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MELENA
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and symptoms include painful dysphagia,
anorexia, and regurgitation.
◆ Esophageal varices (ruptured). This life-
threatening disorder can produce melena,
hematochezia, and hematemesis. Melena is
preceded by signs of shock, such as tachycardia,
tachypnea, hypotension, and cool, clammy skin.
Agitation or confusion signals developing hepatic encephalopathy.
◆ Gastric cancer. Melena and altered bowel
habits may occur late with this uncommon cancer. More common findings include insidious
onset of upper abdominal or retrosternal discomfort and chronic dyspepsia, which are unrelieved by antacids and exacerbated by food.
Anorexia and slight nausea often occur, along
with hematemesis, pallor, fatigue, weight loss,
and a feeling of abdominal fullness.
◆ Gastritis. Melena and hematemesis are
common. The patient may also experience mild
epigastric or abdominal discomfort that’s exacerbated by eating; belching; nausea; vomiting;
and malaise.
◆ Malaria. Melena may accompany persistent
high fever and orthostatic hypotension in severe
malaria. Other features include hemoptysis,
vomiting, abdominal pain, diarrhea, oliguria,
and headache, seizures, delirium, or coma.
These findings are interspersed throughout the
malarial paroxysm—chills, then high fever, and
then profuse diaphoresis.
◆ Mallory-Weiss syndrome. This condition is
characterized by massive bleeding from the upper GI tract due to a tear in the mucous membrane of the esophagus or the junction of the
esophagus and the stomach. Melena and hematemesis follow vomiting. Severe upper abdominal bleeding leads to signs and symptoms
of shock, such as tachycardia, tachypnea, hypotension, and cool, clammy skin. The patient
may also report epigastric or back pain.
◆ Mesenteric vascular occlusion. This life-
threatening disorder produces slight melena
with 2 to 3 days of persistent, mild abdominal
pain. Later, abdominal pain becomes severe
and may be accompanied by tenderness, distention, guarding, and rigidity. The patient may
also experience anorexia, vomiting, fever, and
profound shock.
◆ Peptic ulcer. Melena may signal life-threat-
ening hemorrhage from vascular penetration.
The patient may also develop decreased appetite, nausea, vomiting, hematemesis, hematochezia, and left epigastric pain that’s gnawing,
burning, or sharp and may be described as
heartburn or indigestion. With hypovolemic
shock come tachycardia, tachypnea, hypotension, dizziness, syncope, and cool, clammy skin.
◆ Small-bowel tumors. These tumors may
bleed and produce melena. Other signs and
symptoms include abdominal pain, distention,
and increasing frequency and pitch of bowel
sounds.
◆ Thrombocytopenia. Melena or hema-
tochezia may accompany other manifestations
of bleeding tendency: hematemesis, epistaxis,
petechiae, ecchymoses, hematuria, vaginal
bleeding, and characteristic blood-filled oral
bullae. Typically, the patient displays malaise,
fatigue, weakness, and lethargy.
◆ Typhoid fever. Melena or hematochezia oc-
curs late in this disorder and may occur with hypotension and hypothermia. Other late findings
include mental dullness or delirium, marked abdominal distention and diarrhea, marked weight
loss, and profound fatigue.
◆ Yellow fever. Melena, hematochezia, and he-
matemesis are ominous signs of hemorrhage, a
classic feature, which occurs along with jaundice. Other findings include fever, headache,
nausea, vomiting, epistaxis, albuminuria, petechiae and mucosal hemorrhage, and dizziness.
O
THER CAUSES
◆ Drugs and alcohol. Aspirin, other nons-
teroidal anti-inflammatories, or alcohol can
cause melena as a result of gastric irritation.
S
PECIAL CONSIDERATIONS
Monitor vital signs, and look closely for signs of
hypovolemic shock. For general comfort, encourage bed rest, and keep the patient’s perianal area clean and dry to prevent skin irritation
and breakdown. A nasogastric tube may be
necessary to assist with drainage of gastric contents and decompression. Prepare him for diagnostic tests, including blood studies, gastroscopy or other endoscopic studies, barium
swallow, and upper GI series. Prepare the patient for blood transfusions as indicated by his
hematocrit.
P
EDIATRIC POINTERS
Neonates may experience melena neonatorum
due to extravasation of blood into the alimentary canal. In older children, melena usually results from peptic ulcer, gastritis, or Meckel’s diverticulum.
G
ERIATRIC POINTERS
In elderly patients with recurrent intermittent GI
bleeding without a clear etiology, angiography
442 MENORRHAGIA
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or exploratory laparotomy should be considered
once the risk from continued anemia is deemed
to outweigh the risk associated with the procedures.
Menorrhagia
Abnormally heavy or long menstrual bleeding,
menorrhagia may occur as a single episode or a
chronic sign. In menorrhagia, bleeding is heavier than the patient’s normal menstrual flow;
menstrual blood loss is 80 ml or more per
monthly period. A form of dysfunctional uterine
bleeding, menorrhagia can result from endocrine and hematologic disorders, stress, and
certain drugs and procedures.
EMERGENCY INTERVENTIONS Evaluate
hemodynamic status by taking orthostatic
vital signs. Insert a large-gauge I.V. catheter to begin fluid replacement if the patient shows an increase of 10 beats/minute in pulse rate, a decrease of 10 mm Hg in systolic blood pressure, or
other signs of hypovolemic shock, such as pallor,
tachycardia, tachypnea, and cool, clammy skin.
Place the patient in a supine position with her feet
elevated, and administer supplemental oxygen as
needed.
Use menstrual pads to obtain information related to the quality and quantity of bleeding. Then
prepare the patient for a pelvic examination to
help determine the cause of bleeding.
H
ISTORY AND PHYSICAL
EXAMINATION
When the patient’s condition permits, obtain a
history. Determine her age at menarche, the average duration of menstrual periods, and the interval between them. Establish the date of the
patient’s last menses, and ask about any recent
changes in her normal menstrual pattern. Have
the patient describe the character and amount
of bleeding. For example, how many pads or
tampons does the patient use? Has she noted
clots or tissue in the blood? Also ask about the
development of other signs and symptoms before and during the menstrual period.
Next, ask if the patient is sexually active.
Does she use a method of birth control? If so,
what kind? Could the patient be pregnant? Be
sure to note the number of pregnancies, the
outcome of each, and any pregnancy-related
complications. Find out the dates of her most
recent pelvic examination and Papanicolaou
smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to
ask about any previous episodes of abnormal
bleeding and the outcome of any treatment. If
possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was
exposed in utero to diethylstilbestrol. (This drug
has been linked to vaginal adenosis.)
Be sure to ask the patient about her general
health and medical history. Note particularly if
the patient or her family has a history of thyroid,
adrenal, or hepatic disease; blood dyscrasias; or
tuberculosis because these may predispose the
patient to menorrhagia. Also, ask about the patient’s past surgical procedures and any recent
emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for
menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or
aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy
testing.
M
EDICAL CAUSES
◆ Blood dyscrasias. Menorrhagia is one of
several possible signs of a bleeding disorder.
Other possible associated findings include epistaxis, bleeding gums, purpura, hematemesis,
hematuria, and melena.
◆ Endometriosis. Menorrhagia may be a sign
of this disorder, in which endometrial tissue is
found outside the lining of the uterine cavity.
However, the classic symptom is dysmenorrhea.
Other findings depend on the location of the ectopic tissue outside the uterus but may include
dyspareunia, suprapubic pain, dysuria, nausea,
vomiting, abdominal cramps, cyclic pelvic pain,
and infertility. Often a tender, fixed adnexal
mass is palpable on bimanual examination.
◆ Hypothyroidism. Menorrhagia is a common
early sign and is accompanied by such nonspecific findings as fatigue, cold intolerance, constipation, and weight gain despite anorexia. As
hypothyroidism progresses, intellectual and motor activity decrease; the skin becomes dry, pale,
cool, and doughy; the hair becomes dry and
sparse; and the nails become thick and brittle.
Myalgia, hoarseness, decreased libido, and infertility commonly occur. Eventually, the patient
develops a characteristic dull, expressionless
face and edema of the face, hands, and feet.
Also, deep tendon reflexes are delayed, and
bradycardia and abdominal distention may
occur.
◆ Uterine fibroids. Menorrhagia is the most
common sign, but other forms of abnormal
uterine bleeding as well as dysmenorrhea or
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leukorrhea, can also occur. Possible related
findings include abdominal pain, a feeling of abdominal heaviness, backache, constipation, urinary urgency or frequency, and an enlarged
uterus, which is usually nontender.
O
THER CAUSES
◆ Drugs. Use of a hormonal contraceptive may
cause sudden onset of profuse, prolonged menorrhagia. Anticoagulants have also been associated with excessive menstrual flow. Injectable
or implanted contraceptives may cause menorrhagia in some women.
HERB ALERT Herbal remedies, such as
ginseng, can cause postmenopausal bleeding.
◆ Intrauterine devices. Menorrhagia can re-
sult from the use of intrauterine contraceptive
devices.
S
PECIAL CONSIDERATIONS
Continue to monitor the patient closely for
signs of hypovolemia. Encourage the patient
to maintain adequate fluid intake. Monitor intake and output, and estimate uterine blood
loss by recording the number of sanitary napkins or tampons used during an abnormal period and comparing this with usage during a
normal period. To help decrease blood flow,
encourage the patient to rest and to avoid
strenuous activities. Obtain blood samples for
hematocrit, prothrombin time, partial thromboplastin time, and international normalized
ratio levels.
P
EDIATRIC POINTERS
Irregular menstrual function in young girls may
be accompanied by hemorrhage and resulting
anemia.
G
ERIATRIC POINTERS
In postmenopausal women, menorrhagia cannot occur. In such patients, vaginal bleeding is
usually caused by endometrial atrophy. Malignancy must be ruled out.
Metrorrhagia
Metrorrhagia—uterine bleeding that occurs irregularly between menstrual periods—is usually
light, although it can range from staining to hemorrhage. Usually, this common sign reflects
slight physiologic bleeding from the endometrium during ovulation. However, metrorrhagia
may be the only indication of an underlying gynecologic disorder and can also result from
stress, drugs, treatments, and intrauterine devices.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin your evaluation by obtaining a thorough
menstrual history. Ask the patient when she began menstruating and about the duration of
menstrual periods, the interval between them,
and the average number of tampons or pads she
uses. When does metrorrhagia usually occur in
relation to her period? Does she experience other signs or symptoms? Find out the date of her
last menses, and ask about any other recent
changes in her normal menstrual pattern. Get
details of any previous gynecologic problems. If
applicable, obtain a contraceptive and obstetric
history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it
was protected. Next, ask about her general
health and any recent changes. Is she under
emotional stress? If possible, obtain a pregnancy
history of the patient’s mother. Was the patient
exposed in utero to diethylstilbestrol? (This drug
has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated,
and obtain blood and urine samples for pregnancy testing.
M
EDICAL CAUSES
◆ Cervicitis. This nonspecific infection may
cause spontaneous bleeding, spotting, or posttraumatic bleeding. Assessment reveals red,
granular, irregular lesions on the external
cervix. Purulent vaginal discharge (with or without odor), lower abdominal pain, and fever may
occur.
◆ Dysfunctional uterine bleeding. Abnormal
uterine bleeding not caused by pregnancy or
major gynecologic disorders usually occurs as
metrorrhagia, although menorrhagia is possible.
Bleeding may be profuse or scant, intermittent
or constant.
◆ Endometrial polyps. In most patients, this
disorder causes abnormal bleeding, usually intermenstrual or postmenopausal; however,
some patients do remain asymptomatic.
◆ Endometriosis. Metrorrhagia (usually pre-
menstrual) may be the only indication of this
disorder, or it may accompany cyclical pelvic
discomfort, infertility, and dyspareunia. A tender, fixed adnexal mass may be palpable on bimanual examination.
◆ Endometritis. This disorder causes metror-
rhagia, purulent vaginal discharge, and
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enlargement of the uterus. It also produces
fever, lower abdominal pain, and abdominal
muscle spasm.
◆ Gynecologic cancer. Metrorrhagia is com-
monly an early sign of cervical or uterine cancer. Later, the patient may experience weight
loss, pelvic pain, fatigue and, possibly, an abdominal mass.
◆ Syphilis. Primary- or secondary-stage
syphilis may cause metrorrhagia and postcoital
bleeding. In primary syphilis, one or more usually painless chancres erupt on the genitalia and
possibly other areas. In secondary syphilis, generalized lymphadenopathy may appear, along
with a rash on the arms, trunk, palms, soles,
face, and scalp.
◆ Uterine leiomyomas. Besides metrorrhagia,
these tumors may cause increasing abdominal
girth and heaviness in the abdomen, constipation, and urinary frequency or urgency. The patient may report pain if the uterus attempts to
expel the tumor through contractions and if the
tumors twist or necrose after circulatory occlusion or infection, but many women with leiomyomas are asymptomatic.
◆ Vaginal adenosis. This disorder commonly
produces metrorrhagia. Palpation reveals
roughening or nodules in affected vaginal
areas.
O
THER CAUSES
◆ Drugs. Anticoagulants and oral, injectable,
or implanted contraceptives may cause metrorrhagia.
HERB ALERT Herbal remedies, such as
ginseng, can cause postmenopausal bleeding.
◆ Surgery and procedures. Cervical coniza-
tion and cauterization may cause metrorrhagia.
S
PECIAL CONSIDERATIONS
Encourage bed rest to reduce bleeding. Give an
analgesic for discomfort.
Miosis
Miosis—pupillary constriction caused by contraction of the sphincter muscle in the iris—
occurs normally as a response to fatigue, increased light, or administration of a miotic; as
part of the eye’s accommodation reflex; and as
part of the aging process (pupil size steadily decreases from adolescence to about age 60).
However, it can also stem from an ocular or
neurologic disorder, trauma, use of a systemic
drug, or contact lens overuse. A rare form of
miosis—Argyll Robertson pupils—can stem from
tabes dorsalis and diverse neurologic disorders.
Occurring bilaterally, these miotic (often pinpoint), unequal, and irregularly shaped pupils
don’t dilate properly with mydriatic use and fail
to react to light, although they do constrict on
accommodation.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by asking the patient if he has experienced other ocular symptoms, and have him describe their onset, duration, and intensity. Does
he wear contact lenses? During your history, be
sure to ask about trauma, serious systemic disease, and use of topical and systemic drugs.
Next, perform a thorough eye examination.
Test visual acuity in each eye, with and without
correction, paying particular attention to blurred
or decreased vision in the miotic eye. Examine
and compare both pupils for size (many persons
have a normal discrepancy), color, shape, reaction to light, accommodation, and consensual
light response. Examine both eyes for additional
signs, and then evaluate extraocular muscle
function by assessing the six cardinal fields of
gaze.
M
EDICAL CAUSES
◆ Cerebrovascular arteriosclerosis. Miosis is
usually unilateral, depending on the site and extent of vascular damage. Other findings include
visual blurring, slurred speech or possibly aphasia, loss of muscle tone, memory loss, vertigo,
and headache.
◆ Cluster headache. Ipsilateral miosis, tear-
ing, conjunctival injection, and ptosis commonly accompany a severe cluster headache,
along with facial flushing and sweating, bradycardia, restlessness, and nasal stuffiness or
rhinorrhea.
◆ Corneal foreign body. Miosis in the affected
eye occurs with pain, a foreign-body sensation,
slight vision loss, conjunctival injection, photophobia, and profuse tearing.
◆ Corneal ulcer. Miosis in the affected eye ap-
pears with moderate pain, visual blurring and
possibly some vision loss, and diffuse conjunctival injection.
◆ Horner’s syndrome. Moderate miosis is
common in this neurologic syndrome and occurs ipsilaterally to the spinal cord lesion. Related ipsilateral findings include a sluggish pupillary reflex, slight enophthalmos, moderate
ptosis, facial anhidrosis, transient conjunctival
injection, and vascular headache. When the
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syndrome is congenital, the iris on the affected
side may appear lighter.
◆ Hyphema. Usually the result of blunt trauma,
hyphema can cause miosis with moderate pain,
visual blurring, diffuse conjunctival injection,
and slight eyelid swelling. The eyeball may feel
harder than normal.
◆ Iritis (acute). Miosis typically occurs in the
affected eye along with decreased pupillary reflex, severe eye pain, photophobia, visual blurring, conjunctival injection and, possibly, pus
accumulation in the anterior chamber. The eye
appears cloudy, the iris bulges, and the pupil is
constricted on ophthalmic examination.
◆ Neuropathy. Two forms of neuropathy occa-
sionally produce Argyll Robertson pupils. With
diabetic neuropathy, related effects include
paresthesia and other sensory disturbances, extremity pain, orthostatic hypotension, impotence, incontinence, and leg muscle weakness
and atrophy.
With alcoholic neuropathy, related effects include progressive, variable muscle weakness
and wasting, various sensory disturbances, and
hypoactive deep tendon reflexes.
◆ Parry-Romberg syndrome. This facial
hemiatrophy typically produces miosis, sluggish
pupillary reflexes, enophthalmos, nystagmus,
ptosis, and different-colored irises.
◆ Pontine hemorrhage. Bilateral miosis is
characteristic, along with rapid onset of coma,
total paralysis, decerebrate posture, absent
doll’s eye sign, and a positive Babinski’s sign.
◆ Tabes dorsalis. This tertiary form of syphilis
is marked by Argyll Robertson pupils, a wide
base ataxic gait, paresthesia, loss of proprioception, analgesia, thermanesthesia, Charcot’s
joints, incontinence and, possibly, impotence.
◆ Uveitis. Anterior uveitis commonly produces
miosis in the affected eye, moderate-to-severe
eye pain, severe conjunctival injection, photophobia, and pus in the anterior chamber.
With posterior uveitis, miosis is accompanied
by gradual onset of eye pain, photophobia, visual floaters, visual blurring, conjunctival injection
and, commonly, distorted pupil shape.
O
THER CAUSES
◆ Chemical burns. An opaque cornea may
make miosis hard to detect. However, chemical
burns may also cause moderate-to-severe pain,
diffuse conjunctival injection, inability to keep
the eye open, visual blurring, and blistering.
◆ Drugs. Such topical drugs as acetylcholine,
carbachol, echothiophate iodide, and pilocarpine are used to treat eye disorders specifi-
cally for their miotic effect. Such systemic drugs
as barbiturates, cholinergics, anticholinesterases, clonidine hydrochloride (overdose), opiates,
and reserpine also cause miosis, as does deep
anesthesia.
S
PECIAL CONSIDERATIONS
Because any ocular abnormality can be a
source of fear and anxiety, reassure and support
the patient. Clearly explain any diagnostic tests
ordered, which may include a complete ophthalmologic examination or a neurologic
workup.
P
EDIATRIC POINTERS
Miosis is common in neonates, simply because
they’re asleep or sleepy most of the time. Bilateral miosis occurs with congenital microcoria,
an uncommon bilateral disease transmitted as
an autosomal dominant trait and marked by the
absence of the dilator muscle of the pupil. At
birth, these infants have pupils less than 2 mm
and seem to gaze far away.
Moon face
Moon face, a distinctive facial adiposity, usually
indicates hypercortisolism resulting from ectopic or excessive pituitary production of corticotropin, adrenal adenoma or carcinoma, or
long-term glucocorticoid therapy. Its typical
characteristics include marked facial roundness
and puffiness, a double chin, a prominent upper
lip, and full supraclavicular fossae. Although the
presence of moon face doesn’t help differentiate
causes of hypercortisolism, it does indicate a
need for diagnostic testing.
H
ISTORY AND PHYSICAL
EXAMINATION
Ask the patient when he first noticed his facial
adiposity, and try to obtain a preonset photograph to help evaluate the extent of the change.
Ask about weight gain and any personal or
family history of endocrine disorders, obesity, or
cancer. Has the patient noticed any fatigue, irritability, depression, or confusion? If the patient
is a female of childbearing age, determine the
date of her last menses and whether she’s experienced any menstrual irregularities.
If the patient is receiving a glucocorticoid,
ask the name of the drug, dosage and schedule,
route of administration, and reason for therapy.
Also ask if the dosage has ever been modified
and, if so, when and why.
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Take the patient’s vital signs, weight, and
height. Assess the patient’s overall appearance
for other characteristic signs of hypercortisolism, including virilism in a female or gynecomastia in a male. Also assess for purple striae
on the skin, muscle weakness due to loss of
muscle mass from increased catabolism, and
skeletal growth retardation in children.
M
EDICAL CAUSES
◆ Hypercortisolism. Moon face varies in
severity, depending on the degree of cortisol excess and weight gain. The patient typically exhibits buffalo hump, truncal obesity with slender
arms and legs, and thin, transparent skin with
purple striae and ecchymoses. Other cushingoid
features include acne, diaphoresis, fatigue, muscle wasting and weakness, poor wound healing,
elevated blood pressure, and personality
changes.
In addition to these findings, a woman may
experience hirsutism and amenorrhea or
oligomenorrhea; a man may experience gynecomastia and impotence.
O
THER CAUSES
◆ Drugs. Most cases (more than 99%) of moon
face result from prolonged use of a glucocorticoid, such as cortisone, dexamethasone, hydrocortisone, or prednisone.
S
PECIAL CONSIDERATIONS
Relieve the patient’s concern about his body image by explaining that moon face and other disconcerting cushingoid effects can usually be
corrected by treating the underlying disorder or
by discontinuing or modifying glucocorticoid
therapy. Explain to the patient that he should
only discontinue or modify glucocorticoid therapy as directed by the physician.
Clearly explain to the patient any diagnostic
tests ordered. These may include serum and
urine 17-hydroxycorticosteroid studies; a 2-day,
low-dose dexamethasone test followed by a 2day, high-dose dexamethasone test; plasma corticotropin studies; and a corticotropin-releasing
hormone test.
Mouth lesions
Mouth lesions include ulcers (the most common
type), cysts, firm nodules, hemorrhagic lesions,
papules, vesicles, bullae, and erythematous lesions. They may occur anywhere on the lips,
cheeks, hard and soft palate, salivary glands,
tongue, gingivae, or mucous membranes. Many
are painful and can be readily detected. Some,
however, are asymptomatic; when they occur
deep in the mouth, they may be discovered only
through a complete oral examination. (See
Common mouth lesions.)
Mouth lesions can result from trauma, infection, systemic disease, drug use, or radiation
therapy.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin your evaluation with a thorough history.
Ask the patient when the lesions appeared and
whether he has noticed any pain, odor, or
drainage. Also ask about associated complaints,
particularly skin lesions. Obtain a complete drug
history, including drug allergies and antibiotic
use, and a complete medical history. Note especially any malignancy, sexually transmitted disease, I.V. drug use, recent infection, or trauma.
Ask about his dental history, including oral hygiene habits, frequency of dental examinations,
and the date of his most recent dental visit.
Next, perform a complete oral examination,
noting lesion sites and character. Examine the
patient’s lips for color and texture. Inspect and
palpate the buccal mucosa and tongue for color,
texture, and contour; note especially any painless ulcers on the sides or base of the tongue.
Hold the tongue with a piece of gauze, lift it,
and examine its underside and the floor of the
mouth. Depress the tongue with a tongue blade,
and examine the oropharynx. Inspect the teeth
and gums, noting missing, broken, or discolored
teeth; dental caries; excessive debris; and bleeding, inflamed, swollen, or discolored gums.
Palpate the neck for adenopathy, especially in
patients who smoke tobacco or use alcohol excessively.
P
EDIATRIC POINTERS
Moon face is rare in children. In an infant or a
young child, it usually indicates adrenal adenoma or carcinoma or, rarely, cri du chat syndrome. After age 7, it usually indicates abnormal pituitary secretion of corticotropin in
bilateral adrenal hyperplasia.
M
EDICAL CAUSES
◆ Acquired immunodeficiency syndrome
(AIDS). Oral lesions may be an early indication
of the immunosuppression that’s characteristic
of this disease. Fungal infections can occur,
with oral candidiasis being the most common.
Bacterial or viral infections of oral mucosa,
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SQUAMOUS CELL CARCINOMA LICHEN PLANUS
MOUTH LESIONS
447
APHTHOUS STOMATITIS
tongue, gingivae, and periodontal tissue may
also occur.
The primary oral neoplasm associated with
AIDS is Kaposi’s sarcoma. The tumor is usually
found on the hard palate and may appear initially as an asymptomatic, flat or raised lesion,
ranging in color from red to blue to purple. As
these tumors grow, they may ulcerate and become painful.
◆ Actinomycosis (cervicofacial). This chronic
fungal infection typically produces small, firm,
flat, usually painless swellings on the oral mucosa and under the skin of the jaw and neck.
Swellings may indurate and abscess, producing
fistulas and sinus tracts with a characteristic purulent yellow discharge.
◆ Behçet’s syndrome. This chronic, progres-
sive syndrome that generally affects young
males produces small, painful ulcers on the lips,
gums, buccal mucosa, and tongue. In severe
cases, the ulcers also develop on the palate,
pharynx, and esophagus. The ulcers typically
have a reddened border and are covered with a
GINGIVAL HYPERPLASIA
gray or yellow exudate. Similar lesions appear
on the scrotum and penis or labia majora; small
pustules or papules on the trunk and limbs; and
painful erythematous nodules on the shins. Ocular lesions may also develop.
◆ Candidiasis. This common fungal infection
characteristically produces soft, elevated
plaques on the buccal mucosa, tongue, and
sometimes the palate, gingivae, and floor of the
mouth; the plaques may be wiped away. The lesions of acute atrophic candidiasis are red and
painful. The lesions of chronic hyperplastic candidiasis are white and firm. Localized areas of
redness, pruritus, and foul odor may be present.
◆ Discoid lupus erythematosus. Oral lesions
are common, typically appearing on the tongue,
buccal mucosa, and palate as erythematous areas with white spots and radiating white striae.
Associated findings include skin lesions on the
face, possibly extending to the neck, ears, and
scalp; if the scalp is involved, alopecia may result. Hair follicles are enlarged and filled with
scale.
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GENDER CUE This chronic, recurrent
disease is most common in women ages 30
to 40.
◆ Epulis (giant cell). This rare tumor or
growth occurs on the gingival or alveolar
process, anterior to the molars. Dark red, pedunculated or sessile, and 0.5 to 1.5 cm in diameter, it commonly ulcerates to produce a
concave defect in the underlying bone. Gingivae
bleed easily with slight trauma.
◆ Erythema multiforme. This acute inflam-
matory skin disease produces sudden onset of
vesicles and bullae on the lips and buccal mucosa. Also, erythematous macules and papules
form symmetrically on the hands, arms, feet,
legs, face, and neck and, possibly, in the eyes
and on the genitalia. Lymphadenopathy may
also occur. With visceral involvement, other
findings include fever, malaise, cough, throat
and chest pain, vomiting, diarrhea, myalgias,
arthralgias, fingernail loss, blindness, hematuria, and signs of renal failure.
◆ Gingivitis (acute necrotizing ulcerative).
This recurring periodontal condition causes a
sudden onset of gingival ulcers covered with a
grayish white pseudomembrane. Other findings
include tender or painful gingivae, intermittent
gingival bleeding, halitosis, enlarged lymph
nodes in the neck, and fever.
◆ Gonorrhea. Painful lip ulcerations may oc-
cur, along with rough, reddened, bleeding gingivae (possibly necrotic and covered by a yellowish pseudomembrane), and a swollen, ulcerated
tongue. Related effects vary. Most men develop
dysuria, purulent urethral discharge, and a reddened, edematous urinary meatus. Most women
remain asymptomatic, but others develop inflammation and a greenish yellow cervical discharge.
◆ Herpes simplex 1. With primary infection, a
brief period of prodromal tingling and itching,
which is accompanied by fever and pharyngitis,
is followed by eruption of small and irritating
vesicles on any part of the oral mucosa, especially the tongue, gums, and cheeks. Vesicles
form on an erythematous base and then rupture, leaving a painful ulcer, followed by a yellowish crust. Other findings include submaxillary lymphadenopathy, increased salivation,
halitosis, anorexia, and keratoconjunctivitis.
◆ Herpes zoster. This common viral infection
may produce painful vesicles on the buccal mucosa, tongue, uvula, pharynx, and larynx. Small
red nodules often erupt unilaterally around the
thorax or vertically on the arms and legs, and
rapidly become vesicles filled with clear fluid or
pus; vesicles dry and form scabs about 10 days
after eruption. Fever and general malaise accompany pruritus, paresthesia or hyperesthesia,
and tenderness along the course of the involved
sensory nerve.
◆ Inflammatory fibrous hyperplasia. This
painless nodular swelling of the buccal mucosa
typically results from cheek trauma or irritation
and is characterized by pink, smooth, pedunculated areas of soft tissue.
◆ Leukoplakia, erythroplakia. Leukoplakia is
a white lesion that cannot be removed simply
by rubbing the mucosal surface—unlike candidiasis. It may occur in response to chronic irritation from dentures or tobacco or pipe smoking,
or it may represent dysplasia or early squamous
cell carcinoma.
Erythroplakia is red and edematous and has a
velvety surface. About 90% of all cases of erythroplakia are either dysplasia or cancer.
◆ Lichen planus. Oral lesions develop on the
buccal mucosa or, less commonly, on the
tongue as painless, white or gray, velvety,
threadlike papules. These precede the eruption
of violet papules with white lines or spots, usually on the genitalia, lower back, ankles, and
anterior lower legs; pruritus; nails with longitudinal ridges; and alopecia.
◆ Mucous duct obstruction. Obstruction pro-
duces a ranula—a painless, slow-growing mucocele on the floor of the mouth near the ducts
of the submandibular and sublingual glands.
◆ Pemphigoid (benign mucosal). This rare
autoimmune disease is characterized by thickwalled vesicles on the oral mucous membranes,
the conjunctiva and, less often, the skin. Mouth
lesions typically develop months or even years
before other manifestations and may occur as
desquamative patchy gingivitis or as a vesicobullous eruption. Secondary fibrous bands may
lead to dysphagia, hoarseness, and blindness.
Recurrent skin lesions include vesicobullous
eruptions, usually on the inguinal area and extremities, and an erythematous, vesicobullous
plaque on the scalp and face near the affected
mucous membranes.
◆ Pemphigus. This chronic skin disease is
characterized by thin-walled vesicles and bullae
that appear in cycles on skin or mucous membranes that otherwise appear normal. On the
oral mucosa, bullae rupture, leaving painful lesions and raw patches that bleed easily. Associated findings include bullae anywhere on the
body, denudation of the skin, and pruritus.
◆ Pyogenic granuloma. Commonly the result
of injury, trauma, or irritation, this soft, tender
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nodule, papule, or polypoid mass of excessive
granulation tissue usually appears on the gingivae but can also erupt on the lips, tongue, or
buccal mucosa. The lesions bleed easily because they contain many capillaries. The affected area may be smooth or have a warty surface;
erythema develops in the surrounding mucosa.
The lesions may ulcerate, producing a purulent
exudate.
◆ Squamous cell carcinoma. This is typically
a painless ulcer with an elevated, indurated border. It may erupt in areas of leukoplakia and is
most common on the lower lip, but it may also
occur on the edge of the tongue or the floor of
the mouth. High risk factors include chronic
smoking and alcohol intake.
◆ Stomatitis (aphthous). This common dis-
ease is characterized by painful ulcerations of
the oral mucosa, usually on the dorsum of the
tongue, gingivae, and hard palate.
With recurrent aphthous stomatitis minor, the
ulcer begins as one or more erosions covered
by a gray membrane and surrounded by a red
halo. It’s commonly found on the buccal and lip
mucosa and junction, tongue, soft palate, pharynx, gingivae, and all places not bound to the
periosteum.
With recurrent aphthous stomatitis major,
large, painful ulcers commonly occur on the
lips, cheek, tongue, and soft palate; they may
last up to 6 weeks and leave a scar.
◆ Syphilis. Primary syphilis typically produces
a solitary painless, red ulcer (chancre) on the
lip, tongue, palate, tonsil, or gingivae. The ulcer
appears as a crater with undulated, raised edges
and a shiny center; lip chancres may develop a
crust. Similar lesions may appear on the fingers,
breasts, or genitals, and regional lymph nodes
may become enlarged and tender.
During the secondary stage, multiple painless
ulcers covered by a grayish white plaque may
erupt on the tongue, gingivae, or buccal mucosa. A macular, papular, pustular, or nodular
rash appears, usually on the arms, trunk, palms,
soles, face, and scalp; genital lesions usually
subside. Other findings include generalized
lymphadenopathy, headache, malaise, anorexia,
weight loss, nausea, vomiting, sore throat, low
fever, metrorrhagia, and postcoital bleeding.
At the tertiary stage, lesions (often chronic,
painless, superficial nodules or deep granulomatous lesions, called gummas) develop on the
skin and mucous membranes, especially the
tongue and palate.
◆ Systemic lupus erythematosus. Oral le-
sions are common and appear as erythematous
areas associated with edema, petechiae, and
superficial ulcers with a red halo and a tendency
to bleed. Primary effects include nondeforming
arthritis, butterfly rash across the nose and
cheeks, and photosensitivity.
◆ Trauma. The most common cause of oral le-
sions, trauma can produce ulcers anywhere in
the mouth, especially on the tongue and buccal
mucosa.
◆ Tuberculosis (oral mucosal). This rare dis-
order produces a painless ulcer (usually on the
tongue) and, sometimes, caseation. Other findings include lymphadenopathy, fatigue, weakness, anorexia, weight loss, cough, low fever,
and night sweats.
O
THER CAUSES
◆ Drugs. Various chemotherapeutic agents can
directly produce stomatitis. Also, allergic reactions to penicillin, sulfonamides, gold, quinine,
streptomycin, phenytoin, aspirin, and barbiturates commonly cause lesions to develop and
erupt. Inhaled steroids used for pulmonary disorders can also cause oral lesions.
◆ Orthodontics. The rubbing of orthodontic
equipment or prosthesis on the buccal mucosa
may cause eroded, tender areas.
◆ Radiation therapy. Radiation therapy may
cause oral lesions.
S
PECIAL CONSIDERATIONS
If the patient’s mouth ulcers are painful, provide
a topical anesthetic such as lidocaine.
P
EDIATRIC POINTERS
Causes of mouth ulcers in children include
chickenpox, measles, scarlet fever, diphtheria,
and hand-foot-and-mouth disease. In neonates,
mouth ulcers can result from candidiasis or
congenital syphilis.
P
ATIENT COUNSELING
Instruct the patient to avoid irritants, such as
highly seasoned foods, citrus fruits, foods that
contain salt or vinegar, alcohol, and tobacco.
For mouth care, warn against using lemonglycerin swabs because these can dry and irritate the lesions.
As appropriate, teach the patient proper oral
hygiene. If toothbrushing is contraindicated, instruct him to use a mouth rinse, such as normal
saline solution or half-strength hydrogen peroxide, and to avoid commercial mouthwashes that
contain alcohol. Stress the importance of frequently changing to a new toothbrush. If the
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patient uses an inhaled steroid, instruct him to
rinse his mouth after each use. Also, tell him to report mouth lesions that don’t heal within 2 weeks.
Murmurs
Murmurs are auscultatory sounds heard within
the heart chambers or major arteries. They’re
classified by their timing and duration in the
cardiac cycle, auscultatory location, loudness,
configuration, pitch, and quality.
Timing can be characterized as systolic (be-
tween S
throughout systole), diastolic (between S
S
tole; systolic and diastolic murmurs can be further characterized as early, middle, or late.
ness, such as the apex, the lower left sternal
border, or an intercostal space. Loudness is
graded on a scale of 1 to 6. A grade 1 murmur is
very faint, only detected after careful auscultation. A grade 2 murmur is a soft, evident murmur. Murmurs considered to be grade 3 are
moderately loud. A grade 4 murmur is a loud
murmur with a possible intermittent thrill. Grade
5 murmurs are loud and associated with a palpable precordial thrill. Grade 6 murmurs are loud
and, like grade 5 murmurs, are associated with a
thrill. A grade 6 murmur is audible even when
the stethoscope is lifted from the thoracic wall.
of loudness—crescendo (grows louder), decrescendo (grows softer), crescendo-decrescendo (first rises, then falls), decrescendo-crescendo (first falls, then rises), plateau (even
intensity), or variable (uneven intensity). The
murmur’s pitch may be high or low. Its quality
and S2), holosystolic (continuous
1
), or continuous throughout systole and dias-
1
Location refers to the area of maximum loud-
Configuration, or shape, refers to the nature
2
and
may be described as harsh, rumbling, blowing,
scratching, buzzing, musical, or squeaking.
Murmurs can reflect accelerated blood flow
through normal or abnormal valves; forward
blood flow through a narrowed or irregular valve
or into a dilated vessel; blood backflow through
an incompetent valve, septal defect, or patent
ductus arteriosus; or decreased blood viscosity.
Commonly the result of organic heart disease,
murmurs occasionally may signal an emergency
situation—for example, a loud holosystolic murmur after an acute myocardial infarction (MI)
may signal papillary muscle rupture or ventricular septal defect. Murmurs may also result from
surgical implantation of a prosthetic valve. (See
When murmurs mean emergency.)
Some murmurs are innocent, or functional. An
innocent systolic murmur is generally soft, medium-pitched, and loudest along the left sternal border at the second or third intercostal space. It’s exacerbated by physical activity, excitement, fever,
pregnancy, anemia, or thyrotoxicosis. Examples
include Still’s murmur in children and mammary
souffle, often heard over either breast during late
pregnancy and early postpartum. (See Detecting
congenital murmurs, pages 451 and 452.)
H
ISTORY AND PHYSICAL
EXAMINATION
If you discover a murmur, try to determine its
type through careful auscultation. (See Identify-
ing common murmurs, page 453.) Use the bell of
your stethoscope for low-pitched murmurs; the
diaphragm for high-pitched murmurs.
Next, obtain a patient history. Ask if the murmur is a new discovery, or if it has been known
since birth or childhood. Find out if the patient
has experienced any associated symptoms, particularly palpitations, dizziness, syncope, chest
EMERGENCY INTERVENTION
When murmurs mean emergency
Although not normally a sign of an emergency,
murmurs—especially newly developed ones—
may signal a serious complication in patients
with bacterial endocarditis or a recent acute
myocardial infarction (MI).
When caring for a patient with known or
suspected bacterial endocarditis, carefully auscultate for any new murmurs. Their development along with crackles, distended jugular
veins, orthopnea, and dyspnea may signal
heart failure.
Regular auscultation is also important in a
patient who has experienced an acute MI. A
loud decrescendo holosystolic murmur at the
apex that radiates to the axilla and left sternal
border or throughout the chest is significant,
particularly in association with a widely split S
and an atrial gallop (S4). This murmur, when
accompanied by signs of acute pulmonary edema, usually indicates the development of acute
mitral insufficiency due to rupture of the chordae tendineae—a medical emergency.
2
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