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Diseases » Tourette Syndrome » Diagnosis
 

Diagnosis of Tourette Syndrome

Tourette Syndrome Diagnosis: Book Excerpts

Tests and diagnosis discussion for Tourette Syndrome:

TS is diagnosed by observing the symptoms and evaluating family history. Tics must be present for at least one year. TS is a clinical diagnosis. (Source: excerpt from NINDS Tourette Syndrome Information Page: NINDS)

Diagnosis of Tourette Syndrome: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Tourette Syndrome:

Diagnostic Tests for Tourette Syndrome: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Tourette Syndrome.


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

  • Huntington's disease (chronic progressive hereditary chorea)
    –Autosomal dominant transmission
    –Associated with psychiatric symptoms and progressive dementia
    –Caudate atrophy on neuroimaging studies
    –Marker on chromosome 4
    • Sydenham's chorea
      –Symptoms follow febrile illness (20–30%
      of cases are associated with group A strep)
      –Seen in rheumatic fever
      –Peak ages: 5–13 years
      –More common in females
  • Systemic lupus erythematosus
  • AIDS
  • Hyperthyroidism
    • Chorea gravidarum
      –Develops in the first 4–5 months of
      pregnancy
      –Resolves following delivery
  • Drug-induced (e.g., levodopa, stimulants, anticonvulsants, antidepressants, neuroleptics, oral contraceptives)
  • Stroke
  • Neoplasm
    • Wilson's disease
      –Autosomal recessive disorder
      –Deficiency in copper metabolism
      –Associated with hepatic dysfunction,
      dystonia, dysarthria
  • Benign hereditary chorea
    –Autosomal dominant
    –Onset before age 5
    –Symptoms are nonprogressive
    • Neuroacanthocytosis
      –Etiology unknown
      –Characterized by chorea and deformed
      erythrocytes
  • DRPLA
    –Most common in Japan
    –Characterized by chorea, ataxia, epilepsy, and dementia

    • Workup and Diagnosis

    • History and physical examination
      –Clinical diagnosis is sufficient for Sydenham's chorea
      –Huntington's disease may present with psychiatric symptoms (e.g., depression) before other manifestations; onset of symptoms typically occurs in the fourth and fifth decades of life
      –The appearance of Kayser-Fleischer rings in the cornea on slit-lamp exam is diagnostic for Wilson's disease
    • Neuroimaging (CT, MRI) to rule out mass lesions and Huntington's disease (cerebral/basal ganglion atrophy)
    • Genetic testing for Huntington's disease
    • Echocardiography to diagnose carditis
    • Throat culture or serology (ASO) for streptococcal infection
    • Low level of serum ceruloplasmin and elevated 24-hour urine copper in Wilson's disease
    • Thyroid function tests to rule out hyperthyroidism
    • ANA to rule out lupus
    • Neuroacanthocytosis: Acanthocytes appear on peripheral smear with clinical symptoms of chorea, dystonia, and tics
    • DRPLA: Imaging studies may reveal cerebral and cerebellar atrophy

    » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Chorea: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

      • Toxins
        –Neuroleptics, phenytoin, antiemetics, oral contraceptives, theophylline, L-dopa, stimulants, lithium, carbon monoxide, manganese
    • Sydenham chorea (in rheumatic fever)
      –Migratory chorea, hypotonia, dysarthria, emotional liability
      –Usually 4 months after group A β-hemolytic Streptococcus infection
      –Molecular mimicry between streptococcal and CNS antigens results in formation of cross-reactive antibodies that disrupt basal ganglia function
      –Carditis is present in 80% of Sydenham chorea patients
        • Inherited choreas
          –Benign familial chorea
          –Juvenile Huntington chorea (usually presents with rigidity)
          –Familial paroxysmal choreoathetosis
      • Postinfectious: Mycoplasma, HSV, EBV, echovirus 25, varicella
      • Encephalitis: viral, mycoplasma, Lyme
      • Post-cardiac surgery
        –“Post-pump chorea”
        –Usually 2 weeks after cardiac surgery
      • Syndrome or disease associated
        –Wilson disease
        –Hallervorden-Spatz (disorder of iron metabolism with degeneration of globus pallidus)
        –Fahr disease: Encephalopathy and progressive calcification of basal ganglia
        –Lesch-Nyhan syndrome
        –Ataxia-telangiectasia
      • Endocrine: Hyperthyroidism, pregnancy (chorea gravidarum)
        • Acquired brain disorders
          –Multiple sclerosis, basal ganglia stroke, hypoxic ischemic encephalopathy, neoplasm
      • Abetalipoproteinemia
      • Glutaric aciduria type I
      • Neuroacanthocytosis
      • Systemic lupus erythematosus
      • Kernicterus
      • Antiphospholipid antibody syndrome
      • Mitochondrial encephalopathies

      Workup and Diagnosis

        • History
          –Fever, rash associated symptoms
          –History of streptococcal infections, rheumatic fever, arthritis
          –Birth history, family history, medications, ingestions
        • Physical exam
          –Eye exam: Kayser-Fleischer rings (Wilson disease)
          –Cardiac, joint, and skin exam (for rheumatic fever)
          –Neurologic exam should include eye movement, dysarthria, evaluation of tone, motor impersistence
      • Labs
        –Electrolytes, glucose, calcium, magnesium, LFTs, BUN/Cr, acetate, pyruvate
        –TSH, parathyroid hormone, hCG
        –CBC and blood smear (for acanthocytes)
        –Throat culture, antistreptolysin O titer
        –Ceruloplasmin (low in Wilson disease), amino acids
        –Lyme titer
        –Anti-nuclear, anti-cardiolipin, anti-phospholipid, anti dsDNA antibodies
        –Rheumatoid factor, lipid profile
        –Huntington disease genetic testing
        • Studies
          –Cardiac evaluation with Echo, ECG
          –LP useful in infectious or postinfectious cases
                –Multiple sclerosis (find oligoclonal bands)
          –Neuroimaging: CT or preferably MRI

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    LYMPHADENOPATHY, GENERALIZED: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Obviously, it is tempting simply to do a lymph node biopsy, but certain other procedures should be done first. If the patient is febrile, febrile agglutinins, Monospot test, blood cultures, and cultures of any other suspicious body fluid should be made. An FTA-ABS test should be done as well as a chest x-ray and tuberculin test to rule out tuberculosis. A blood count usually shows leukemia, but a bone marrow may be necessary to diagnose leukemia, Hodgkin disease, and the reticuloendothelioses. Other x-rays, skin tests, and special diagnostic procedures may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    WEAKNESS AND FATIGUE, GENERALIZED: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs with generalized weakness and fatigue is very important in pinning down a diagnosis. Generalized lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or tuberculosis or other chronic infection such as AIDS. Weakness and weight loss and polyphagia with polyuria and polydypsia would suggest hyperthyroidism or diabetes mellitus. Generalized weakness with polyuria and no significant weight loss suggests hyperparathyroidism. Weakness with pallor suggests some type of anemia. Weakness and weight loss without polyuria or polyphagia suggest malignancy or malabsorption syndrome. Weakness with other significant neurologic signs and symptoms prompts the consideration of muscular dystrophy, amyotrophic lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use prompts the investigation of drug or alcohol abuse. Caffeine, especially in large quantities, can also cause significant weakness and chronic fatigue.

    The initial workup of weakness and fatigue requires a CBC, sedimentation rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray and ECG. If muscular dystrophy or dermatomyositis is suspected, urine for creatinine, creatine and myoglobin can be done. Ultimately, a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum for acetylcholine receptor antibody may be done. If Addison disease is suspected, a serum cortisol may be done. A 24-hour urine aldosterone level may be done to exclude primary aldosteronism. Serum PTH may be done to exclude hyperparathyroidism.

    It would be wise to consult an infectious disease specialist before ordering an expensive workup. It would also be wise to consult an oncologist when searching for a malignancy before ordering an expensive workup.

    When all tests have negative findings, many clinicians have been tempted to make a diagnosis of chronic fatigue syndrome. It is questionable whether this is truly a disease or not.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    RASH, GENERAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or the if symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Myoclonus: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If the patient is stable, evaluate his level of consciousness (LOC) and mental status. Ask about the frequency, severity, location, and circumstances of myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes.

    » READ BOOK EXCERPT ONLINE »

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

    Tics: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Begin by asking the parents how long the child has had the tic. How often does the child have the tic? Can they identify any precipitating or exacerbating factors? Can the patient control the tics with conscious effort? Ask about stress in the child’s life such as difficult school work. Next, carefully observe the tic. Is it a purposeful or involuntary movement? Note whether it’s localized or generalized, and describe it in detail.

    » READ BOOK EXCERPT ONLINE »

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

    Seizures, generalized tonic-clonic: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

    If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of a headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

    Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

    » READ BOOK EXCERPT ONLINE »

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

    Tic disorders: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    For characteristic findings in patients with this condition, see Diagnosing tic disorders.

    » READ BOOK EXCERPT ONLINE »

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

    Myoclonus: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If the patient is stable, evaluate level of consciousness and mental status. Ask about the frequency, severity, location, and circumstances of the myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is the myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes.

    » READ BOOK EXCERPT ONLINE »

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

    Chorea [Choreiform movements]: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Ask the patient and his family when they first noticed the choreiform movements. Do the movements disappear when the patient is asleep? Find out if anyone in the patient’s family exhibits the same type of movements, and ask about a family history of such diseases as Huntington’s disease. Also ask which medications the patient is taking. Obtain an occupational history, noting especially prolonged exposure to manganese or other metals. As you obtain the history, observe the patient for excessive restlessness and periodic facial grimaces that may interrupt his speech.

    Perform a physical examination to evaluate the severity of the patient’s chorea. Ask him to stick out his tongue and keep it out. Typically, he’ll be unable to do this; instead, his tongue will dart in and out of his mouth. Observe the patient’s arms and legs separately for involuntary jerky movements. Ask him to extend and flex his hand as if halting traffic; the choreiform movements will be extremely evident in this position. Also, check for such related signs as athetosis, rigidity, or tremor.

    To assess the patient for choreoathetotic gait, ask him to walk. He may change the position of his trunk and upper body parts with each step and jerk and tilt his head to one side. Because of superimposed involuntary movements and postures, the patient’s legs may move slowly and awkwardly. (An involuntary movement suspending his leg momentarily with each step may give a dancing quality to his gait.)

    » READ BOOK EXCERPT ONLINE »

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

    Tics: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Begin by asking the parents how long the child has had the tic and how often he experiences it. Can they identify any precipitating or exacerbating factors? Can the patient control the tics with conscious effort? Ask about stressors in the child’s life, such as difficult school work. Next, carefully observe the tic. Is it a purposeful or involuntary movement? Note whether it’s localized or generalized, and describe it in detail.

    » READ BOOK EXCERPT ONLINE »

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

    Seizures, generalized tonic-clonic: History and physical examination
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report any unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have any other seizures before recovering?

    If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

    Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

    » READ BOOK EXCERPT ONLINE »

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

    Lymphadenopathy, Generalized: History
    (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

     should focus on those common causes of generalized lymphadenopathy.

     A. History of present illness should focus on the duration, location, quality, and context of the lymphadenopathy. Note associated signs and symptoms such as rash, fever, sore throat, and cough (4) (Chapters 2.6, 8.1, and 13.6). The goal is to ascertain if the adenopathy is attributable to a specific cause.

     B. Past medical history should focus on known illness, medication usage, and allergies. Serum sickness from antibiotic use as well as diphenylhydantoin for seizure prevention can cause generalized lymphadenopathy. Common chronic illnesses (e.g., lupus erythematosus and rheumatoid arthritis) can also cause generalized lymphadenopathy.

     C. Social history should focus on the patient’s occupation, sexual history, and alcohol use. Hepatitis B, secondary syphilis, and early human immunodeficiency virus (HIV) can all present with generalized lymphadenopathy. Patients with Hodgkin’s disease can develop painful adenopathy with alcohol use.

    D. Family history. Inquire about family illness with a genetic predisposition as well as any exposures to household contacts with infectious diseases (e.g., tuberculosis, infectious mononucleosis, or hepatitis B).

     E. Review of systems should focus on constitutional symptoms such as weight loss, fatigue, night sweats, malaise, arthralgias, nausea, and vomiting (1).

    Physical examination

     A. General. A comprehensive physical examination should be performed on all patients with generalized lymphadenopathy. Focus on those findings consistent with the most frequent causes of generalized lymphadenopathy. Note the patient’s temperature and weight, because fever and weight loss are frequent findings. Examine the skin, mucous membranes, abdominal organs, and joints; specifically, the presence of rash, mucocutaneous ulceration, organomegaly, and arthritis can be a guide to possible causes of the adenopathy. The presence of splenomegaly in a patient with adenopathy implies a systemic illness (e.g., infectious mononucleosis, lymphoma, leukemia, lupus, sarcoidosis, toxoplasmosis, or cat scratch disease) (Chapter 15.4). Additionally, search for other abnormal lymph nodes. Studies have shown that clinicians identified only 17% of those cases of generalized lymphadenopathy when it was present (1).

     B. Nodal examination. The abnormal lymph node groups should be specifically examined.

    1. Size. Lymph nodes enlarged up to 1 cm in diameter can be considered normal in size. These have a low malignancy risk and can usually be observed. Lymph nodes greater than 1.5 cm × 1.5 cm in area have been shown to have a 38% risk of cancer involvement and merit further workup (2).

     2. Location. Anterior cervical, submandibular, and inguinal nodes are normally palpable. The presence of supraclavicular adenopathy is always abnormal and carries a 90% cancer risk in those aged more than 40 years. Postocciptal nodes are associated with infectious mononucleosis, scalp lesions, toxoplasmosis, and non-Hodgkin’s lymphoma. Axillary nodes are associated with upper extremity infections, breast cancer, cat scratch disease, and lymphomas. Epitrochlear nodes are associated with pyogenic infections, sarcoidosis, tularemia, and syphilis. Inguinal nodes are associated with lower extremity infections and sexually transmitted diseases.

     3. Pain. The presence or absence of pain is not a reliable indicator of the cause of adenopathy. Capsular swelling from acute infections can cause pain as can necrotic hemorrhage from a malignant lymph node.

     4. Consistency. Rock hard nodes are consistent with metastatic disease (2). Firm rubbery nodes are found with lymphomas. Soft nodes tend to occur with infectious causes; however, this should not be considered diagnostic.

    » READ BOOK EXCERPT ONLINE »

    Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

    Motor Weakness: Differential Overview
    (Field Guide to Bedside Diagnosis)

    Generalized

    ❑ Steroid myopathy

    ❑ Diabetic amyotrophy

    ❑ Polymyalgia rheumatica

    ❑ Polymyositis

    ❑ Myasthenia gravis

    ❑ Guillain-Barré syndrome

    ❑ Hyperthyroidism

    ❑ Muscular dystrophy

    ❑ Eaton-Lambert syndrome

    ❑ Metabolic myopathy

    Paraparesis

    ❑ Trauma

    ❑ Multiple sclerosis

    ❑ Amyotrophic lateral sclerosis

    ❑ Guillain-Barré syndrome

    ❑ Epidural abscess

    ❑ Subacute combined degeneration

    ❑ Syringomyelia

    ❑ Aortic dissection

    ❑ Hysterical

    Diagnostic Approach

    Motor weakness should be distinguished from functional weakness due to systemic disease. Patients with true motor weakness will complain of difficulty performing specific tasks or a feeling of heaviness or stiffness in their limbs. Myopathy can be distinguished by proximal weakness (climbing stairs or combing hair), symmetrical distribution, absence of paresthesias and pain, or disturbance of bowel or bladder function. Proximal muscle weakness is more prominent in myopathy, distal weakness in peripheral nerve or anterior horn cell disease. Bulbar weakness, manifest as difficulty speaking and swallowing, is consistent with anterior horn cell disease or neuromuscular junction disorders. Ocular weakness occurs with myasthenia gravis and myotonic or oculopharyngeal dystrophy.

    Acute generalized weakness with an onset over hours can be caused by low levels of potassium, calcium, sodium, magnesium, or phosphate; by botulism; or by viral inflammatory myopathy. Spasticity, manifest as increased tone and sudden release (“clasp-knife”), occurs with CNS lesions. Rigidity occurs with extrapyramidal disorders. Functional overlay should be suspected in the presence of ratcheting “give-away” weakness.

    Peek sign: Orbicularis oculi weakness is observed on gentle eye closure. After initial complete apposition of the lid margins, they separate within seconds and the white of the sclera peeks through. Ice test: A glove finger filled with crushed ice is placed over the more ptotic eyelid for 2 minutes. An increase in opening of 2 mm or more is a positive result. Quiver eye movements: very fast, small twitch, jerk-like movements of the eyes upon changing the direction of gaze. Unintelligible speech: after prolonged speaking.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Tic disorders: Diagnosis
    (Handbook of Diseases)

    For characteristic findings in patients with this condition, see Diagnosing tic disorders, page 858.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Myoclonus: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If the patient is stable, evaluate his level of consciousness and mental status. Ask about the frequency, severity, location, and circumstances of the myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is the myoclonus ever precipitated by a sensory stimulus? 

    Physical examination

    During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes. Evaluate level of consciousness and mental condition. Perform a complete neurologic and musculoskeletal assessment.

    » READ BOOK EXCERPT ONLINE »

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

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

    Obtain the patient’s medical history. Has he had generalized or focal seizures before? If so, how frequently? Do other family members have seizures? Is the patient receiving drug therapy? Is he compliant? Ask about sleep deprivation and emotional or physical stress at the time the seizure occurred. Ask about the use of alcohol or illicit drugs.

    If you didn’t witness the seizure, obtain a description from the patient’s family. Ask when it started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body immediately? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering? Does he complain of headache and muscle soreness?

    Physical examination

    If the patient may have sustained a head injury, perform a complete neurologic examination, observing closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Assess his vital signs. Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

    » READ BOOK EXCERPT ONLINE »

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

    Chorea: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Ask the patient and his family when they first noticed the choreiform movements. Do the movements disappear when the patient is asleep? Find out if anyone in the patient’s family exhibits the same type of movements, and ask about a family history of such diseases as Huntington’s disease. Also ask which medications the patient is taking. Obtain an occupational history, noting especially prolonged exposure to manganese or other metals. As you obtain history information, observe the patient for excessive restlessness and periodic facial grimaces that may interrupt his speech.

    » READ BOOK EXCERPT ONLINE »

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

    Myoclonus: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If the patient is stable, evaluate level of consciousness (LOC) and mental status. Ask about the frequency, severity, location, and circumstances of myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is the myoclonus ever precipitated by a sensory stimulus?

    » READ BOOK EXCERPT ONLINE »

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

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

    If you didn’t witness the seizure, obtain a description from the patient’s companion. Ask when the seizure started and how long it lasted. Did the patient report any unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have any other seizures before recovering? Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals?

    Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

    » READ BOOK EXCERPT ONLINE »

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

    Myoclonus: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient is stable, evaluate his level of consciousness (LOC) and mental status. Ask about the frequency, severity, location, and circumstances of myoclonus. Has he ever had a seizure? If so, did myoclonus precede it? Is myoclonus ever precipitated by a sensory stimulus? During the physical examination, check for muscle rigidity and wasting, and test deep tendon reflexes. Then perform a neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Tics: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by asking the parents how long the child has had the tic. How often does it occur? Can they identify any precipitating or exacerbating factors? Can the patient control the tics with conscious effort? Ask about stress in the child's life such as difficult schoolwork. Next, carefully observe the tic. Is it a purposeful or involuntary movement? Note whether it's localized or generalized, and describe it in detail.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Seizures, generalized tonic-clonic: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you didn't witness the patient's seizure, obtain a description from his companion. Ask when the seizure started and how long it lasted. Did the patient report unusual sensations before the seizure began? Did the seizure start in one area of the body and spread, or did it affect the entire body right away? Did the patient fall on a hard surface? Did his eyes or head turn? Did he turn blue? Did he lose bladder control? Did he have other seizures before recovering?

    If the patient may have sustained a head injury, observe him closely for loss of consciousness, unequal or nonreactive pupils, and focal neurologic signs. Does he complain of headache and muscle soreness? Is he increasingly difficult to arouse when you check on him at 20-minute intervals? Examine his arms, legs, and face (including tongue) for injury, residual paralysis, or limb weakness.

    Next, obtain a history. Has the patient ever had generalized or focal seizures before? If so, do they occur frequently? Do other family members also have them? Is the patient receiving drug therapy? Is he compliant? Also, ask about sleep deprivation and emotional or physical stress at the time the seizure occurred.

    Next, assess the patient's level of consciousness (LOC) and proceed with a complete neurologic examination.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    LYMPHADENOPATHY, GENERALIZED: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Obviously, it is tempting simply to do a lymph node biopsy, but certain other procedures should be done first. If the patient is febrile, febrile agglutinins, monospot test, blood cultures, and cultures of any other suspicious body fluid should be made. A fluorescent treponemal antibody absorption test (FTA-ABS) test should be done as well as a chest x-ray and tuberculin test to rule out tuberculosis. A blood count usually shows leukemia, but a bone marrow biopsy may be necessary to diagnose leukemia, Hodgkin lymphoma, and the reticuloendothelioses. Other x-rays, skin tests, and special diagnostic procedures may be necessary.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    WEAKNESS AND FATIGUE, GENERALIZED: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The association of other symptoms and signs with generalized weakness and fatigue is very important in pinning down a diagnosis. Generalized lymphadenopathy and fatigue suggest infectious mononucleosis, lymphoma, or tuberculosis or other chronic infection such as acquired immunodeficiency syndrome (AIDS). Weakness, weight loss, and polyphagia with polyuria and polydipsia would suggest hyperthyroidism or diabetes mellitus. Generalized weakness with polyuria and no significant weight loss suggests hyperparathyroidism. Weakness with pallor suggests some type of anemia. Weakness and weight loss without polyuria or polyphagia suggest malignancy or malabsorption syndrome. Weakness with other significant neurologic signs and symptoms prompts the consideration of muscular dystrophy, amyotrophic lateral sclerosis, or multiple sclerosis. Weakness with drug or alcohol use prompts the investigation of drug or alcohol abuse. Caffeine, especially in large quantities, can also cause significant weakness and chronic fatigue. The initial workup of weakness and fatigue requires a CBC, sedimentation rate, drug screen, chemistry panel, thyroid profile, ANA, chest x-ray, and echocardiogram (ECG). If muscular dystrophy or dermatomyositis is suspected, urine tests for creatinine, creatine, and myoglobin can be done. Ultimately, a muscle biopsy may be indicated. If myasthenia gravis is suspected, serum for acetylcholine receptor antibody may be done. If Addison disease is suspected, a serum cortisol test may be done. A 24-hour urine aldosterone level may be done to exclude primary aldosteronism. Serum parathyroid hormone (PTH) may be done to exclude hyperparathyroidism. It would be wise to consult an infectious disease specialist before ordering an expensive workup. It would also be wise to consult an oncologist when searching for a malignancy before ordering an expensive workup. When all tests have negative findings, many clinicians have been tempted to make a diagnosis of chronic fatigue syndrome. It is questionable whether this is truly a disease or not.

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    Source: Differential Diagnosis in Primary Care, 2007

    RASH, GENERAL: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Any condition with pus should be cultured. If a fungus is suspected, a Wood’s lamp examination and a fresh potassium hydroxide (KOH) preparation should be done. Skin biopsy is useful and is necessary in some cases. A dermatologist should be consulted if there is any question about a malignancy, if the condition persists, or if the symptoms are systemic. It is foolish to persist in treatment without a definitive diagnosis for more than 2 or 3 weeks when one may be dealing with something serious.

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    Source: Differential Diagnosis in Primary Care, 2007

    Tics: Tics - DIAGNOSIS
    (The 5-Minute Pediatric Consult)

    The diagnosis of tics is clinical. Physical exam and laboratory and imaging studies are typically normal.

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    Source: The 5-Minute Pediatric Consult, 2008


     » Next page: Signs of Tourette Syndrome

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