Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
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infection with a sore throat, cough, nasal discharge, and headache. Related signs and symptoms include dizziness, a sensation of fullness in the ear, intermittent or constant ear pain, a fever, nausea, and vomiting. Rupture of the bulging, swollen tympanic membrane relieves the pain and produces a brief, bloody, purulent discharge. Hearing returns after the infection subsides.
Hearing loss also develops gradually in patients with chronic otitis media. Assessment may reveal a perforated tympanic membrane, purulent ear drainage, an earache, nausea, and vertigo.
Commonly associated with an upper respiratory tract infection or nasopharyngeal cancer, serous otitis media commonly produces a stuffy feeling in the ear and pain that worsens at night. Examination reveals a retracted — and perhaps discolored — tympanic membrane and possibly air bubbles behind the membrane.
Otosclerosis. Otosclerosis is a hereditary disorder in which unilateral conductive hearing loss usually begins when the patient is in his early 20s and may gradually progress to bilateral mixed loss. The patient may report tinnitus and an ability to hear better in a noisy environment. The deafness is usually noticed between ages 11 and 30.
GENDER CUE
Otosclerosis affects twice as many women as men, and the condition may worsen during pregnancy.
Skull fracture. Auditory nerve injury causes sudden unilateral sensorineural hearing loss. Accompanying signs and symptoms include ringing tinnitus, blood behind the tympanic membrane, scalp wounds, and other findings.
Temporal bone fracture. Temporal bone fracture can cause sudden unilateral sensorineural hearing loss accompanied by hissing tinnitus. The tympanic membrane may be perforated, depending on the fracture’s location. Loss of consciousness, Battle’s sign, and facial paralysis may also occur.
Tympanic membrane perforation. Commonly caused by trauma from sharp objects or rapid pressure changes, perforation of the tympanic membrane causes abrupt hearing loss along with ear pain, tinnitus, vertigo, and a sensation of fullness in the ear.
Other Causes
Drugs. Ototoxic drugs typically produce ringing or buzzing tinnitus and a feeling of fullness in the ear. Chloroquine, cisplatin, vancomycin, and aminoglycosides (especially neomycin, kanamycin, and amikacin) may cause irreversible hearing loss. Loop diuretics, such as furosemide, ethacrynic acid, and bumetanide, usually produce a brief, reversible hearing loss. Quinine, quinidine, and high doses of erythromycin or salicylates (such as aspirin) may also cause reversible hearing loss.
Radiation therapy. Irradiation of the middle ear, thyroid, face, skull, or nasopharynx may cause eustachian tube dysfunction, resulting in hearing loss.
Surgery. Myringotomy, myringoplasty, simple or radical mastoidectomy, or fenestrations may
cause scarring that interferes with hearing.
Special Considerations
When talking with the patient, remember to face him and speak slowly. Don’t shout, smoke, eat, or chew gum when talking.
Prepare the patient for audiometryand auditory-evoked response testing. After testing, the patient may require a hearing aid or cochlear implant to improve his hearing.
Patient Counseling
Explain the importance of ear protection and avoidance of loud noises. Stress the importance of following instructions for taking prescribed antibiotics.
Pediatric Pointers
About 3,000 profoundly deaf infants are born in the United States each year. In about half of these infants, hereditary disorders (such as Paget’s disease and Alport’s, Hurler’s, and Klippel-Feil syndromes) cause typically sensorineural hearing loss. Nonhereditary disorders associated with congenital sensorineural hearing loss include albinism, onychodystrophy syndrome, cochlear dysplasia, and Pendred’s, Usher’s, Waardenburg’s, and Jervell and Lange-Nielsen syndromes. This type of hearing loss may also result from maternal use of ototoxic drugs, birth trauma, and anoxia during or after birth.
Mumps is the most common pediatric cause of unilateral sensorineural hearing loss. Other causes are meningitis, measles, influenza, and acute febrile illness.
Disorders that may produce congenital conductive hearing loss include atresia, ossicle malformation, and other abnormalities. Serous otitis media commonly causes bilateral conductive hearing loss in children. Conductive hearing loss may also occur in children who put foreign objects in their ears.
Hearing disorders in a child may lead to speech, language, and learning problems. Early identification and treatment of hearing loss is thus crucial to avoid incorrectly labeling the child as mentally retarded, brain damaged, or a slow learner.
When assessing an infant or a young child for hearing loss, remember that you can’t use a tuning fork. Instead, test the startle reflex in an infant younger than age 6 months or have an audiologist test brain stem–evoked response in a neonate, an infant, and a young child. Also, obtain a gestational, perinatal, and family history from the parents.
Geriatric Pointers
In older patients, presbycusis may be aggravated by exposure to noise as well as other factors.
REFERENCES
Neitzel, R. , Daniell, W. E. , Sheppard, L. , Davies, H., & Seixas, N. (2009) . Comparison of perceived and quantitative measures of occupational noise exposure. Annals of Occupational Hygiene, 53, 41–54.
Rabinowitz, P. M. , Galusha, D., Kirsche, S. R., Cullen, M. R., Slade, M. D., & Dixon-Ernst, C. (2011). Effect of daily noise exposure monitoring on annual rates of hearing loss in industrial workers. Occupational and Environmental Medicine, 68(6), 414–418.
Heat Intolerance
Heat intolerance refers to the inability to withstand high temperatures or to maintain a comfortable body temperature. This symptom produces a continuous feeling of being overheated and, at times, profuse diaphoresis. It usually develops gradually and is chronic.
Thyrotoxicosis is a common cause of heat intolerance. With this disorder, excess thyroid hormone stimulates peripheral tissues, increasing basal metabolism and producing excess heat. Although rare, hypothalamic disease may also cause intolerance to heat and cold.
History and Physical Examination
Ask the patient when he first noticed his heat intolerance. Did he gradually use fewer blankets at night? Does he have to turn up the air conditioning to keep cool? Is it hard for him to adjust to warm weather? Does he sweat in a hot environment? Find out if his appetite or weight has changed. Also, ask about unusual nervousness or other personality changes. Then take a drug history, especially noting the use of amphetamines or amphetamine-like drugs. Ask the patient if he takes a thyroid drug. If so, what’s the daily dose? When did he last take it?
As you begin the examination, notice how much clothing the patient is wearing. After taking his vital signs, inspect his skin for flushing and diaphoresis. Also, note tremors and lid lag.
Medical Causes
Hypothalamic disease. With hypothalamic disease, body temperature fluctuates dramatically, causing alternating heat and cold intolerance. Related features include amenorrhea, disturbed sleep patterns, increased thirst and urination, increased appetite with weight gain, impaired visual acuity, a headache, and personality changes, such as bursts of rage or laughter. Common causes of hypothalamic disease are pituitary adenoma and hypothalamic and pineal tumors.
Menopause. During menopause, estrogen and progesterone levels decline. Approximately 75% of women experience heat intolerances described as “hot flashes.” During a hot flash, the skin becomes warm and flushed, followed by profuse sweating that can last up to 5 minutes or more. Other symptoms, including night sweats, mood swings, weight gain, and insomnia, can also manifest.
Thyrotoxicosis. A classic symptom of thyrotoxicosis, heat intolerance may be accompanied by an enlarged thyroid, nervousness, weight loss despite increased appetite, diaphoresis, diarrhea, tremor, and palpitations. Although exophthalmos is characteristic, many patients don’t display this sign. Associated findings may affect virtually every body system. Some common findings include irritability, difficulty concentrating, mood swings, insomnia, muscle weakness, fatigue, lid lag, tachycardia, full and bounding pulse, a widened pulse pressure, dyspnea, amenorrhea, and gynecomastia. Typically, the patient’s skin is warm and flushed; premature graying and alopecia occur in both sexes.
Other Causes
Drugs. Amphetamines, amphetamine-like appetite suppressants, and excessive doses of thyroid hormone may cause heat intolerance. Anticholinergics may interfere with sweating, resulting in
heat intolerance.
Special Considerations
Adjust the room temperature to make the patient comfortable. If the patient is diaphoretic, change his clothing and bed linens as necessary, and encourage him to drink lots of fluids.
Patient Counseling
Teach the patient about the disease and its treatments. Discuss the importance of proper hygiene and drinking plenty of fluids.
Pediatric Pointers
Rarely, maternal thyrotoxicosis may be passed to the neonate, resulting in heat intolerance. More commonly, acquired thyrotoxicosis appears between ages 12 and 14, although this too is infrequent. Dehydration may also make a child sensitive to heat.
REFERENCES
Brothers, R. M., Wingo, J. E., Hubing, K. A., & Crandall, C. G. (2009) . The effects of reduced end-tidal carbon dioxide tension on cerebral blood flow during heat stress. Journal of Physiology, 587, 3921–3927.
Bundgaard-Nielsen, M. , Wilson, T. E. , Seifert, T. , Secher, N. H., & Crandall C. G. (2010) . Effect of volume loading on the FrankStarling relation during reductions in central blood volume in heat stressed humans. Journal of Physiology, 588, 3333–3339.
Hematemesis
Hematemesis, the vomiting of blood, usually indicates GI bleeding above the ligament of Treitz, which suspends the duodenum at its junction with the jejunum. Bright red or blood-streaked vomitus indicates fresh or recent bleeding. Dark red, brown, or black vomitus (the color and consistency of coffee grounds) indicates that blood has been retained in the stomach and partially digested.
Although hematemesis usually results from a GI disorder, it may stem from a coagulation disorder or a treatment that irritates the GI tract. Esophageal varices may also cause hematemesis. Swallowed blood from epistaxis or oropharyngeal erosion may also cause bloody vomitus. Hematemesis may be precipitated by straining, emotional stress, and the use of an anti-inflammatory or alcohol. In a patient with esophageal varices, hematemesis may be a result of trauma from swallowing hard or partially chewed food. (See Rare Causes of Hematemesis.)
Hematemesis is always an important sign, but its severity depends on the amount, source, and rapidity of the bleeding. Massive hematemesis (vomiting 500 to 1,000 mL of blood) may be life threatening.
EMERGENCY INTERVENTIONS
If the patient has massive hematemesis, check his vital signs. If you detect signs of shock — such as tachypnea, hypotension, and tachycardia — place the patient in a supine position, and elevate his feet 20 to 30 degrees. Start a large-bore I.V. line for emergency fluid replacement. Also, send a blood sample for typing and cross matching, hemoglobin level, and
hematocrit and administer oxygen. Emergency endoscopy may be necessary to locate the source of bleeding. Prepare to insert a nasogastric (NG) tube for suction or iced lavage. A Sengstaken-Blakemore tube may be used to compress esophageal varices. (See Managing Hematemesis with Intubation, page 378.)
History and Physical Examination
If the patient’s hematemesis isn’t immediately life threatening, begin with a thorough history. First, have the patient describe the amount, color, and consistency of the vomitus. When did he first notice this sign? Has he ever had hematemesis before? Find out if he also has bloody or black, tarry stools. Note whether hematemesis is usually preceded by nausea, flatulence, diarrhea, or weakness. Has he recently had bouts of retching with or without vomiting?
Rare Causes of Hematemesis
Two rare disorders commonly cause hematemesis. Malaria produces this and other GI signs, but its most characteristic effects are chills, a fever, a headache, muscle pain, and splenomegaly. Yellow fever also causes hematemesis as well as a sudden fever, bradycardia, jaundice, and severe prostration.
Two relatively common disorders may cause hematemesis in rare cases. When acute diverticulitis affects the duodenum, GI bleeding and resultant hematemesis occur with abdominal pain and a fever. With GI involvement, secondary syphilis can cause hematemesis; more characteristic signs and symptoms include a primary chancre, a rash, a fever, weight loss, malaise, anorexia, and a headache.
Next, ask about a history of ulcers or of liver or coagulation disorders. Find out how much alcohol the patient drinks, if any. Does he regularly take aspirin or other nonsteroidal antiinflammatory drug (NSAID), such as phenylbutazone or indomethacin? These drugs may cause erosive gastritis or ulcers. Does he take warfarin or other drugs with anticoagulant properties? These drugs increase the patient’s risk of bleeding.
Begin the physical examination by checking for orthostatic hypotension, an early warning sign of hypovolemia. Take blood pressure and pulse with the patient in the supine, sitting, and standing positions. A decrease of 10 mm Hg or more in systolic pressure or an increase of 10 beats/minute or more in pulse rate indicates volume depletion. After obtaining other vital signs, inspect the mucous membranes, nasopharynx, and skin for signs of bleeding or other abnormalities. Finally, palpate the abdomen for tenderness, pain, or masses. Note lymphadenopathy.
Managing Hematemesis with Intubation
A patient with hematemesis will need to have a GI tube inserted to allow blood drainage, aspirate gastric contents, or facilitate gastric lavage, if necessary. Here are the most common tubes and their uses.
NASOGASTRIC TUBES
The Salem-Sump tube (at right), a double-lumen nasogastric (NG) tube, is used to remove stomach fluid and gas or to aspirate gastric contents. It may also be used for gastric lavage, drug administration, or feeding. Its main advantage over the Levin tube — a single-lumen NG tube — is that it allows atmospheric air to enter the patient's stomach so the tube can float freely instead of risking adhesion and damage to the gastric mucosa.
WIDE-BORE GASTRIC TUBES
The Edlich tube (at right) has one wide-bore lumen with four openings near the closed distal tip. A funnel or syringe can be connected at the proximal end. Like the other tubes, the Edlich tube can be used for gastric lavage and to aspirate a large volume of gastric contents quickly.
The Ewald tube, a wide-bore tube that allows quick passage of a large amount of fluid and clots, is especially useful for gastric lavage in patients with profuse GI bleeding and in those who have ingested poison that isn't acidic or alkaline. Another wide-bore tube, the double-lumen Levacuator, has a large lumen for evacuation of gastric contents and a small one for lavage.
ESOPHAGEAL TUBES
The Sengstaken-Blakemore tube (at right), a triple-lumen double-balloon esophageal tube, provides a gastric aspiration port that allows drainage from below the gastric balloon. It can also be used to instill medication. A similar tube, the Linton-Nachlas tube, can aspirate esophageal and gastric contents without risking necrosis because it has no esophageal balloon. The Minnesota esophagogastric tamponade tube, which has four lumina and two balloons, provides pressure-monitoring ports for both balloons without the need for Y-connectors.
Medical Causes
Anthrax (GI). Initial signs and symptoms after eating contaminated meat from an animal infected with the gram-positive, spore-forming bacterium Bacillus anthracis include a loss of appetite, nausea, vomiting, and a fever. Signs and symptoms may progress to hematemesis, abdominal pain, and severe bloody diarrhea.
Coagulation disorders. Any disorder that disrupts normal clotting may result in GI bleeding and moderate to severe hematemesis. Bleeding may occur in other body systems as well, resulting in such signs as epistaxis and ecchymosis. Other associated effects vary, depending on the specific coagulation disorder, such as thrombocytopenia or hemophilia.
Esophageal cancer. A late sign of esophageal cancer, hematemesis may be accompanied by steady chest pain that radiates to the back. Other features include substernal fullness, severe dysphagia, nausea, vomiting with nocturnal regurgitation and aspiration, hemoptysis, a fever, hiccups, a sore throat, melena, and halitosis.
Esophageal rupture. The severity of hematemesis depends on the cause of the rupture. When an instrument damages the esophagus, hematemesis is usually slight. However, rupture due to Boerhaave’s syndrome (increased esophageal pressure from vomiting or retching) or other esophageal disorders typically causes more severe hematemesis. This life-threatening disorder may also produce severe retrosternal, epigastric, neck, or scapular pain accompanied by chest and neck edema. Examination reveals subcutaneous crepitation in the chest wall, supraclavicular fossa, and neck. The patient may also show signs of respiratory distress, such as dyspnea and cyanosis.
Esophageal varices (ruptured). Life-threatening rupture of esophageal varices may produce coffee-ground or massive, bright red vomitus. Signs of shock, such as hypotension or tachycardia, may follow or even precede hematemesis if the stomach fills with blood before vomiting occurs. Other symptoms may include abdominal distention and melena or painless hematochezia, ranging from slight oozing to massive rectal hemorrhage.
Gastric cancer. Painless bright red or dark brown vomitus is a late sign of gastric cancer, which usually begins insidiously with upper abdominal discomfort. The patient then develops anorexia, mild nausea, and chronic dyspepsia unrelieved by antacids and exacerbated by food. Later symptoms may include fatigue, weakness, weight loss, feelings of fullness, melena, altered bowel habits, and signs of malnutrition, such as muscle wasting and dry skin.
Gastritis (acute). Hematemesis and melena are the most common signs of acute gastritis. They
may even be the only signs, although mild epigastric discomfort, nausea, a fever, and malaise may also occur. Massive blood loss precipitates signs of shock. Typically, the patient has a history of alcohol abuse or has used aspirin or some other NSAID. Gastritis may also occur secondary to Helicobacter pylori infection.
Mallory-Weiss syndrome. Characterized by a mucosal tear of the mucous membrane at the junction of the esophagus and stomach, this syndrome may produce hematemesis and melena. It’s commonly triggered by severe vomiting, retching, or straining (as from coughing), most commonly in alcoholics or in people whose pylorus is obstructed. Severe bleeding may precipitate signs of shock, such as tachycardia, hypotension, dyspnea, and cool, clammy skin.
Peptic ulcer. Hematemesis may occur when a peptic ulcer penetrates an artery, vein, or highly vascular tissue. Massive — and possibly life-threatening — hematemesis is typical when an artery is penetrated. Other features include melena or hematochezia, chills, a fever, and signs and symptoms of shock and dehydration, such as tachycardia, hypotension, poor skin turgor, and thirst. The patient may have a history of nausea, vomiting, epigastric tenderness, and epigastric pain that’s relieved by foods or antacids. He may also have a history of habitually using tobacco, alcohol, or NSAIDs.
Other Causes
Treatments. Traumatic NG or endotracheal intubation may cause hematemesis associated with swallowed blood. Nose or throat surgery may also cause this sign in the same way.
Special Considerations
Closely monitor the patient’s vital signs, and watch for signs of shock. Check the patient’s stools regularly for occult blood, and keep accurate intake and output records. Place the patient on bed rest in a low or semi-Fowler’s position to prevent aspiration of vomitus. Keep suctioning equipment nearby, and use it as needed. Provide frequent oral hygiene and emotional support — the sight of bloody vomitus can be very frightening. Administer a histamine-2 receptor antagonist I.V.; vasopressin may be required for variceal hemorrhage. As the bleeding tapers off, monitor the pH of gastric contents, and give hourly doses of antacids by NG tube, as necessary.
Patient Teaching
Explain which foods and fluids the patient should avoid, and stress the importance of avoiding alcohol.
Pediatric Pointers
Hematemesis is much less common in children than in adults and may be related to foreign body ingestion. Occasionally, neonates develop hematemesis after swallowing maternal blood during delivery or breast-feeding from a cracked nipple. Hemorrhagic disease of the neonate and esophageal erosion may also cause hematemesis in infants; such cases require immediate fluid replacement.
Geriatric Pointers
In elderly patients, hematemesis may be caused by a vascular anomaly, an aortoenteric fistula, or
upper GI cancer. In addition, chronic obstructive pulmonary disease, chronic liver or renal failure, and chronic NSAID use all predispose elderly people to hemorrhage secondary to coexisting ulcerative disorders.
REFERENCES
Al-Ebrahim, F. , Khan, K. J., Alhazzani, W. , Alnemer, A . , Alzahrani, A. , Marshall, J., & Armstrong, D. (2012) . Safety of esophagogastroduodenoscopy within 30 days of myocardial infarction: A retrospective cohort study from a Canadian tertiary centre .
Canadian Journal of Gastroenterology, 26, 151–154.
Cappell, M. S. (2009) . Problems with combining together EGD, PEG, flexible sigmoidoscopy, and colonoscopy to analyze risks of endoscopic procedures after MI: A call for stratifying risk according to individual endoscopic procedures . Journal of Clinical Gastroenterology, 43, 98–99.
Hematochezia[Rectal bleeding]
The passage of bloody stools, also known as hematochezia, usually indicates — and may be the first sign of — GI bleeding below the ligament of Treitz. However, this sign — usually preceded by hematemesis — may also accompany rapid hemorrhage of 1 L or more from the upper GI tract.
Hematochezia ranges from formed, blood-streaked stools to liquid, bloody stools that may be bright red, dark mahogany, or maroon in color. This sign usually develops abruptly and is heralded by abdominal pain.
Although hematochezia is commonly associated with GI disorders, it may also result from a coagulation disorder, exposure to toxins, or certain diagnostic tests. Always a significant sign, hematochezia may precipitate life-threatening hypovolemia.
EMERGENCY INTERVENTIONS
If the patient has severe hematochezia, check his vital signs. If you detect signs of shock, such as hypotension and tachycardia, place the patient in a supine position and elevate his feet 20 to 30 degrees. Prepare to administer oxygen, and start a large-bore I.V. line for emergency fluid replacement. Next, obtain a blood sample for typing and crossmatching, hemoglobin level, and hematocrit. Insert a nasogastric tube. Iced lavage may be indicated to control bleeding. Endoscopy may be necessary to detect the source of bleeding.
History and Physical Examination
If hematochezia isn’t immediately life threatening, ask the patient to fully describe the amount, color, and consistency of his bloody stools. (If possible, also inspect and characterize the stools yourself.) How long have the stools been bloody? Do they always look the same, or does the amount of blood seem to vary? Ask about associated signs and symptoms.
Next, explore the patient’s medical history, focusing on GI and coagulation disorders. Ask about the use of GI irritants, such as alcohol, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs).
Begin the physical examination by checking for orthostatic hypotension, an early sign of shock. Take the patient’s blood pressure and pulse while he’s lying down, sitting, and standing. If systolic pressure decreases by 10 mm Hg or more or if the pulse rate increases by 10 beats/minute or more
when he changes position, suspect volume depletion and impending shock.
Examine the skin for petechiae or spider angiomas. Palpate the abdomen for tenderness, pain, or masses. Also, note lymphadenopathy. Finally, a digital rectal examination must be done to rule out rectal masses or hemorrhoids.
Medical Causes
Anal fissure. Slight hematochezia characterizes anal fissure; blood may streak the stools or appear on toilet tissue. Accompanying hematochezia is severe rectal pain that may make the patient reluctant to defecate, thereby causing constipation.
Angiodysplastic lesions. Most common in elderly patients, these arteriovenous lesions of the ascending colon typically cause chronic, bright red rectal bleeding. Occasionally, this painless hematochezia may result in life-threatening blood loss and signs of shock, such as tachycardia and hypotension.
Coagulation disorders. Patients with a coagulation disorder (such as thrombocytopenia and disseminated intravascular coagulation) may experience GI bleeding marked by moderate to severe hematochezia. Bleeding may also occur in other body systems, producing such signs as epistaxis and purpura. Associated findings vary with the specific coagulation disorder.
Colitis. Ischemic colitis commonly causes bloody diarrhea, especially in elderly patients. Hematochezia may be slight or massive and is usually accompanied by severe, cramping lower abdominal pain, and hypotension. Other effects include abdominal tenderness, distention, and absent bowel sounds. Severe colitis may cause life-threatening hypovolemic shock and peritonitis.
Ulcerative colitis typically causes bloody diarrhea that may also contain mucus. Hematochezia is preceded by mild to severe abdominal cramps and may cause slight to massive blood loss. Associated signs and symptoms include fever, tenesmus, anorexia, nausea, vomiting, hyperactive bowel sounds and, occasionally, tachycardia. Weight loss and weakness occur late.
Colon cancer. Bright red rectal bleeding with or without pain is a telling sign, especially in cancer of the left colon.
Usually, a left colon tumor causes early signs of obstruction, such as rectal pressure, bleeding, and intermittent fullness or cramping. As the disease progresses, the patient also develops obstipation, diarrhea or ribbon-shaped stools, and pain, which is typically relieved by the passage of stools or flatus. Stools are grossly bloody.
Early tumor growth in the right colon may cause melena, abdominal aching, pressure, and dull cramps. As the disease progresses, the patient develops weakness and fatigue. Later, he may also experience diarrhea, anorexia, weight loss, anemia, vomiting, an abdominal mass, and signs of obstruction, such as abdominal distention and abnormal bowel sounds.
Colorectal polyps. Colorectal polyps are the most common cause of intermittent hematochezia in adults younger than age 60; however, sometimes such polyps produce no symptoms. When located high in the colon, polyps may cause blood-streaked stools. The stools yield a positive response when tested with guaiac. If the polyps are located closer to the rectum, they may bleed freely.
Diverticulitis. Most common in the elderly patient, diverticulitis can suddenly cause mild to moderate rectal bleeding after the patient feels the urge to defecate. The bleeding may end abruptly or may progress to life-threatening blood loss with signs of shock. Associated signs and