Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
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Folliculitis and furunculosis. Hair follicle infection may cause red, sharply pointed lesions that are tender and swollen with central pustules. If folliculitis progresses to furunculosis, these lesions become hard, painful nodules that may gradually enlarge and rupture, discharging pus and necrotic material. Rupture relieves the pain, but erythema and edema may persist for days or weeks.
Genital herpes. Caused by herpesvirus type 1 or 2, genital herpes is an STD that produces fluid-filled vesicles on the glans penis, foreskin, or penile shaft and, occasionally, on the mouth or anus. Usually painless at first, these vesicles may rupture and become extensive, shallow, painful ulcers accompanied by redness, marked edema, and tender, inguinal lymph nodes. Other findings may include a fever, malaise, and dysuria. If the vesicles recur in the same area, the patient usually feels localized numbness and tingling before they erupt. Associated inflammation is typically less marked.
Genital warts. Most common in sexually active males, genital warts initially develop on the subpreputial sac or urethral meatus, and less commonly on the penile shaft; they then spread to the perineum and perianal area. These painless warts start as tiny red or pink swellings that may grow to 4″ (10 cm) and become pedunculated. Multiple swellings are common, giving the warts a cauliflower appearance. Infected warts are also malodorous.
Leukoplakia. Leukoplakia is a precancerous disorder that’s characterized by white, scaly patches on the glans and prepuce accompanied by skin thickening and occasionally fissures. Pediculosis pubis. Pediculosis pubis is a parasitic infestation that’s characterized by erythematous, itching papules in the pubic area and around the anus, abdomen, and thigh. Inspection may detect grayish white specks (lice eggs) attached to hair shafts. Skin irritation from scratching in these areas is common.
Penile cancer. Penile cancer usually produces a painless, enlarging wartlike lesion on the glans or foreskin. However, if the foreskin becomes unretractable, the patient may experience localized pain. Examination may reveal a foul-smelling discharge from the prepuce, a firm lump in the glans, and enlarged lymph nodes. Late signs and symptoms may include dysuria, pain, bleeding from the lesion, and urine retention and bladder distention associated with urinary tract obstruction.
Scabies. Mites that burrow under the skin in scabies may cause crusted lesions or large papules on the glans and shaft of the penis and on the scrotum. Lesions may also occur on the wrists, elbows, axillae, and waist. They’re usually raised, threadlike, and 1 to 10 cm long and have a swollen nodule or red papule that contains the mite. Nocturnal itching is typical and commonly causes excoriation.
Syphilis. Two to four weeks after exposure to the spirochete Treponema pallidum, one or more primary lesions, or chancres, may erupt on the genitalia; occasionally, they also erupt elsewhere on the body, typically on the mouth or perianal area. The chancre usually starts as a small, red, fluid-filled papule and then erodes to form a painless, firm, indurated, shallow ulcer with a clear base and a scant, yellow serous discharge or, less commonly, a hard papule. This lesion gradually involutes and disappears. Painless, unilateral regional lymphadenopathy is also typical.
Tinea cruris. Also called jock itch, tinea cruris is a superficial fungal infection that usually causes sharply defined, slightly raised, scaling patches on the inner thigh or groin (typically bilaterally) and, less commonly, on the scrotum and penis. Pruritus may be severe.
Urticaria. Urticaria is a common allergic reaction that’s characterized by intensely pruritic hives, which may appear on the genitalia, especially on the foreskin or shaft of the penis. These distinct, raised, evanescent wheals are surrounded by an erythematous flare.
Other Causes
Drugs. Phenolphthalein, barbiturates, and certain broad-spectrum antibiotics, such as tetracycline and sulfonamides, may cause a fixed drug eruption and a genital lesion.
Special Considerations
Many disorders produce penile lesions that resemble those of syphilis. Expect to screen every patient with penile lesions for STDs, using the dark-field examination and the Venereal Disease Research Laboratory test. In addition, you may need to prepare the patient for a biopsy to confirm or rule out penile cancer. Provide emotional support, especially if cancer is suspected.
To prevent cross-contamination, wash your hands before and after every patient contact. Wear gloves when handling urine or performing catheter care. Dispose of all needles carefully, and doublebag all material contaminated by secretions.
Patient Counseling
Explain the use of ointments and creams and methods to relieve crusting and itching. Emphasize which lesion changes the patient should report. Discuss and teach the proper use of condoms.
Pediatric Pointers
In infants, contact dermatitis (diaper rash) may produce minor irritation or bright red, weepy, excoriated lesions. Using disposable diapers and carefully cleaning the penis and scrotum can help reduce diaper rash.
In children, impetigo may cause pustules with thick, yellow, weepy crusts. Like adults, children may develop genital warts, but they’ll need more reassurance that the treatment (excision) won’t hurt or castrate them. Children with an STD must be evaluated for signs of sexual abuse.
Adolescents ages 15 to 19 have a high incidence of STDs and related genital lesions. The spirochete that causes syphilis can pass through the human placenta, producing congenital syphilis.
Geriatric Pointers
Elderly adults who are sexually active with multiple partners have as high a risk of developing STDs as younger adults. However, because of decreased immunity, poor hygiene, poor symptom reporting, and, possibly, several concurrent conditions, they may present with different symptoms. Seborrheic dermatitis lasts longer and is more extensive in patients who are bedridden and those with Parkinson’s disease.
REFERENCES
Batista, C. S., Attallah, A. N., Saconato, H., & da Silva, E. M. (2009). 5-FU for genital warts in non-immunocompromised individuals.
Cochrane Database Systematic Review, 4, CD006562.
Garland, S. M., Steben, M. , Sings, H. L., James, M. , Lu, S. , Railkar, R., … Joura, E. A.. (2009) . Natural history of genital warts: Analysis of the placebo arm of 2 randomized Phase III trials of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine. Journal of Infectious Disease, 199(6), 805–814.
Gum Bleeding
[Gingival bleeding]
Bleeding gums usually result from dental disorders; less commonly, they may stem from a blood dyscrasia or the effects of certain drugs. Physiologic causes of this common sign include pregnancy, which can produce gum swelling in the first or second trimester (pregnancy epulis); atmospheric pressure changes, which usually affect divers and aviators; and oral trauma. Bleeding ranges from slight oozing to life-threatening hemorrhage. It may be spontaneous or may follow trauma. Occasionally, direct pressure can control it.
EMERGENCY INTERVENTIONS
If you detect profuse, spontaneous bleeding in the oral cavity, quickly check the patient’s airway and look for signs of cardiovascular collapse, such as tachycardia and hypotension. Suction the patient. Apply direct pressure to the bleeding site. Expect to insert an airway, administer I.V. fluids, and collect serum samples for diagnostic evaluation.
History and Physical Examination
If gum bleeding isn’t an emergency, obtain a history. Find out when the bleeding began. Has it been continuous or intermittent? Does it occur spontaneously or when the patient brushes his teeth or flosses? Have the patient show you the site of the bleeding, if possible.
Find out if the patient or any family members have bleeding tendencies; for example, ask about easy bruising and frequent nosebleeds. How much does the patient bleed after a tooth extraction? Does he have a history of liver or spleen disease? Next, check the patient’s dental history. Find out how often he brushes his teeth, flosses, and goes to the dentist and what kind of toothbrush and floss he uses. Has he seen a dentist recently? To evaluate nutritional status, have the patient describe his normal diet and alcohol intake. Finally, note the prescription and over-the-counter drugs he takes.
Next, perform a complete oral examination. If the patient wears dentures, have him remove them. Examine the gums to determine the site and amount of bleeding. Gums normally appear pink and rippled with their margins snugly against the teeth. Check for inflammation, pockets around the teeth, swelling, retraction, hypertrophy, discoloration, and gum hyperplasia. Note obvious decay, discoloration, foreign material such as food, and absence of teeth.
Medical Causes
Agranulocytosis. Spontaneous gum bleeding and other systemic hemorrhages may occur in agranulocytosis, which typically causes progressive fatigue and weakness, followed by signs of
infection, such as a fever and chills. Inspection may reveal oral and perianal lesions, which are usually rough edged with a gray or black membrane.
Aplastic anemia. In aplastic anemia, profuse or scant gum bleeding may follow trauma. Other signs of bleeding, such as epistaxis and ecchymoses, are also characteristic. The patient exhibits progressive weakness and fatigue, shortness of breath, a headache, pallor and, possibly, a fever. Eventually, tachycardia and signs of heart failure, such as jugular vein distention and dyspnea, also develop.
Ehlers-Danlos syndrome. In Ehlers-Danlos syndrome, gums bleed easily after tooth brushing. Easy bruising and other signs of abnormal bleeding are also typical. The skin is fragile and hyperelastic; joints are hyperextendible.
Gingivitis. Reddened and edematous gums are characteristic of gingivitis. The gingivae between the teeth become bulbous and bleed easily with slight trauma. However, with acute necrotizing ulcerative gingivitis, bleeding is spontaneous and the gums become so painful that the patient may be unable to eat. A characteristic grayish yellow pseudomembrane develops over punchedout gum erosions. Offensive halitosis is typical and may be accompanied by a headache, malaise, fever, and cervical adenopathy.
Hemophilia. Hemorrhage occurs from many sites in the oral cavity, especially the gums. Mild hemophilia causes easy bruising, hematomas, epistaxis, bleeding gums, and prolonged bleeding during even minor surgery and up to 8 days afterward. Moderate hemophilia produces more frequent episodes of abnormal bleeding and occasional bleeding into the joints, which may cause swelling and pain. Severe hemophilia causes spontaneous or severe bleeding after minor trauma, possibly resulting in large subcutaneous and intramuscular hematomas. Bleeding into joints and muscles causes pain, swelling, extreme tenderness and, possibly, permanent deformity. Bleeding near peripheral nerves causes peripheral neuropathies, pain, paresthesia, and muscle atrophy. Signs of anemia and a fever may follow bleeding. Severe blood loss may lead to shock and death.
Hereditary hemorrhagic telangiectasia. Hereditary hemorrhagic telangiectasia is characterized by red to violet spider-like hemorrhagic areas on the gums, which blanch on pressure and bleed spontaneously. These telangiectases may also occur on the lips, buccal mucosa, and palate; on the face, ears, scalp, hands, arms, and feet; and under the nails. Epistaxis commonly occurs early and is difficult to control. Hemoptysis and signs of GI bleeding may develop.
Leukemia. Easy gum bleeding, which is an early sign of acute monocytic, lymphocytic, or myelocytic leukemia, is accompanied by gum swelling, necrosis, and petechiae. The soft, tender gums appear glossy and bluish. Acute leukemia causes severe prostration marked by a high fever and bleeding tendencies, such as epistaxis and prolonged menses. It may also cause dyspnea, tachycardia, palpitations, and abdominal or bone pain. Later effects may include confusion, headaches, vomiting, seizures, papilledema, and nuchal rigidity.
a.Chronic leukemia usually develops insidiously, producing less severe bleeding tendencies. Other effects may include anorexia, weight loss, a low-grade fever, chills, skin eruptions, and an enlarged spleen, tonsils, and lymph nodes. Signs of anemia, such as fatigue and pallor, may occur.
Pemphigoid (benign mucosal). Most common in women between ages 40 and 50, pemphigoid typically causes thick-walled gum lesions that rupture, desquamate, and then bleed easily. Extensive scars form with healing, and the gums remain red for months. Lesions may also
develop on other parts of the oral mucosa, conjunctiva, and, less commonly, the skin. Secondary fibrous bands may lead to dysphagia, hoarseness, or blindness.
Periodontal disease. Gum bleeding typically occurs after chewing, tooth brushing, or gum probing but may also occur spontaneously. As gingivae separate from the bone, pus-filled pockets develop around the teeth; occasionally, pus can be expressed. Other findings include an unpleasant taste with halitosis, facial pain, loose teeth, and dental calculi and plaque.
Polycythemia vera. In polycythemia vera, engorged gums ooze blood after even slight trauma. This disorder usually turns the oral mucosa — especially the gums and tongue — a deep redviolet. Among associated findings are a headache, dyspnea, dizziness, fatigue, paresthesia, tinnitus, double or blurred vision, aquagenic pruritus, epigastric distress, weight loss, increased blood pressure, ruddy cyanosis, ecchymosis, and hepatosplenomegaly.
Thrombocytopenia. Blood usually oozes between the teeth and gums; however, severe bleeding may follow minor trauma. Associated signs of hemorrhage include large blood-filled bullae in the mouth, petechiae, ecchymosis, epistaxis, and hematuria. Malaise, fatigue, weakness, and lethargy eventually develop.
Thrombocytopenic purpura (idiopathic). Profuse gum bleeding occurs in idiopathic thrombocytopenic purpura. Its classic feature, however, is spontaneous hemorrhagic skin lesions that range from pinpoint petechiae to massive hemorrhages. The patient has a tendency to bruise easily, develops petechiae on the oral mucosa, and may exhibit melena, epistaxis, or hematuria.
Vitamin K deficiency. The first sign of vitamin K deficiency is usually gums that bleed when the teeth are brushed. Other signs of abnormal bleeding, such as ecchymosis, epistaxis, and hematuria, may also occur. GI bleeding may produce hematemesis and melena; intracranial bleeding may cause a decreased level of consciousness and focal neurologic deficits.
Other Causes
Drugs. Warfarin and heparin interfere with blood clotting and may cause prolonged gum bleeding. Abuse of aspirin and nonsteroidal anti-inflammatory drugs may alter platelets, producing bleeding gums. Localized gum bleeding may also occur with mucosal “aspirin burn” caused by dissolving aspirin near an aching tooth.
Special Considerations
Prepare the patient for diagnostic tests, such as blood studies or facial X-rays. Prepare him for the possibility of a blood or blood product transfusion, if necessary (platelets or fresh frozen plasma). When providing mouth care, avoid using lemon-glycerin swabs, which may burn or dry the gums.
Patient Counseling
Instruct the patient in proper mouth and gum care.
Pediatric Pointers
In neonates, bleeding gums may result from vitamin K deficiency associated with a lack of normal intestinal flora or poor maternal nutrition. In infants who primarily drink cow’s milk and don’t receive vitamin supplements, bleeding gums can result from vitamin C deficiency.
Encourage parents to teach proper oral hygiene early. Daily brushing in the morning and before bedtime should begin with eruption of the first tooth. When the child has all of his baby teeth, he should begin receiving regular dental checkups.
Geriatric Pointers
In patients who have no teeth, constant gum trauma and bleeding may result from using a dental prosthesis.
REFERENCES
Epstein, J. B., Raber-Durlacher, J. E., Wilkins, A., Chavarria, M. G., & Myint, H. (2009). Advances in hematologic stem cell transplant: An update for oral health care providers. Oral Surgery Oral Medicine Oral Pathology Oral Radiology Endod, 107, 301–312.
Kashiwazaki, H., Matsushita, T., Sugita, J., Shigematsu, A., Kasashi, K., Yamazaki,Y., … Inoue, N. (2012). Professional oral health care reduces oral mucositis and febrile neutropenia in patients treated with allogeneic bone marrow transplantation. Support Care Cancer, 20, 367–373.
Gynecomastia
Occurring only in males, gynecomastia refers to increased breast size due to excessive mammary gland development. This change in breast size may be barely palpable or immediately obvious. Usually bilateral, gynecomastia may be associated with breast tenderness and milk secretion.
Normally, several hormones regulate breast development. Estrogens, growth hormone, and corticosteroids stimulate ductal growth, while progesterone and prolactin stimulate growth of the alveolar lobules. Although the pathophysiology of gynecomastia isn’t fully understood, a hormonal imbalance — particularly a change in the estrogen-androgen ratio and an increase in prolactin — is a likely contributing factor. This explains why gynecomastia commonly results from the effects of estrogens and other drugs. It may also result from hormone-secreting tumors and from endocrine, genetic, hepatic, or adrenal disorders. Physiologic gynecomastia may occur in neonatal, pubertal, and geriatric males because of normal fluctuations in hormone levels.
History and Physical Examination
Begin the history by asking the patient when he first noticed his breast enlargement. How old was he at the time? Since then, have his breasts gotten progressively larger, smaller, or stayed the same? Does he also have breast tenderness or discharge? Have him describe the discharge, if any. Ask him if he’s ever had his nipples pierced. If so, were there any complications due to the piercings? Next, take a thorough drug history, including prescription, over-the-counter, herbal, and street drugs. Then explore associated signs and symptoms, such as testicular mass or pain, loss of libido, decreased potency, and loss of chest, axillary, or facial hair.
Focus the physical examination on the breasts, testicles, and penis. As you examine the breasts, note asymmetry, dimpling, abnormal pigmentation, or ulceration. Observe the testicles for size and symmetry. Then palpate them to detect nodules, tenderness, or unusual consistency. Look for normal penile development after puberty and note hypospadias.
Medical Causes
Adrenal carcinoma. Estrogen production by an adrenal tumor may produce a feminizing syndrome in males characterized by bilateral gynecomastia, loss of libido, impotence, testicular atrophy, and reduced facial hair growth. Cushingoid signs, such as moon face and purple striae, may also occur.
Breast cancer. Painful unilateral gynecomastia develops rapidly in males with breast cancer. Palpation may reveal a hard or stony breast lump suggesting a malignant tumor. Breast examination may also detect changes in breast symmetry; skin changes, such as thickening, dimpling, peau d’orange, or ulceration; a warm, reddened area; and nipple changes, such as itching, burning, erosion, deviation, flattening, retraction, and a watery, bloody, or purulent discharge.
Hyperthyroidism. Gynecomastia can occur when the delicate balance of estrogen and testosterone levels are altered. This can occur when the thyroid gland becomes overactive and produces too much thyroxine. Other symptoms include sudden weight loss, a rapid heartbeat, nervousness, sensitivity to heat, difficulty sleeping, muscle weakness, and fatigue.
Klinefelter’s syndrome. Painless bilateral gynecomastia first appears during adolescence in Klinefelter’s syndrome, a genetic disorder. Before puberty, symptoms also include abnormally small testicles and a slight mental deficiency; after puberty, sparse facial hair, a small penis, decreased libido, and impotence.
Liver cancer. Liver cancer may produce bilateral gynecomastia and other characteristics of feminization, such as testicular atrophy, impotence, and reduced facial hair growth. The patient may complain of severe epigastric or right upper quadrant pain associated with a right upper quadrant mass. A large tumor may also produce a bruit on auscultation. Related findings may include anorexia, weight loss, dependent edema, fever, cachexia and, possibly, jaundice or ascites.
Pituitary tumor. A pituitary tumor is a hormone-secreting tumor that causes bilateral gynecomastia accompanied by galactorrhea, impotence, and decreased libido. Other hormonal effects may include enlarged hands and feet, coarse facial features with prognathism, voice deepening, weight gain, increased blood pressure, diaphoresis, heat intolerance, hyperpigmentation, and thickened, oily skin. Paresthesia or sensory loss and muscle weakness commonly affect the limbs. If the tumor expands, it may cause blurred vision, diplopia, a headache, or partial bitemporal hemianopia that may progress to blindness.
Reifenstein’s syndrome. Reifenstein’s syndrome is a genetic disorder that produces painless bilateral gynecomastia at puberty. Associated signs may include hypospadias, testicular atrophy, and an underdeveloped penis.
Other Causes
Drugs. When gynecomastia is an effect of drugs, it’s typically painful and unilateral. Estrogens used to treat prostate cancer, including diethylstilbestrol, estramustine, and chlorotrianisene, directly affect the estrogen-androgen ratio. Drugs that have an estrogen-like effect, such as cardiac glycosides and human chorionic gonadotropin, may do the same. Regular use of alcohol, marijuana, or heroin reduces plasma testosterone levels, causing gynecomastia. Other drugs — such as flutamide, cyproterone, spironolactone, cimetidine, and ketoconazole — produce this sign by interfering with androgen production or action. Some common drugs, including
phenothiazines, tricyclic antidepressants, and antihypertensives, produce gynecomastia in an unknown way.
Treatments. Gynecomastia may develop within weeks of starting hemodialysis for chronic renal failure. It may also follow major surgery or testicular irradiation.
Special Considerations
To make the patient as comfortable as possible, apply cold compresses to his breasts and administer analgesics. Prepare him for diagnostic tests, including chest and skull X-rays and blood hormone levels.
Because gynecomastia may alter the patient’s body image, provide emotional support. Reassure the patient that treatment can reduce gynecomastia. Some patients are helped by tamoxifen, an antiestrogen, or by testolactone, an inhibitor of testosterone-to-estrogen conversion. Surgical removal of breast tissue may be an option if drug treatment fails.
Patient Counseling
Explain treatment and procedures the patient needs.
Pediatric Pointers
In neonates, gynecomastia may be associated with galactorrhea (“witch’s milk”). This sign usually disappears within a few weeks but may persist until age 2.
Most males have physiologic gynecomastia at some time during adolescence, usually around age 14. This gynecomastia is usually asymmetrical and tender; it commonly resolves within 2 years and rarely persists beyond age 20.
REFERENCES
Block, S. L. (2012). The possible link between gynecomastia, topical lavender, and tea tree oil. Pediatric Annals, 41, 56–58.
Deepinder, F., & Braunstein, G. D. (2012). Drug-induced gynecomastia: An evidence-based review. Expert Opinion on Drug Safety, 11, 779–795.
H
Halo Vision
Halo vision refers to seeing rainbowlike, colored rings around lights or bright objects. This effect can be explained by this physical principle: As light passes through water (in the eye, through tears or the cells of various anteretinal media), it breaks up into spectral colors.
Halo vision usually develops suddenly; its duration depends on the causative disorder. It may occur with disorders associated with excessive tearing and corneal epithelial edema. Among these causes, the most common and significant is acute angle-closure glaucoma, which can lead to blindness. With this disorder, increased intraocular pressure (IOP) forces fluid into corneal tissues anterior to the Bowman’s membrane, causing edema. Halo vision is also an early symptom of cataracts, resulting from dispersion of light by abnormal opacities in the lens.
Nonpathologic causes of excessive tearing associated with halo vision include poorly fitted or overworn contact lenses, emotional extremes, and exposure to intense light such as in snow blindness.
History and Physical Examination
First, ask the patient how long he has been seeing halos around lights and when he usually sees them. The patient with glaucoma usually sees halos in the morning, when IOP is most elevated. Ask the patient if light bothers his eyes. Does he have eye pain? If so, have him describe it. Remember that halos associated with excruciating eye pain or a severe headache may point to acute angle-closure glaucoma, an ocular emergency. Note a history of glaucoma or cataracts.
Next, examine the patient’s eyes, noting conjunctival injection, excessive tearing, and lens changes. Examine pupil size, shape, and response to light.
Medical Causes
Cataract. Halo vision may be an early symptom of painless, progressive cataract formation. The glare of headlights may blind the patient, making nighttime driving impossible. Other features include blurred vision, impaired visual acuity, and lens opacity, all of which develop gradually. Corneal endothelial dystrophy. Typically, halo vision is a late symptom. Impaired visual acuity may also occur.
Glaucoma. Halo vision characterizes all types of glaucoma. Acute angle-closure glaucoma — an ophthalmic emergency — also causes blurred vision, followed by a severe headache or excruciating pain in and around the affected eye. Examination reveals a moderately dilated fixed pupil that doesn’t respond to light, conjunctival injection, a cloudy cornea, impaired visual acuity and, possibly, nausea and vomiting.
Chronic angle-closure glaucoma is usually asymptomatic until pain and blindness occur in advanced disease. Sometimes, halos and blurred vision develop slowly.
With chronic open-angle glaucoma, halo vision is a late symptom that’s accompanied by a mild
eye ache, peripheral vision loss, and impaired visual acuity.
Other Causes
Drugs. It’s well known that, with digoxin toxicity, patients commonly report seeing halos, bright spots, or rings of yellow to green light around objects. Patients may also complain of other visual disturbances, such as blurred vision, diplopia, flashes of light, photophobia, changes in color perception, and blind spots.
Special Considerations
To help minimize halo vision, remind the patient not to look directly at bright lights.
Patient Counseling
Teach the patient how to instill eyedrops, if prescribed. Discuss the importance of reporting eye discharge, eye watering, blurred or cloudy vision, halos, floaters, flashes of light, or eye pain.
Pediatric Pointers
Halo vision in a child usually results from congenital cataracts or glaucoma. In a young child, limited verbal ability may make halo vision difficult to assess.
Geriatric Pointers
Primary glaucoma, the most common cause of halo vision, is most common in patients older than age 60.
REFERENCES
Biswas, J. , Krishnakumar, S., & Ahuja, S. (2010) . Manual of ocular pathology. New Delhi, India: Jaypee—Highlights Medical Publishers.
Gerstenblith, A. T., & Rabinowitz, M. P. (2012). The wills eye manual. Philadelphia, PA: Lippincott Williams & Wilkins. Roy, F. H. (2012). Ocular differential diagnosis. Clayton, Panama: Jaypee—Highlights Medical Publishers, Inc.
Headache
The most common neurologic symptom, headaches may be localized or generalized, producing mild to severe pain. About 90% of all headaches are benign and can be described as vascular, muscle contraction, or a combination of both. (See Clinical Features of Headache.) Occasionally, however, headaches indicate a severe neurologic disorder associated with intracranial inflammation, increased intracranial pressure (ICP), or meningeal irritation. They may also result from an ocular or a sinus disorder, tests, drugs, or other treatments.
Other causes of headache include a fever, eyestrain, dehydration, and systemic febrile illnesses. Headaches may occur in certain metabolic disturbances — such as hypoxemia, hypercapnia, hyperglycemia, and hypoglycemia — but they aren’t a diagnostic or prominent symptom. Some individuals get headaches after seizures or from coughing, sneezing, heavy lifting, or stooping.