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

History and Physical Examination

If the patient isn’t in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.

Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he’s under unusual stress.

Medical Causes

Anthrax, GI. Anthrax manifests after the patient has eaten contaminated meat from an animal infected with Bacillus anthracis. Early signs and symptoms include decreased appetite, nausea, vomiting, and a fever. Later signs and symptoms include severe bloody diarrhea, abdominal pain, and hematemesis.

Carcinoid syndrome. With carcinoid syndrome, severe diarrhea occurs with flushing — usually of the head and neck — that’s commonly caused by emotional stimuli or the ingestion of food, hot water, or alcohol. Associated signs and symptoms include abdominal cramps, dyspnea, weight loss, anorexia, weakness, palpitations, valvular heart disease, and depression.

Cholera. After ingesting water or food contaminated by the bacterium Vibrio cholerae, the patient experiences abrupt watery diarrhea and vomiting. Other signs and symptoms include thirst (due to severe water and electrolyte loss), weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Clostridium difficile infection. The patient may be asymptomatic or may have soft, unformed stools or watery diarrhea that may be foul smelling or grossly bloody; abdominal pain, cramping, and tenderness; a fever; and a white blood cell count as high as 20,000/μL. In severe cases, the patient may develop toxic megacolon, colon perforation, or peritonitis.

Crohn’s disease. Crohn’s disease is a recurring inflammatory disorder that produces diarrhea accompanied by abdominal pain with guarding and tenderness and nausea. The patient may also display a fever, chills, weakness, anorexia, and weight loss.

Escherichia coli 0157:H7. Watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps occur after the patient eats undercooked beef or other foods contaminated with this particular strain of bacteria. Hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, is a complication of E. coli 0157:H7 in children age 5 and younger and elderly people.

Infections. Acute viral, bacterial, and protozoal infections (such as cryptosporidiosis) cause the sudden onset of watery diarrhea as well as abdominal pain, cramps, nausea, vomiting, and a fever. Significant fluid and electrolyte loss may cause signs of dehydration and shock. Chronic tuberculosis and fungal and parasitic infections may produce a less severe but more persistent diarrhea, accompanied by epigastric distress, vomiting, weight loss and, possibly, passage of blood and mucus.

Intestinal obstruction. Partial intestinal obstruction increases intestinal motility, resulting in

diarrhea, abdominal pain with tenderness and guarding, nausea and, possibly, distention. Irritable bowel syndrome. Diarrhea alternates with constipation or normal bowel function. Related findings include abdominal pain, tenderness, and distention, dyspepsia, and nausea. Ischemic bowel disease. Ischemic bowel disease is a life-threatening disorder that causes bloody diarrhea with abdominal pain. If severe, shock may occur, requiring surgery.

Lactose intolerance. Diarrhea occurs within several hours of ingesting milk or milk products. It’s accompanied by cramps, abdominal pain, borborygmi, bloating, nausea, and flatus. Listeriosis. With listeriosis, diarrhea occurs in conjunction with a fever, myalgia, abdominal pain, nausea, and vomiting. A fever, a headache, nuchal rigidity, and an altered level of consciousness may occur if the infection spreads to the nervous system and causes meningitis. This infection, caused by the ingestion of food contaminated with the bacterium Listeria monocytogenes, primarily affects pregnant women, neonates, and those with weakened immune systems.

GENDER CUE

Listeria infections during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Norovirus. Diarrhea caused by Norovirus has an acute onset; it’s watery, nonbloody, and generally self-limiting, with symptoms lasting 24 to 60 hours. Noroviruses are transmitted primarily through the fecal-oral route or through direct person-to-person contact. Accompanying gastrointestinal symptoms include nausea, abdominal pain, abdominal cramps, weight loss, lowgrade fever, and malaise. However, in elderly and very young patients, and those with underlying diseases, diarrhea can be severe. Patients have been known to shed the Norovirus in their stools for up to several weeks following infection.

Pseudomembranous enterocolitis. Pseudomembranous enterocolitis is a potentially lifethreatening disorder that commonly follows antibiotic administration. It produces copious watery, green, foul-smelling, bloody diarrhea that rapidly precipitates signs of shock. Other signs and symptoms include colicky abdominal pain, distention, a fever, and dehydration.

Q fever. Q fever is caused by the bacterium Coxiella burnetii and causes diarrhea along with a fever, chills, a severe headache, malaise, chest pain, and vomiting. In severe cases, hepatitis or pneumonia may follow.

Rotavirus gastroenteritis. Rotavirus gastroenteritis commonly starts with a fever, nausea, and vomiting, followed by diarrhea. The illness can range from mild to severe and can last from 3 to 9 days. Diarrhea and vomiting may result in dehydration.

Thyrotoxicosis. With thyrotoxicosis, nervousness, tremors, diaphoresis, weight loss despite increased appetite, dyspnea, palpitations, tachycardia, an enlarged thyroid, heat intolerance and, possibly, exophthalmos accompany diarrhea.

Ulcerative colitis. The hallmark of ulcerative colitis is recurrent bloody diarrhea with pus or mucus. Other signs and symptoms include tenesmus, hyperactive bowel sounds, cramping lower abdominal pain, a low-grade fever, anorexia and, at times, nausea and vomiting. Weight loss, anemia, and weakness are late findings.

Other Causes

HERB ALERT

Herbal remedies — such as ginkgo biloba, ginseng, and licorice — may cause diarrhea.

Drugs. Many antibiotics — such as ampicillin, cephalosporins, tetracyclines, and clindamycin

— cause diarrhea. Other drugs that may cause diarrhea include magnesium-containing antacids, colchicine, guanethidine, lactulose, dantrolene, ethacrynic acid, mefenamic acid, methotrexate, metyrosine and, in high doses, cardiac glycosides and quinidine. Laxative abuse can cause acute or chronic diarrhea.

EXAMINATION TIP Testing Extraocular Muscles

The coordinated action of six muscles controls eyeball movements. To test the function of each muscle and the cranial nerve (CN) that innervates it, ask the patient to look in the direction controlled by that muscle. The six directions you can test make up the cardinal fields of gaze. The patient’s inability to turn the eye in the designated direction indicates muscle weakness or paralysis.

SR = superior rectus (CN III)

LR = lateral rectus (CN VI)

IR = inferior rectus (CN III)

IO = inferior oblique (CN III)

MR = medial rectus (CN III)

SO = superior oblique (CN IV)

Radiation therapy. Diarrhea may occur as a symptom of radiation sickness after a patient receives usually high doses of radiation.

Treatments. Gastrectomy, gastroenterostomy, and pyloroplasty may produce diarrhea. High-

dose radiation therapy may produce enteritis associated with diarrhea.

Special Considerations

Administer an analgesic for pain and an opiate to decrease intestinal motility, unless the patient has a possible or confirmed stool infection. Ensure the patient’s privacy during defecation, and empty bedpans promptly. Clean the perineum thoroughly, and apply ointment to prevent skin breakdown. Quantify the amount of liquid stool. Monitor and document intake and output every hour. Obtain serum samples for electrolytes, and treat abnormalities.

Stress the need for medical follow-up to patients with inflammatory bowel disease (particularly ulcerative colitis) who have an increased risk of developing colon cancer.

Patient Counseling

Emphasize the importance of maintaining adequate hydration, and explain any foods or fluids the patient should avoid. Discuss stress reduction techniques and the importance of medical follow-up with an inflammatory bowel disease. Refer for counseling as needed.

Pediatric Pointers

Diarrhea in children commonly results from infection, although chronic diarrhea may result from malabsorption syndrome, an anatomic defect, or allergies. Because dehydration and electrolyte imbalance occur rapidly in children, diarrhea can be life threatening. Diligently monitor all episodes of diarrhea, and immediately replace lost fluids.

Geriatric Pointers

In the elderly patient with new-onset segmental colitis, always consider ischemia before labeling him as having Crohn’s disease.

Diplopia

Diplopia is double vision — seeing one object as two. This symptom results when extraocular muscles fail to work together, causing images to fall on noncorresponding parts of the retinas. What causes this muscle incoordination? Orbital lesions, the effects of surgery, or impaired function of cranial nerves (CNs) that supply extraocular muscles (oculomotor, CN III; trochlear, CN IV; abducens, CN VI) may be responsible. (See Testing Extraocular Muscles.)

Diplopia usually begins intermittently and can affect near or far vision. It can be classified as monocular or binocular. More common binocular diplopia may result from ocular deviation or displacement, extraocular muscle palsies, or psychoneurosis, or it may occur after retinal surgery. Monocular diplopia may result from an early cataract, retinal edema or scarring, iridodialysis, a subluxated lens, a poorly fitting contact lens, or an uncorrected refractive error such as astigmatism. Diplopia may also occur in hysteria or malingering.

History and Physical Examination

If the patient complains of double vision, first check his neurologic status. Evaluate his level of consciousness (LOC); pupil size, equality, and response to light; and motor and sensory function.

Then, take his vital signs. Briefly ask about associated symptoms, especially a severe headache. Find out about associated neurologic symptoms first because diplopia can accompany serious disorders.

Next, continue with a more detailed examination. Find out when the patient first noticed diplopia. Are the images side by side (horizontal), one above the other (vertical), or a combination? Does diplopia affect near or far vision? Does it affect certain directions of gaze? Ask if diplopia has worsened, remained the same, or subsided. Does its severity change throughout the day? Diplopia that worsens or appears in the evening may indicate myasthenia gravis. Find out if the patient can correct diplopia by tilting his head. If so, ask him to show you. (If the patient has a fourth nerve lesion, tilting of the head toward the opposite shoulder causes compensatory tilting of the unaffected eye. If he has incomplete sixth nerve palsy, tilting of the head toward the side of the paralyzed muscle may relax the affected lateral rectus muscle.)

Explore associated symptoms such as eye pain. Ask about hypertension, diabetes mellitus, allergies, and thyroid, neurologic, or muscular disorders. Also, note a history of extraocular muscle disorders, trauma, or eye surgery.

Observe the patient for ocular deviation, ptosis, proptosis, lid edema, and conjunctival injection. Distinguish monocular from binocular diplopia by asking the patient to occlude one eye at a time. If he still sees double out of one eye, he has monocular diplopia. Test his visual acuity and extraocular muscles. Check his vital signs.

Medical Causes

Alcohol intoxication. Diplopia is a common symptom of alcohol intoxication. It’s accompanied by confusion, slurred speech, halitosis, a staggering gait, behavior changes, nausea, vomiting and, possibly, conjunctival injection.

Botulism. Hallmark signs of botulism include diplopia, dysarthria, dysphagia, and ptosis. Early findings include a dry mouth, a sore throat, vomiting, and diarrhea. Later, descending weakness or paralysis of extremity and trunk muscles causes hyporeflexia and dyspnea.

Brain tumor. Diplopia may be an early symptom of a brain tumor. Accompanying signs and symptoms vary with the tumor’s size and location, but may include eye deviation, emotional lability, a decreased LOC, a headache, vomiting, absence or generalized tonic-clonic seizures, hearing loss, visual field deficits, abnormal pupillary responses, nystagmus, motor weakness, and paralysis.

Cavernous sinus thrombosis. Cavernous sinus thrombosis may produce diplopia and limited eye movement. Associated signs and symptoms include proptosis, orbital and lid edema, diminished or absent pupillary responses, impaired visual acuity, papilledema, and a fever.

Diabetes mellitus. Among the long-term effects of diabetes mellitus may be diplopia due to isolated CN III or CN VI palsy. Diplopia typically begins suddenly and may be accompanied by pain.

Encephalitis. Initially, encephalitis may cause a brief episode of diplopia and eye deviation. However, it usually begins with the sudden onset of a high fever, a severe headache, and vomiting. As the inflammation progresses, the patient may display signs of meningeal irritation, a decreased LOC, seizures, ataxia, and paralysis.

Head injury. Potentially life-threatening head injuries may cause diplopia, depending on the site and extent of the injury. Associated signs and symptoms include eye deviation, pupillary changes, a headache, a decreased LOC, altered vital signs, nausea, vomiting, and motor

weakness or paralysis.

Intracranial aneurysm. Intracranial aneurysm is a life-threatening disorder that initially produces diplopia and eye deviation, perhaps accompanied by ptosis and a dilated pupil on the affected side. The patient complains of a recurrent, severe, unilateral, frontal headache. After the aneurysm ruptures, the headache becomes violent. Associated signs and symptoms include neck and spinal pain and rigidity, a decreased LOC, tinnitus, dizziness, nausea, vomiting, and unilateral muscle weakness or paralysis.

Multiple sclerosis (MS). Diplopia, a common early symptom in MS, is usually accompanied by blurred vision and paresthesia. As MS progresses, signs and symptoms may include nystagmus, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, gait ataxia, dysphagia, dysarthria, impotence, emotional lability, and urinary frequency, urgency, and incontinence.

Myasthenia gravis. Myasthenia gravis initially produces diplopia and ptosis, which worsen throughout the day. It then progressively involves other muscles, resulting in a blank facial expression; a nasal voice; difficulty chewing, swallowing, and making fine hand movements; and, possibly, signs of life-threatening respiratory muscle weakness.

Complicated migraine. Most common in children and young adults, complicated migraine occasionally results in diplopia that can persist for days after the headache. Accompanying signs and symptoms include severe, unilateral pain; ptosis; and extraocular muscle palsies. Irritability, depression, or slight confusion may also occur.

Orbital blowout fracture. An orbital blowout fracture usually causes monocular diplopia affecting the upward gaze. However, with marked periorbital edema, diplopia may affect other directions of gaze. This fracture commonly causes periorbital ecchymosis, but doesn’t affect visual acuity, although eyelid edema may prevent accurate testing. Subcutaneous crepitation of the eyelid and orbit is typical. Occasionally, the patient’s pupil is dilated and unreactive, and he may have a hyphema.

Orbital cellulitis. Inflammation of the orbital tissues and eyelids causes sudden diplopia. Other findings are eye deviation and pain, lid edema, chemosis and redness, proptosis, nausea, and a fever.

Orbital tumor. An enlarging orbital tumor can cause diplopia. Proptosis and possibly blurred vision may also occur.

Stroke. Diplopia characterizes stroke when it affects the vertebrobasilar artery. Other signs and symptoms include unilateral motor weakness or paralysis, ataxia, a decreased LOC, dizziness, aphasia, visual field deficits, circumoral numbness, slurred speech, dysphagia, and amnesia.

Thyrotoxicosis. Diplopia occurs when exophthalmos characterizes the disorder. It usually begins in the upper field of gaze because of infiltrative myopathy involving the inferior rectus muscle. It’s accompanied by impaired eye movement, excessive tearing, lid edema and, possibly, an inability to close the lids. Other cardinal findings include tachycardia, palpitations, weight loss, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, and heat intolerance.

Transient ischemic attack (TIA). TIA is generally accompanied by diplopia, dizziness, tinnitus, hearing loss, and numbness. It can last for a few seconds or up to 24 hours and may be a warning sign of a future stroke.

Other Causes

Eye surgery. Fibrosis associated with eye surgery may restrict eye movement, resulting in diplopia.

Special Considerations

Continue to monitor the patient’s vital signs and neurologic status if you suspect an acute neurologic disorder. Prepare the patient for neurologic tests such as a computed tomography scan. Provide a safe environment. If the patient has severe diplopia, remove sharp obstacles and assist him with ambulation. Also, institute seizure precautions, if indicated. Reinforce that the patient must not drive or operate heavy machinery upon discharge.

Patient Counseling

Explain the safety measures that are needed. Teach the patient skills of ambulation with assistance. Orient the patient to the room and his meal tray.

Pediatric Pointers

Strabismus, which can be congenital or acquired at an early age, produces diplopia; however, in young children, the brain rapidly compensates for double vision by suppressing one image, so diplopia is a rare complaint. School-age children who complain of double vision require a careful examination to rule out serious disorders such as a brain tumor.

REFERENCES

Ansons, A. M. & Davis, H. (2014). Diagnosis and management of ocular motility disorders. West Sussex, UK: Wiley Blackwell. Gerstenblith, A. T. & Rabinowitz, M. P. (2012). The wills eye manual. Philadelphia, PA: Lippincott Williams & Wilkins.

Roy, F. H. (2012). Ocular differential diagnosis. Clayton, Panama: Jaypee–Highlights Medical Publishers, Inc.

Sheth, V. S. , Marcet, M. M., Chiranand, P., Bhatt, H. K., Lamkin, J. C., & Jager, R. D. (2012). Review manual for ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins.

Dizziness

A common symptom, dizziness is a sensation of imbalance or faintness, sometimes associated with giddiness, weakness, confusion, and blurred or double vision. Episodes of dizziness are usually brief; they may be mild or severe with an abrupt or a gradual onset. Dizziness may be aggravated by standing up quickly and alleviated by lying down and by rest.

Dizziness typically results from inadequate blood flow and oxygen supply to the cerebrum and spinal cord. It may occur with anxiety, respiratory and cardiovascular disorders, and postconcussion syndrome. It’s a key symptom in certain serious disorders, such as hypertension and vertebrobasilar artery insufficiency.

Dizziness is commonly confused with vertigo — a sensation of revolving in space or of surroundings revolving about oneself. However, unlike dizziness, vertigo is commonly accompanied by nausea, vomiting, nystagmus, a staggering gait, and tinnitus or hearing loss. Dizziness and vertigo may occur together, as in postconcussion syndrome.

EMERGENCY INTERVENTIONS

If the patient complains of dizziness, first ensure his safety by assisting him back to bed and preventing falls. Then, determine the severity and onset of the dizziness. Ask him to describe it. Is the dizziness associated with a headache or blurred vision? Next, take his blood pressure while he’s lying down, sitting, and standing to check for orthostatic hypotension. Ask about a history of high blood pressure. Determine if he’s at risk for hypoglycemia. Check his blood glucose level. Tell him to lie down, and recheck his vital signs every 15 minutes. Start an I.V. line, and prepare to administer medications as ordered.

History and Physical Examination

Ask about a history of diabetes and cardiovascular disease. Is the patient taking drugs prescribed for high blood pressure? If so, when did he take his last dose?

If the patient’s blood pressure is normal, obtain a more complete history. Ask about myocardial infarction, heart failure, kidney disease, or atherosclerosis, which may predispose the patient to cardiac arrhythmias, hypertension, and a transient ischemic attack. Does he have a history of anemia, chronic obstructive pulmonary disease, anxiety disorders, or head injury? Obtain a complete drug history.

Next, explore the patient’s dizziness. How often does it occur? How long does each episode last? Does the dizziness abate spontaneously? Does it lead to loss of consciousness? Find out if dizziness is triggered by sitting or standing up suddenly or stooping over. Does being in a crowd make the patient feel dizzy? Ask about emotional stress. Has the patient been irritable or anxious lately? Does he have insomnia or difficulty concentrating? Look for fidgeting and eyelid twitching. Does the patient startle easily? Also, ask about palpitations, chest pain, diaphoresis, shortness of breath, and chronic cough.

Next, perform a physical examination. Begin with a quick neurologic assessment, checking the patient’s level of consciousness (LOC), motor and sensory functions, and reflexes. Then, inspect for poor skin turgor and dry mucous membranes — signs of dehydration. Auscultate heart rate and rhythm. Inspect for barrel chest, clubbing, cyanosis, and use of accessory muscles. Also, auscultate breath sounds. Take the patient’s blood pressure while he’s lying down, sitting, and standing to check for orthostatic hypotension. Test capillary refill time in the extremities, and palpate for edema.

Medical Causes

Anemia. Typically, anemia causes dizziness that’s aggravated by postural changes or exertion. Other signs and symptoms include pallor, dyspnea, fatigue, tachycardia, and a bounding pulse. The capillary refill time is increased.

Cardiac arrhythmias. Dizziness lasts for several seconds or longer and may precede fainting in arrhythmias. The patient may experience palpitations; irregular, rapid, or thready pulse; and, possibly, hypotension. He may also experience weakness, blurred vision, paresthesia, and confusion.

Emphysema. Dizziness may follow exertion or the chronic productive cough in patients with emphysema. Associated signs and symptoms include dyspnea, anorexia, weight loss, malaise, use of accessory muscles, pursed-lip breathing, tachypnea, peripheral cyanosis, and diminished

breath sounds. Barrel chest and clubbing may be seen.

Generalized anxiety disorder. Generalized anxiety disorder produces continuous dizziness that may intensify as the disorder worsens. Associated signs and symptoms are persistent anxiety (for at least 1 month), insomnia, difficulty concentrating, and irritability. The patient may show signs of motor tension — for example, twitching or fidgeting, muscle aches, a furrowed brow, and a tendency to be startled. He may also display signs of autonomic hyperactivity, such as diaphoresis, palpitations, cold and clammy hands, dry mouth, paresthesia, indigestion, hot or cold flashes, frequent urination, diarrhea, a lump in the throat, pallor, and increased pulse and respiratory rates.

Hypertension. With hypertension, dizziness may precede fainting, but it may also be relieved by rest. Other common signs and symptoms include a headache and blurred vision. Retinal changes include hemorrhage, sclerosis of retinal blood vessels, exudate, and papilledema.

Hyperventilation syndrome. Episodes of hyperventilation cause dizziness that usually lasts a few minutes; however, if these episodes occur frequently, dizziness may persist between them. Other effects include apprehension, diaphoresis, pallor, dyspnea, chest tightness, palpitations, trembling, fatigue, and peripheral and circumoral paresthesia.

Hypovolemia. Dizziness is caused by a lack of circulating volume and may be accompanied by other signs of fluid volume deficit (dry mucous membranes, decreased blood pressure, increased heart rate).

Orthostatic hypotension. Orthostatic hypotension produces dizziness that may terminate in fainting or disappear with rest. Related findings include dim vision, spots before the eyes, pallor, diaphoresis, hypotension, tachycardia and, possibly, signs of dehydration.

Postconcussion syndrome. Occurring 1 to 3 weeks after a head injury, postconcussion syndrome is marked by dizziness, a headache (throbbing, aching, bandlike, or stabbing), emotional lability, alcohol intolerance, fatigue, anxiety and, possibly, vertigo. Dizziness and other symptoms are intensified by mental or physical stress. The syndrome may persist for years, but symptoms eventually abate.

Rift Valley fever. Typical signs and symptoms of Rift Valley fever include dizziness, a fever, myalgia, weakness, and back pain. A small percentage of patients may develop encephalitis or may progress to hemorrhagic fever that can lead to shock and hemorrhage. Inflammation of the retina may result in some permanent vision loss.

Transient ischemic attack (TIA). Lasting from a few seconds to 24 hours, a TIA commonly signals an impending stroke and may be triggered by turning the head to the side. Besides dizziness of varying severity, TIAs are accompanied by unilateral or bilateral diplopia, blindness or visual field deficits, ptosis, tinnitus, hearing loss, paresis, and numbness. Other findings include dysarthria, dysphagia, vomiting, hiccups, confusion, a decreased LOC, and pallor.

Other Causes

Drugs. Anxiolytics, central nervous system depressants, opioids, decongestants, antihistamines, antihypertensives, and vasodilators commonly cause dizziness.

HERB ALERT

Herbal remedies, such as St. John’s wort, can produce dizziness.

Special Considerations

Prepare the patient for diagnostic tests, such as blood studies, arteriography, a computed tomography scan, EEG, magnetic resonance imaging, and tilt-table studies.

Patient Counseling

Teach the patient about his underlying disorder and treatment. Discuss safety measures and how to control dizziness.

Pediatric Pointers

Dizziness is less common in children than in adults. Many children have difficulty describing this symptom and instead complain of tiredness, stomachache, or feeling sick. If you suspect dizziness, assess for vertigo as well. A more common symptom in children, vertigo may result from a vision disorder, an ear infection, or antibiotic therapy.

REFERENCES

Fife, T. D. (2009). Benign paroxysmal positional vertigo. Seminars in Neurology, 29(5), 500–508.

Fife, T. D. (2012). Positional dizziness. Neurology, 18, 1060–1085.

Doll’s Eye Sign, Absent[Negative oculocephalic reflex]

An indicator of brain stem dysfunction, the absence of the doll’s eye sign is detected by rapid, gentle turning of the patient’s head from side to side. The eyes remain fixed in midposition, instead of the normal response of moving laterally toward the side opposite the direction the head is turned. (See

Testing for Absent Doll’s Eye Sign.)

The absence of doll’s eye sign indicates injury to the midbrain or pons, involving cranial nerves III and VI. It typically accompanies coma caused by lesions of the cerebellum and brain stem. This sign usually can’t be relied upon in a conscious patient because he can control eye movements voluntarily. Absent doll’s eye sign is necessary for a diagnosis of brain death.

A variant of absent doll’s eye sign that develops gradually is known as abnormal doll’s eye sign. Because conjugate eye movement is lost, one eye may move laterally while the other remains fixed or moves in the opposite direction. An abnormal doll’s eye sign usually accompanies metabolic coma or increased intracranial pressure (ICP). Associated brain stem dysfunction may be reversible or may progress to deeper coma with absent doll’s eye sign.

History and Physical Examination

After detecting an absent doll’s eye sign, perform a neurologic examination. First, evaluate the