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Diseases » Generalized anxiety disorder » Causes

Causes of Generalized anxiety disorder

Contents

Generalized anxiety disorder Causes: Book Excerpts

Generalized anxiety disorder Causes: Male-Female Gender Ratio

Gender of Patients for Generalized anxiety disorder: Twice as many women as men...more »

Generalized anxiety disorder: Related Medical Conditions

To research the causes of Generalized anxiety disorder, consider researching the causes of these these diseases that may be similar, or associated with Generalized anxiety disorder:

Generalized anxiety disorder: Causes and Types

Causes of Broader Categories of Generalized anxiety disorder: Review the causal information about the various more general categories of medical conditions:

Related information on causes of Generalized anxiety disorder:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Generalized anxiety disorder may be found in:

Hidden causes of Generalized anxiety disorder

Causes of Generalized anxiety disorder: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Generalized anxiety disorder.

Anxiety: Differential Diagnosis
(In a Page: Signs and Symptoms)

Generalized anxiety disorder
–Excessive worry associated with at least three symptoms, including restlessness or edgy feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
–The most common anxiety disorder in primary care
Panic disorder
–Recurrent, unpredictable panic attacks with intense apprehension, fear or terror, and somatic symptoms (e.g., tachycardia)
–May present with or without agoraphobia
Depression: Anxiety often presents in a mixed state with depression
Medications (e.g., bronchodilators, steroids, antidepressants, antihypertensives)
Substance use, including drugs (e.g., alcohol, caffeine, cocaine, cannabis)
Obsessive-compulsive disorder
–Obsessions are persistent ideas, images, or impulses that generate anxiety
–Compulsions are intentional repetitive behaviors or mental acts aimed at reducing the distress of obsessions
- Anxiety disorder due to a general medical condition
  –Cardiovascular etiologies include MI, angina, arrhythmias, CAD, CHF, MVP
  –Respiratory etiologies include asthma, COPD, and pulmonary embolism
  –Endocrine etiologies include hyper- or hypothyroidism, hypoglycemia, and Cushing's syndrome
  –Neurological etiologies include Parkinson's disease and epilepsy
  –Cancer
- Pheochromocytoma: Adrenal tumor that usually presents with hypertension and increased heart rate and sometimes with fright reaction of sweating, headache, and pale facial appearance
- Parkinson's disease: Presents with tremor at rest, usually in one hand (as opposed to the more generalized essential tremor in anxiety)
- Post-traumatic or acute stress disorder
- Social anxiety disorder
- Specific phobia
- Bipolar disorder (especially manic stage)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Agitation: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Alcohol withdrawal syndrome. Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient’s pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.

❑ Anxiety. Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.

❑ Dementia. Mild to severe agitation can result from many common syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.

❑ Drug withdrawal syndrome. Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.

❑ Hepatic encephalopathy. Agitation occurs only with fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.

❑ Hypersensitivity reaction. Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.

With anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.

❑ Hypoxemia. Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.

❑ Increased intracranial pressure (ICP). Agitation usually precedes other early signs and symptoms, such as head-ache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.

❑ Post-head trauma syndrome. Shortly after, or even years after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.

❑ Vitamin B₆ deficiency. Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.

Other causes

❑ Drugs. Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants — especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.

❑ Radiographic contrast media. Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Anxiety: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Acute respiratory distress syndrome. Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.

❑ Anaphylactic shock. Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

❑ Angina pectoris. Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.

❑ Asthma. With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

❑ Autonomic hyperreflexia. The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

❑ Cardiogenic shock. Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

❑ Chronic obstructive pulmonary disease (COPD). Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.

❑ Heart failure. With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.

❑ Hyperthyroidism. Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.

❑ Mitral valve prolapse. Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.

❑ Mood disorder. Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.

❑ Myocardial infarction (MI). With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.

❑ Obsessive-compulsive disorder. Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.

❑ Pheochromocytoma. Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.

❑ Phobias. With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.

❑ Pneumonia. Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.

❑ Pneumothorax. Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.

❑ Postconcussion syndrome. Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.

❑ Posttraumatic stress disorder. Posttraumatic stress disorder occurs in the patient who has experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

❑ Pulmonary edema. With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and a thready pulse. The patient’s skin may be cool, clammy, and cyanotic.

❑ Pulmonary embolism. With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.

❑ Rabies. Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.

❑ Somatoform disorder. Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.

Other causes

❑ Drugs. Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Depression: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Organic disorders

Various organic disorders and chronic illnesses produce mild, moderate, or severe depression. Among these are metabolic and endocrine disorders,such as hypothyroidism, hyperthyroidism, and diabetes; infectious diseases, such as influenza, hepatitis, and encephalitis; degenerative diseases, such as Alzheimer's disease, multiple sclerosis, and multi-infarct dementia; and neoplastic disorderssuch as cancer.

Psychiatric disorders

Affective disordersare typically characterized by abrupt mood swings from depression to elation (mania) or by prolonged episodes of either mood. In fact, severe depression may last for weeks. More moderate depression occurs in cyclothymic disordersand usually alternates with moderate mania. Moderate depression that's more or less constant over a 2-year period typically results from dysthymic disorders. Also, chronic anxiety disorders,such as panic and obsessive-compulsive disorder, may be accompanied by depression.

Other causes

Alcohol abuse

Long-term alcohol use, intoxication, or withdrawal commonly produces depression.

Drugs.

Various drugs cause depression as an adverse effect. Among the more common are barbiturates; chemotherapeutic drugs, such as asparaginase; anticonvulsants, such as diazepam; and antiarrhythmics, such as disopyramide. Other depression-inducing drugs include centrally acting antihypertensives, such as reserpine (common in high dosages), methyldopa, and clonidine; beta-adrenergic blockers, such as propranolol; levodopa; indomethacin; cycloserine; corticosteroids; and hormonal contraceptives.

Postpartum period.

Although the cause hasn't been proved, depression occurs in about 1 in every 2,000 to 3,000 pregnancies and is characterized by various symptoms. Symptoms range from mild postpartum blues to an intense, suicidal, depressive psychosis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Skin, clammy: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anxiety

An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, a dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, a headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, a headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute)

Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, a headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With hypovolemic shock, generalized pale, cold, clammy skin accompanies a subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, an increased capillary refill time, decreased urine output, confusion, and a decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Fontanel depression: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Dehydration

With mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. The infant has pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and, possibly, irritability

Moderate dehydration (10% weight loss) causes slightly more pronounced fontanel depression, along with gray skin with poor turgor, dry mucous membranes, decreased tears, and decreased urine output. The infant has normal or decreased blood pressure, an increased pulse rate and, possibly, lethargy.

Severe dehydration (15%or greater weight loss) may result in a markedly sunken fontanel, along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as a rapid, thready pulse; very low blood pressure; and obtundation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Seizures, generalized tonic-clonic: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess, site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include a fever, a headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and a headache.

Hepatic encephalopathy

Generalized seizures may occur late in hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypoglycemia

Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and a decreased LOC.

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, a headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke

Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, a headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Generalized anxiety disorder: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Theorists share a common premise: Conflict, whether intrapsychic, sociopersonal, or interpersonal, promotes an anxiety state.

Generalized anxiety disorder has a 1-year prevalence range from 3% to 8%. It’s more common in women than in men, and half of all cases begin in childhood or adolescence.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Major depression: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The multiple causes of depression aren’t completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes. Psychological causes (the focus of many nursing interventions) may include feelings of helplessness and vulnerability, anger, hopelessness and pessimism, and low self-esteem. They may be related to abnormal character and behavior patterns and troubled personal relationships. In many cases, the history identifies a specific personal loss or severe stressor that probably interacts with the person’s predisposition to provoke major depression.

Depression may be secondary to a specific medical condition — for example, metabolic disturbances, such as hypoxia and hypercalcemia; endocrine disorders, such as diabetes and Cushing’s syndrome; neurologic diseases, such as Parkinson’s and Alzheimer’s diseases; cancer (especially of the pancreas); viral and bacterial infections, such as influenza and pneumonia; cardiovascular disorders, such as heart failure; pulmonary disorders, such as chronic obstructive lung disease; musculoskeletal disorders, such as degenerative arthritis; GI disorders, such as irritable bowel syndrome; genitourinary problems, such as incontinence; collagen vascular diseases, such as lupus; and anemias.

Drugs prescribed for medical and psychiatric conditions as well as many commonly abused substances can also cause depression. Examples include antihypertensives, psychotropics, opioid and nonopioid analgesics, antiparkinsonian drugs, numerous cardiovascular medications, oral antidiabetics, antimicrobials, steroids, chemotherapeutic agents, cimetidine, and alcohol. Depression occurs in up to 18 million Americans, affecting all racial, ethnic, and socioeconomic groups. It affects both sexes, but is more common in women.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Agitation: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Affective disturbances

Agitation may occur in either the depressive or manic phase of affective disturbances and in personality disorders, such as borderline and antisocial personality disorders. The hallmark of the depressive form is depressed mood upon awakening, which eases during the day. Chronic anxiety may be mild or severe. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in the manic state may include decreased sleep, pressured speech, and grandiosity.

Alcohol withdrawal syndrome

Mild to severe agitation occurs with hyperactivity, tremors, and anxiety. In delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. Pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac arrhythmias, and shock can occur.

Anxiety

Anxiety is a common symptom that produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings may include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.

Chronic renal failure

Moderate to severe agitation occurs in chronic renal failure, which is marked by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.

Dementia

Mild to severe agitation can result from many common dementia syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.

Drug withdrawal syndrome

Findings vary with the drug but include mild to severe agitation, anxiety, abdominal cramps, diaphoresis, and anorexia. In opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.

Hepatic encephalopathy

Agitation occurs only in fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.

Hypersensitivity reaction

Moderate to severe agitation may be the first sign of a hypersensitivity reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.

In anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.

Hypoxemia

Beginning as restlessness, agitation rapidly worsens in hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.

Increased intracranial pressure (ICP)

Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.

Organic brain syndrome

In organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.

Post–head trauma syndrome

Shortly—or even years—after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Fatigue, wandering behavior, and poor judgment are other findings.

Vitamin B6 Deficiency

Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.

Other causes

Drugs

Mild to moderate agitation, which is commonly dose related, is an adverse effect of central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics such as ephedrine; caffeine; and theophylline.

Radiographic contrast media

Injection of a contrast medium during various diagnostic tests may produce moderate to severe agitation along with other signs of hypersensitivity.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Anxiety: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Acute respiratory distress syndrome

Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.

Anaphylactic shock

Acute anxiety is usually the first sign of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

Angina pectoris

Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.

Asthma

In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Autonomic hyperreflexia

The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by a severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

Cardiogenic shock

Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

Chronic obstructive pulmonary disease (COPD)

Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.

Heart failure

In heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.

Hyperthyroidism

Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, diaphoresis, an enlarged thyroid, and diarrhea. Exophthalmos also may occur.

Hyperventilation syndrome

Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.

Hypochondriasis

Mild to moderate chronic anxiety occurs in hypochondriasis. The patient focuses more on the belief that he has a specific serious disease rather than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.

Hypoglycemia

Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis.

Mitral valve prolapse

Panic may occur in patients with this valvular disorder, also known as click-murmur syndrome because its hallmark is a midsystolic click, followed by an apical systolic murmur. Mitral valve prolapse also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain.

Mood disorder

Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. In the depressive form, chronic anxiety of varying severity occurs along with dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. In the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.

Myocardial infarction (MI)

In this life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. MI may be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.

Obsessive-compulsive disorder

Chronic anxiety occurs in obsessive-compulsive disorder, which is marked by recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.

Pheochromocytoma

Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Other common findings include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.

Phobias

In phobias, chronic anxiety accompanies persistent fear of an object, an activity, or a situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.

Pneumonia

Acute anxiety may occur in pneumonia because of hypoxemia. Other findings include productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.

Pneumothorax

Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.

Postconcussion syndrome

Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache.

Posttraumatic stress disorder

Posttraumatic stress disorder occurs in patients who have experienced an extremely traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Pulmonary edema

In pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.

Pulmonary embolism

Acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.

Rabies

Anxiety signals the beginning of the acute phase of rabies. This rare disorder is characterized by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.

Somatoform disorder

Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.

Other causes

Drugs

Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Depression: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Organic disorders

Various organic disorders and chronic illnesses produce mild, moderate, or severe depression. Among these are metabolic and endocrine disorders, such as hypothyroidism, hyperthyroidism, and diabetes; infectious diseases, such as influenza, hepatitis, and encephalitis; degenerative diseases, such as Alzheimer’s disease, multiple sclerosis, and multi-infarct dementia; and neoplastic disorders such as cancer.

Psychiatric disorders

Affective disorders are typically characterized by abrupt mood swings from depression to elation (mania) or by prolonged episodes of either mood. In fact, severe depression may last for weeks. More moderate depression occurs in cyclothymic disorders and usually alternates with moderate mania. Moderate depression that’s more or less constant over a 2-year period typically results from dysthymic disorders. Also, chronic anxiety disorders, such as panic and obsessive-compulsive disorder, may be accompanied by depression.

Other causes

Alcohol abuse

Long-term alcohol use, intoxication, or withdrawal commonly produces depression.

Drugs

Various drugs cause depression as an adverse effect. Among the more common are barbiturates, chemotherapeutic drugs such as asparaginase, anticonvulsants such as diazepam, and antiarrhythmics such as disopyramide. Other depression-inducing drugs include centrally acting antihypertensives, such as reserpine (common with high doses), methyldopa, and clonidine; beta-adrenergic blockers such as propranolol; levodopa; indomethacin; cycloserine; corticosteroids; and hormonal contraceptives.

Postpartum period

Although its cause hasn’t been determined, postpartum depression occurs in about 1 in every 2,000 to 3,000 women who have given birth. Symptoms range from mild postpartum blues to an intense, suicidal, depressive psychosis.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Skin, clammy: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anxiety

An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute)

Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With this common form of shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Fontanel depression: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Dehydration

In mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. Other findings include pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and possibly irritability.

Moderate dehydration (10% weight loss) causes slightly more pronounced fontanel depression along with gray skin with poor turgor, dry mucous membranes, decreased tears, and decreased urine output. The infant has normal or decreased blood pressure and an increased pulse rate; he may also be lethargic.

Severe dehydration (15% or greater weight loss) may result in a markedly sunken fontanel along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as rapid, thready pulse, very low blood pressure, and obtundation.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Seizures, generalized tonic-clonic: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Alcohol withdrawal syndrome

i> Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Depending on the size and location of the abscess, decreased level of consciousness (LOC) varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Generalized seizures may occur, depending on the tumor’s location and type. Other findings include a slowly decreasing LOC, morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure, and (eventually) decorticate posture.

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysmal rupture. Premonitory signs and symptoms may last several days, but onset is typically abrupt with severe headache, nausea, vomiting, and decreased LOC. Depending on the site and amount of bleeding, related signs and symptoms vary but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of this disorder. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Seizures are an early sign of this disorder, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Generalized seizures may occur late in this disorder. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski’s sign.

Hypertensive encephalopathy

This life-threatening disorder may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop
when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, this disorder may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis

This disorder rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Multiple brain lesions from this disorder cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Porphyria (intermittent acute)

Generalized seizures are a late sign of this disorder, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Lesions may affect the brain, causing generalized and focal seizures. Associated findings include a nonproductive cough with dyspnea, substernal pain, malaise, fatigue, arthralgia, myalgia, weight loss, tachypnea, dysphagia, skin lesions, and impaired vision.

Stroke

Seizures (focal more often than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Anxiety: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Situational/characterologic

❑ Post-traumatic stress disorder

❑ Drugs/withdrawal

❑ Generalized anxiety disorder

❑ Panic disorder

❑ Phobia

❑ Agitated depression

❑ Hypoglycemia

❑ Hyperthyroidism

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Source: Field Guide to Bedside Diagnosis, 2007

Depression: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Dysthymia

❑ Major depression

❑ Adjustment disorder with depressed mood

❑ Seasonal affective disorder

❑ Bipolar disorder

❑ Drug-induced

❑ Grief

❑ Thyroid disease

❑ Dementia

❑ Stroke

❑ Paraneoplastic

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Source: Field Guide to Bedside Diagnosis, 2007

Anxiety disorder, generalized: Causes
(Handbook of Diseases)

Etiology is thought to involve the y-aminobutyric acid (GABA) A receptor–chloride ion channel complex. Benzodiazepines bind two separate GABA-A receptor sites: Type I has broad anatomic distribution, and type II is concentrated in the hippocampus, striatum, and neocortex. Serotonin (5-hydroxytryptamine [5-HT]) also appears to have a role in anxiety. Theorists share a common premise: Con-flict — whether intrapsychic, sociopersonal, or interpersonal — promotes an anxiety state.

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Source: Handbook of Diseases, 2003

Depression, major: Causes
(Handbook of Diseases)

The multiple causes of depression aren’t completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes.

Psychological factors

Such causes may include feelings of helplessness and vulnerability, anger, hopelessness and pessimism, and low self-esteem; they may be related to abnormal character and behavior patterns and troubled personal relationships.

In many patients, the history identifies a specific personal loss or severe stressor that probably interacts with the person’s predisposition to provoke major depression.

Medical conditions

Other medical conditions that may underlie depression include viral and bacterial infections, such as influenza and pneumonia; cardiovascular disorders such as heart failure; pulmonary disorders such as chronic obstructive pulmonary disease; musculoskeletal disorders such as degenerative arthritis; GI disorders such as irritable bowel syndrome; genitourinary problems such as incontinence; collagen vascular diseases such as lupus; and anemias.

Drugs

Drugs prescribed for medical and psychiatric conditions as well as many commonly abused substances, can also cause depression. Examples include antihypertensives, psychotropics, narcotic and nonnarcotic analgesics, antiparkinsonian drugs, numerous cardiovascular medications, oral antidiabetics, antimicrobials, steroids, chemotherapeutic agents, cimetidine, and alcohol.

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Source: Handbook of Diseases, 2003

Skin, clammy: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Anxiety

Arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock

Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion

Hypoglycemia (acute)

Hypovolemic shock

With this common form of shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and a decreased level of consciousness.

Septic shock

The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Seizures, generalized tonic-clonic: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Alcohol withdrawal syndrome

Seizures as well as status epilepticus may develop 7 to 48 hours after abrupt cessation of alcohol consumption by the individual with alcohol dependency. Restlessness, hallucinations, profuse diaphoresis, and tachycardia may also occur.

Brain abscess

Generalized seizures may occur in the acute stage of abscess formation or after the abscess disappears. Decreased level of consciousness (LOC) varies from drowsiness to deep stupor according to the size and location of the abscess. Early signs and symptoms reflect increased intracranial pressure (ICP) and include constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site, but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor

Cerebral aneurysm

Occasionally, generalized seizures may occur with an aneurysm rupture. Premonitory signs and symptoms may last several days, but the onset is typically abrupt with severe headache, nausea, vomiting, and a decreased LOC. Related signs and symptoms vary according to the site and amount of bleeding, but may include nuchal rigidity, irritability, hemiparesis, hemisensory defects, dysphagia, photophobia, diplopia, ptosis, and unilateral pupil dilation.

Chronic renal failure

End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul’s respirations.

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and a decreased LOC.

Encephalitis

Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic)

In most cases, the cause of recurrent seizures is unknown.

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma. Other signs and symptoms may include soft-tissue injury of the face, head, or neck as well as facial edema and clear or bloody drainage from the mouth, nose, or ears. The patient may also exhibit Battle’s sign, lack of response to oculocephalic and oculovestibular stimulation, and bony deformity of the face, head, or neck. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy

Hypertensive encephalopathy

A life-threatening disorder, hypertensive encephalopathy may cause seizures along with severely increased blood pressure, a decreased LOC, intense headache, vomiting, transient blindness, paralysis and, eventually, Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Multiple sclerosis (MS)

MS rarely produces generalized seizures. Characteristic findings include vision deficits, paresthesia, constipation, muscle weakness, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, impotence, and emotional lability. Urinary frequency, urgency, and incontinence may also occur.

Neurofibromatosis

Porphyria (intermittent acute)

Generalized seizures are a late sign of porphyria, indicating severe CNS involvement. Acute porphyria also causes severe abdominal pain, tachycardia, psychotic behavior, muscle weakness, and sensory loss in the trunk.

Sarcoidosis

Stroke

Seizures (focal more common than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include a decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning

Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation, paresthesia of the extremities, alopecia, irritated mucous membranes, weakness, muscle aches, peripheral neuropathy, and sharply defined edema of the eyelids, face, and ankles.

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

Toxic blood levels of some drugs, such as theophylline, lidocaine, Indocin, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Agitation: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Affectivedisturbance

Agitation may occur in depressed and manic phases of affectivedisturbance and in personality disorders, such as borderline and antisocial personality disorders. In its depressive form, chronic anxiety occurs with varying severity. The hallmark is depressed mood upon awakening, which eases during the day. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in manic states may include decreased sleep, pressured speech, and grandiosity.

Alcohol withdrawal syndrome

With alcohol withdrawal syndrome, mild to severe agitation occurs. It may be accompanied by hyperactivity, tremors, and anxiety. With delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. Pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.

Anxiety

Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.

Chronic renal failure

Moderate to severe agitation occurs with chronic renal failure, marked especially by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.

Dementia

Mild to severe agitation related to dementia can result from many common syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.

Drug withdrawal syndrome

In drug withdrawal syndrome, mild to severe agitation occurs. Related findings vary with the drug but include anxiety, abdominal cramps, diaphoresis, and anorexia. With narcotic or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.

Hepatic encephalopathy

Agitation occurs with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus (musty, sweet breath odor), asterixis, and hyperreflexia. Lethargy, aberrant behavior, and apraxia may also occur.

Hypersensitivity reaction

With anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, skin that’s warm and moist, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.

Hypoxemia

Beginning as restlessness, agitation rapidly worsens with hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.

Increased intracranial pressure

With increased intracranial pressure (ICP), agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.

Organic brain syndrome

With organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.

Post–head trauma syndrome

Shortly after — or even years after — head trauma, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.

Vitamin B₆ deficiency

With vitamin B₆ deficiency, agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.

Other causes

Drugs

Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants — especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics such as ephedrine; caffeine; and theophylline.

Radiographic contrast media

Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Anxiety: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Acute respiratory distress syndrome

With acute respiratory distress syndrome (ARDS), acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.

Anaphylactic shock

Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

Angina pectoris

Asthma

During allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Autonomic hyperreflexia

The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

Cardiogenic shock

With cardiogenic shock, acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

Chronic obstructive pulmonary disease

Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize chronic obstructive pulmonary disease (COPD). Other signs and symptoms include barrel chest, pursed-lip breathing, and finger clubbing (late in the disease).

Heart failure

Acute anxiety is commonly the first symptom of inadequate oxygenation in a patient with heart failure. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.

Hyperthyroidism

Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.

Hyperventilation syndrome

Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms. Other signs and symptoms include chest pain, tachycardia, belching, flatus, and dizziness.

Hypochondriasis

Mild to moderate chronic anxiety occurs with hypochondriasis. The patient focuses more on the belief that he has a specific serious disease than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.

Hypoglycemia

Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis. Other signs and symptoms include nervousness, dizziness, and tingling and numbness around the mouth.

Mitral valve prolapse

Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.

Mood disorder

Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.

Myocardial infarction

With myocardial infarction, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.

Obsessive-compulsive disorder

Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but can’t control them. Anxiety builds if he can’t perform these acts and diminishes after he does.

Pheochromocytoma

Acute, severe anxiety accompanies the cardinal sign of pheochromocytoma: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.

Phobias

With phobias, chronic anxiety occurs along with persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.

Postconcussion syndrome

Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.

Posttraumatic stress disorder

Posttraumatic stress disorder occurs in patients who have experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Pulmonary edema

With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.

Pulmonary embolism

Hypoxia resulting from a pulmonary embolus may lead to acute anxiety and restlessness. The patient may also experience dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.

Somatoform disorder

Other causes

Drugs

Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Skin, clammy: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anxiety

Cardiac arrhythmias

Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension. The pulse rate may be rapid, slow, or irregular. The patient may report palpitations, chest pain, diaphoresis, light-headedness, and weakness.

Cardiogenic shock

With cardiogenic shock, generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria. Associated signs and symptoms include anginal pain, dyspnea, jugular vein distention, ventricular gallop, and a weak, rapid pulse.

Heat exhaustion

Hypoglycemia (acute)

With acute hypoglycemia, generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock

With hypovolemic shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock

The cold shock stage of septic shock causes generalized cold, clammy skin. Associated findings include rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Seizures, generalized tonic-clonic: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Alcohol withdrawal syndrome

Sudden withdrawal from alcohol dependence may cause seizures 7 to 48 hours later as well as status epilepticus. The patient may also be restless and exhibit hallucinations, profuse diaphoresis, and tachycardia.

Arsenic poisoning

Brain abscess

Brain tumor

Cerebral aneurysm

Eclampsia

Generalized seizures are a hallmark of eclampsia. Related findings include severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis

Head trauma

In severe cases, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause a decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle’s sign; and lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit vision deficits, behavioral changes, and headache.

Hepatic encephalopathy

Hypertensive encephalopathy

Hypertensive encephalopathy, a life-threatening disorder, may cause seizures along with severely increased blood pressure, decreased LOC, intense headache, vomiting, transient blindness, paralysis, and (eventually) Cheyne-Stokes respirations.

Hypoglycemia

Hyponatremia

Seizures develop when serum sodium levels fall below 125 mEq/L, especially if the decrease is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism

Worsening tetany causes generalized seizures. Chronic hypoparathyroidism produces neuromuscular irritability, Chvostek’s sign, dysphagia, tetany, and hyperactive DTRs.

Hypoxic encephalopathy

Besides generalized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis

Renal failure (chronic)

Stroke

Other causes

Barbiturate withdrawal

In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests

Contrast agents used in radiologic tests may cause generalized seizures.

Drugs

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Agitation: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Alcohol withdrawal syndrome.Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient's pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.

Anxiety.Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.

Dementia.Mild to severe agitation can result from many common syndromes, such as Alzheimer's and Huntington's diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.

Drug withdrawal syndrome.Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.

Hepatic encephalopathy.Agitation occurs only with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.

Hypersensitivity reaction.Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.

With anaphylactic shock,a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.

Hypoxemia.Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.

Increased intracranial pressure (ICP).Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.

Post-head trauma syndrome.Shortly after, or even years after a head injury, mild to severe agitation may develop, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.

Vitamin B₆ deficiency.Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.

Other causes

Drugs.Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.

Radiographic contrast media.Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Anxiety: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute respiratory distress syndrome (ARDS).Acute anxiety occurs with ARDS along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, rhonchi, and decreased pulse oximetry.

Anaphylactic shock.Acute anxiety usually signals the onset of anaphylacticshock. It's accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

Angina pectoris.Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.

Asthma.With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, decreased pulse oximetry, tachycardia, and diaphoresis.

Autonomic hyperreflexia.The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

Cardiogenic shock.Acute anxiety in cardiogenic shock is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

Chronic obstructive pulmonary
disease (COPD).Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.

Generalized anxiety disorder.Anxiety may be the patient's chief complaint in this type of anxiety disorder. It's characterized by excessive, unrealistic worry lasting 6 months or more. Associated findings include trembling, insomnia, GI disturbances, dizziness, irritability, and muscle aches.

Heart failure.With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, cyanosis, and decreased pulse oximetry.

Hyperthyroidism.Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.

Mitral valve prolapse.Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.

Myocardial infarction (MI).With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.

Obsessive-compulsive disorder.Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can't perform these acts and diminishes after he does.

Pheochromocytoma.Acute, severe anxiety accompanies pheochromocytoma's cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.

Phobias.With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can't suppress it.

Pneumonia.Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.

Pneumothorax.Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It's accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.

Postconcussion syndrome.Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.

Posttraumatic stress disorder.Posttraumatic stress disorder produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient may relive the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Pulmonary edema.With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, decreased pulse oximetry, ventricular gallop, hypotension, and a thready pulse. The patient's skin may be cool, clammy, and cyanotic.

Pulmonary embolism.With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.

Rabies.Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.

Somatoform disorder.Somatoform disorder is characterized by anxiety and multiple somatic complaints that can't be explained physiologically. The symptoms aren't produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.

Other causes

Drugs.Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Skin, clammy: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anxiety.An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, a dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.

Arrhythmias.Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.

Cardiogenic shock.Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.

Heat exhaustion.In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.

Hypoglycemia (acute).Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.

Hypovolemic shock.With hypovolemic shock, generalized pale, cold, clammy skin accompanies a subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, an increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.

Septic shock.The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Fontanel depression: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Dehydration.With mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. The infant has pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and, possibly, irritability.

Severe dehydration (15% or greater weight loss) may result in a markedly sunken fontanel, along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as a rapid, thready pulse; very low blood pressure; and obtundation.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Seizures, generalized tonic-clonic: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Brain abscess.Generalized seizures may occur in the acute stage of a brain abscess formation or after the abscess disappears. Depending on the size and location of the abscess, a decreased LOC varies from drowsiness to deep stupor. Early signs and symptoms reflect increased intracranial pressure (ICP) and include a constant headache, nausea, vomiting, and focal seizures. Typical later features include ocular disturbances, such as nystagmus, impaired vision, and unequal pupils. Other findings vary with the abscess site but may include aphasia, hemiparesis, abnormal behavior, and personality changes.

Brain tumor.Generalized seizures may occur with a brain tumor, depending on it's location and type. Other findings include a slowly decreasing LOC, a morning headache, dizziness, confusion, focal seizures, vision loss, motor and sensory disturbances, aphasia, and ataxia. Later findings include papilledema, vomiting, increased systolic blood pressure, widening pulse pressure and, eventually, a decorticate posture.

Chronic renal failure.End-stage renal failure produces the rapid onset of twitching, trembling, myoclonic jerks, and generalized seizures. Related signs and symptoms include anuria or oliguria, fatigue, malaise, irritability, decreased mental acuity, muscle cramps, peripheral neuropathies, anorexia, and constipation or diarrhea. Integumentary effects include skin color changes (yellow, brown, or bronze), pruritus, and uremic frost. Other effects include an ammonia breath odor, nausea and vomiting, ecchymoses, petechiae, GI bleeding, mouth and gum ulcers, hypertension, and Kussmaul's respirations.

Eclampsia.Generalized seizures are a hallmark of eclampsia. Related findings include a severe frontal headache, nausea and vomiting, vision disturbances, increased blood pressure, a fever of up to 104° F (40° C), peripheral edema, and sudden weight gain. The patient may also exhibit oliguria, irritability, hyperactive deep tendon reflexes (DTRs), and decreased LOC.

Encephalitis.Seizures are an early sign of encephalitis, indicating a poor prognosis; they may also occur after recovery as a result of residual damage. Other findings include fever, headache, photophobia, nuchal rigidity, neck pain, vomiting, aphasia, ataxia, hemiparesis, nystagmus, irritability, cranial nerve palsies (causing facial weakness, ptosis, and dysphagia), and myoclonic jerks.

Epilepsy (idiopathic).In most cases, the cause of recurrent seizures is unknown.

Head trauma.With severe head trauma, generalized seizures may occur at the time of injury. (Months later, focal seizures may occur.) Severe head trauma may also cause decreased LOC, leading to coma; soft-tissue injury of the face, head, or neck; clear or bloody drainage from the mouth, nose, or ears; facial edema; bony deformity of the face, head, or neck; Battle's sign; and a lack of response to oculocephalic and oculovestibular stimulation. Motor and sensory deficits may occur along with altered respirations. Examination may reveal signs of increasing ICP, such as a decreased response to painful stimuli, nonreactive pupils, bradycardia, increased systolic pressure, and widening pulse pressure. If the patient is conscious, he may exhibit visual deficits, behavioral changes, and headache.

Hepatic encephalopathy.Generalized seizures may occur latein hepatic encephalopathy. Associated late-stage findings in the comatose patient include fetor hepaticus, asterixis, hyperactive DTRs, and a positive Babinski's sign.

Hypoglycemia.Generalized seizures usually occur with severe hypoglycemia, accompanied by blurred or double vision, motor weakness, hemiplegia, trembling, excessive diaphoresis, tachycardia, myoclonic twitching, and decreased LOC.

Hyponatremia.Seizures may develop when the serum sodium level falls below 125 mEq/L, especially if the sodium loss is rapid. Hyponatremia also causes orthostatic hypotension, headache, muscle twitching and weakness, fatigue, oliguria or anuria, cold and clammy skin, decreased skin turgor, irritability, lethargy, confusion, and stupor or coma. Excessive thirst, tachycardia, nausea, vomiting, and abdominal cramps may also occur. Severe hyponatremia may cause cyanosis and vasomotor collapse, with a thready pulse.

Hypoparathyroidism.Chronic hypoparathyroidism produces neuromuscular irritability and hyperactive DTRs. Worsening tetany causes generalized seizures.

Hypoxic encephalopathy.Besidesgeneralized seizures, hypoxic encephalopathy may produce myoclonic jerks and coma. Later, if the patient has recovered, dementia, visual agnosia, choreoathetosis, and ataxia may occur.

Neurofibromatosis.Multiple brain lesions from neurofibromatosis cause focal and generalized seizures. Inspection reveals café-au-lait spots, multiple skin tumors, scoliosis, and kyphoscoliosis. Related findings include dizziness, ataxia, monocular blindness, and nystagmus.

Stroke.Seizures (focal more commonly than generalized) may occur within 6 months of an ischemic stroke. Associated signs and symptoms vary with the location and extent of brain damage. They include decreased LOC, contralateral hemiplegia, dysarthria, dysphagia, ataxia, unilateral sensory loss, apraxia, agnosia, and aphasia. The patient may also develop visual deficits, memory loss, poor judgment, personality changes, emotional lability, urine retention or urinary incontinence, constipation, headache, and vomiting.

Other causes

Arsenic poisoning.Besides generalized seizures, arsenic poisoning may cause a garlicky breath odor, increased salivation, and generalized pruritus. GI effects include diarrhea, nausea, vomiting, and severe abdominal pain. Related effects include diffuse hyperpigmentation; sharply defined edema of the eyelids, face, and ankles; paresthesia of the extremities; alopecia; irritated mucous membranes; weakness; muscle aches; and peripheral neuropathy.

Barbiturate withdrawal.In chronically intoxicated patients, barbiturate withdrawal may produce generalized seizures 2 to 4 days after the last dose. Status epilepticus is possible.

Diagnostic tests.Contrast agents used in radiologic tests may cause generalized seizures.

Drugs.Toxic blood levels of some drugs, such as theophylline, lidocaine, meperidine, penicillins, and cimetidine, may cause generalized seizures. Phenothiazines, tricyclic antidepressants, amphetamines, isoniazid, and vincristine may cause seizures in patients with preexisting epilepsy.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

» Next page: Symptoms of Generalized anxiety disorder

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Dr. Huntley's Diagnosis Checklist

Causes of Generalized anxiety disorder

Generalized anxiety disorder Causes: Book Excerpts

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Generalized anxiety disorder: Related Medical Conditions

Generalized anxiety disorder: Causes and Types

Related information on causes of Generalized anxiety disorder:

Causes of Generalized anxiety disorder: Online Medical Books

Anxiety: Differential Diagnosis (In a Page: Signs and Symptoms)

Agitation: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Other causes

Anxiety: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Other causes

Depression: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Organic disorders

Psychiatric disorders

Other causes

Alcohol abuse

Drugs.

Postpartum period.

Skin, clammy: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Anxiety

Arrhythmias

Cardiogenic shock

Heat exhaustion

Hypoglycemia (acute)

Hypovolemic shock

Septic shock

Fontanel depression: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Dehydration

Seizures, generalized tonic-clonic: Medical causes (Handbook of Signs & Symptoms (Third Edition))

Brain abscess

Brain tumor

Chronic renal failure

Eclampsia

Encephalitis

Epilepsy (idiopathic)

Head trauma

Hepatic encephalopathy

Hypoglycemia

Hyponatremia

Hypoparathyroidism

Hypoxic encephalopathy

Neurofibromatosis

Stroke

Other causes

Arsenic poisoning

Barbiturate withdrawal

Diagnostic tests

Drugs

Generalized anxiety disorder: Causes and incidence (Professional Guide to Diseases (Eighth Edition))

Major depression: Causes and incidence (Professional Guide to Diseases (Eighth Edition))

Agitation: Medical causes (Professional Guide to Signs & Symptoms (Fifth Edition))

Affective disturbances

Alcohol withdrawal syndrome

Anxiety

Chronic renal failure

Dementia

Drug withdrawal syndrome

Hepatic encephalopathy

Hypersensitivity reaction

Hypoxemia

Increased intracranial pressure (ICP)

Organic brain syndrome

Post–head trauma syndrome

Vitamin B6 Deficiency

Other causes

Drugs

Radiographic contrast media

Anxiety: Medical causes (Professional Guide to Signs & Symptoms (Fifth Edition))

Acute respiratory distress syndrome

Anaphylactic shock

Angina pectoris

Asthma

Autonomic hyperreflexia

Cardiogenic shock

Chronic obstructive pulmonary disease (COPD)

Heart failure

Hyperthyroidism

Hyperventilation syndrome

Dr. Huntley's
Diagnosis
Checklist

Anxiety: Differential Diagnosis
(In a Page: Signs and Symptoms)

Agitation: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anxiety: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Depression: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Skin, clammy: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Fontanel depression: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Seizures, generalized tonic-clonic: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Generalized anxiety disorder: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Major depression: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Agitation: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anxiety: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Depression: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Skin, clammy: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Fontanel depression: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Seizures, generalized tonic-clonic: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anxiety: Differential Overview
(Field Guide to Bedside Diagnosis)

Depression: Differential Overview
(Field Guide to Bedside Diagnosis)

Anxiety disorder, generalized: Causes
(Handbook of Diseases)

Depression, major: Causes
(Handbook of Diseases)

Skin, clammy: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)