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Score
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Neuromuscular
Physical
Total
Maturity ratings
Total maturity
Gestational age
score
⫺10
⫺5
0
5
10
15
20
25
30
35
40
45
50
Gestestional age (weeks)
By dates
By ultrasound
By score
(weeks)
20
22
24
26
28
30
32
34
36
38
40
42
44
LYMPHADENOPATHY
move the skin over underlying tissues at the
nodal area. If you detect enlarged nodes, note
their size in centimeters and whether they’re
fixed or mobile, tender or nontender, and erythematous or not. Note their texture: Is the node
discrete, or does the area feel matted? If you
detect tender, erythematous lymph nodes,
check the area drained by that part of the lymph
system for signs of infection, such as erythema
and swelling. Also, palpate for and percuss the
spleen.
M
EDICAL CAUSES
431
◆ Acquired immunodeficiency syndrome.
Besides lymphadenopathy, findings include a
history of fatigue, night sweats, afternoon
fevers, diarrhea, weight loss, and cough with
several concurrent infections appearing soon
afterward.
◆ Anthrax (cutaneous). Lymphadenopathy,
malaise, headache and fever may develop along
with a lesion that progresses into a painless,
necrotic-centered ulcer.
◆ Brucellosis. Generalized lymphadenopathy
usually affects cervical and axillary lymph
nodes, making them tender. This disease usually begins insidiously with easy fatigability,
malaise, headache, backache, anorexia,
weight loss, and arthralgias; it may also begin
abruptly with chills, fever that usually rises in
the morning and subsides during the day, and
diaphoresis.
◆ Chronic fatigue syndrome. Lymph-
adenopathy may occur with incapacitating fatigue, sore throat, low-grade fevers, myalgia,
cognitive dysfunction, and sleep disturbances.
The diagnosis is one of exclusion and the cause
of this syndrome is unknown.
◆ Cytomegalovirus infection. Generalized
lymphadenopathy occurs in the immunocompromised patient and is accompanied by
fever, malaise, rash, and hepatosplenomegaly.
◆ Hodgkin’s disease. The extent of lymph-
adenopathy reflects the stage of malignancy—
from stage I involvement of a single lymph node
region to stage IV generalized lymphadenopathy. Common early signs and symptoms include
pruritus and, in older patients, fatigue, weakness, night sweats, malaise, weight loss, and
unexplained fever (usually to 101⬚ F [38.3⬚ C]).
Also, if mediastinal lymph nodes enlarge, tracheal and esophageal pressure produces dyspnea and dysphagia.
432 LYMPHADENOPATHY
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Areas of localized lymphadenopathy
When you detect an enlarged lymph node, palpate the entire lymph node system to determine the
extent of lymphadenopathy. Include the lymph nodes indicated below in your assessment.
Right
lymphatic
duct
Axillary
nodes
Mammary
vessels
Thoracic
duct
Mesenteric
nodes
Lumbar
nodes
Femoral
vessels
Popliteal
nodes
Tibial
vessels
Parotid
nodes
Occipital
nodes
Mandibular
nodes
Cervical
nodes
Cubital
nodes
Cisterna
chyli
Iliac nodes
and vessels
Inguinal
nodes
LYMPHADENOPATHY
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Causes of localized lymphadenopathy
Various disorders can cause localized lymphadenopathy, but this sign usually results from infection or trauma affecting the specific area. Here are some common causes of lymphadenopathy,
listed according to the area affected.
433
Occipital
◆ Infection
◆ Roseola
◆ Scalp infection
◆ Seborrheic dermatitis
◆ Tick bite
◆ Tinea capitis
Auricular
◆ Erysipelas
◆ Herpes zoster ophthalmicus
◆ Infection
◆ Rubella
◆ Squamous cell carcinoma
◆ Styes or chalazion
◆ Tularemia
Supraclavicular
◆ Infection
◆ Neoplastic disease
Cervical
◆ Cat-scratch fever
◆ Facial or oral cancer
◆ Infection
◆ Mononucleosis
◆ Monocutaneous lymph
node syndrome
◆ Rubella
◆ Rubeola
◆ Thyrotoxicosis
◆ Tonsillitis
◆ Tuberculosis
◆ Varicella
Axillary
◆ Breast cancer
◆ Infection
◆ Lymphoma
◆ Mastitis
◆ Kawasaki syndrome. Cervical lymph-
adenopathy is a characteristic sign of this potentially life-threatening illness. Affected individuals present with high, spiking fever, along
with other diagnostic signs including erythema,
bilateral conjunctival injection, and swelling in
the peripheral extremities. Kawasaki syndrome
isn’t contagious, however the cause remains
unknown and typically affects children under
age 5. Prompt detection and treatment with I.V.
gamma globulin is essential in preventing serious complications, such as coronary artery dilations and aneurysms.
◆ Leptospirosis. Lymphadenopathy occurs in-
frequently in this rare disease. More common
findings include sudden onset of fever and
chills, malaise, myalgia, headache, nausea and
vomiting, and abdominal pain.
◆ Leukemia (acute lymphocytic). General-
ized lymphadenopathy is accompanied by fatigue, malaise, pallor, and low fever. The patient
also experiences prolonged bleeding time,
swollen gums, weight loss, bone or joint pain,
and hepatosplenomegaly.
◆ Leukemia (chronic lymphocytic). General-
ized lymphadenopathy appears early, along
with fatigue, malaise, and fever. As the disease
Submaxillary and
submental
◆ Cystic fibrosis
◆ Dental infection
◆ Gingivitis
◆ Glossitis
◆ Infection
Inguinal and femoral
◆ Carcinoma
◆ Chancroid
◆ Infection
◆ Lymphogranuloma
venereum
◆ Syphilis
Popliteal
◆ Infection
progresses, hepatosplenomegaly, severe fatigue,
and weight loss occur. Other late findings include bone tenderness, edema, pallor, dyspnea,
tachycardia, palpitations, bleeding, anemia, and
macular or nodular lesions.
◆ Lyme disease. Spread by the bite of certain
ticks, Lyme disease begins with a skin lesion
called erythema chronicum migrans. As the disease progresses, the patient may suffer from
lymphadenopathy, constant malaise and fatigue, and intermittent headache, fever, chills,
and aches. He may go on to develop arthralgias
and, eventually, neurologic and cardiac abnormalities.
◆ Monkeypox. Lymphadenopathy is the one
symptom that clearly distinguishes monkeypox
from smallpox. Humans infected with monkeypox usually develop cervical or inguinal lymphadenopathy, along with other characteristic
symptoms such as fever, chills, throat pain, muscle aches, and rash. This rare viral disease acquired its name after being discovered in laboratory monkeys; however, many other animals can
carry this disease. Although the monkeypox virus
is similar to smallpox, the smallpox vaccine is
only used in limited circumstances to protect certain at-risk individuals against the disease.
434 LYMPHADENOPATHY
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◆ Mononucleosis (infectious). Characteristic,
painful lymphadenopathy involves cervical, axillary, and inguinal nodes. Posterior cervical
adenopathy is also common. Prodromal symptoms, such as malaise, fatigue, and headache,
typically occur 3 to 5 days before the appearance
of the classic triad of lymphadenopathy, sore
throat, and temperature fluctuations with an
evening peak of about 102⬚ F (38.9⬚ C). Hepatosplenomegaly may develop, along with
findings of stomatitis, exudative tonsillitis, or
pharyngitis.
◆ Mycosis fungoides. Lymphadenopathy oc-
curs in stage III of this rare, chronic malignant
lymphoma and is accompanied by ulcerated
brownish red tumors that are painful and itchy.
◆ Non-Hodgkin’s lymphoma. Painless en-
largement of one or more peripheral lymph
nodes is the most common sign of this disease,
with generalized lymphadenopathy characterizing stage IV. Dyspnea, cough, and hepatosplenomegaly occur, along with systemic complaints of fever to 101⬚ F (38.3⬚ C), night sweats,
fatigue, malaise, and weight loss.
◆ Plague (Yersinia pestis). Signs and symp-
toms of the bubonic form of this bacterial infection include lymphadenopathy, fever, and chills.
◆ Rheumatoid arthritis. Lymphadenopathy is
an early, nonspecific finding associated with fatigue, malaise, continuous low fever, weight
loss, and vague arthralgias and myalgias. Later,
the patient develops joint tenderness, swelling,
and warmth; joint stiffness after inactivity (especially in the morning); and subcutaneous
nodules on the elbows. Eventually joint deformity, muscle weakness, and atrophy may
occur.
◆ Sarcoidosis. Generalized, bilateral hilar and
right paratracheal forms of lymphadenopathy
(seen on chest X-ray) with splenomegaly are
common. Initial findings are arthralgia, fatigue,
malaise, weight loss, and pulmonary symptoms.
Other findings vary with the site and extent of
fibrosis. Typical cardiopulmonary findings include
breathlessness, cough, substernal chest pain,
and arrhythmias. About 90% of patients have an
abnormal chest X-ray at sometime during their
illness. Musculoskeletal and cutaneous features
may include muscle weakness and pain, phalangeal and nasal mucosal lesions, and subcutaneous skin nodules. Common ophthalmic
findings include eye pain, photophobia, and
nonreactive pupils. Central nervous system involvement may produce cranial or peripheral
nerve palsies and seizures.
◆ Sjögren’s syndrome. Lymphadenopathy of
the parotid and submaxillary nodes may occur
in this rare disorder. Assessment reveals cardinal signs of dry mouth, eyes, and mucous membranes, which may be accompanied by photosensitivity, poor vision, eye fatigue, nasal
crusting, and epistaxis.
◆ Syphilis (primary). Localized lymph-
adenopathy and a painless ulcer (canker) with
an indurated border and relatively smooth base
at the site of sexual exposure characterize this
infection. The ulcer is usually single but more
than one may be present.
◆ Syphilis (secondary). Generalized
lymphadenopathy occurs in the second stage
and may be accompanied by a macular, papular, pustular, or nodular rash on the arms, trunk,
palms, soles, face, and scalp. A palmar rash is a
significant diagnostic sign. Headache, malaise,
anorexia, weight loss, nausea, vomiting, sore
throat, and low fever may occur.
◆ Systemic lupus erythematosus. General-
ized lymphadenopathy typically accompanies
the hallmark butterfly rash, photosensitivity,
Raynaud’s phenomenon, and joint pain and
stiffness. Pleuritic chest pain and cough may appear with systemic findings, such as fever,
anorexia, and weight loss.
◆ Tuberculous lymphadenitis. Lymph-
adenopathy may be generalized or restricted to
superficial lymph nodes. Affected lymph nodes
may become fluctuant and drain to surrounding
tissue. They may be accompanied by fever,
chills, weakness, and fatigue.
◆ Waldenström’s macroglobulinemia. Lym-
phadenopathy may appear along with hepatosplenomegaly. Associated findings include
retinal hemorrhage, pallor, and signs of heart
failure, such as jugular vein distention and
crackles. The patient shows decreased level of
consciousness, abnormal reflexes, and signs of
peripheral neuritis. Weakness, fatigue, weight
loss, epistaxis, and GI bleeding may also occur.
Circulatory impairment occurs because of an increased viscosity of the blood.
O
THER CAUSES
◆ Drugs. Phenytoin may cause generalized
lymphadenopathy.
◆ Immunizations. Typhoid vaccination may
cause generalized lymphadenopathy.
S
PECIAL CONSIDERATIONS
If the patient has fever above 101⬚ F (38.3⬚ C),
don’t automatically assume that the tempera-
ture should be lowered. A patient with a bacter-
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ial or viral infection must tolerate the fever,
which may assist recovery. Provide an antipyretic
if the patient is uncomfortable. Tepid sponge
baths or a hypothermia blanket may also be
used.
Expect to obtain blood for routine blood
work, platelet and white blood cell counts, liver
and renal function studies, erythrocyte sedimentation rate, and blood cultures. Prepare the
patient for other scheduled diagnostic tests,
such as chest X-ray, liver and spleen scan,
lymph node biopsy, or lymphography, to visualize the lymphatic system. If tests reveal infection, check your facility’s policy regarding infection control.
P
EDIATRIC POINTERS
Infection is the most common cause of lymphadenopathy in children. The condition is
commonly associated with otitis media and
pharyngitis.
Provide an antipyretic if the child has a history of febrile seizures.
LYMPHADENOPATHY
435
M
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Masklike facies
A total loss of facial expression, masklike facies
results from bradykinesia usually due to extrapyramidal damage. The rate of eye blinking is
reduced to 1 to 4 blinks per minute, producing a
characteristic “reptilian” stare. Although a neurologic disorder is the most common cause,
masklike facies can also result from certain systemic diseases and the effects of drugs and toxins. The sign commonly develops insidiously, at
first mistaken by the observer for depression or
apathy.
H
ISTORY AND PHYSICAL
EXAMINATION
Ask the patient and his family or friends when
they first noticed the masklike facial expression
and any other signs or symptoms. Find out what
medications the patient is taking, if any, and ask
about any changes in dosage or schedule. Determine the degree of facial muscle weakness
by asking the patient to smile and to wrinkle his
forehead. Typically, the patient’s responses are
slowed.
M
EDICAL CAUSES
◆ Dermatomyositis. Masklike facies reflects
muscle soreness, weakness, and destruction extending from the face and neck to the shoulder
and pelvic girdle. Dysphagia and dysphonia develop. Characteristic cutaneous signs involve
edema and dusky lilac suffusion of the eyelid
margin or periorbital tissue; an erythematous
436
rash on the face, neck, upper back, chest, arms,
and nail beds; and violet (Gottron’s) papules
dorsal to the interphalangeal joint.
◆ Facial palsy. Masklike facies is a hallmark of
bilateral Bell’s palsy and is characterized by periaural pain, hyperacusis, and disturbance of
taste.
◆ Guillain-Barré syndrome. Bilateral facial
weakness may occur in this disorder and is accompanied by hypoactive reflexes, paresthesia
in the extremities, and limb weakness. Respiratory insufficiency may also occur, which requires pulmonary function testing and respiratory support.
◆ Myasthenia gravis. Ptosis and generalized
facial muscle weakness are common in this disorder and may be accompanied by diplopia,
dysarthria, dysphagia, and limb weakness.
Weakness typically worsens with repetitive use
of muscles, and also later in the day. Pulmonary
function tests may be needed to rule out impending respiratory crisis.
◆ Parkinson’s disease. Masklike facies occurs
early but is commonly overlooked. This mask
includes raised eyebrows and smooth facial
muscles. More noticeable signs include muscle
rigidity, which may be uniform (lead-pipe rigidity) or jerky (cogwheel rigidity), and an insidious
tremor, which usually begins in the fingers (pillroll tremor), increases during stress or anxiety,
and decreases during purposeful movement or
sleep. Typically, the patient exhibits stooped
posture and propulsive gait, speaks in a monotone, and may develop drooling, dysphagia, and
dysarthria.
MCBURNEY’S SIGN
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437
◆ Scleroderma. A late sign, masklike facies
develops along with a smooth, wrinkle-free appearance, “pinching” of the mouth and, possibly,
contractures as facial skin becomes tight and
inelastic. Other late features include pain, stiffness, and swelling of joints and foreshortened
fingers. Skin on the fingers and then on the
hands and forearms thickens and becomes
taut and shiny. GI dysfunction produces frequent reflux and heartburn; weight loss; diarrhea or constipation; and malodorous floating
stools.
O
THER CAUSES
◆ Carbon monoxide poisoning. Masklike fa-
cies usually develops several weeks after acute
poisoning. The patient may also have rigidity,
dementia, impaired sensory function, choreoathetosis, generalized seizures, and myoclonus.
◆ Drugs. Phenothiazines (particularly piper-
azine derivatives) and other antipsychotic drugs
commonly cause masklike facies as well as other extrapyramidal effects. In addition, metoclopramide and metyrosine can sometimes cause
masklike facies. This sign usually improves
when the drug dosage is reduced or the drug
therapy discontinued.
◆ Manganese poisoning (chronic). Masklike
facies develops gradually, along with a resting
tremor and personality changes. The patient
may also experience Huntington’s disease,
propulsive gait, dystonia, and rigidity. Later, extreme muscle weakness and fatigue occur.
S
PECIAL CONSIDERATIONS
If the patient’s facial weakness results from
Guillain-Barré syndrome or myasthenia gravis,
be prepared to initiate emergency respiratory
support.
P
EDIATRIC POINTERS
Masklike facies occurs in the juvenile form of
Parkinson’s disease.
P
ATIENT COUNSELING
If the patient’s masklike facies results from
Parkinson’s disease, explain to his family
that the sign may hide facial clues to
depression—a common symptom of Parkinson’s
disease.
McBurney’s sign
A telltale indicator of localized peritoneal inflammation in acute appendicitis, McBurney’s
sign is tenderness elicited by palpating the right
lower quadrant over McBurney’s point. McBurney’s point is about 2” (5 cm) above the anterior
superior spine of the ilium, on the line between
the spine and the umbilicus where pressure produces pain and tenderness in acute appendicitis. Before McBurney’s sign is elicited, the abdomen is inspected for distention, auscultated
for hypoactive or absent bowel sounds, and
tested for tympany.
H
ISTORY AND PHYSICAL
EXAMINATION
Ask the patient to describe the abdominal pain.
When did it begin? Does coughing, movement,
eating, or elimination worsen or help relieve it?
Also ask about the development of any other
signs and symptoms such as vomiting and a
low grade fever. Ask the patient to point with a
finger to the spot where the pain is worst.
Continue light palpation of the patient’s abdomen to detect additional tenderness, rigidity,
guarding, or pain. Observe the patient’s facial
expression for signs of pain, such as grimacing
or wincing. (See Eliciting McBurney’s sign, page
438.) Auscultate the abdomen, noting decreased
bowel sounds.
M
EDICAL CAUSES
◆ Appendicitis. McBurney’s sign appears with-
in the first 2 to 12 hours after the onset of appendicitis, after initial pain in the epigastric and
periumbilical area shifts to the right lower quadrant (McBurney’s point). This persistent pain increases with walking or coughing. Nausea and
vomiting may occur from the start. Boardlike
abdominal rigidity and rebound tenderness that
worsen as the condition progresses accompany
cutaneous hyperalgia, fever, constipation or diarrhea, tachycardia, retractive respirations,
anorexia, and moderate malaise.
Rupture of the appendix causes sudden cessation of pain. Then, signs and symptoms of
peritonitis develop, such as severe abdominal
pain, pallor, hypoactive or absent bowel
sounds, diaphoresis, and high fever.
S
PECIAL CONSIDERATIONS
Draw blood for laboratory tests such as a complete blood count, including a white blood cell
count, erythrocyte sedimentation rate, and
blood cultures, and prepare the patient for abdominal X-rays to confirm appendicitis. Make
sure the patient receives nothing by mouth, and
expect to prepare the patient for an appendectomy. Administration of a cathartic or an enema
438 MCMURRAY’S SIGN
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EXAMINATION TIP
Eliciting McBurney’s sign
To elicit McBurney’s sign, help the
patient into a supine position,
with his knees slightly flexed and
his abdominal muscles relaxed.
Then, palpate deeply and slowly
in the right lower quadrant over
McBurney’s point—located about
2⬙ (5 cm) from the right anterior
superior spine of the ilium, on a
line between the spine and the
umbilicus. Point pain and tenderness, a positive McBurney’s sign,
indicates appendicitis.
Umbilicus
Anterior superior
iliac spine
may cause the appendix to rupture and should
be avoided.
P
EDIATRIC POINTERS
McBurney’s sign is also elicited in children with
appendicitis.
G
ERIATRIC POINTERS
In elderly patients, McBurney’s sign (as well as
other peritoneal signs) may be decreased or
absent.
McMurray’s sign
Often an indicator of medial meniscal injury,
McMurray’s sign is a palpable, audible click or
pop elicited by rotating the tibia on the femur. It
results when gentle manipulation of the leg
traps torn cartilage and then lets it snap free.
Because eliciting this sign forces the surface of
such manipulation is contraindicated in patients
with suspected fractures of the tibial plateau or
femoral condyles.
A positive McMurray’s sign augments other
findings commonly associated with meniscal injury, such as severe joint line tenderness, locking or clicking of the joint, and decreased range
of motion.
H
ISTORY AND PHYSICAL
EXAMINATION
After McMurray’s sign has been elicited, find out
if the patient is experiencing acute knee pain.
Then ask him to describe any recent knee in-
jury. For example, did his injury place twisting
external or internal force on the knee, or did he
experience blunt knee trauma from a fall? Also,
ask about previous knee injury, surgery, prosthetic replacement, or other joint problems such
as arthritis, which could have weakened the
knee. Ask if anything aggravates or relieves the
pain and if he needs assistance to walk.
Have the patient point to the exact area of
pain. Assess the leg’s range of motion, both
passive and with resistance. Next, check for
cruciate ligament stability by noting anterior or
posterior movement of the tibia on the femur
(drawer sign). Finally, measure the quadriceps
muscles in both legs for symmetry. (See Eliciting
McMurray’s sign.)
M
EDICAL CAUSES
◆ Meniscal tear. McMurray’s sign can usually
be elicited with this type of injury. Associated
signs and symptoms include acute knee pain at
the medial or lateral joint line (depending on injury site) and decreased range of motion or
locking of the knee joint. Quadriceps weakening
and atrophy may also occur.
S
PECIAL CONSIDERATIONS
Prepare the patient for knee X-rays, arthroscopy,
and arthrography, and obtain any previous Xrays for comparison. If trauma precipitated the
knee pain and McMurray’s sign, an effusion or
hemarthrosis may occur. Prepare the patient for
aspiration of the joint. Immobilize and apply ice
to the knee, and apply a cast or a knee
immobilizer.
EXAMINATION TIP
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Eliciting
McMurray’s sign
Eliciting McMurray’s sign requires special
training and gentle manipulation of the
patient’s leg to avoid extending a meniscal
tear or locking the knee. If you’ve been
trained to elicit McMurray’s sign, place the
patient in a supine position and flex his affected knee until his heel nearly touches his
buttock. Place your thumb and index finger
on either side of the knee joint space and
grasp his heel with your other hand. Then
rotate the foot and lower leg laterally to test
the posterior aspect of the medial meniscus.
Keeping his foot in a lateral position, extend the knee to a 90-degree angle to test
the anterior aspect of the medial meniscus.
A palpable or audible click—a positive
McMurray’s sign—indicates injury to meniscal structures.
MELENA 439
P
EDIATRIC POINTERS
McMurray’s sign in adolescents is usually elicited in meniscal tear caused by sports injury. It
may also be elicited in children with congenital
discoid meniscus.
P
ATIENT COUNSELING
Instruct the patient to elevate the affected leg
and to perform up to 200 straight-leg raises per
day. As appropriate, teach him how to use
crutches. Also, tell him the prescribed dosage
and schedule of any analgesics or anti-inflammatories. Help him adjust to lifestyle changes by
providing support and including significant others in teaching.
Melena
A common sign of upper GI bleeding, melena is
the passage of black, tarry stools containing digested blood. Characteristic color results from
bacterial degradation and hydrochloric acid acting on the blood as it travels through the GI
tract. At least 60 ml of blood is needed to produce this sign. (See Comparing melena to hema-
tochezia, page 440.)
Severe melena can signal acute bleeding and
life-threatening hypovolemic shock. Usually,
melena indicates bleeding from the esophagus,
stomach, or duodenum, although it can also indicate bleeding from the jejunum, ileum, or ascending colon. This sign can also result from
swallowing blood, as in epistaxis; from taking
certain drugs; or from ingesting alcohol. Because false melena may be caused by ingestion
of lead, iron, bismuth, or licorice (which produces black stools without the presence of
blood), all black stools should be tested for occult blood.
EMERGENCY INTERVENTIONS If the pa-
tient is experiencing severe melena, quickly
take orthostatic vital signs to detect hypovolemic
shock. A decline of 10 mm Hg or more in systolic
pressure or an increase of 10 beats/minute or
more in pulse rate indicates volume depletion.
Quickly examine patient for other signs of shock,
such as tachycardia, tachypnea, and cool, clammy
skin. Insert a large-bore I.V. catheter to administer
replacement fluids and allow blood transfusion.
Obtain hematocrit, prothrombin time, international normalized ratio, and partial thromboplastin
time. Place the patient flat with his head turned to
the side and his feet elevated. Administer supplemental oxygen as needed.
440 MELENA
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Comparing melena to hematochezia
With GI bleeding, the site, amount, and rate of blood flow through the GI tract determine if a patient will develop melena (black, tarry stools) or hematochezia (bright red, bloody stools). Usually,
melena indicates upper GI bleeding, and hematochezia indicates lower GI bleeding. However,
with some disorders, melena may alternate with hematochezia. This chart helps differentiate
these two commonly related signs.
Sign
Sites
Characteristics
Melena
Hematochezia
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient’s condition permits, ask when he
discovered his stools were black and tarry. Ask
about the frequency and quantity of bowel
movements. Has he had melena before? Ask
about other signs and symptoms, notably hematemesis or hematochezia, and about use of
anti-inflammatories, alcohol, or other GI irritants. Also, find out if he has a history of GI lesions. Ask if the patient takes iron supplements,
which may also cause black stools. Obtain a
drug history, noting the use of warfarin or other
anticoagulants.
Next, inspect the patient’s mouth and nasopharynx for evidence of bleeding. Perform an
abdominal examination that includes auscultation, palpation, and percussion.
M
EDICAL CAUSES
◆ Colon cancer. On the right side of the colon,
early tumor growth may cause melena accompanied by abdominal aching, pressure, or
cramps. As the disease progresses, the patient
develops weakness, fatigue, and anemia. Eventually, he also experiences diarrhea or obstipation, anorexia, weight loss, vomiting, and other
signs and symptoms of intestinal obstruction.
Esophagus, stomach, duodenum;
rarely, jejunum,
ileum, ascending
colon.
Usually distal to or
affecting the colon;
rapid hemorrhage of
1 L or more is associated with esophageal, stomach, or
duodenal bleeding.
With a tumor on the left side, melena is a rare
sign until late in the disease. Early tumor growth
commonly causes rectal bleeding with intermittent abdominal fullness or cramping and rectal
pressure. As the disease progresses, the patient
may develop obstipation, diarrhea, or pencilshaped stools. At this stage, bleeding from the
colon is signaled by melena or bloody stools.
Black, loose, tarry
stools. Delayed or
minimal passage of
blood through GI
tract.
Bright red or dark,
mahogany-colored
stools; pure blood;
blood mixed with
formed stool; or
bloody diarrhea. Reflects lower GI bleeding or rapid blood loss
and passage of undigested blood through
GI tract.
◆ Ebola virus. Melena, hematemesis, and
bleeding from the nose, gums, and vagina may
occur later with this disorder. Patients usually
report abrupt onset of headache, malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy on the fifth day of illness.
Pleuritic chest pain, dry hacking cough, and
pharyngitis have also been noted. A maculopapular rash develops between days 5 and 7
of the illness.
◆ Esophageal cancer. Melena is a late sign of
this malignant neoplastic disease that’s three
times more common in men than women. Increasing obstruction first produces painless dysphagia, then rapid weight loss. The patient may
experience steady chest pain with substernal
fullness, nausea, vomiting, and hematemesis.
Other findings include hoarseness, persistent
cough (possibly hemoptysis), hiccups, sore
throat, and halitosis. In the later stages, signs
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