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

Prévost’s sign Conjugate deviation of the head and eyes in hemiplegia. Typically, the eyes gaze toward the affected hemisphere.

prognathism An enlarged, protuberant jaw associated with normal mandible condyles and temporomandibular joints. This sign usually appears in acromegaly.

R

rectal tenesmus Spasmodic contraction of the anal sphincter with a persistent urge to defecate and involuntary, ineffective straining. This occurs in inflammatory bowel disorders, such as ulcerative colitis and Crohn’s disease, and in rectal tumors. Often painful, rectal tenesmus usually accompanies passage of small amounts of blood, pus, or mucus.

regression Return to a behavioral level appropriate to an earlier developmental age. This defense mechanism may occur in various psychiatric and organic disorders. It may also result from worsening of symptoms or of a disease process.

repression The unconscious retreat or thrusting back from awareness of unacceptable ideas or impulses. This defense mechanism may occur normally or may accompany psychiatric disorders.

Rosenbach’s sign Absence of the abdominal skin reflex, associated with intestinal inflammation and hemiplegia. This sign also refers to the fine, rapid tremor of gently closed eyelids in Graves’ disease and to the inability to close the eyes immediately on command, as is seen in neurasthenia.

Rotch’s sign Dullness on percussion over the right lung at the fifth intercostal space. This sign occurs in pericardial effusion.

Rovsing’s sign Pain in the right lower quadrant upon palpation and quick withdrawal of the fingers in the left lower quadrant. This referred rebound tenderness suggests appendicitis.

Rumpel-Leede sign Extensive petechiae distal to a tourniquet placed around the upper arm, indicating capillary fragility in scarlet fever and in severe thrombocytopenia. To elicit this sign, place a tourniquet around the upper arm for 5 to 10 minutes, and observe for distal petechiae. Also known as

Rumpel-Leede phenomenon.

S

Seeligmüller’s sign Pupillary dilation on the affected side, in facial neuralgia.

Siegert’s sign Short, inwardly curved little fingers, typically appearing in Down syndrome.

SIEGERT’S SIGN

Simon’s sign Incoordination of the movements of the diaphragm and thorax, occurring early in meningitis. Also refers to retraction or fixation of the umbilicus during inspiration.

Soto-Hall sign Pain in the area of a lesion, occurring on passive flexion of the spine. To elicit this sign, help the patient into a supine position and progressively flex the spine from the neck downward. The patient will complain of pain at the area of the lesion.

spasmodic torticollis Intermittent or continuous spasms of the shoulder and neck muscles that turn the head to one side. Often transient and idiopathic, this sign can occur in patients with extrapyramidal disorders or shortened neck muscles. (See “Dystonia,” page 269–271.)

spine sign Resistance to anterior flexion of the spine, resulting from pain in poliomyelitis.

spoon nails Malformation of the nails characterized by a concave outer surface instead of the normal convex outer surface. The nail is also abnormally thin. This commonly occurs in severe hypochromic anemia but occasionally may be hereditary.

Stellwag’s sign Incomplete and infrequent blinking, usually related to exophthalmos in Graves’ disease.

stepping reflex In the neonate, spontaneous stepping movements that simulate walking. This reciprocal flexion and extension of the legs disappears after about age 4 weeks. To elicit this sign, hold the neonate erect with the soles of the feet touching a hard surface. However, scissoring movements with persistent extension and crossing of the legs or asymmetrical stepping is abnormal, possibly indicating central nervous system damage.

STEPPING REFLEX

Strunsky’s sign Pain on plantar flexion of the toes and forefoot, caused by inflammatory disorders of the anterior arch. To detect this sign, have the patient assume a relaxed position with the foot exposed, and then grasp the toes and quickly plantarflex the toes and forefoot.

succussion splash A splashing sound heard over a hollow organ or body cavity, such as the stomach or thorax, after rocking or shaking the patient’s body. Indicating the presence of fluid or air and gas, this sound may be auscultated in pyloric or intestinal obstruction, a large hiatal hernia, or hydropneumothorax. However, it may also be auscultated over a normal, empty stomach.

sucking reflex Involuntary circumoral sucking movements in response to stimulation. Present at about 26 weeks’ gestation, this reflex is initially weak and is not synchronized with swallowing. It persists through infancy, becoming more discriminating during the first few months and disappearing by age 1. To elicit this response, place your finger in the infant’s mouth. Rhythmic sucking movements are normal. Weakness or absence of these movements may indicate elevated intracranial pressure.

T

tangentiality Speech characterized by tedious detail that prevents ever reaching the point of the statement. This occurs in schizophrenia and organic brain disorders.

Terry’s nails A white, opaque surface over more than 80% of the nail and a normal pink distal edge. This sign is often associated with cirrhosis.

testicular pain Unilateral or bilateral pain localized in or around the testicle and possibly radiating along the spermatic cord and into the lower abdomen. It usually results from trauma, infection, or torsion. Typically, its onset is sudden and severe; however, its intensity can vary from sharp pain accompanied by nausea and vomiting to a chronic, dull ache. In a child, sudden onset of severe testicular pain is a urologic emergency. Assume torsion is the cause until disproved. If a young male complains of abdominal pain, always carefully examine the scrotum because abdominal pain often precedes testicular pain in testicular torsion.

Thornton’s sign Severe flank pain resulting from nephrolithiasis.

thrill A palpable sensation resulting from the vibration of a loud murmur or from turbulent blood flow in an aneurysm. Thrills are associated with heart murmurs of grades IV to VI and may be palpable over major arteries. (See “Bruits,” page 137–140, and “Murmurs,” page 471–477.)

tibialis sign Involuntary dorsiflexion and inversion of the foot upon brisk, voluntary flexion of the patient’s knee and hip, occurring in spastic paralysis of the lower limb. Also known as Strümpell’s sign .To detect this sign, help the patient into a supine position, and have him or her flex the leg at the hip and knee so that the thigh touches the abdomen. Or, you can help the patient into a prone position, and have him or her flex the leg at the knee so that the calf touches the thigh. If this sign is present, you may observe dorsiflexion of the great toe, or of all toes, as the foot dorsiflexes and inverts. Normally, plantar flexion of the foot occurs with this action.

Tinel’s sign Distal paresthesia on percussion over an injured nerve in an extremity, as in carpal tunnel syndrome. To elicit this sign in the patient’s wrist, tap over the median nerve on the wrist’s flexor surface. This sign indicates a partial lesion or the early regeneration of the nerve.

tongue, hairy Hypertrophy and elongation of the tongue’s filiform papillae. Normally white, the papillae may turn yellow, brown, or black from bacteria, food, tobacco, coffee, or dyes in drugs and food. Hairy tongue may also result from antibiotic therapy, irradiation of the head and neck, chronic debilitating disorders, and habitual use of mouthwashes containing oxidizing or astringent agents.

HAIRY TONGUE

tongue, magenta, cobblestone Swelling and hyperemia of the tongue, forming rows of elevated fungiform and filiform papillae that give the tongue a magenta-colored or cobblestone appearance. It’s most often a sign of vitamin B2 (riboflavin) deficiency.

tongue, red Patchy or uniform redness (ranging from pink to magenta) of the tongue, which may be swollen and smooth, rough, or fissured. It usually indicates glossitis, resulting from emotional stress or nutritional disorders, such as pernicious anemia, Plummer-Vinson syndrome, pellagra, sprue, and folic acid and vitamin B deficiency.

tongue, smooth Absence or atrophy of the filiform papillae, causing a smooth (patchy or

uniform), glossy, red tongue. This primary sign of malnutrition results from anemia and vitamin B deficiency.

tongue, white A uniform white coating or plaques on the tongue. Lesions associated with a white tongue may be premalignant or malignant and may require a biopsy. Necrotic white lesions — collections of cells, bacteria, and debris — are painful and can be scraped from the tongue. They often appear in children, commonly resulting from candidiasis and thermal burns. Keratotic white lesions — thickened, keratinized patches — are usually asymptomatic and can’t be scraped from the tongue. These lesions commonly result from alcohol use and local irritation from tobacco smoke or other substances.

tongue enlargement An increase in the tongue’s size, causing it to protrude from the mouth. Its causes include Down syndrome, acromegaly, lymphangioma, Beckwith’s syndrome, and congenital micrognathia. An enlarged tongue can also result from cancer of the tongue, amyloidosis, and neurofibromatosis.

tongue fissures Shallow or deep grooving of the dorsum of the tongue. Usually a congenital defect, tongue fissures occur normally in about 10% of the population. However, deep fissures may promote collection of food particles, leading to chronic inflammation and tenderness.

TONGUE FISSURES

tongue swelling Edema of the tongue, usually associated with pernicious anemia, pellagra, hypothyroidism, and allergic angioneurotic edema.

tongue ulcers Circumscribed necrotic lesions of the dorsum, margin, tip, and inferior surface of the tongue. Ulcers usually result from biting, chewing, or burning of the tongue. They may also stem from Type I herpes simplex virus, tuberculosis, histoplasmosis, and cancer of the tongue.

tonic neck reflex Extension of the limbs on the side to which the head is turned and flexion of the opposite limbs. In the neonate, this normal reflex appears between 28 and 32 weeks’ gestation, diminishes as voluntary muscle control increases, and disappears by age 3 to 4 months. The absence or persistence of this reflex may indicate central nervous system damage. To elicit this response, place the neonate supine, then turn the head to one side.

tooth discoloration Bluish yellow or gray teeth may result from hypoplasia of the dentin and

pulp, nerve damage, or caries. Yellow teeth may indicate caries. Mottling and staining suggest fluorine excess and may also be associated with the effects of certain drugs, such as tetracycline. Tooth discoloration (and small tooth size) may occur in osteogenesis imperfecta.

tophi Deposits of sodium urate crystals in cartilage, soft tissue, synovial membranes, and tendon sheaths, producing painless nodular swellings, a classic symptom of gout. Tophi commonly appear on the ears, hands, and feet. They may erode the skin, producing open lesions, and cause gross deformity, limiting joint mobility. Inflammatory flare-ups may occur.

transference Unconscious process of transferring feelings and attitudes originally associated with important figures, such as parents, to another. Used therapeutically in psychoanalysis, transference can also occur in other settings and relationships.

Trendelenburg’s test A demonstration of valvular incompetence of the saphenous vein and inefficiency of the communicating veins at different levels. To perform this test, raise the patient’s legs above the heart level until the veins empty; and then rapidly lower the legs. If the valves are incompetent, the veins immediately distend.If the patient has poliomyelitis, unlimited femoral neck fracture, coxa vara, or a congenital dislocation, have the patient disrobe with the back to the examiner. Tell the patient to lift first one foot and then the other. Note the position and movements of the gluteal fold: When the patient is standing on the affected limb, the gluteal fold on the sound side falls instead of rising.

Troisier’s sign Enlargement of a single lymph node, usually in the left supraclavicular group. It indicates metastasis from a primary carcinoma in the upper abdomen, often the stomach. To detect this sign, have the patient sit erect facing you. Palpate the region behind the sternocleidomastoid muscle as the patient performs Valsalva’s maneuver. Although the enlarged node often lies so deep that it escapes detection, it may rise and become palpable with this maneuver.

Trousseau’s sign In tetany, carpal spasm upon ischemic compression of the upper arm. To elicit this sign, apply a blood pressure cuff to the patient’s arm; then inflate the cuff to a pressure between the patient’s diastolic and systolic readings, maintaining it for 4 minutes. The patient’s hand and fingers assume the “obstetrical hand” position, with wrist and metacarpophalangeal joints flexed, interphalangeal joints extended, and fingers and thumb adducted. Also known as Trousseau’s phenomenon. (See “Carpopedal spasm,” page 145–147.)

Turner’s sign A bruiselike discoloration of the skin of the flanks. This sign appears 6 to 24 hours after onset of retroperitoneal hemorrhage in acute pancreatitis.

twitching Nonspecific intermittent contraction of muscles or muscle bundles. (See “Fasciculations,” page 309–310, and “Tics,” page 698–699.)

U

urinary tenesmus Persistent, ineffective, painful straining to empty the bladder. This results from irritation of nerve endings in the bladder mucosa, caused by infection or an indwelling catheter.

V

vaginal bleeding abnormalities Passage of blood from the vagina at times other than menses. It may indicate abnormalities of the uterus, cervix, ovaries, fallopian tubes, or vagina. It may also indicate an abnormal pregnancy. (See “Menorrhagia,” page 461–463, “Metrorrhagia,” page 463– 465, and “Vaginal bleeding, postmenopausal,” page 726–727.)

vein sign A palpable, bluish, cordlike swelling along the line formed in the axilla by the junction of the thoracic and superficial epigastric veins. This sign appears in tuberculosis and obstruction of the superior vena cava.

W

Weill’s sign In infantile pneumonia, absence of expansion in the subclavicular area of the affected side on inspiration.

Westphal’s sign Absence of the knee jerk reflex, occurring in tabes dorsalis.

Wilder’s sign Subtle twitching of the eyeball on medial or lateral gaze. This early sign of Graves’ disease is discernible as a slight jerk of the eyeball when the patient changes the direction of gaze.

Y

yawning, excessive Persistent involuntary opening of the mouth, accompanied by attempted deep inspiration. In the absence of sleepiness, excessive yawning may indicate cerebral hypoxia.

References

Berkowitz, C. D. (2012) Berkowitz’s pediatrics: A primary care approach (4th ed.) . Washington, DC: American Academy of Pediatrics.

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.

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.

Sarwark, J. F. (2010). Essentials of musculoskeletal care. Rosemont, IL: American Academy of Orthopaedic Surgeons. 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.

Potential Agents of Bioterrorism

Listed below are examples of biological agents that may be used as biological weapons and the major signs and symptoms for each.

References

Bork, C. E., & Rega, P. P. (2012) . An assessment of nurses’ knowledge of botulism. Public Health Nursing, 29(2) , 168–174.

doi:10.1111/j.1525-1446.2011.00988.x.

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. doi:10.1038/478444a.

Callaway, E. (2011). Plague genome: The Black Death decoded. Nature, 478(7370), 444–446. Handley, A. (2010). Being alert to anthrax. Nursing Standard, 24(27), 21.

Karabay, O., Karadenizli, A., Durmaz, Y., & Ozturk, G. (2011). Tularemia: A rare cause of cervical lymphadenopathy . Indian Journal of Pathology & Microbiology, 54(3), 642–643. doi:10.4103/0377-4929.85130.

Richard, J. L., & Grimes, D. E. (2008). Bioterrorism: Class A agents and their potential presentations in immunocompromised patients . Clinical Journal of Oncology Nursing, 12(2), 295–302. doi:10.1188/08.CJON.295-302.

COMMON SIGNS AND SYMPTOMS ASSOCIATED WITH HERBS

Listed below are commonly used herbs and the signs and symptoms that may develop as a result of an adverse reaction to the herb.

References

Braun, L. & Cohen, M. (2010). Herbs & natural supplement: An evidence-based guide (3rd ed.). New York, NY: Elsevier.

Tisserand, R. & Young, R. (2014). Essential oil safety (2nd ed.). Philadelphia, PA: Elsevier.

OBTAINING A HEALTH HISTORY

Use a health history to gather subjective data about your patient and to explore the patient’s previous and current health problems. The information you obtain, combined with the results of the physical examination and diagnostic testing, will assist you in making an accurate patient diagnosis.

Start the history by asking the patient about his or her general physical and emotional health, and then ask questions about the specific body systems.

Make the Patient Comfortable

Before asking your first question, make sure you establish a good rapport with the patient. The