Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015
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Pediatric Pointers
Children who complain of slowly progressive vision loss may have an optic nerve glioma (a slowgrowing, usually benign, tumor) or retinoblastoma (a malignant tumor of the retina). Congenital rubella and syphilis may cause vision loss in infants. Retrolental fibroplasia may cause vision loss in premature infants. Other congenital causes of vision loss include Marfan’s syndrome, retinitis pigmentosa, and amblyopia.
Geriatric Pointers
In elderly patients, reduced visual acuity may be caused by morphologic changes in the choroid, pigment epithelium, or retina or by decreased function of the rods, cones, and other neural elements. Elderly patients often have difficulty turning their eyes upward. IOP also increases with age.
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. Levin, L. A., & Albert, D. M. (2010). Ocular disease: Mechanisms and management. London, UK: Saunders Elsevier. Roy, F. H. (2012). Ocular differential diagnosis. Clayton, Panama: Jaypee — Highlights Medical Publishers, Inc.
Visual Blurring
Visual blurring is a common symptom that refers to the loss of visual acuity with indistinct visual details. It may result from eye injury, a neurologic or eye disorder, or a disorder with vascular complications, such as diabetes mellitus. Visual blurring may also result from mucus passing over the cornea, a refractive error, improperly fitted contact lenses, or certain drugs.
History and Physical Examination
If your patient has visual blurring accompanied by sudden, severe eye pain, a history of trauma, or sudden vision loss, order an ophthalmologic examination. (See Managing Sudden Vision Loss , page 738.) If the patient has a penetrating or perforating eye injury, don’t touch the eye.
If the patient isn’t in distress, ask him how long he has had the visual blurring. Does it occur only at certain times? Ask about associated signs and symptoms, such as pain or discharge. If visual blurring followed injury, obtain details of the accident, and ask if vision was impaired immediately after the injury. Obtain a medical and drug history.
Inspect the patient’s eye, noting lid edema, drainage, or conjunctival or scleral redness. Also note an irregularly shaped iris, which may indicate previous trauma, and excessive blinking, which may indicate corneal damage. Assess the patient for pupillary changes, and test visual acuity in both eyes. (See Testing Visual Acuity, page 740.)
Medical Causes
Brain tumor. Visual blurring may occur with a brain tumor. Associated findings include decreased level of consciousness (LOC), headache, apathy, behavioral changes, memory loss, decreased attention span, dizziness, and confusion. A tumor can also cause aphasia, seizures,
ataxia, and signs of hormonal imbalance. Its later effects are papilledema, vomiting, increased systolic blood pressure, widened pulse pressure, and decorticate posture.
Cataract. Cataract is a painless disorder that causes gradual visual blurring. Other effects include halo vision (an early sign), visual glare in bright light, progressive vision loss, and a gray pupil that later turns milky white.
Concussion. Immediately or shortly after blunt head trauma, vision may be blurred, double, or temporarily lost. Other findings include changes in LOC and behavior.
Corneal abrasions. Visual blurring may occur with severe eye pain, photophobia, redness, and excessive tearing.
Corneal foreign bodies. Visual blurring may accompany a foreign-body sensation, excessive tearing, photophobia, intense eye pain, miosis, conjunctival injection, and a dark corneal speck. Diabetic retinopathy. Retinal edema and hemorrhage produce gradual blurring, which may progress to blindness.
Dislocated lens. Dislocation of the lens, especially beyond the line of vision, causes visual blurring and (with trauma) redness.
Eye tumor. If the tumor involves the macula, visual blurring may be the presenting symptom. Related findings include varying visual field losses.
Glaucoma. With acute angle-closure glaucoma, an ocular emergency, unilateral visual blurring and severe pain begin suddenly. Other findings include halo vision; a moderately dilated, nonreactive pupil; conjunctival injection; a cloudy cornea; and decreased visual acuity. Severely elevated intraocular pressure may cause nausea and vomiting.
With chronic angle-closure glaucoma, transient visual blurring and halo vision may precede pain and blindness.
Hereditary corneal dystrophies. Visual blurring may remain stable or may progressively worsen throughout life. Some dystrophies cause associated pain, vision loss, photophobia, tearing, and corneal opacities.
Hypertension. Hypertension may cause visual blurring and a constant morning headache that decreases in severity during the day. If diastolic blood pressure exceeds 120 mm Hg, the patient may report a severe, throbbing headache. Associated findings include restlessness, confusion, nausea, vomiting, seizures, and decreased LOC.
Hyphema. Blunt eye trauma with hemorrhage into the anterior chamber causes visual blurring. Other effects include moderate pain, diffuse conjunctival injection, visible blood in the anterior chamber, ecchymoses, eyelid edema, and a hard eye.
Iritis. Acute iritis causes sudden visual blurring, moderate to severe eye pain, photophobia, conjunctival injection, and a constricted pupil.
Optic neuritis. Inflammation, degeneration, or demyelinization of the optic nerve usually causes an acute attack of visual blurring and vision loss. Related findings include scotomas and eye pain. Ophthalmoscopic examination reveals hyperemia of the optic disk, large vein distention, blurred disk margins, and filling of the physiologic cup.
Retinal detachment. Sudden visual blurring may be the initial symptom of retinal detachment. Blurring worsens, accompanied by visual floaters and recurring flashes of light. Progressive detachment increases vision loss.
Retinal vein occlusion (central). Retinal vein occlusion causes gradual unilateral visual blurring and varying degrees of vision loss.
Senile macular degeneration. Senile macular degeneration may cause visual blurring (initially worse at night) and slowly or rapidly progressive vision loss.
Stroke. Brief attacks of bilateral visual blurring may precede or accompany a stroke. Associated findings include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, and apraxia. Stroke may also cause agnosia, aphasia, homonymous hemianopia, diplopia, disorientation, memory loss, and poor judgment. Other features include urine retention or urinary incontinence, constipation, personality changes, emotional lability, headache, vomiting, and seizures.
Temporal arteritis. Most common in women older than age 60, this disorder causes sudden blurred vision accompanied by vision loss and a throbbing unilateral headache in the temporal or frontotemporal region. Prodromal signs and symptoms include malaise, anorexia, weight loss, weakness, low-grade fever, and generalized muscle aches. Other findings include confusion; disorientation; swollen, nodular, tender temporal arteries; and erythema of overlying skin.
Vitreous hemorrhage. Sudden unilateral visual blurring and varying vision loss occur with this condition. Visual floaters or dark streaks may also occur.
Other Causes
Drugs. Visual blurring may stem from the effects of cycloplegics, reserpine, clomiphene, phenylbutazone, thiazide diuretics, antihistamines, anticholinergics, or phenothiazines.
Special Considerations
Prepare the patient for diagnostic tests, such as tonometry, slit-lamp examination, X-rays of the skull and orbit and, if a neurologic lesion is suspected, a computed tomography scan. As necessary, teach him how to instill ophthalmic medication. If visual blurring leads to permanent vision loss, provide emotional support, orient him to his surroundings, and provide for his safety. If necessary, prepare him for surgery.
Patient Counseling
Teach the patient the correct way to instill eye drops. Instruct him in safety measures, and emphasize the importance of remaining oriented to his environment.
Pediatric Pointers
Visual blurring in children may stem from congenital syphilis, congenital cataracts, refractive errors, eye injuries or infections, and increased intracranial pressure. Refer the child to an ophthalmologist if appropriate.
Test vision in school-age children as you would in adults; test children ages 3 to 6 with the Snellen symbol chart. (See Testing Visual Acuity , page 740.) Test toddlers with Allen cards, each illustrated with a familiar object, such as an animal. Ask the child to cover one eye and identify the objects as you flash them. Then, ask him to identify them as you gradually back away. Record the maximum distance at which he can identify at least three pictures.
Geriatric Pointers
Elderly patients may experience increased myopia caused by lens changes. Also, the closest distance at which one can see clearly slowly decreases with age.
REFERENCES
Gerstenblith, A. T., & Rabinowitz, M. P. (2012). The wills eye manual. Philadelphia, PA: Lippincott Williams & Wilkins.
Holland, E. J., Mannis, M. J., & Lee, W. B. (2013) . Ocular surface disease: Cornea, conjunctiva, and tear film. London, UK: Elsevier Saunders.
Roy, F. H. (2012). Ocular differential diagnosis. Clayton, Panama: Jaypee — Highlights Medical Publishers, Inc.
Visual Floaters
Visual floaters are particles of blood or cellular debris that move about in the vitreous. As these enter the visual field, they appear as spots or dots. Chronic floaters may occur normally in elderly or myopic patients. However, the sudden onset of visual floaters commonly signals retinal detachment, an ocular emergency.
EMERGENCY INTERVENTIONS
Sudden onset of visual floaters may signal retinal detachment. Does the patient also see flashing lights or spots in the affected eye? Is he experiencing a curtain-like loss of vision? If so, notify an ophthalmologist immediately. Restrict his eye movements until the diagnosis is made.
History and Physical Examination
If the patient’s condition permits, obtain a drug and allergy history. Ask about any nearsightedness (a predisposing factor), use of corrective lenses, eye trauma, or other eye disorders. Also, ask about a history of granulomatous disease, diabetes mellitus, or hypertension, which may have predisposed him to retinal detachment, vitreous hemorrhage, or uveitis. If appropriate, inspect his eyes for signs of injury, such as bruising or edema, and determine his visual acuity. (See Testing Visual Acuity , page 740.)
Medical Causes
Retinal detachment. Floaters and light flashes appear suddenly in the portion of the visual field where the retina is detached from the choroid. As the retina detaches further (a painless process), gradual vision loss occurs, likened to a cloud or curtain falling in front of the eyes. Ophthalmoscopic examination reveals a gray, opaque, detached retina with an indefinite margin. Retinal vessels appear almost black.
Uveitis (posterior). Uveitis may cause visual floaters accompanied by gradual eye pain, photophobia, blurred vision, and conjunctival injection.
Vitreous hemorrhage. Rupture of retinal vessels produces a shower of red or black dots or a red haze across the visual field. Vision is suddenly blurred in the affected eye, and visual acuity may be greatly reduced.
Special Considerations
Encourage bed rest, and provide a calm environment. Depending on the cause, the patient may require eye patches, surgery, or a corticosteroid or other drug therapy. If bilateral eye patches are necessary
— as with retinal detachment — you will need to ensure the patient’s safety. You should identify yourself when you approach the patient, and orient him to time frequently. Provide sensory stimulation, such as a radio or tape player. Place pillows or towels behind the patient’s head to maintain the appropriate patient position. Be sure to warn him not to touch or rub his eyes and to avoid straining or sudden movements.
Patient Counseling
Instruct the patient to avoid touching or rubbing his eyes and to avoid straining or sudden movements.
Pediatric Pointers
Visual floaters in children usually follow trauma that causes retinal detachment or vitreous hemorrhage. However, they may also result from vitreous debris, a benign congenital condition with no other signs or symptoms.
REFERENCES
Biswas, J. , Krishnakumar, S., & Ahuja, S. (2010) . Manual of ocular pathology. New Delhi, India: Jaypee — Highlights Medical Publishers.
Eagle, R. C. Jr. (2011). Eye pathology: An atlas and text. Philadelphia, PA: Lippincott Williams & Wilkins. Gerstenblith, A. T., & Rabinowitz, M. P. (2012). The wills eye manual. Philadelphia, PA: Lippincott Williams & Wilkins. Levin, L. A., & Albert, D. M. (2010). Ocular disease: Mechanisms and management. London, UK: Saunders Elsevier. Roy, F. H. (2012). Ocular differential diagnosis. Clayton, Panama: Jaypee — Highlights Medical Publishers, Inc.
Vomiting
Vomiting is the forceful expulsion of gastric contents through the mouth. Characteristically preceded by nausea, vomiting results from a coordinated sequence of abdominal muscle contractions and reverse esophageal peristalsis.
A common sign of GI disorders, vomiting also occurs with fluid and electrolyte imbalances; infections; and metabolic, endocrine, labyrinthine, central nervous system (CNS), and cardiac disorders. It can also result from drug therapy, surgery, or radiation.
Vomiting occurs normally during the first trimester of pregnancy, but its subsequent development may signal complications. It can also result from stress, anxiety, pain, alcohol intoxication, overeating, or ingestion of distasteful foods or liquids.
History and Physical Examination
Ask your patient to describe the onset, duration, and intensity of his vomiting. What started the vomiting? What makes it subside? If possible, collect, measure, and inspect the character of the vomitus. (See Vomitus: Characteristics and Causes .) Explore any associated complaints, particularly nausea, abdominal pain, anorexia and weight loss, changes in bowel habits or stools, excessive belching or flatus, and bloating or fullness.
Vomitus: Characteristics and Causes
When you collect a sample of underlying disorder. Here’s what
the patient’s vomitus, observe it carefully for clues to the vomitus may indicate:
BILE-STAINED (GREENISH) VOMITUS
Obstruction below the pylorus, as from a duodenal lesion
BLOODY VOMITUS
Upper GI bleeding (if bright red, may result from gastritis or a peptic ulcer; if dark red, from esophageal or gastric varices)
BROWN VOMITUS WITH A FECAL ODOR
Intestinal obstruction or infarction
BURNING, BITTER-TASTING VOMITUS
Excessive hydrochloric acid in gastric contents
COFFEE-GROUND VOMITUS
Digested blood from slowly bleeding gastric or duodenal lesion
UNDIGESTED FOOD
Gastric outlet obstruction, as from gastric tumor or ulcer
Obtain a medical history, noting GI, endocrine, and metabolic disorders, recent infections, and cancer, including chemotherapy or radiation therapy. Ask about current medication use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Ask which contraceptive method she’s using.
Inspect the abdomen for distention, and auscultate for bowel sounds and bruits. Palpate for rigidity and tenderness, and test for rebound tenderness. Next, palpate and percuss the liver for enlargement. Assess other body systems as appropriate.
During the examination, keep in mind that projectile vomiting unaccompanied by nausea may indicate increased intracranial pressure, a life-threatening emergency. If this occurs in a patient with CNS injury, you should quickly check his vital signs. Be alert for widened pulse pressure or bradycardia.
Medical Causes
Adrenal insufficiency. Common GI findings with the disorder include vomiting, nausea, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; orthostatic hypotension; and weak, irregular pulse.
Anthrax (GI). Initial signs and symptoms after eating contaminated meat from an infected animal include vomiting, loss of appetite, nausea, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.
Appendicitis. Vomiting and nausea may follow or accompany abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe, stabbing pain in the right lower quadrant. The patient generally has a positive McBurney’s sign
— severe pain and tenderness on palpation about 2″ (5 cm) from the right anterior superior spine of the ilium, on a line between that spine and the umbilicus. Associated findings usually include abdominal rigidity and tenderness, anorexia, constipation or diarrhea, cutaneous hyperalgesia, fever, tachycardia, and malaise.
Cholecystitis (acute). With cholecystitis, nausea and mild vomiting commonly follow severe right upper quadrant pain that may radiate to the back or shoulders. Associated findings include abdominal tenderness and, possibly, rigidity and distention, fever, and diaphoresis.
Cholelithiasis. Nausea and vomiting accompany severe unlocalized right upper quadrant or epigastric pain after ingestion of fatty foods. Other findings include abdominal tenderness and guarding, flatulence, belching, epigastric burning, pyrosis, tachycardia, and restlessness.
Cholera. Signs and symptoms include vomiting and abrupt watery diarrhea. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
Cirrhosis. Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, aching abdominal pain, and constipation or diarrhea. Later findings include jaundice, hepatomegaly, and abdominal distention.
Electrolyte imbalances. Such disturbances as hyponatremia, hypernatremia, hypokalemia, and hypercalcemia frequently cause nausea and vomiting. Other effects include arrhythmias, tremors, seizures, anorexia, malaise, and weakness.
Escherichia coli (E. coli) O157:H7. The signs and symptoms of this infection include vomiting, watery or bloody diarrhea, nausea, fever, and abdominal cramps. In children younger than age 5 and the elderly, hemolytic uremic syndrome may develop in which the red blood cells are destroyed, and this may ultimately lead to acute renal failure.
Food poisoning. Vomiting is a common finding of food poisoning, caused by preformed toxins produced by bacteria typically found in foods, such as Bacillus cereus, Clostridium, and Staphylococcus. Diarrhea and fever also usually occur.
Gastric cancer. This rare cancer may produce mild nausea, vomiting (possibly of mucus or blood), anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, melena, and altered bowel habits are also common.
Gastritis. Nausea and vomiting of mucus or blood are common with gastritis, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Epigastric pain, belching, and fever may occur.
Gastroenteritis. Gastroenteritis causes nausea, vomiting (often of undigested food), diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, and abdominal pain and tenderness may also occur.
Heart failure. Nausea and vomiting may occur, especially with right-sided heart failure. Associated findings include tachycardia, ventricular gallop, fatigue, dyspnea, crackles, peripheral edema, and jugular vein distention.
Hepatitis. Vomiting commonly follows nausea as an early sign of viral hepatitis. Other early findings include fatigue, myalgia, arthralgia, headache, photophobia, anorexia, pharyngitis, cough, and fever.
Hyperemesis gravidarum. Unremitting nausea and vomiting that last beyond the first trimester characterize this disorder of pregnancy. Vomitus contains undigested food, mucus, and small amounts of bile early in the disorder; later, it has a coffee-ground appearance. Associated findings include weight loss, headache, and delirium. Thyroid dysfunction may be associated with this condition.
Increased intracranial pressure. Projectile vomiting that isn’t preceded by nausea is a sign of increased intracranial pressure. The patient may exhibit a decreased LOC and Cushing’s triad (bradycardia, hypertension, and respiratory pattern changes). He may also have a headache, widened pulse pressure, impaired motor movement, visual disturbances, pupillary changes, and papilledema.
Intestinal obstruction. Nausea and vomiting (bilious or fecal) are common with intestinal obstruction, especially of the upper small intestine. Abdominal pain is usually episodic and colicky but can become severe and steady. Constipation occurs early in large intestinal obstruction and late in small intestinal obstruction. Obstipation, however, may signal complete obstruction. In partial obstruction, bowel sounds are typically high pitched and hyperactive; in complete obstruction, bowel sounds are typically hypoactive or absent. Abdominal distention and tenderness also occur, possibly with visible peristaltic waves and a palpable abdominal mass.
Labyrinthitis. Nausea and vomiting commonly occur with this acute inner ear inflammation. Other findings include severe vertigo, progressive hearing loss, nystagmus, and possibly otorrhea.
Listeriosis. After the ingestion of food contaminated with the bacterium Listeria monocytogenes, vomiting, fever, myalgias, abdominal pain, nausea, and diarrhea occur. If the infection spreads to the nervous system, meningitis may develop. Signs and symptoms may include fever, headache, nuchal rigidity, and change in LOC. The food-borne illness primarily affects pregnant women, neonates, and those with weakened immune systems.
GENDER CUE
Infections that occur during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.
Mesenteric venous thrombosis. Insidious or acute onset of nausea, vomiting, and abdominal pain occurs here, with diarrhea or constipation, abdominal distention, hematemesis, and melena. Migraine headache. Nausea and vomiting are prodromal signs and symptoms, with fatigue, photophobia, light flashes, increased noise sensitivity, and possibly partial vision loss and paresthesia.
Motion sickness. Nausea and vomiting may be accompanied by headache, vertigo, dizziness, fatigue, diaphoresis, and dyspnea.
Norovirus. Within 24 to 60 hours of exposure to Norovirus, the patient typically experiences vomiting along with other acute gastroenteritis symptoms, such as watery nonbloody diarrhea, abdominal cramps, nausea, and low-grade fever. Signs and symptoms usually last 1 to 5 days, and most people recover without any treatment. Dehydration, a more severe complication, is typically seen in very young and elderly patients.
Pancreatitis (acute). Vomiting, usually preceded by nausea, is an early sign of pancreatitis. Associated findings include steady, severe epigastric or left upper quadrant pain that may radiate to the back, abdominal tenderness and rigidity, hypoactive bowel sounds, anorexia, vomiting, and fever. Tachycardia, restlessness, hypotension, skin mottling, and cold, sweaty extremities may occur in severe cases.
Peritonitis. Nausea and vomiting usually accompany acute abdominal pain in the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness; weakness; pale, cold skin; diaphoresis; hypotension; signs of dehydration; and shallow respirations.
Preeclampsia. Nausea and vomiting are common with preeclampsia, a disorder of pregnancy. Rapid weight gain, epigastric pain, generalized edema, elevated blood pressure, oliguria, severe frontal headache, and blurred or double vision also occur.
Q fever. Signs and symptoms of Q fever, a rickettsial infection, include vomiting, fever, chills, severe headache, malaise, chest pain, nausea, and diarrhea. Fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.
Renal and urologic disorders. Cystitis, pyelonephritis, calculi, and other disorders of this system can cause vomiting. Accompanying findings reflect the specific disorder. Persistent nausea and vomiting are typical findings in patients with acute or worsening chronic renal failure.
Rhabdomyolysis. Signs and symptoms of this disorder include vomiting, muscle weakness or pain, fever, nausea, 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 kidney’s attempt to filter the myoglobin from the bloodstream.
Typhus. Typhus is a rickettsial disease transmitted to humans by fleas, mites, or body louse. Initial symptoms include headache, myalgia, arthralgia, and malaise, followed by an abrupt onset of vomiting, nausea, chills, and fever. A maculopapular rash may be present in some cases.
Other Causes
Drugs. Drugs that commonly cause vomiting include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium, chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, and overdoses of cardiac glycosides and theophylline.
Radiation and surgery. Radiation therapy may cause nausea and vomiting if it disrupts the gastric mucosa. Postoperative nausea and vomiting are common, especially after abdominal surgery.
Special Considerations
Draw blood to determine fluid, electrolyte, and acid-base balance. (Prolonged vomiting can cause dehydration, electrolyte imbalances, and metabolic alkalosis.) Have the patient breathe deeply to ease his nausea and help prevent further vomiting. Keep his room fresh and clean smelling by removing bedpans and emesis basins promptly after use. Elevate his head, or position him on his side to prevent aspiration of vomitus. Continuously monitor vital signs and intake and output (including vomitus and liquid stools). If necessary, administer I.V. fluids, or have the patient sip clear liquids to maintain hydration.
Because pain can precipitate or intensify nausea and vomiting, administer pain medications promptly. If possible, give these by injection or suppository to prevent exacerbating associated nausea. If an opioid is used to treat pain, monitor bowel sounds, flatus, and bowel movements carefully because they may slow down GI motility and exacerbate vomiting. If you administer an antiemetic, be alert for abdominal distention and hypoactive bowel sounds, which may indicate gastric retention. If this occurs, insert a nasogastric tube.
Pediatric Pointers
In a neonate, pyloric obstruction may cause projectile vomiting, whereas Hirschsprung’s disease may cause fecal vomiting. Intussusception may lead to vomiting of bile and fecal matter in an infant or toddler. Because an infant may aspirate vomitus as a result of his immature cough and gag reflexes, position him on his side or abdomen and clear any vomitus immediately.
Patient Counseling
Teach the patient to adjust his diet by starting with clear liquids and then advancing to a bland diet. Explain how to replace fluid losses and to perform deep breathing exercises.
Geriatric Pointers
Although elderly patients can develop several of the disorders mentioned earlier, always rule out intestinal ischemia first — it’s especially common in patients of this age group, and it has a high mortality rate.
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.
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.
Vulvar Lesions
Vulvar lesions are cutaneous lumps, nodules, papules, vesicles, or ulcers that result from benign or malignant tumors, dystrophies, dermatoses, or infection. They can appear anywhere on the vulva and may go undetected until a gynecologic examination. Usually, however, the patient notices lesions because of associated symptoms, such as pruritus, dysuria, or dyspareunia.
History and Physical Examination
Ask the patient when she first noticed a vulvar lesion, and find out about associated features, such as swelling, pain, tenderness, itching, or discharge. Does she have lesions elsewhere on her body? Ask about signs and symptoms of systemic illness, such as malaise, fever, or rash on other body areas. Is the patient sexually active? Could she have been exposed to sexually transmitted disease?
Also, examine the lesion, do a pelvic examination, and obtain cultures. (See Recognizing Common Vulvar Lesions, page 752.)