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FEVER
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301
Infection and
inflammatory
disorders
Additional signs and
symptoms
◆ Low or extremely high
temperature that may be
intermittent or sustained
and may rise abruptly or
insidiously
◆ Chills
◆ Diaphoresis
◆ Weakness
◆ Associated signs that
may in
volve every system
Diagnosis:
depending on additional
signs and symptoms
Treatment: Varies
depending on source of
fever but usually includes
antipyretics
Follow-up: As needed
(depending on source of
infection)
Other causes: anticholinergics ◆ chemotherapy (especially with bleomycin, vincristine, and
asparaginase)
barbiturates, phenytoin, quinidine, iodides, phenolphthalein, methyldopa, procainamide, and some antitoxins
◆ inhalant anesthetics ◆ monoamine oxidase inhibitors ◆ muscle relaxants ◆ phenothiazines
◆ radiographic tests that use contrast medium ◆ surgery ◆ toxic doses of salicylates, amphetamines, and
tricyclic antidepressants
Varies
◆ hypersensitivity to antifungals, sulfonamides, penicillins, cephalosporins, tetracyclines,
◆ transfusion reactions
Immune complex
dysfunction
Additional signs and
symptoms
◆ Low-grade fever that
may be remittent, intermittent, or sustained
◆ Nocturnal diaphoresis
Diagnosis: V
depending on additional
signs and symptoms
reatment: Varies
T
depending on specific
cause of fever but usually
includes antipyretics
Follow-up: As needed
(depending on cause of
fever)
aries
West Nile
encephalitis
Additional signs and
symptoms
◆ Mild to moderate fever
◆ Headache
◆ Myalgia
◆ Rash
◆ Swollen lymph glands
◆ Neck stiffness
◆ Decreased LOC
◆ Seizures
Diagnosis: History of
recent mosquito bite
West Nile activity reported
in locality, blood culture
Treatment: Supportive
treatment, treatment of
symptoms, medication
(antipyretics, analgesics)
Follow-up: As needed
(depending on severity of
infection)
,
that’s resistant to antibiotics commonly
used to treat staphylococcal infections. The
incidence of MRSA has greatly increased in
recent years. This increase is thought to be
related to the increase in antibiotic use in
hospital and outpatient settings and the
widespread use of hand sanitizers and disinfectants. Older adults and patients with compromised immune systems are at greatest risk
for MRSA, although it’s becoming more
common in community settings. Patients with
MRSA may have a variety of signs and
symptoms (most commonly fatigue and
fever), depending on where the infection is
located.
◆ Monkeypox. Fever is one of the initial symp-
toms that occurs in almost all patients infected
with this rare viral disease. A papular rash that
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How fever develops
Body temperature is regulated by the hypothalamic thermostat, which has a specific set point under normal conditions. Fever can result from a resetting of this set point or from an abnormality
in the thermoregulatory system itself, as shown in this flowchart.
Disruption of
hypothalamic
thermostat by:
◆ central nervous system
disease
◆ inherited malignant
hyperthermia
Increased
production of
heat from:
◆ strenuous exercise or
other stress
◆ chills (skeletal muscle
response)
◆ thyrotoxicosis
Failure of the body’s
temperature-regulating mechanisms
Decreased loss of
heat from:
◆ anhidrotic asthenia
(heatstroke)
◆ heart failure
◆ skin conditions, such as
ichthyosis and congenital
absence of sweat glands
◆ drugs that impair
sweating
FEVER
Elevation of hypothalamic set point
Production of endogenous pyrogens
Entrance of exogenous pyrogens, such as bacteria,
viruses, or immune complexes, into the body
may be localized or generalized appears within
1 to 3 days after the fever begins. Additional
symptoms commonly include sore throat, chills,
and lymphadenopathy. There is no treatment for
monkeypox, but the disease is rarely fatal in
developed countries and usually lasts 2 to
4 weeks.
◆ Neoplasms. Primary neoplasms and metas-
tases can produce prolonged fever of varying elevations. For instance, acute leukemia may
manifest insidiously with a low fever, pallor,
and bleeding tendencies, or more abruptly with
a high fever, frank bleeding, and prostration.
Occasionally, Hodgkin’s disease produces undu-
lant fever or Pel-Ebstein fever, an irregularly relapsing fever.
Besides fever and nocturnal diaphoresis, neoplastic disease commonly causes anorexia, fatigue, malaise, and weight loss. Examination
may reveal lesions, lymphadenopathy, palpable
masses, and hepatosplenomegaly.
◆ Plague. Caused by Yersinia pestis, plague is
one of the most virulent bacterial infections
known. The bubonic form of plague is transmitted to man from the bite of infected fleas
and causes fever, chills, and swollen, inflamed,
and tender lymph nodes near the site of the
bite. Septicemic plague may deveop as a
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complication of untreated bubonic or pneumonic plague, and occurs when bacteria enter
the bloodstream and multiply. Pneumonic
plague manifests as a sudden onset of chills,
fever, headache, and myalgia after person-toperson transmission by respiratory droplets.
Other signs and symptoms of the pneumonic
form include a productive cough, chest pain,
tachypnea, dyspnea, hemoptysis, increasing
respiratory distress, and cardiopulmonary insufficiency.
◆ Popcorn lung disease. Popcorn lung dis-
ease occurs in factory workers who experience
respiratory symptoms after inhaling butter flavoring chemicals such as diacetyl, used in the
manufacture of microwave popcorn. The patient typically complains of gradual onset of a
nonproductive cough that worsens over time,
progressive shortness of breath, and unusual fatigue. Clinical findings include wheezing, chest
pain, fever, night sweats, and weight loss. Bronchiolitis fibrosa obliterans, an irreversible fixed
airway obstructive lung disorder, is the most severe condition reported.
◆ Q fever. This rickettsial disease caused by
Coxiella burnetii causes fever (which may last up
to 2 weeks), chills, severe headache, malaise,
chest pain, nausea, vomiting, and diarrhea. In
severe cases, the patient may develop hepatitis
or pneumonia.
◆ Respiratory syncytial virus (RSV). Fever is
one of the initial symptoms of this common illness that affects most children by age 2. Healthy
adults and children older than age 3 usually develop a low-grade fever along with other common coldlike symptoms of runny nose, cough,
and wheezing. Many children less than age 3
have a high-grade fever that may be accompanied by a severe cough, rapid breathing, and
high-pitched expiratory wheezing. Infants with
RSV typically exhibit lethargy, poor eating, irritability, and difficulty breathing; severe cases
may require hospitalization. To avoid repeated
RSV infection, individuals should practice
infection-control techniques, such as proper
hand-washing and avoiding contact with contaminated surfaces.
◆ Rhabdomyolysis. This disorder results in
muscle breakdown and release of the muscle
cell contents (myoglobin) into the bloodstream.
Signs and symptoms include fever, muscle
weakness or pain, nausea, vomiting, malaise,
and dark urine. Acute renal failure, the most
common complication rhabdomyolysis, results
from renal structure obstruction and injury dur-
ing the kidneys’ attempt to filter the myoglobin
from the bloodstream.
◆ Rift Valley fever. Typical signs and symp-
toms of this infection include fever, myalgia,
weakness, dizziness, and back pain. A small
percentage of patients may develop encephalitis
or may progress to hemorrhagic fever that can
lead to shock and hemorrhage. Inflammation of
the retina may result in some permanent vision
loss.
◆ Severe acute respiratory syndrome
(SARS). SARS is an acute infectious disease of
unknown etiology; however, a novel coronavirus has been implicated as a possible cause.
Although most cases have been reported in Asia
(China, Vietnam, Singapore, Thailand), cases
have cropped up in Europe and North America.
After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually
greater than 100.4° F [38° C]). Other symptoms
include headache, malaise, a nonproductive
cough, and dyspnea. SARS may produce only
mild symptoms, or it may progress to pneumonia and, in some cases, even respiratory failure
and death.
◆ Smallpox (variola major). Initial signs and
symptoms of this virus include high fever,
malaise, prostration, severe headache, backache, and abdominal pain. A maculopapular
rash develops on the mucosa of the mouth,
pharynx, face, and forearms and then spreads to
the trunk and legs. Within 2 days, the rash becomes vesicular and later pustular. The lesions
develop at the same time, appear identical, and
are more prominent on the face and extremities. The pustules are round, firm, and deeply
embedded in the skin. After 8 or 9 days, they
form a crust, which later separates from the
skin, leaving a pitted scar. Death may result
from encephalitis, extensive bleeding, or secondary infection.
◆ Thermoregulatory dysfunction. Sudden
onset of fever that rises rapidly and remains as
high as 107° F (41.7° C) occurs in life-threatening
disorders, such as heatstroke, thyroid storm,
neuroleptic malignant syndrome, and malignant
hyperthermia, and in lesions of the central nervous system (CNS). A low or moderate fever occurs in dehydrated patients.
Prolonged high fever commonly produces
vomiting, anhidrosis, decreased level of consciousness (LOC), and hot, flushed skin. Related
cardiovascular effects may include tachycardia,
tachypnea, and hypotension. Other diseasespecific findings include skin changes (dry skin
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and mucous membranes, poor skin turgor) and
oliguria in dehydration; mottled cyanosis in malignant hyperthermia; diarrhea in thyroid storm;
and ominous signs of increased intracranial
pressure (decreased LOC with bradycardia,
widened pulse pressure, and increased systolic
pressure) in CNS tumor, trauma, or hemorrhage.
◆ Tularemia. This infectious disease, also
known as “rabbit fever,” causes abrupt onset of
fever, chills, headache, generalized myalgia,
nonproductive cough, dyspnea, pleuritic chest
pain, and empyema.
◆ Typhus. In this rickettsial disease, the patient
initially experiences headache, myalgia, arthralgia, and malaise. These symptoms are followed
by an abrupt onset of fever, chills, nausea, vomiting, and—in some cases—a maculopapular
rash.
◆ Vancomycin-resistant enterococci (VRE)
infection. Enterococci are bacteria naturally
present in the intestinal tract of all people; however, some strains of enterococci have become
resistant to vancomycin. Serious VRE infections
may occur in hospitalized patients with such
comorbidities as cancer, kidney disease, or immune deficiencies. Elderly patients and those
hospitalized for long periods are also at risk for
developing VRE infections. Symptoms of VRE
infection depend on where the infection is; patients with VRE infections may have diarrhea,
fever, and fatigue.
◆ Vancomycin-resistant Staphylococcus
aureus (VRSA). VRSA is a strain of staphylo-
coccus that’s resistant to vancomycin, an
antibiotic commonly used to treat staphylococcal infections. Patients most susceptible to
VRSA infections include those with diabetes,
kidney disease, or previous infection with
MRSA, and those with I.V. catheters. VRSA can
be difficult to diagnose because of the patient’s
overlying medical problems. Patients with
VRSA commonly complain of fatigue and
fever that don’t respond to treatment with
vancomycin. VRSA is usually diagnosed when
cultures are done to see why the patient isn’t
responding to vancomycin; after the patient is
started on a different antibiotic, the infection
improves.
◆ West Nile encephalitis. This brain infection
is caused by West Nile virus, a mosquito-borne
flavivirus commonly found in Africa, West Asia,
and the Middle East and rarely in North America. Most patients have mild signs and symptoms, including fever, headache, body aches,
rash, and swollen lymph glands. More severe
infection is marked by high fever, headache,
neck stiffness, stupor, disorientation, coma,
tremors and, occasionally, paralysis or seizures.
Death rarely occurs.
O
THER CAUSES
◆ Diagnostic tests. Immediate or delayed
fever infrequently follows radiographic tests
that use a contrast medium.
◆ Drugs. Fever and rash commonly result from
hypersensitivity to antifungals, sulfonamides,
penicillins, cephalosporins, tetracyclines, barbiturates, phenytoin, quinidine, iodides, methyldopa, procainamide, and some antitoxins. Fever
can accompany chemotherapy, especially with
bleomycin, vincristine, and asparaginase. It can
result from drugs that impair sweating, such as
anticholinergics, phenothiazines, and
monoamine oxidase inhibitors. A drug-induced
fever typically disappears after the drug is discontinued. Fever can also stem from toxic doses
of salicylates, amphetamines, and tricyclic antidepressants.
Inhaled anesthetics and muscle relaxants can
trigger malignant hyperthermia in patients with
this inherited trait.
◆ Treatments. A remittent or intermittent low
fever may occur for several days after surgery.
Transfusion reactions characteristically produce
an abrupt onset of fever and chills.
S
PECIAL CONSIDERATIONS
Regularly monitor the patient’s temperature,
and record it on a chart for easy follow-up of
the temperature curve. Provide increased fluid
and nutritional intake. When administering a
prescribed antipyretic, minimize resultant
chills and diaphoresis by following a regular
dosage schedule. Promote patient comfort by
maintaining a stable room temperature and
providing frequent changes of bedding and
clothing. Prepare the patient for laboratory
tests, such as complete blood count and cultures of blood, urine, sputum, and wound
drainage.
P
EDIATRIC POINTERS
Infants and young children experience higher
and more prolonged fevers, more rapid temperature increases, and greater temperature fluctuations than older children and adults.
Keep in mind that seizures commonly accompany extremely high fever, so take appropriate precautions. Also, instruct parents not to
give aspirin to a child with varicella or flulike
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305
symptoms because of the risk of precipitating
Reye’s syndrome.
Common pediatric causes of fever include
varicella, croup syndrome, dehydration, meningitis, mumps, otitis media, pertussis, roseola infantum, rubella, rubeola, and tonsillitis. Fever
can also occur as a reaction to immunizations
and antibiotics.
G
ERIATRIC POINTERS
Elderly people may have an altered sweating
mechanism that predisposes them to heatstroke
when exposed to high temperatures; they may
also have an impaired thermoregulatory mechanism, making temperature change a much less
reliable measure of disease severity.
P
ATIENT COUNSELING
If the patient has not been admitted to the hospital, ask him to measure his oral temperature
at home and record the time and value. Explain
to him that fever is a response to an underlying
condition and that it plays an important role in
fighting infection. For this reason, advise him
not to take an antipyretic until his body temperature reaches 101° F (38.3° C).
Flank pain
Pain in the flank, the area extending from the
ribs to the ilium, is a leading indicator of renal
and upper urinary tract disease or trauma. Depending on the cause, this symptom may vary
from a dull ache to severe stabbing or throbbing pain, and may be unilateral or bilateral
and constant or intermittent. It’s aggravated
by costovertebral angle (CVA) percussion and,
in patients with renal or urinary tract obstruction, by increased fluid intake and ingestion of
alcohol, caffeine, or diuretics. Unaffected by
position changes, flank pain typically responds
only to analgesics or, of course, to treatment
of the underlying disorder. (See Flank pain:
Causes and associated findings, pages 306 and
307.)
EMERGENCY INTERVENTIONS If the pa-
tient has suffered trauma, quickly look for a
visible or palpable flank mass, associated injuries,
CVA pain, hematuria, Turner’s sign, and signs of
shock (such as tachycardia and cool, clammy
skin). If one or more of these signs is present, insert an I.V. catheter to allow fluid or drug infusion.
Insert an indwelling urinary catheter to monitor
urine output and evaluate hematuria. Obtain
blood samples for typing and crossmatching,
complete blood count, and electrolyte levels.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient’s condition isn’t critical, take a
thorough history. Ask about the pain’s onset
and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and
duration. Find out if anything aggravates or alleviates it.
Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI)
or obstruction, renal disease, or recent streptococcal infection.
During the physical examination, palpate the
patient’s flank area and percuss the CVA to determine the extent of pain.
M
EDICAL CAUSES
◆ Bladder cancer. Dull, constant flank pain
may be unilateral or bilateral and may radiate to
the leg, back, and perineum. Commonly, the
first sign of bladder cancer is gross, painless, intermittent hematuria, often with clots. Related
effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis,
back, or legs; diarrhea; vomiting; and sleep disturbances.
◆ Calculi. Renal and ureteral calculi produce
intense unilateral, colicky flank pain. Typically,
initial CVA pain radiates to the flank, suprapubic
region, and perhaps the genitalia; abdominal
and low back pain are also possible. Nausea
and vomiting commonly accompany severe
pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and,
possibly, signs and symptoms of UTI (urinary
frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).
◆ Cortical necrosis (acute). Unilateral flank
pain is usually severe in this disorder. Accompanying findings include gross hematuria,
anuria, leukocytosis, and fever.
◆ Cystitis (bacterial). Unilateral or bilateral
flank pain occurs secondarily to an ascending
UTI in bacterial cystitis. The patient may also report perineal, low back, and suprapubic pain.
Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus,
fatigue, and low-grade fever.
◆ Glomerulonephritis (acute). Flank pain in
patients with this disorder is bilateral, constant,
(Text continues on page 308.)
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SIGNS & SYMPTOMS
Flank pain: Causes and associated findings
Common
causes
Major associated signs and symptoms
Abdominal
distention
Abdominal mass
Abdominal pain
Anuria
Back pain
Bladder distention
Blood pressure, de-
creased
Blood pressure, in-
creased
Bowel sounds, hy-
poactive
Chills
Costovertebral
angle tenderness
Bladder cancer
Calculi
Cortical necrosis
(acute)
Cystitis (bacterial)
Glomerulonephritis
(acute)
Obstructive
uropathy
Pancreatitis
(acute)
Papillary necrosis
(acute)
Perirenal abscess
Polycystic kidney
disease
Pyelonephritis
(acute)
••
•••
•
•
••
•••• • • •
•• • •
•
•
•••
•••
••
•••
Renal cancer
Renal infarction
Renal trauma
Renal vein
thrombosis
•• ••
•
•• • •
••
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Edema, generalized
Fatigue
Fever
Flank mass
Groin pain
Hematuria
Leg pain
Nausea
Nocturia
Oliguria
Perineal pain
Polyuria
Pyuria
FLANK PAIN 307
Suprapubic pain
Tenesmus
Urinary frequency
Urinary urgency
Urine retention
Vomiting
••••••••
••••••• ••••
••
••• • •• ••••
••• • • •
••••
•••
•• ••
••
•••••
•
•
••• • • •••
•
•
•
•
•
•
•• • • •
••• •
••• • •
••••
•
•
•
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and of moderate intensity. The most common
findings are moderate facial and generalized
edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased
blood pressure, low-grade fever, malaise,
headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.
◆ Obstructive uropathy. In an acute obstruc-
tion, flank pain may be excruciating; in a gradual obstruction, it’s typically a dull ache. In both
types, the pain may also localize in the upper
abdomen and radiate to the groin. Nausea and
vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and
hypoactive bowel sounds may also occur. Additional findings—a palpable abdominal mass,
CVA tenderness, and bladder distention—vary
with the site and cause of the obstruction.
◆ Pancreatitis (acute). Bilateral flank pain
may develop as severe epigastric or left-upperquadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and
rigidity, hypoactive bowel sounds and, possibly,
restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s
signs.
◆ Papillary necrosis (acute). In this disorder,
intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain
and rigidity. Urinary signs and symptoms—
oliguria or anuria, hematuria, and pyuria—are
associated with high fever, chills, vomiting, and
hypoactive bowel sounds.
◆ Perirenal abscess. Intense unilateral flank
pain and CVA tenderness accompany dysuria,
persistent high fever, chills and, in some patients, a palpable abdominal mass.
◆ Polycystic kidney disease. Dull, aching, bi-
lateral flank pain is commonly the earliest
symptom of this renal disorder. The pain can
become severe and colicky if cysts rupture and
clots migrate or cause an obstruction. Nonspecific early findings include polyuria, increased
blood pressure, and signs and symptoms of UTI.
Later findings include hematuria and perineal,
low back, and suprapubic pain.
◆ Pyelonephritis (acute). Intense, constant,
unilateral or bilateral flank pain develops over a
few hours or days along with typical urinary
features: dysuria, nocturia, hematuria, urgency,
frequency, and tenesmus. Other common findings include persistent high fever, chills,
anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.
◆ Renal cancer. Unilateral flank pain, gross
hematuria, and a palpable flank mass form the
classic clinical triad in renal cancer. Flank pain
is usually dull and vague, although severe colicky pain can occur during bleeding or passage
of clots. Associated signs and symptoms include
fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and
vomiting are indications of advanced disease.
◆ Renal infarction. Unilateral, constant, se-
vere flank pain and tenderness typically accompany persistent, severe upper abdominal pain in
this disorder. The patient may also develop CVA
tenderness, anorexia, nausea and vomiting,
fever, hypoactive bowel sounds, hematuria, and
oliguria or anuria.
◆ Renal trauma. Variable bilateral or unilater-
al flank pain, a visible or palpable flank mass,
and CVA or abdominal pain (which may be severe and radiate to the groin) are common findings in renal trauma. Other findings include
hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea
and vomiting. Severe injury may produce signs
of shock, such as tachycardia and cool, clammy
skin.
◆ Renal vein thrombosis. Severe unilateral
flank and low back pain with CVA and epigastric
tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms
(nausea, vomiting, and uremic fetor) typify bilateral obstruction.
S
PECIAL CONSIDERATIONS
Administer pain medication. Continue to monitor the patient’s vital signs, and maintain a precise record of the patient’s intake and output.
Diagnostic evaluation may involve serial
urine and serum analysis, excretory urography,
flank ultrasonography, computed tomography
scan, voiding cystourethrography, cystoscopy,
and retrograde ureteropyelography, urethrography, and cystography.
P
EDIATRIC POINTERS
Assessment of flank pain can be difficult if a
child can’t describe the pain. In such cases,
transillumination of the abdomen and flanks
may help to detect bladder distention and
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identify masses. Common causes of flank pain
in children include obstructive uropathy, acute
poststreptococcal glomerulonephritis, infantile
polycystic kidney disease, and nephroblastoma.
Flatulence
A sensation of gaseous abdominal fullness, flatulence can result from GI disorders, abdominal
surgery, excessive intake of certain foods, and
stress. It may be accompanied by belching, discomfort, and excessive passage of flatus.
Flatulence reflects slowed intestinal motility,
which hampers the passage of gas; excessive
swallowing of air (aerophagia), often brought
on by stress; or increased intraluminal gas production due to an excess of fermentable substrates, such as digested, unabsorbed carbohydrates and proteins.
Although generally not considered a serious
symptom, flatulence—and accompanying expulsion of flatus—may cause the patient embarrassment and discomfort.
H
ISTORY AND PHYSICAL
EXAMINATION
Determine how long the patient has noticed the
flatulence. Find out if he passes an excessive
amount of flatus. Also, ask about frequent
belching or snoring, and observe for overly
rapid speech. These signs are all possible clues
to aerophagia.
In addition, be sure to ask the patient if he’s
undergoing unusual emotional stress because
this can cause aerophagia or irritable bowel
syndrome. Obtain a medical history, focusing on
GI disorders and systemic illnesses such as scleroderma, which can cause malabsorption syndrome. Then inspect the patient’s abdomen for
distention, and auscultate for abnormal bowel
sounds. Percuss for increased tympany due to
gas accumulation, and palpate for tenderness
and masses.
M
EDICAL CAUSES
◆ Cirrhosis. Flatulence typically develops early
and insidiously in cirrhosis along with anorexia,
dyspepsia, nausea, vomiting, diarrhea or constipation, dull right-upper-quadrant pain, hepatomegaly, splenomegaly, fatigue, and malaise.
◆ Colon cancer. Obstruction of the colon by a
tumor may cause flatulence; an acute obstruction also produces abdominal distention and
tympany on percussion. Other findings may include abdominal pain, anorexia, weight loss,
malaise, and altered bowel habits (constipation,
diarrhea, or a change in the timing, frequency,
or consistency of stools).
◆ Crohn’s disease. In this disease, flatulence
accompanies other acute inflammatory signs
and symptoms that mimic those of appendicitis:
abdominal pain, cramps, and tenderness; diarrhea; low-grade fever; nausea; and melena.
◆ Irritable bowel syndrome. The effects of
this disorder include chronic flatulence, belching, and excessive flatus. Chronic constipation
is typical, although the patient may also experience diurnal diarrhea. Intermittent lower abdominal pain characteristically abates with
defecation or passage of flatus.
◆ Lactose intolerance. In this disorder, flatu-
lence develops within several hours after the ingestion of dairy products. Accompanying signs
and symptoms include abdominal pain and
cramping and, possibly, diarrhea.
◆ Malabsorption syndrome. Findings vary
considerably, depending on which dietary constituent isn’t absorbed, but may include flatulence, abdominal pain, anorexia, weight loss,
and passage of bulky, oily, malodorous, or
slightly watery stools. Severe malabsorption
may also cause muscle wasting and weakness
as well as skeletal pain, edema, ecchymosis,
and ulceration of the tongue.
O
THER CAUSES
◆ Abdominal surgery. When peristalsis re-
turns after postoperative paralytic ileus, gas accumulation in hypomotile areas produces flatulence.
HERB ALERT Some herbal products, such
as garlic, can cause flatulence.
S
PECIAL CONSIDERATIONS
Prepare the patient for diagnostic studies, such
as blood tests, stool analysis, upper GI series,
barium enema, and endoscopy. To aid expulsion
of excessive flatus, position the patient on his
left side. To prevent gas buildup, encourage frequent repositioning, ambulation, and normal
fluid intake, as permitted. If these measures
aren’t effective, try inserting a rectal tube into
his anus to relieve flatus or administering an enema, a suppository, an antiflatulent, or an anticholinergic. As appropriate, provide the patient
with a diet plan that excludes gaseous foods.
(See Antiflatulence diet, page 310.)
310 FONTANEL BULGING
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PATIENT-TEACHING AID
Antiflatulence diet
Dear Patient:
To help reduce gas, follow these dietary suggestions:
◆ Try to avoid such vegetables and fruits as
broccoli, brussels sprouts, cabbage, cauliflower, cucumbers, dried beans, green peppers, kohlrabi, lettuce, lima beans, onions,
peas, radishes, melons, prunes, and raw apples.
◆ Avoid all fatty foods, such as red meats, fried
foods, and pastries.
This patient-teaching aid may be reproduced by office copier for distribution to patients. © 2011, Lippincott Williams &
Wilkins.
P
EDIATRIC POINTERS
The common childhood complaint of stomachache commonly results from flatulence. Children may also be more sensitive than adults to
flatus-producing foods. They’re also generally
more prone to aerophagia, especially during
eating.
G
ERIATRIC POINTERS
In elderly patients, increased flatulence may result from poor dentition, leading to poor mastication of food, poor dietary intake, and decreased GI motility. However, pathology must
first be ruled out.
Fontanel bulging
In a normal infant, the anterior fontanel, or “soft
spot,” is flat, soft yet firm, and well demarcated
against surrounding skull bones. The posterior
fontanel shouldn’t be fused at birth but may be
overriding after the birthing process. This
fontanel usually closes by age 3 months. (See
Locating fontanels.) Subtle pulsations may be
visible, reflecting the arterial pulse.
A bulging fontanel—widened, tense, and
with marked pulsations—is a cardinal sign of
meningitis associated with increased intracranial pressure (ICP), a medical emergency. It
can also be an indication of encephalitis or
fluid overload. Because prolonged coughing,
crying, or lying down can cause transient,
physiologic bulging, the infant’s head should
be observed and palpated while the infant is
◆ Avoid foods and beverages that contain ex-
cess air, including soufflés, carbonated drinks,
and milk shakes.
◆ If you have lactose intolerance, avoid milk,
cheese, ice cream, and all other dairy products.
◆ Don’t overeat, eat too rapidly, or eat while
under emotional stress.
◆ Don’t drink large amounts of liquids with
meals.
◆ Don’t take laxatives.
upright and relaxed to detect pathologic
bulging.
EMERGENCY INTERVENTIONS If you
detect a bulging fontanel, measure fontanel
size and head circumference, and note the overall shape of the head. Take vital signs, and determine level of consciousness by observing spontaneous activity, postural reflex activity, and
sensory responses. Note whether the infant assumes a normal, flexed posture or one of extreme extension, opisthotonos, or hypotonia.
Observe arm and leg movements; excessive
tremulousness or frequent twitching may herald
the onset of a seizure. Look for other signs of increased ICP: abnormal respiratory patterns
and a distinctive high-pitched cry.
Ensure airway patency, and have sizeappropriate emergency equipment on hand.
Provide oxygen and establish I.V. access; if the
infant is having a seizure, stay with him to prevent injury and administer an anticonvulsant.
Administer an antibiotic, antipyretic, and osmotic diuretic to help reduce cerebral edema and
decrease ICP. If these measures fail to reduce
ICP, neuromuscular blockade, intubation, mechanical ventilation and, in rare cases, a barbiturate coma and total body hypothermia may be
necessary.
H
ISTORY AND PHYSICAL
EXAMINATION
Once the infant’s condition is stabilized, you
can begin investigating the underlying cause of
increased ICP. Obtain the child’s medical history
from a parent or caregiver, paying particular
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