks.
S
PECIAL CONSIDERATIONS
Changing the patient’s position usually doesn’t
relieve dyspepsia, but providing food or an
antacid may, so have food available at all times,
and give an antacid 30 minutes before or 1 hour
after a meal. Because various drugs can cause
dyspepsia, give these after meals, if possible.
Provide a calm environment to reduce stress,
and make sure the patient gets plenty of rest.
Discuss other ways to deal with stress, such as
deep breathing and guided imagery. In addition,
prepare the patient for endoscopy to determine
the cause of dyspepsia.
P
EDIATRIC POINTERS
Dyspepsia may occur in adolescents with peptic
ulcer disease, but it isn’t relieved by food. It may
also occur in congenital pyloric stenosis, but
projectile vomiting after meals is a more characteristic sign. It may also result from lactose
intolerance.
G
ERIATRIC POINTERS
Most older patients with chronic pancreatitis
experience less severe pain than younger
adults; some have no pain at all.
P
ATIENT COUNSELING
Advise the patient to eat frequent small meals
and to avoid foods known to cause symptoms
as well as coffee, tea, chocolate, alcohol, and
tobacco.
Dysphagia
Dysphagia—difficulty swallowing—is a common
symptom that’s usually easy to localize. It may
be constant or intermittent and is classified by
the phase of swallowing it affects. (See Classify-
ing dysphagia, page 236.) Among the factors
that interfere with swallowing are severe pain,
obstruction, abnormal peristalsis, impaired gag
reflex, and excessive, scanty, or thick oral secretions.
Dysphagia is the most common—and sometimes the only—symptom of esophageal disorders. However, it may also result from oropharyngeal, respiratory, neurologic, and collagen
disorders or from the effects of toxins and treatments. Dysphagia increases the risk of choking
and aspiration and may lead to malnutrition
and dehydration.
EMERGENCY INTERVENTIONS If the
patient suddenly complains of dysphagia
and displays signs of respiratory distress, such
as dyspnea and stridor, suspect an airway obstruction and quickly perform abdominal
thrusts. Prepare to administer oxygen by mask
or nasal cannula or to assist with endotracheal
intubation.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient’s dysphagia doesn’t suggest an airway obstruction, begin a health history. Ask the
patient if swallowing is painful. If so, is the pain
constant or intermittent? Have the patient point
to where dysphagia feels most intense. Does
eating alleviate or aggravate the symptom? Are
solids or liquids more difficult to swallow? If the
answer is liquids, ask if hot, cold, and lukewarm
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Classifying dysphagia
Because swallowing occurs in three distinct phases, dysphagia can be classified by the phase that
it affects. Each phase suggests a specific pathology for dysphagia.
Phase 1
Swallowing begins in the transfer phase
with chewing and moistening of food with
saliva. The tongue presses against the hard
palate to transfer the chewed food to the back
of the throat; cranial nerve V then stimulates
the swallowing reflex. Phase 1 dysphagia typically results from a neuromuscular disorder.
Phase 2
In the transport phase, the soft palate
closes against the pharyngeal wall to prevent
nasal regurgitation. At the same time, the lar-
1
2
3
ynx rises and the vocal cords close to keep
food out of the lungs; breathing stops momentarily as the throat muscles constrict to move
food into the esophagus. Phase 2 dysphagia
usually indicates spasm or cancer.
Phase 3
Peristalsis and gravity work together in
the entrance phase to move food through the
esophageal sphincter and into the stomach.
Phase 3 dysphagia results from lower esophageal narrowing by diverticula, esophagitis,
and other disorders.
fluids affect him differently. Does the symptom
disappear after he tries to swallow a few times?
Is swallowing easier if he changes position? Ask
if he has recently experienced vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or a cough.
To evaluate the patient’s swallowing reflex,
place your finger along his thyroid notch and instruct him to swallow. If you feel his larynx rise,
the reflex is intact. Next, have him cough to assess his cough reflex. Check his gag reflex if
you’re sure he has a good swallow or cough reflex. Listen closely to his speech for signs of
muscle weakness. Does he have aphasia or
dysarthria? Is his voice nasal, hoarse, or
breathy? Assess the patient’s mouth carefully.
Check for dry mucous membranes and thick,
sticky secretions. Observe for tongue and facial
weakness and obvious obstructions (for example, enlarged tonsils). Assess the patient for disorientation, which may make him neglect to
swallow.
M
EDICAL CAUSES
◆ Achalasia. Most common in patients ages 20
to 40, this disorder produces phase 3 dysphagia
for solids and liquids. The dysphagia develops
gradually and may be precipitated or exacerbated by stress. Occasionally, it’s preceded by
esophageal colic. Regurgitation of undigested
food, especially at night, may cause wheezing,
coughing, or choking as well as halitosis.
Weight loss, cachexia, hematemesis and, possibly, heartburn are late findings.
◆ Airway obstruction. Life-threatening upper
airway obstruction is marked by signs of respiratory distress, such as crowing and stridor.
Phase 2 dysphagia occurs with gagging and dysphonia. When hemorrhage obstructs the trachea, dysphagia is usually painless and rapid in
onset. When inflammation causes the obstruction, dysphagia may be painful and develop
slowly.
◆ Amyotrophic lateral sclerosis. Besides dys-
phagia, this disorder causes muscle weakness
and atrophy, fasciculations, dysarthria, dyspnea,
DYSPHAGIA 237
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shallow respirations, tachypnea, slurred speech,
hyperactive deep tendon reflexes, and emotional lability.
◆ Botulism. This type of food poisoning causes
phase 1 dysphagia and dysuria, usually within
36 hours of toxin ingestion. Other early findings
include blurred or double vision, dry mouth,
sore throat, nausea, vomiting, and diarrhea.
Symmetrical descending weakness or paralysis
occurs gradually.
◆ Bulbar paralysis. Phase 1 dysphagia occurs
along with drooling, difficulty chewing,
dysarthria, and nasal regurgitation in this disorder. Dysphagia for both solids and liquids is
painful and progressive. Accompanying features
may include arm and leg spasticity, hyperreflexia, and emotional lability.
◆ Dysphagia lusoria. This disorder is caused
by compression of the esophagus by a congenital vascular abnormality (usually an aberrant
right subclavian artery arising from the left side
of the aortic arch). Phase 3 dysphagia symptoms
may start in childhood or may develop later
from changes in the aberrant vessel such as arteriosclerosis.
◆ Esophageal cancer. Phase 2 or 3 dysphagia
is the earliest and most common symptom of
esophageal cancer. Typically, this painless, progressive symptom is accompanied by rapid
weight loss. As the cancer advances, dysphagia
becomes painful and constant. In addition, the
patient complains of steady chest pain, cough
with hemoptysis, hoarseness, and sore throat.
He may also develop nausea and vomiting,
fever, hiccups, hematemesis, melena, and
halitosis.
◆ Esophageal compression (external). Usu-
ally caused by a dilated carotid or aortic
aneurysm, this rare condition causes phase 3
dysphagia as the primary symptom. Other features depend on the cause of the compression.
◆ Esophageal diverticulum. This disorder
causes phase 3 dysphagia when the enlarged
diverticulum obstructs the esophagus. Associated signs and symptoms include food regurgitation, chronic cough, hoarseness, chest pain, and
halitosis.
◆ Esophageal leiomyoma. A relatively rare
benign tumor, esophageal leiomyoma may
cause phase 3 dysphagia along with retrosternal
pain or discomfort. In addition, the patient experiences weight loss and a feeling of fullness.
◆ Esophageal obstruction by foreign body.
Sudden onset of phase 2 or 3 dysphagia, gagging, coughing, and esophageal pain character-
ize this potentially life-threatening condition.
Dyspnea may occur if the obstruction compresses the trachea.
◆ Esophageal spasm. The most striking symp-
toms of this disorder are phase 2 dysphagia for
solids and liquids and dull or squeezing substernal chest pain. The pain may last up to an hour
and may radiate to the neck, arm, back, or jaw;
however, it may be relieved by drinking a glass
of water. Bradycardia may also occur.
◆ Esophageal stricture. Usually caused by
scar tissue or ingestion of a chemical, this condition causes phase 3 dysphagia. Drooling,
tachypnea, and gagging may also be evident.
◆ Esophagitis. Corrosive esophagitis, resulting
from ingestion of alkalies or acids, causes severe phase 3 dysphagia. Accompanying it are
marked salivation, hematemesis, tachypnea,
fever, and intense pain in the mouth and anterior chest that’s aggravated by swallowing. Signs
of shock, such as hypotension and tachycardia,
may also occur.
Candidal esophagitis causes phase 2 dysphagia, sore throat and, possibly, retrosternal pain
on swallowing. In reflux esophagitis, phase 3
dysphagia is a late symptom that usually accompanies stricture development. The patient complains of heartburn, which is aggravated by
strenuous exercise, bending over, or lying down
and is relieved by sitting up or taking an antacid.
Other features include regurgitation; frequent, effortless vomiting; a dry, nocturnal
cough; and substernal chest pain that may mimic angina pectoris. If the esophagus ulcerates,
signs of bleeding, such as melena and hematemesis, may occur along with weakness
and fatigue.
◆ Gastric carcinoma. Infiltration of the cardia
or esophagus by gastric carcinoma causes
phase 3 dysphagia along with nausea, vomiting,
and pain that may radiate to the neck, back, or
retrosternum. In addition, perforation causes
massive bleeding with coffee-ground vomitus or
melena.
◆ Hypocalcemia. Although tetany is its primary
sign, severe hypocalcemia may cause neuromuscular irritability, producing phase 1 dysphagia associated with numbness and tingling in the
nose, ears, fingertips, and toes and around the
mouth. Carpopedal spasms, muscle twitching,
and laryngeal spasms may also occur.
◆ Laryngeal cancer (extrinsic). Phase 2 dys-
phagia and dyspnea develop late in this disorder. Accompanying features include muffled
voice, stridor, pain, halitosis, weight loss,
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