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

(Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?

Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then, obtain a complete drug history.

Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.

Medical Causes

Anemia (iron deficiency). Iron deficiency anemia occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, a headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails (cheilosis), cracked mouth corners, a smooth tongue (glossitis), and dysphagia.

Anthrax (cutaneous). Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. It can occur in humans who are exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or an abrasion on the skin. The infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, it develops into a vesicle and then a painless ulcer with a characteristic black, necrotic center. Lymphadenopathy, malaise, a headache, or a fever may develop.

Conjunctivitis. All forms of conjunctivitis cause eye itching, burning, and pain along with photophobia, conjunctival injection, a foreign body sensation, excessive tearing, and a feeling of fullness around the eye. Allergic conjunctivitis may also cause milky redness and a stringy eye discharge. Bacterial conjunctivitis typically causes brilliant redness and a mucopurulent discharge that may make the eyelids stick together. Fungal conjunctivitis produces a thick, purulent discharge and crusting and sticking of the eyelid. Viral conjunctivitis may cause copious tearing — but little discharge — and preauricular lymph node enlargement.

Dermatitis. Several types of dermatitis can cause pruritus accompanied by a skin lesion. Atopic dermatitis begins with intense, severe pruritus and an erythematous rash on dry skin at flexion points (antecubital fossa, popliteal area, and neck). During a flareup, scratching may produce edema, scaling, and pustules. With chronic atopic dermatitis, lesions may progress to dry, scaly skin with white dermatographia, blanching, and lichenification.

Mild irritants and allergies can cause contact dermatitis, with itchy small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.

Dermatitis herpetiformis, most common in men between ages 20 and 50, initially causes intense pruritus and stinging. Between 8 and 12 hours later, symmetrically distributed lesions form on the buttocks, shoulders, elbows, and knees. Sometimes, they also form on the neck, face, and

scalp. These lesions are erythematous and papular, bullous, or pustular.

Hepatobiliary disease. An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right upper quadrant pain, clay-colored stools, chills and a fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.

Herpes zoster. Within 2 to 4 days of a fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.

Leukemia (chronic lymphocytic). Pruritus is an uncommon finding in leukemia. More characteristic signs and symptoms include fatigue, malaise, generalized lymphadenopathy, a fever, hepatomegaly, splenomegaly, weight loss, pallor, bleeding, and palpitations.

Lichen simplex chronicus. Persistent rubbing and scratching cause localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form. Myringitis (chronic). Myringitis produces pruritus in the affected ear, along with a purulent discharge and gradual hearing loss.

Pediculosis. A prominent symptom, pruritus occurs in the area of infestation. Pediculosis capitis (head lice) may also cause scalp excoriation from scratching, along with matted, foul-smelling, lusterless hair; occipital and cervical lymphadenopathy; and oval, gray-white nits on hair shafts. Pediculosis corporis (body lice) initially causes small red papules (usually on the shoulders, trunk, or buttocks), which become urticarial from scratching. Later, rashes or wheals may develop. Untreated, pediculosis corporis produces dry, discolored, thickly encrusted, scaly skin with bacterial infection and scarring. In severe cases, it produces a headache, a fever, and malaise.

With pediculosis pubis (pubic lice), scratching commonly produces skin irritation. Nits or adult lice and erythematous, itching papules may appear in pubic hair or in hair around the anus, abdomen, or thighs.

Pityriasis rosea. Pityriasis rosea occasionally produces mild pruritus that’s aggravated by a hot bath or shower. It usually begins with an erythematous herald patch — a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tan or erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.

Psoriasis. Pruritus and pain are common in psoriasis. This skin disorder typically begins with small erythematous papules that enlarge or coalesce to form red elevated plaques with silver scales on the scalp, chest, elbows, knees, back, buttocks, and genitals. Nail pitting may occur.

Scabies. Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist for up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.

face, hands, and feet of adolescents.

Some childhood diseases, such as measles and chickenpox, can cause pruritus.

REFERENCES

Buttaro, T. M., Tybulski, J., Bailey, P. P. , & Sandberg-Cook, J. (2008) . Primary care: A collaborative practice (pp. 444–447) . St. Louis, MO: Mosby Elsevier.

Colyar, M. R. (2003). Well-child assessment for primary care providers. Philadelphia, PA: F.A. Davis. Lehne, R. A. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders Elsevier.

McCance, K. L., Huether, S. E., Brashers, V. L. , & Rote, N. S. (2010). Pathophysiology: The biologic basis for disease in adults and children. Maryland Heights, MO: Mosby Elsevier.

Schuiling, K. D. (2013). Women’s gynecologic health. Burlington, MA: Jones & Bartlett Learning. Sommers, M. S., & Brunner, L. S. (2012). Pocket diseases. Philadelphia, PA: F.A. Davis.

Wolff, K., & Johnson, R. A. (2009). Fitzpatrick’s color atlas & synopsis of clinical dermatology (6th ed.). New York, NY: McGraw Hill Medical.

Psoas Sign

A positive psoas sign — increased abdominal pain when the patient moves his leg against resistance

— indicates direct or reflexive irritation of the psoas muscles. This sign, which can be elicited on the right or left side, usually indicates appendicitis, but may also occur with localized abscesses. It’s elicited in a patient with abdominal or lower back pain after completion of an abdominal examination to prevent spurious assessment findings. (See Eliciting a Psoas Sign.)

EMERGENCY INTERVENTIONS

If you elicit a positive psoas sign in a patient with abdominal pain, suspect appendicitis. Quickly check the patient’s vital signs, and prepare him for surgery: Explain the procedure, restrict food and fluids, and withhold analgesics, which can mask symptoms. Administer I.V. fluids to prevent dehydration, but don’t give a cathartic or an enema, because it can cause a ruptured appendix and lead to peritonitis.

Check for Rovsing’s sign by deeply palpating the patient’s left lower quadrant. If he reports pain in the right lower quadrant, the sign is positive, indicating peritoneal irritation.

Medical Causes

Appendicitis. An inflamed retrocecal appendix can cause a positive right psoas sign. Early epigastric and periumbilical pain disappears, only to worsen and localize in the right lower quadrant. This pain also worsens with walking or coughing. Related findings include nausea and vomiting, abdominal rigidity and rebound tenderness, and constipation or diarrhea. A fever, tachycardia, retractive respirations, anorexia, and malaise may also occur. If the appendix ruptures, additional findings may include sudden, severe pain, followed by signs of peritonitis, such as hypoactive or absent bowel sounds, a high fever, and boardlike abdominal rigidity. A positive obturator sign may also be evident.

Retroperitoneal abscess. After a lower retroperitoneal infection, an iliac or lumbar abscess can produce a positive right or left psoas sign and a fever. An iliac abscess causes iliac or inguinal

pain that may radiate to the hip, thigh, flank, or knee; a tender mass in the lower abdomen or groin may be palpable. A lumbar abscess usually produces back tenderness and spasms on the affected side with a palpable lumbar mass; a tender abdominal mass without back pain may occur instead.

Special Considerations

Monitor the patient’s vital signs to detect complications, such as pain extension along fascial planes in the abdomen, thigh, hip, subphrenic spaces, mediastinum, and pleural cavities, and peritonitis. Promote patient comfort by helping with position changes. For example, have the patient lie down and flex his right leg. Then, have him sit upright.

Prepare the patient for diagnostic tests, such as electrolyte studies and abdominal X-rays.

Pediatric Pointers

Elicit a psoas sign by asking the child to raise his head while you exert pressure on his forehead. Resulting right lower quadrant pain usually indicates appendicitis.

Patient Counseling

Teach the patient about the underlying cause of his condition and its treatments. Discuss signs and symptoms that require immediate attention, and teach the patient how to report pain using a pain rating scale.

Geriatric Pointers

In elderly patients, the psoas sign and other peritoneal signs may be decreased or absent. Make sure to differentiate pain elicited through psoas maneuvers from musculoskeletal or degenerative joint pain.

EXAMINATION TIP Eliciting a Psoas Sign

You can use two techniques to elicit a psoas sign in an adult with abdominal pain. With either technique, increased abdominal pain is a positive result, indicating psoas muscle irritation from an inflamed appendix or a localized abscess.

With the patient in a supine position, instruct her to move her flexed left leg against your hand to test for a left psoas sign. Then, perform this maneuver on the right leg to test for a right psoas sign.