Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015

acute onset of myoclonus and confusion.

Special Considerations

If the patient’s myoclonus is progressive, take seizure precautions. Keep an oral airway and suction equipment at his bedside, and pad the side rails. Because myoclonus may cause falls, remove potentially harmful objects from the patient’s environment, and remain with him while he walks. Be sure to instruct the patient and his family about the need for safety precautions.

As needed, administer drugs that suppress myoclonus: ethosuximide, L-5-hydroxytryptophan, phenobarbital, clonazepam, or carbidopa. An EEG may be needed to evaluate myoclonus and related brain activity.

Patient Counseling

Discuss safety measures and seizure precautions with the patient. Refer the patient to social service or community resources, as needed.

Pediatric Pointers

Although myoclonus is relatively uncommon in infants and children, it can result from subacute sclerosing panencephalitis, severe meningitis, progressive poliodystrophy, childhood myoclonic epilepsy, and encephalopathies such as Reye’s syndrome.

REFERENCES

Civardi, C. , Collini, A. , Stecco, A. , Carriero, A., & Monaco, F. (2010) . Neurological picture. Putamen hyperperfusion in subcorticalsupraspinal myoclonus. Journal of Neurology, Neurosurgery and Psychiatry, 81, 330.

Dijk, J. M., & Tijssen, M. A. (2010). Management of patients with myoclonus: Available therapies and the need for an evidence-based approach. Lancet Neurology, 9, 1028–1036.

N

Nasal Flaring

Nasal flaring is the abnormal dilation of the nostrils. Usually occurring during inspiration, nasal flaring may occasionally occur during expiration or throughout the respiratory cycle. It indicates respiratory dysfunction, ranging from mild difficulty to potentially life-threatening respiratory distress.

EMERGENCY INTERVENTIONS

If you note nasal flaring in the patient, quickly evaluate his respiratory status. Absent breath sounds, cyanosis, diaphoresis, and tachycardia point to complete airway obstruction. As necessary, deliver back blows or abdominal thrusts (Heimlich’s maneuver) to relieve the obstruction. If these don’t clear the airway, emergency intubation or tracheostomy and mechanical ventilation may be necessary.

If the patient’s airway isn’t obstructed but he displays breathing difficulty, give oxygen by nasal cannula or face mask and obtain baseline vital signs. Intubation and mechanical ventilation may be necessary. Insert an I.V. line for fluid and drug access. Begin cardiac monitoring. Obtain a chest X- ray and samples for arterial blood gas (ABG) analysis and electrolyte studies.

History and Physical Examination

When the patient’s condition is stabilized, obtain a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection, or trauma? Does the patient smoke or have a history of smoking? Obtain a drug history.

Medical Causes

Acute respiratory distress syndrome (ARDS). ARDS causes increased respiratory difficulty and hypoxemia, with nasal flaring, dyspnea, tachypnea, diaphoresis, cyanosis, scattered crackles, and rhonchi. It also produces tachycardia, anxiety, and a decreased level of consciousness (LOC).

Airway obstruction. Complete obstruction above the tracheal bifurcation causes sudden nasal flaring, absent breath sounds despite intercostal retractions and marked accessory muscle use, tachycardia, diaphoresis, cyanosis, a decreasing LOC and, eventually, respiratory arrest.

Partial obstruction causes nasal flaring with inspiratory stridor, gagging, wheezing, a violent cough, marked accessory muscle use, agitation, cyanosis, and hoarseness.

Anaphylaxis. Severe reactions can produce respiratory distress with nasal flaring, stridor,

wheezing, accessory muscle use, intercostal retractions, and dyspnea. Associated signs and symptoms include nasal congestion, sneezing, pruritus, urticaria, erythema, diaphoresis, angioedema, weakness, hoarseness, dysphagia and, rarely, vomiting, nausea, diarrhea, urinary urgency, and incontinence. Cardiac arrhythmias and signs of shock may occur late.

Asthma (acute). An asthma attack can cause nasal flaring, dyspnea, tachypnea, prolonged expiratory wheezing, accessory muscle use, cyanosis, and a dry or productive cough. Auscultation may reveal rhonchi, crackles, and decreased or absent breath sounds. Other findings include anxiety, tachycardia, and increased blood pressure.

Blast lung injury. Nasal flaring may occur as an immediate response to the powerful gust of explosive metals or chemical or biological agents strewn at the victim in a blast lung injury. Patients may also display the following respiratory symptoms: dyspnea, hemoptysis, cough, tachypnea, hypoxia, wheezing, apnea, cyanosis, decreased breath sounds, and hemodynamic instability. Chest X-rays, ABG measurements, computerized tomography scans, and Doppler technology are common diagnostic tools. Treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved. Global acts of terrorism have increased the incidence of this condition.

Chronic obstructive pulmonary disease (COPD). COPD can lead to acute respiratory failure secondary to pulmonary infection or edema. Nasal flaring is accompanied by prolonged pursedlip expiration; accessory muscle use; a loose, rattling, productive cough; cyanosis; reduced chest expansion; crackles; rhonchi; wheezing; and dyspnea.

Pneumothorax. Pneumothorax is an acute disorder that can result in respiratory distress with nasal flaring, dyspnea, tachypnea, shallow respirations, hyperresonance or tympany on percussion, agitation, jugular vein distention, tracheal deviation, and cyanosis. Other findings typically include sharp chest pain, tachycardia, hypotension, cold and clammy skin, diaphoresis, subcutaneous crepitation, and anxiety. Breath sounds may be decreased or absent on the affected side; similarly, chest wall motion may be decreased on the affected side.

Similar findings can occur with hydrothorax, chylothorax, or hemothorax, depending on the amount of fluid accumulation.

Popcorn lung disease. Nasal flaring occurs as a later sign as this disease progresses. The first onset of symptoms, including coughing, wheezing, and shortness of breath on exertion, usually occurs gradually and worsens over time. The National Institute for Occupational Safety and Health (NIOSH) investigated the first reported cases of this disease in 2000 when eight former employees who worked in a microwave popcorn flavoring plant were diagnosed with bronchiolitis obliterans, the most severe form of this disease. Diagnostic tests include spirometry, chest X-rays, computerized tomography, lung biopsy, and pulmonary function tests.

Pulmonary edema. Pulmonary edema typically produces nasal flaring, severe dyspnea, wheezing, and a cough that produces frothy, pink sputum. Increased accessory muscle use may occur with tachycardia, cyanosis, hypotension, crackles, jugular vein distention, peripheral edema, and a decreased LOC.

Pulmonary embolus. Signs of pulmonary embolus, a potentially life-threatening disorder, may include nasal flaring, dyspnea, tachypnea, wheezing, cyanosis, a pleural friction rub, and a productive cough (possibly hemoptysis). Its other effects include sudden chest tightness or pleuritic pain, tachycardia, atrial arrhythmias, hypotension, a low-grade fever, syncope, marked anxiety, and restlessness.

Respiratory syncytial virus (RSV). Nasal flaring typically occurs in patients with RSV

bronchiolitis or pneumonia and with infections of the lower respiratory tract — commonly seen in children under age 1 year. Other symptoms include apnea, coughing, rapid breathing, wheezing, fever, and chest retractions. In healthy adults and children aged 3 years and older, RSV usually causes mild cold-like signs and symptoms; patients typically recover within 8 to 15 days without sequelae. However, premature infants and those with underlying respiratory, cardiac, neuromuscular, and immunological conditions require special consideration.

Other Causes

Diagnostic tests. Pulmonary function tests, such as vital capacity testing, can produce nasal flaring with forced inspiration or expiration.

Treatments. Certain respiratory treatments, such as deep breathing, can cause nasal flaring.

Special Considerations

To help ease breathing, place the patient in high Fowler’s position. If he’s at risk for aspirating secretions, place him in a modified Trendelenburg’s or side-lying position. If necessary, suction frequently to remove oropharyngeal secretions. Administer humidified oxygen to thin secretions and decrease airway drying and irritation. Provide adequate hydration to liquefy secretions. Reposition the patient every hour, and encourage coughing and deep breathing. Avoid administering sedatives or opiates, which can depress the cough reflex or respirations. Continually assess the patient’s respiratory status, and check his vital signs and oxygen saturation every 30 minutes, or as necessary.

Prepare the patient for diagnostic tests, such as chest X-rays, a lung scan, pulmonary arteriography, sputum culture, complete blood count, ABG analysis, and 12-lead electrocardiogram.

Patient Counseling

Explain all procedures and treatments to the patient or parents, if the patient is a child, and review how to treat the underlying disorder. Discuss the continued importance of not smoking. Demonstrate the correct way to use an inhaler, if one is prescribed.

Pediatric Pointers

Nasal flaring is an important sign of respiratory distress in infants and very young children, who can’t verbalize their discomfort. Common causes include airway obstruction, hyaline membrane disease, croup, and acute epiglottiditis. The use of a croup tent may improve oxygenation and humidification for such patients.

REFERENCES

Berkowitz, C. D. (2012). Berkowitz’s pediatrics: A primary care approach (4th ed.). USA: American Academy of Pediatrics. Colyar, M. R.(2003). Well-child assessment for primary care providers. Philadelphia, PA: F.A. Davis.

Gott, K., & Froh, D. K. (2010). Alterations of pulmonary function in children. In K. L. McCance, S. E. Huether, V. L. Brashers, & N. S. Rote (Eds.), Pathophysiology: The biologic basis for disease in adults and children (pp. 1310–1343). Maryland Heights, MO: Mosby Elsevier.

Murphy, D. P. (2008). Dyspnea. In Primary care: A collaborative practice (pp. 444–447). St. Louis, MO: Mosby Elsevier.

Nausea

Nausea is a sensation of profound revulsion to food or of impending vomiting. Typically accompanied by autonomic signs, such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, it’s closely associated with anorexia and vomiting.

Nausea, a common symptom of GI disorders, also occurs with fluid and electrolyte imbalance; infection; metabolic, endocrine, labyrinthine, and cardiac disorders; and as a result of drug therapy, surgery, and radiation. Commonly present during the first trimester of pregnancy, nausea may also arise from severe pain, anxiety, alcohol intoxication, overeating, or ingestion of distasteful food or liquids.

History and Physical Examination

Begin by obtaining a complete medical history. Focus on GI, endocrine, and metabolic disorders; recent infections; and cancer and its treatment. Ask about drug use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Have the patient describe the onset, duration, and intensity of the nausea as well as what causes or relieves it. Ask about related complaints, particularly vomiting (color, amount), abdominal pain, anorexia and weight loss, changes in bowel habits or stool character, excessive belching or flatus, and a sensation of bloating.

Inspect the skin for jaundice, bruises, and spider angiomas, and assess skin turgor. Next, inspect the abdomen for distention, auscultate for bowel sounds and bruits, palpate for rigidity and tenderness, and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

Medical Causes

Adrenal insufficiency. Common GI findings in adrenal insufficiency include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; hypotension; a weak, irregular pulse; vitiligo; and depression.

Anthrax (GI). Initial signs and symptoms include nausea, vomiting, loss of appetite, and a fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis. Appendicitis. With acute appendicitis, a brief period of nausea may accompany the onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, a fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

Cholecystitis (acute). With acute cholecystitis, nausea commonly follows severe right upper quadrant pain that may radiate to the back or shoulders, usually following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, a fever with chills, diaphoresis, and a positive Murphy’s sign.

Cholelithiasis. With cholelithiasis, nausea accompanies attacks of severe right upper quadrant

or epigastric pain after eating fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, a fever, and chills.

Cirrhosis. Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

Diverticulitis. Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, a low-grade fever, and commonly a palpable, tender, firm, fixed mass. Escherichia coli O157:H7. Signs and symptoms include nausea, watery or bloody diarrhea, vomiting, a fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic-uremic syndrome — in which red blood cells are destroyed — may develop. This may ultimately lead to acute renal failure.

Gastritis. Nausea is common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, a fever, and malaise may also occur.

Gastroenteritis. Usually viral, gastroenteritis causes nausea, vomiting, diarrhea, and abdominal cramping. A fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

Heart failure. Heart failure may produce nausea and vomiting, particularly with right-sided heart failure. Associated findings include tachycardia, a ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

Hepatitis. Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, a headache, anorexia, photophobia, pharyngitis, a cough, and a fever also occur early in the preicteric phase.

Hyperemesis gravidarum. Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of hyperemesis gravidarum, a pregnancy disorder. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffee-ground appearance in later stages. Associated findings include weight loss, signs of dehydration, a headache, and delirium.

Intestinal obstruction. Nausea commonly occurs, especially with high small intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky but can become severe and steady with strangulation. Constipation occurs early in large intestinal obstruction and later in small intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

Labyrinthitis. Nausea and vomiting commonly occur with labyrinthitis, an acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

Listeriosis. Signs and symptoms include nausea, vomiting, diarrhea, a fever, myalgia, and abdominal pain. If listeriosis spreads to the nervous system and causes meningitis, signs and

symptoms include a fever, a headache, nuchal rigidity, and a change in the level of consciousness (LOC).

GENDER CUE

Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or still birth.

Ménière’s disease. Ménière’s disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

Mesenteric venous thrombosis. An insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena. Metabolic acidosis. Metabolic acidosis is an acid-base imbalance that may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and a decreased LOC.

Migraine headache. Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

Motion sickness. With motion sickness, nausea and vomiting are brought on by motion or rhythmic movement. A headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

Myocardial infarction. Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

Norovirus. Nausea, along with other classic gastroenteritis symptoms, is common with norovirus infections. Symptoms last approximately 24 to 60 hours and are usually self-limiting. Additionally, the patient may report abdominal pain, abdominal cramps, diarrhea, weight loss, low-grade fever, and malaise. In elderly and very young patients and those with underlying diseases, symptoms can be severe. Patients can continue to shed the virus in their stools for up to several weeks following infection.

Pancreatitis (acute). Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and a fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.

Peptic ulcer. With peptic ulcer, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty or after the ingestion of alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or antisecretory. Hematemesis or melena may also occur.

Peritonitis. Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include a high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); a positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

Preeclampsia. Nausea and vomiting commonly occur with preeclampsia — a pregnancy disorder — along with rapid weight gain, epigastric pain, oliguria, a severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs includes hypertension, proteinuria, and edema.

Q fever. Signs and symptoms include nausea, vomiting, diarrhea, a fever, chills, a severe headache, malaise, and chest pain. The fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Rhabdomyolysis. Signs and symptoms include nausea, vomiting, muscle weakness or pain, a fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys’ attempt to filter myoglobin from the bloodstream.

Typhus. An abrupt onset of nausea, vomiting, a fever, and chills follows the initial symptoms of a headache, myalgia, arthralgia, and malaise.

Other Causes

Drugs. Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal anti-inflammatory drugs.

HERB ALERT

Herbal remedies, such as Ginkgo biloba and St. John’s wort, can produce adverse reactions, including nausea.

Radiation and surgery. Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

Special Considerations

If the patient is experiencing severe nausea, prepare him for blood tests to determine fluid and electrolyte status and acid-base balance. Have him breathe deeply to ease his nausea; keep his room air fresh and clean-smelling by removing bedpans and emesis basins promptly after use and by providing adequate ventilation. Because he could easily aspirate vomitus when in a supine position, elevate his head or position him on his side.

Because pain can precipitate or intensify nausea, administer pain medications promptly, as needed. If possible, give medications by injection or suppository to prevent exacerbating nausea. Be alert for abdominal distention and hypoactive bowel sounds when you administer an antiemetic: these signs may indicate gastric retention. If you detect these, immediately insert a nasogastric tube, as required.

Prepare the patient for such procedures as a computed tomography scan, an ultrasound scan, endoscopy, and colonoscopy. Consult the nutritionist to determine the patient’s metabolic demands such as total or partial parenteral nutrition.

specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there isn’t a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck Pain: Common Causes and Associated Findings, pages 506 and 507.)

Medical Causes

Ankylosing spondylitis. Intermittent, moderate to severe neck pain and stiffness with a severely restricted range of motion (ROM) is characteristic of ankylosing spondylitis. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include a low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

Applying a Philadelphia Collar

A lightweight molded polyethylene collar designed to hold the neck straight with the chin slightly elevated and tucked in, the Philadelphia cervical collar immobilizes the cervical spine, decreases muscle spasms, and relieves some pain. It also prevents further injury and promotes healing. When applying the collar, fit it snugly around the patient’s neck and attach the Velcro fasteners or buckles at the back. Be sure to check the patient’s airway and his neurovascular status to ensure that the collar isn’t too tight. Also, make sure that the collar isn’t placed too high in front, which can hyperextend the neck. In a patient with a neck sprain, hyperextension may cause the ligaments to heal in a shortened position; in a patient with a cervical spine fracture, it could cause serious neurologic damage.