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a bronchodilator, an antiarrhythmic, a diuretic,
and an analgesic, as needed, to dilate bronchioles, correct cardiac arrhythmias, promote fluid
excretion, and relieve pain, respectively.
P
EDIATRIC POINTERS
Normally, a child’s respirations are abdominal
in infancy and gradually change to costal by age
7. Suspect dyspnea in an infant who breathes
costally, in an older child who breathes abdominally, or in any child who uses his neck or
shoulder muscles to help him breathe.
Both acute epiglottiditis and laryngotracheobronchitis (croup) can cause severe dyspnea in
a child and may even lead to respiratory or cardiovascular collapse. Expect to administer oxygen, using a hood or cool mist tent.
G
ERIATRIC POINTERS
Older patients with dyspnea related to chronic
illness may not be aware initially of a significant
change in their breathing pattern.
P
ATIENT COUNSELING
Tell the patient that oxygen therapy isn’t necessarily indicated for dyspnea. Encourage a patient with chronic dyspnea to pace his daily
activities.
EXAMINATION TIP
Recognizing
dystonia
Dystonia, chorea, and athetosis may occur
simultaneously. To differentiate among
these three, keep the following points in
mind:
◆ Dystonic movements are slow and twisting
and involve large-muscle groups in the
head, neck (as shown below), trunk, and
limbs. They may be intermittent or continuous.
◆ Choreiform movements are rapid, highly
complex, and jerky.
◆ Athetoid movements are slow, sinuous,
and writhing, but always continuous; they
typically affect the hands and extremities.
DYSTONIA OF THE NECK
(SPASMODIC TORTICOLLIS)
Dystonia
Dystonia is marked by slow, involuntary movements of large-muscle groups in the limbs,
trunk, and neck. This extrapyramidal sign may
involve flexion of the foot, hyperextension of
the legs, extension and pronation of the arms,
arching of the back, and extension and rotation of the neck (spasmodic torticollis). It’s typically aggravated by walking and emotional
stress and relieved by sleep. Dystonia may be
intermittent—lasting just a few minutes—or
continuous and painful. Occasionally, it causes
permanent contractures, resulting in a
grotesque posture. Although dystonia may be
hereditary or idiopathic, it usually results from
extrapyramidal disorders or the use of certain
drugs.
H
ISTORY AND PHYSICAL
EXAMINATION
If possible, include the patient’s family in history
taking; they may be more aware of behavior
changes than the patient is. Begin by asking
them when dystonia occurs. Is it aggravated by
emotional upset? Does it disappear during
sleep? Is there a family history of dystonia? Obtain a drug history, noting especially the use of a
phenothiazine or an antipsychotic. Dystonia is a
common adverse effect of these drugs, and the
dosage may need to be adjusted to minimize
this effect.
Next, examine the patient’s coordination and
voluntary muscle movement. Observe his gait
as he walks across the room; then have him
squeeze your fingers to assess muscle strength.
(See Recognizing dystonia.) Check coordination
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by having him touch your fingertip and then his
nose repeatedly. Follow this by testing gross
motor movement of the leg: Have him place his
heel on one knee, slide it down his shin to the
top of his great toe, and then return it to his
knee. Finally, assess fine-motor movement by
asking him to touch each finger to his thumb in
succession.
M
EDICAL CAUSES
◆ Alzheimer’s disease. Dystonia is a late sign
of this disorder, which is marked by slowly progressive dementia. The patient typically displays
decreased attention span, amnesia, agitation,
an inability to carry out activities of daily living,
dysarthria, and emotional lability.
◆ Dystonia musculorum deformans. Pro-
longed, generalized dystonia is the hallmark of
this disorder, which usually develops in childhood and worsens with age. Initially, it causes
foot inversion, which is followed by growth retardation and scoliosis. Late signs include twisted, bizarre postures, limb contractures, and
dysarthria.
◆ Hallervorden-Spatz disease. This degenera-
tive disease causes dystonic trunk movements
accompanied by choreoathetosis, ataxia, myoclonus, and generalized rigidity. The patient
also exhibits a progressive intellectual decline
and dysarthria.
◆ Huntington’s disease. Dystonic movements
mark the preterminal stage of Huntington’s disease. Characterized by progressive intellectual
decline, this disorder leads to dementia and
emotional lability. The patient displays choreoathetosis accompanied by dysarthria, dysphagia,
facial grimacing, and a wide-based, prancing
gait.
◆ Olivopontocerebellar atrophy. Ataxia, an
early sign in this rare disorder, slowly progresses to dystonia. Other findings include dysarthria,
action tremor, bradykinesia, and visual deterioration.
◆ Parkinson’s disease. Dystonic spasms are
common in this disease. Other classic features
include uniform or jerky rigidity, pill-rolling
tremor, bradykinesia, dysarthria, dysphagia,
drooling, masklike facies, monotone voice,
stooped posture, and a propulsive gait.
◆ Pick’s disease. Dystonia appears as a late
sign in this rare disorder, which resembles
Alzheimer’s disease.
◆ Supranuclear ophthalmoplegia. Also
known as Steele-Richardson-Olszewski
syndrome, this rare disorder affects mainly middle-aged people, causing intermittent dystonia
with extreme neck flexion or extension. Other
signs and symptoms include impaired extraocular movement, diminished voice volume,
dysarthria, truncal rigidity, dementia, ataxia,
masklike facies, and dysphagia.
◆ Wilson’s disease. Progressive dystonia and
chorea of the arms and legs mark this disorder.
Other common signs and symptoms include
hoarseness, bradykinesia, behavior changes,
dysphagia, drooling, dysarthria, tremors, and
Kayser-Fleischer rings (rusty-brown rings at the
periphery of the cornea).
O
THER CAUSES
◆ Drugs. Phenothiazines can cause dystonia.
Aliphatics such as chlorpromazine cause it occasionally, and piperidines rarely cause it.
Haloperidol, loxapine, and other antipsychotics usually produce acute facial dystonia, as
do risperidone, metyrosine, antiemetic doses of
metoclopramide, and excessive doses of
levodopa.
S
PECIAL CONSIDERATIONS
Encourage the patient to obtain adequate sleep
and avoid emotional upset. Avoid range-ofmotion exercises, which can aggravate dystonia. If dystonia is severe, protect the patient
from injury by raising and padding his bed rails.
Provide an uncluttered environment if he’s
ambulatory.
P
EDIATRIC POINTERS
Children don’t exhibit dystonia until after they
can walk. Even so, it rarely occurs until after
age 10. Common causes include Fahr’s syndrome, dystonia musculorum deformans,
athetoid cerebral palsy, and the residual effects
of anoxia at birth.
Dysuria
Dysuria—painful or difficult urination—is commonly accompanied by urinary frequency, urgency, or hesitancy. This symptom usually reflects lower urinary tract infection (UTI)—a
common disorder, especially in women. (See
Preventing urinary tract infections, page 250.)
Dysuria results from lower urinary tract irritation or inflammation, which stimulates nerve
endings in the bladder and urethra. The onset
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PATIENT-TEACHING AID
Preventing urinary tract infections
Dear Patient:
To prevent recurrent urinary tract infections,
follow these guidelines:
◆ Drink at least 10 glasses of fluid, especially
water, daily. This helps flush bacteria from the
urinary tract.
◆ Empty your bladder completely every 2 to
3 hours or as soon as you feel the urge to urinate.
◆ Wipe your perineum from front to back after
urinating or defecating to prevent contamination with fecal material.
◆ Wear cotton underpants, which allow better
ventilation and absorption than synthetic ones.
◆ Take showers instead of baths. If you must
bathe, don’t use bubble bath salts, bath oil, per-
This patient-teaching aid may be reproduced by office copier for distribution to patients. © 2011, Lippincott Williams &
Wilkins.
fume, or other chemical irritants in the water.
Also, avoid using feminine deodorants, douches, and similar irritants. Avoid using menstrual
pads, which may also act as irritants.
◆ Urinate before and after intercourse.
◆ Include meats, eggs, cheese, nuts, prunes,
plums, whole grains, and especially cranberry
juice in your daily intake. These foods acidify
the urine, which helps decrease bacterial
growth. Avoid foods containing baking soda or
powder, such as most baked goods.
◆ Avoid coffee, citrus juices, and alcohol,
which tend to irritate the bladder.
◆ Seek medical help for any unusual vaginal
discharge, which suggests infection.
of pain provides clues to its cause. For example, pain just before voiding usually indicates
bladder irritation or distention, whereas pain
at the start of urination typically results from
bladder outlet irritation. Pain at the end of
voiding may signal bladder spasms; in women,
it may indicate vaginal candidiasis. (See Dys-
uria: Causes and associated findings, pages 252
and 253.)
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient complains of dysuria, have him describe its severity and location. When did he first
notice it? Did anything precipitate it? Does
anything aggravate or alleviate it?
Next, ask about previous urinary or genital
tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy
or urethral dilatation, or had a urinary catheter
inserted? Also, ask if he has a history of intestinal disease. Ask the female patient about
menstrual disorders and use of products that irritate the urinary tract, such as bubble bath
salts, feminine deodorants, contraceptive gels,
or perineal lotions. Also ask her about vaginal
discharge or pruritus.
During the physical examination, inspect the
urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination
may be necessary.
M
EDICAL CAUSES
◆ Appendicitis. Occasionally, appendicitis
causes dysuria that persists throughout voiding
and is accompanied by bladder tenderness. Appendicitis is characterized by periumbilical abdominal pain that shifts to McBurney’s point,
anorexia, nausea, vomiting, constipation, slight
fever, abdominal rigidity and rebound tenderness, and tachycardia.
◆ Bladder cancer. In this predominantly male
disorder, dysuria throughout voiding is a late
symptom associated with urinary frequency and
urgency, nocturia, hematuria, and perineal,
back, or flank pain.
CULTURAL CUE Bladder cancer is twice as
common in White males as in Blacks. It’s
relatively uncommon in Asians, Hispanics, and
Native Americans.
◆ Cystitis. Dysuria throughout voiding is
common in all types of cystitis, as are urinary
frequency, nocturia, straining to void, and
hematuria. Bacterial cystitis, the most common cause of dysuria in women, may also
produce urinary urgency, perineal and lower
back pain, suprapubic discomfort, fatigue and,
possibly, a low-grade fever. In chronic interstitial cystitis, dysuria is accentuated at the end
of voiding. In tubercular cystitis, symptoms
may also include urinary urgency, flank pain,
fatigue, and anorexia. In viral cystitis, severe
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dysuria occurs with gross hematuria, urinary
urgency, and fever.
GENDER CUE Women are more prone to
develop cystitis than men because they have
a shorter urethra. For men, age is a factor: Older
men have a 15% higher risk of developing
cystitis.
◆ Diverticulitis. Inflammation near the blad-
der may cause dysuria throughout voiding.
Other effects include urinary frequency and
urgency, nocturia, hematuria, fever, abdominal
pain and tenderness, perineal pain, constipation or diarrhea and, possibly, an abdominal
mass.
◆ Paraurethral gland inflammation. Dysuria
throughout voiding is accompanied by urinary
frequency and urgency, diminished urine
stream, mild perineal pain and, occasionally,
hematuria in this disorder.
◆ Prostatitis. Acute prostatitis commonly
causes dysuria throughout or toward the end
of voiding as well as a diminished urine
stream, urinary frequency and urgency, hematuria, suprapubic fullness, fever, chills, fatigue,
myalgia, nausea, vomiting, and constipation.
In chronic prostatitis, urethral narrowing
causes dysuria throughout voiding. Related effects are urinary frequency and urgency; diminished urine stream; perineal, back, and
buttocks pain; urethral discharge; nocturia;
and, at times, hematospermia and ejaculatory
pain.
◆ Pyelonephritis (acute). More common in
females than in males, this disorder causes dysuria throughout voiding. Other features
include persistent high fever with chills, costovertebral angle tenderness, unilateral or bilateral flank pain, weakness, urinary urgency
and frequency, nocturia, straining on urination,
and hematuria. Nausea, vomiting, and anorexia
may also occur.
◆ Reiter’s syndrome. In this predominantly
male disorder, dysuria occurs 1 to 2 weeks after
sexual contact. Initially, the patient has a mucopurulent discharge, urinary urgency and frequency, meatal swelling and redness, suprapubic pain, anorexia, weight loss, and low-grade
fever. Hematuria, conjunctivitis, arthritic symptoms, a papular rash, and oral and penile
lesions may follow.
◆ Urethral syndrome. Occurring in sexually
active women, this syndrome mimics urethritis.
Dysuria throughout voiding may occur with urinary frequency, diminished urine stream, supra-
pubic aching and cramping, tenesmus, and low
back and unilateral flank pain. In the absence of
pyuria, symptoms will usually resolve without
intervention.
◆ Urethritis. Primarily found in sexually active
males, this infection causes dysuria throughout
voiding. It’s accompanied by a reddened meatus
and a copious, yellow, purulent discharge
(gonorrheal infection) or a white or clear mucoid discharge (nongonorrheal infection).
◆ Urinary obstruction. Outflow obstruction by
urethral strictures or calculi produces dysuria
throughout voiding. (In a complete obstruction,
bladder distention develops and dysuria precedes voiding.) Other features are diminished
urine stream, urinary frequency and urgency,
and a sensation of fullness or bloating in the
lower abdomen or groin.
◆ Vaginitis. Characteristically, dysuria occurs
throughout voiding as urine touches inflamed or
ulcerated labia. Other findings include urinary
frequency and urgency, nocturia, hematuria,
perineal pain, and vaginal discharge and odor.
O
THER CAUSES
◆ Chemical irritants. Dysuria may result from
irritating substances, such as bubble bath salts
and feminine deodorants; it’s usually most intense at the end of voiding. Spermicides may
cause dysuria in both sexes as well as urinary
frequency and urgency, a diminished urine
stream and, possibly, hematuria.
◆ Drugs. Monoamine oxidase inhibitors and
metyrosine can cause dysuria.
S
PECIAL CONSIDERATIONS
Monitor vital signs and intake and output. Administer prescribed drugs, and prepare the patient for such tests as urinalysis and cystoscopy.
G
ERIATRIC POINTERS
Be aware that elderly patients tend to underreport their symptoms, even though older men
have an increased incidence of nonsexually related UTIs and postmenopausal women have an
increased incidence of noninfectious dysuria.
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SIGNS & SYMPTOMS
Dysuria: Causes and associated findings
Major associated signs and symptoms
Common
causes
Appendicitis
Bladder cancer
Cystitis (bacterial)
Cystitis (chronic
interstitial)
Cystitis
(tubercular)
Cystitis (viral)
Diverticulitis
Paraurethral gland
inflammation
Prostatitis (acute)
Prostatitis
(chronic)
Pyelonephritis
(acute)
Abdominal pain
Anorexia
Back pain
Constipation
Costovertebral
angle tenderness
Erythema of
meatus
Fatigue
Fever
Flank pain
Hematuria
Nausea
Nocturia
Perineal pain
Straining to void
•• • •
••••
•••••
•
•
•
•
•••
••••••
••••
•• •••
•
••••
•
•
•
•
•
•
• ••••• ••
Reiter’s syndrome
Urethral syndrome
Urethritis
Urinary
obstruction
Vaginitis
••••
•••
•
•••
Urethral discharge
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Urinary frequency
Urine stream,
diminished
Urinary urgency
••
Vaginal discharge
Vomiting
Weakness
•
DYSURIA 253
•
••
•
••
••
••
•
•
•
•
•
•
••
•
•
•
••
••• •
•••
•
••
•••
•••
F
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Facial pain
Facial pain may result from various neurologic,
vascular, or infectious disorders. The most common cause of facial pain is trigeminal neuralgia
(tic douloureux). In this disorder, intense, paroxysmal facial pain may occur along the pathway
of a specific facial nerve or nerve branch, usually cranial nerve V (trigeminal nerve) or cranial
nerve VII (facial nerve). Pain can also be referred to the face in disorders of the ear, nose,
paranasal sinuses, teeth, neck, and jaw.
Atypical facial pain is a constant burning pain
with limited distribution at onset; it typically
spreads to the rest of the face and may involve
the neck or back of the head as well. This type
of facial pain is common in middle-aged
women, especially those who are clinically depressed.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by characterizing the patient’s facial pain.
Is it stabbing, throbbing, or dull? When did it begin? How long has it lasted? What relieves or
worsens it? Ask the patient to point to the
painful area. If facial pain is recurrent, have him
describe a typical episode. Review his medical
and dental history, noting especially previous
head trauma, dental disease, and infection.
Carefully examine the face and head. Inspect
the ear for vesicles and changes in the tympanic
membrane to rule out referred ear pain. Inspect
the nose for deformity or asymmetry. Evaluate
the condition of the mucous membranes and
septum as well as the size and shape of the
turbinates. Characterize any secretions. Palpate
the frontal, ethmoid, and maxillary sinuses for
tenderness and swelling.
Evaluate oral hygiene by inspecting the teeth
for caries, percussing any diseased teeth for
pain, and asking the patient about any sensitivity to hot, cold, or sweet liquids or foods. Have
him open and close his mouth as you palpate
the temporomandibular joint for tenderness,
spasm, locking, and crepitus.
Examine the function of cranial nerves V and
VII. To evaluate cranial nerve V, instruct the patient to clench his teeth. Then palpate the temporal and masseter muscles and evaluate muscle contraction. Test pain and sensation on his
forehead, cheeks, and jaw. Next, test the
corneal reflex by lightly touching the cornea
with a piece of cotton.
To evaluate cranial nerve VII, inspect the face
for symmetry and then have the patient perform
facial movements that demonstrate facial muscle strength—raising his eyebrows, frowning,
showing his teeth, closing his eyes tightly, and
wrinkling his nose. (See
the face, page 288.)
M
EDICAL CAUSES
◆ Angina pectoris. Occasionally, jaw pain may
indicate angina pectoris. A more comprehensive history and evaluation is needed to determine cardiac origin.
◆ Dental caries. Caries in the mandibular mo-
lars can produce ear, preauricular, and temporal
pain; caries in the maxillary teeth can produce
Major nerve pathways of
287
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Major nerve pathways
of the face
Cranial nerve V has three branches. The
ophthalmic branch supplies sensation to the
anterior scalp, forehead, upper nose, and
cornea. The maxillary branch supplies sensation to the midportion of the face, lower
nose, upper lip, and mucous membrane of
the anterior palate. The mandibular branch
supplies sensation to the lower face, lower
jaw, mucous membrane of the cheek, and
base of the tongue.
CRANIAL NERVE V
Cranial nerve VII innervates the facial muscles. Its motor branch controls the muscles
of the forehead, eye orbit, and mouth.
CRANIAL NERVE VII
maxillary, orbital, retro-orbital, and parietal
pain. Other dental causes of facial pain are an
abnormal bite and faulty dentures. Facial pain
related to chewing or temperature changes may
suggest dental problems.
◆ Glaucoma. In glaucoma, an important cause
of facial pain, the pain is usually located in the
periorbital region.
◆ Glossopharyngeal neuralgia. The pain in
this uncommon disorder is similar to that of
trigeminal neuralgia. It typically occurs in the
throat near the tonsillar fossa and may radiate
to the ear and posterior aspect of the tongue. It
may be aggravated by swallowing, chewing,
talking, or yawning. No underlying structural
abnormality is usually present.
◆ Herpes zoster oticus (Ramsay Hunt syn-
drome). This disorder causes severe pain
around the ear, followed by vesicles in the ear
and occasionally on the oral mucosa, tonsils,
and posterior tongue. Other findings may include hearing loss, vertigo, and transient ipsilateral facial paralysis.
◆ Multiple sclerosis (MS). Facial pain in MS
may resemble that of trigeminal neuralgia and
is accompanied by jaw and facial weakness.
Other common findings include visual blurring,
diplopia, and nystagmus; sensory impairment
such as paresthesia; generalized muscle weakness and gait abnormalities; urinary disturbances; and emotional lability.
◆ Postherpetic neuralgia. Burning, itching,
prickly pain persists along any of the three
trigeminal nerve divisions and worsens with
contact or movement. Mild hypoesthesia or
paresthesia and vesicles affect the area before
the onset of pain.
◆ Sinus cancer. In ethmoid sinus cancer, facial
pain is a late symptom, preceded by exophthalmos. In maxillary sinus cancer, persistent pain
along the second division of cranial nerve V is a
late symptom.
◆ Sinusitis (acute). Acute maxillary sinusitis
produces unilateral or bilateral pressure, fullness, or burning pain over the cheekbone and
upper teeth and around the eyes. Bending over
increases the pain. Other findings include nasal
congestion and purulent discharge; red, swollen
nasal mucosa; tenderness and swelling over the
cheekbone; fever; and malaise.
Acute frontal sinusitis commonly produces
severe pain above or around the eyes, which
worsens when the patient is in a supine position. It also causes nasal obstruction, inflamed
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289
nasal mucosa, fever, and tenderness and
swelling above the eyes.
Acute ethmoid sinusitis produces pain at or
around the inner corner of the eye and sometimes temporal headaches. Other findings include nasal congestion, purulent rhinorrhea,
fever, and tenderness at the medial edge of the
eye.
In acute sphenoid sinusitis, a deep-seated pain
persists behind the eyes or nose or on the top of
the head. The pain increases on bending forward and may be accompanied by fever.
◆ Sinusitis (chronic). Chronic maxillary sinusi-
tis produces a feeling of pressure below the eyes
or a chronic toothache. Discomfort typically
worsens throughout the day. Nasal congestion
and tenderness over the cheekbone are usually
mild.
Chronic frontal sinusitis produces a persistent
low-grade pain above the eyes. The patient usually has a history of trauma or long-standing inflammation.
Chronic ethmoid sinusitis is characterized by
nasal congestion, an intermittent purulent nasal
discharge, and low-grade discomfort at the medial corners of the eyes. Also common are recurrent sore throat, halitosis, ear fullness, and
involvement of the other sinuses.
A low-grade, diffuse headache or retro-
orbital discomfort is common in chronic sphe-
noid sinusitis.
◆ Sphenopalatine neuralgia. In this type of
neuralgia, unilateral deep, boring pain occurs
below the ear and may radiate to the eye, ear,
cheek, nose, palate, maxillary teeth, temple,
back of the head, neck, or shoulder. Attacks
also cause increased tearing and salivation,
rhinorrhea, a sensation of fullness in the ear,
tinnitus, vertigo, taste disturbances, pruritus,
and shoulder stiffness or weakness.
◆ Temporal arteritis. Unilateral pain occurs
behind the eye or in the scalp, jaw, tongue, or
neck. A typical episode consists of a severe
throbbing or boring temporal headache with
redness, swelling, and nodulation of the
temporal artery.
◆ Temporomandibular joint syndrome. In
this syndrome, intermittent pain, usually unilateral, is described as a severe, dull ache or an intense spasm that radiates to the cheek, temple,
lower jaw, ear, or mastoid area. Associated findings include trismus, malocclusion, and clicking, crepitus, and tenderness in the temporomandibular joint.
◆ Trigeminal neuralgia. Paroxysms of intense
pain, lasting up to 15 minutes, shoot along any
or all of the three branches of the trigeminal
nerve. The pain can be triggered by touching
the nose, cheek, or mouth; by being exposed to
hot or cold weather; by consuming hot or cold
foods or beverages; or even by smiling or talking. Between attacks, the pain may diminish to
a dull ache or may disappear. This disorder is
most common in middle and later life, affecting
more women than men.
S
PECIAL CONSIDERATIONS
Prepare the patient for diagnostic tests, such as
sinus, skull, or dental X-rays; sinus transillumination; and intracranial or sinus computed tomography scans. Give pain medications, and
apply direct heat or administer a muscle relaxant to ease muscle spasms. Provide a humidifier, vaporizer, or decongestant to relieve nasal
or sinus congestion.
P
EDIATRIC POINTERS
Facial pain may be difficult to assess in a young
child if his language skills aren’t sufficiently developed for him to describe the pain. Be alert for
subtle signs of pain, such as facial rubbing, irritability, or poor eating habits.
P
ATIENT COUNSELING
If appropriate, instruct the patient with trigeminal neuralgia to avoid stressful situations, hot
and cold foods, and sudden jarring movements,
which can trigger painful attacks.
Fasciculations
Fasciculations are local muscle contractions
representing the spontaneous discharge of a
muscle fiber bundle innervated by a single motor nerve filament. These contractions cause
visible dimpling or wavelike twitching of the
skin, but they aren’t strong enough to cause a
joint to move. Their frequency ranges from once
every several seconds to two or three times per
second; occasionally, myokymia—continuous,
rapid fasciculations that cause a rippling
effect—may occur. Because fasciculations are
brief and painless, they commonly go undetected or are ignored.
Benign, nonpathologic fasciculations are
common and normal. They often occur in tense,
anxious, or overtired people and typically affect
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the eyelid, thumb, or calf. However, fasciculations may also indicate a severe neurologic disorder, most notably a diffuse motor neuron disorder that causes loss of control over muscle
fiber discharge. They’re also an early sign of
pesticide poisoning.
EMERGENCY INTERVENTIONS Begin by
asking the patient about the nature, onset,
and duration of the fasciculations. If the onset was
sudden, ask about any precipitating events, such
as exposure to pesticides. Pesticide poisoning, although uncommon, is a medical emergency requiring prompt and vigorous intervention. You
may need to maintain airway patency, monitor vital signs, give oxygen, and perform gastric lavage
or induce vomiting.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient isn’t in severe distress, find out if
he has experienced any sensory changes, such
as paresthesia, or any difficulty speaking, swallowing, breathing, or controlling bowel or bladder function. Ask him if he’s in pain.
Explore the patient’s medical history for neurologic disorders, cancer, and recent infections.
Also, ask him about his lifestyle, especially
stress at home, on the job, or at school.
Ask the patient about his dietary habits and
for a recall of his food and fluid intake in the recent past because electrolyte imbalances may
also cause muscle twitching.
Perform a physical examination, looking for
fasciculations while the affected muscle is at
rest. Observe and test for motor and sensory
abnormalities, particularly muscle atrophy and
weakness, and decreased deep tendon reflexes.
If you note these signs and symptoms, suspect
motor neuron disease, and perform a comprehensive neurologic examination.
M
EDICAL CAUSES
◆ Amyotrophic lateral sclerosis. In this pro-
gressive motor neuron disease, coarse fasciculations usually begin in the small muscles of
the hands and feet, and then spread to the forearms and legs. Widespread, symmetrical muscle atrophy and weakness may result in
dysarthria; difficulty chewing, swallowing, and
breathing; and, occasionally, choking and
drooling.
◆ Bulbar palsy. Fasciculations of the face and
tongue commonly appear early in bulbar palsy.
Progressive signs and symptoms include
dysarthria, dysphagia, hoarseness, and drooling.
Eventually, weakness spreads to the respiratory
muscles.
◆ Guillain-Barré syndrome. Fasciculations
may occur in Gullain-Barré syndrome, but the
cardinal neurologic symptom is muscle weakness, which typically begins in the legs and
spreads quickly to the arms and face. Other
findings include paresthesia, incontinence, footdrop, tachycardia, dysphagia, and respiratory
insufficiency.
◆ Herniated disk. Fasciculations of the mus-
cles innervated by compressed nerve roots may
be widespread and profound, but the hallmark
of a herniated disk is severe low back pain that
may radiate unilaterally to the leg. Coughing,
sneezing, bending, and straining exacerbate the
pain. Related effects include muscle weakness,
atrophy, and spasms; paresthesia; footdrop;
steppage gait; and hypoactive deep tendon reflexes in the leg.
◆ Poliomyelitis (spinal paralytic). Coarse fas-
ciculations, usually transient but occasionally
persistent, accompany progressive muscle
weakness, spasms, and atrophy in this disorder.
The patient may also exhibit decreased reflexes,
paresthesia, coldness and cyanosis in the affected limbs, bladder paralysis, dyspnea, elevated
blood pressure, and tachycardia.
◆ Spinal cord tumor. Fasciculations, muscle
atrophy, and cramps may develop asymmetrically at first and then bilaterally as cord compression progresses. Motor and sensory
changes distal to the tumor include weakness
or paralysis, areflexia, paresthesia, and a tightening band of pain. Bowel and bladder control
may be lost.
◆ Syringomyelia. In this disorder, fascicula-
tions may occur along with Charcot’s joints,
areflexia, muscle atrophy, and deep, aching
pain. Additional findings include thoracic scoliosis and loss of pain and temperature sensation
over the neck, shoulders, and arms.
O
THER CAUSES
◆ Pesticide poisoning. Ingestion of
organophosphate or carbamate pesticides commonly produces acute onset of long, wavelike
fasciculations and muscle weakness that rapidly
progresses to flaccid paralysis. Other common
effects include nausea, vomiting, diarrhea, loss
of bowel and bladder control, hyperactive bowel
sounds, and abdominal cramping. Cardiopulmonary findings include bradycardia, dyspnea
or bradypnea, and pallor or cyanosis. Seizures,
vision disturbances (pupillary constriction or
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