Clinical evaluation and psychological aspects of temporomandibular joint disorders]

Establishing the patient's clinical diagnosis depends on gathering as much information of the patient and his or her signs and symptoms as possible. This information can be gathered from history, physical and psychological examination, diagnostic analysis. It is also important to look upon pain as a disorder and to consider the relationship between pain and psychological factors. The differential diagnosis is constructed through a biopsychological model of illness rather than through a more traditional biomedical model of disease. To arrive at a consistently accurate clinical diagnosis in patients with TMJ and craniofacial pain, the technique of clinical diagnosis must be well defined, reliable and include examination of the head and the neck, cranial nerves and the stomatognathic system. The craniomandibular index provides a standardized examination of the stomatognathic system that has been tested on validity and reliability. This chapter focuses on the techniques of history taking clinical and psychological examination and diagnostic criteria for temporomandibular joint disorders and muscle pain.     

Acute visual change

Changes in vision or loss of vision are common complaints for patients presenting to the emergency department. Such complaints may represent a simple problem related to recent trauma, early evidence of a systemic disease, or may be a vision-threatening lesion. A logical and organized approach to the history and the physical examination of the patient with eye complaints is key to the diagnosis and treatment of the more significant causes of these complaints. This article reviews an organized approach to the patient with complaint of visual loss and considers the wide differential diagnosis. It focuses specifically on the evaluation of the patient complaining of visual changes resulting from central retinal artery occlusion, central retinal vein occlusion, retinal detachment, acute angle-closure glaucoma, giant cell temporal arteritis, and retrobulbar hemorrhage.     

Poisoning and overdose

The differential diagnosis of all patients with altered mental status must include drug toxicity. In particular, intentional or unintentional overdosing and/or poisoning are common emergency department presenting complaints. A comprehensive approach to managing these patients must incorporate aggressive information gathering, a careful physical examination looking for toxic syndromes, and diagnostic testing. Proper decontamination is the key to effective management, as is the use of specific antidotes when indicated.     

Active laboratory consultation for the clinical supporting system in the general hospital

OBJECTIVE: To study demographic, clinical, and radiographic staging patterns in patients with multifocal osteonecrosis to facilitate earlier diagnosis and optimize treatment. METHODS: Multifocal osteonecrosis was defined as disease of 3 or more anatomic sites. Patients were characterized demographically, which included disease associations, corticosteroid and other agent usage, presenting joints, and symptomatology. Radiographically, patients were evaluated with plain radiographs and magnetic resonance imaging (MRI) scans of all joints to determine the presenting stage of the lesions. RESULTS: We found that 32 of 1056 (3%) osteonecrosis patients under our care had multifocal disease. Associated factors included systemic lupus erythematosus (13 patients), inflammatory bowel disease (5 patients), malignancy (4 patients), and renal transplantation (3 patients). Thirty of the 32 patients (94%) had a history of corticosteroid therapy, with the other 2 patients found to have a coagulopathy. All 32 patients had bilateral femoral head involvement and 30 of 32 had bilateral knee involvement, with the other 2 having only left knee lesions. Osteonecrosis was also seen in the shoulder (28 patients), ankle (8 patients), and 3 other sites. Overall, 201 sites were involved (6.3 per patient). The majority of joints presented in a pre-collapse stage (77%). Patients most commonly presented with hip or multiple joint symptoms (22 patients, 69%). In 8 patients, the knee was the sole presenting symptomatic joint and the ankle and shoulder were the sole presenting symptomatic joints in one patient each. CONCLUSION: In patients with a diagnosis of osteonecrosis and complaints in other joints, these other areas should be fully evaluated with plain radiographs and, if inconclusive, with MRI. In patients with osteonecrosis not involving the femoral head, the patient's hips should be radiographically evaluated regardless of whether the patient is symptomatic. Patients diagnosed with osteonecrosis of the knee, shoulder, or ankle should have other joints evaluated, as such patients have multifocal disease roughly 50% of the time.     

The assessment of light intensity preference in psychiatric patients: a questionnaire

PROBLEM: Psoas abscesses are really rare so that the diagnostic onset is commonly very late. The differential diagnosis to other retroperitoneal processes is therefore important. METHOD: In a period of observation of 6 years 21 patient were treated with psoas abscesses. The evaluation of 16 records was done retrospectively under consideration of etiology, history, clinical examination, lab results and x-ray/CT/MRI etc. RESULTS: With the knowledge of the anatomy of the ilio-psoas muscle the clinical examination gives us important information about the diagnosis of psoas abscess. The history and the clinical examination precede the further diagnostics and are condition for high rates of sensitivity and specificity. Lab results indicate an absedation without being specific. The exclusive position of radiological diagnostics is undisputed. Ultrasound, x-ray and leucocyte marked bonescan are proven to be helpful in cases of unknown location of the abscesses. Method of choice seems to be the contrast enhanced CT-scan. The differential diagnosis includes gastrointestinal or renal disorders as well as pathology of bone or joints. In our cases differential diagnosis was complicated since the diagnostic onset was delayed and the initial therapy was not adequate. The diagnosis "abscess of the psoas" does not imply a general regime for therapy therefore an individual treatment in consideration of percutaneous and operative drainage has to be recommended. In selected cases a combination therapy is advised. CONCLUSION: In every case of retroperitoneal symptoms the differential diagnosis of an abscess of the psoas has to be regarded. The diagnosis is subtil and requires clinical and laboratory examinations as well as contrast enhanced computerscan. The therapy follows operative measures. The technique has to be individually decided.     

Work stress and recovery measured by urinary catecholamines and cortisol excretion in long distance coach drivers

Severe and frequently occurring epistaxis is a common problem in the praxis of the general practitioner. It may be a symptom of another disease which should be found. A specific pharmacological history has to be taken. This article tries to review the most important rhinologic aspects for the general practitioner that the development of the rhinologic disease works as guidance for the differential diagnosis of recurrent epistaxis.     

Referred earache; an important symptom of head-and-neck cancers

Otalgia is a common symptom in general practice and represents the sensation of pain in the ear. In four patients, three women aged 63, 57 and 37 years, and a man aged 64 years, ear pain was found to be caused by laryngeal carcinoma (two patients), oropharyngeal carcinoma and nasopharyngeal carcinoma (in a Turkish patient). Referred otalgia is an earache that is caused by a nonotologic source. In many cases it is difficult to identify the underlaying disease of referred otalgia. It may be the first symptom of a head-and-neck carcinoma. In case of otalgia with normal otologic findings, the differential diagnostic process must be specifically directed to the common sensory innervation of the ear and the head-and-neck structures. By carefully taking the patient's history with special attention to epidemiological factors such as smoking and drinking habits, racial traits, a positive family history of head-and-neck neoplasms and accompanying complaints and by performing repeated ENT examination including advanced imaging techniques, long delay in diagnosing head-and-neck cancer can be prevented.     

Primary torsion of the greater omentum mimicking duodenal ulcer

The diagnosis of primary torsion of the omentum is a diagnostic enigma and is made almost exclusively at laparotomy. The difficulty is enhanced when the patient has a chronic problem mimicking a specific entity, e.g. peptic ulcer disease. The case presented is an example of this situation. The patient's history and acute presentation were compatible with chronic peptic ulcer disease with acute perforation. At laparotomy, the findings of torsion of the right lower omentum with infarction, along with marked scarring of the remainder of the greater omentum explained the clinical picture. Torsion of the greater omentum, therefore, must be added to the list of differential diagnoses when one is considering peptic ulcer disease.     

The non-operative management of collateral ligament injuries of the knee joint

Severe knee ligament injuries are frequently underestimated, and this results in later problems of chronic instability. A history of an appropriate mechanism coupled with immediate reduction in function should arouse suspicion of a major disruption. Examination with the patient under anesthesia may be required to assess the extent of the injury. If the lesion is an isolated collateral tear, the intact cruciate ligaments prevent wide displacement. Such an injury can be managed non-operatively. A long leg plaster at 90 degrees for 2 weeks followed by 4 weeks in a cast brace with motion from 45 degrees to 100 degrees is recommended. The knee is then protected in a brace during athletic activities for approximately 6 months. Thirty collateral ligament tears have been managed in this fashion. Only one has significant residual complaints. It is emphasized that an isolated collateral ligament tear is a positive diagnosis, and associated cruciate lesions must be ruled out. The recovery is faster in those patients managed non-operatively than in those who have surgical repair. There has not been a problem with late instability.     

Management of the complications of long-term venous access

A syncope is defined as a sudden, temporary loss of consciousness, associated with loss of postural tone with spontaneous recovery. The incidence is high and the differential diagnosis broad; therefore, the first observations are essential for the management of the patient. In this review diseases will be described which manifest themselves with syncopes that fall under the auspices of either internal medicine or neurology. First, the etiologies of syncopes are discussed in the strict sense of the word, i.e. due to a global cerebral ischemia such as in orthostatic hypotension and vasopressor syncopes. Thereafter, a discussion concerning the differential diagnosis of syncopes will be introduced, including mainly psychogenic and epileptic seizures as well as vertebrobasilar hypoperfusion. Depending on the reason of the loss of consciousness, it can be a common benign disorder or a severe life-threatening disease. The personal history or witness account of the incidence provides the most useful information concerning diagnosis. The cardiological diagnostic procedures are discussed elsewhere. In some instances an EEG can further help with the diagnosis. In many cases an etiology can't be found, even if extensive investigations have been performed.     

Special diagnostic problems in primary malignant bone tumors

The diagnosis of primary malignant bone tumors, which only account for 1% of malignancies in humans, represents quite a challenge for the pathologist. Apart from the often overlapping morphology between different entities, heterogeneity within one and the same tumor has to be kept in mind. Furthermore, in most cases the diagnosis must be established based on small biopsy specimens and occasionally even on frozen sections. In this context detailed clinical information including the patient's age and exact localization of the tumor, as depicted by X-ray or MRI, are essential requirements for a correct diagnosis. In addition, multiple biopsies from different tumor sites may be of help. For example, 25% of osteogenic sarcomas (OSA) are chondroplastic. Others may contain areas similar to fibrosarcoma (FSA) or malignant fibrous histiocytoma (MFH). Since 90% of OSA occur in the second decade of life whereas chondrosarcomas, FSA and MFH usually manifest after the age of 40 years, a biopsy solely composed of malignant chondromatous tissue obtained from a tibial lesion of a 10-year-old child should most likely be considered as part of an OSA. In the differential diagnosis of the so-called small, round cell tumors, which include Ewing sarcoma, malignant lymphoma and small-cell OSA, immunohistochemical staining of the paraffin-embedded material and a molecular biological/genetic work-up of frozen material are most helpful. In this paper the histomorphological characteristics and criteria for differential diagnosis of the most common primary malignant bone tumors are discussed.     

Clinical judgement and decision making in practice. A patient with hemoptysis

A 43-year-old man was admitted because of severe and recurring haemoptysis, which was eventually ascribed to Goodpasture's syndrome. In case of an aspecific sign such as haemoptysis experienced clinicians will try to restrict the differential diagnosis by concentrating on other signs that are relevant to the main problem. In haemoptysis these other signs are general illness, fever, shortness of breath, painful respiration, chronic productive cough, and signs or a history of cardiac or pulmonary disease. If the differential diagnosis consists mainly of rare disorders or rare manifestations of common disorders, all possibilities should be considered. If Goodpasture's syndrome is suspected, further specific diagnostic tests should be done without delay.     

Dependence of marital problems on parental family history.

Examined the relation of marital complaints to family history in 1,624 psychiatric outpatients. Marital complaints were recognized to be an aspect of a broader "depressive spectrum disorder" with distinctive age, gender, alcohol, and neurotic depressive symptom characteristics. However, holding constant the depressive spectrum characteristics, a specific independent relation of marital complaints to family history of parental marital discord was verified. It is concluded that marital problems have 2 primary etiologies in the psychiatric population, one as part of a broader depressive spectrum disorder and the other a more specific familial behavior patterning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nursing management of sleep disorders: Part 1--Assessment

Insomnia and hypersomnia are the two most frequent sleep complaints. This article will focus on the assessment of these two symptoms. A thorough assessment, which includes a sleep history, information about the person's habits, a family history, a social history, a health history and a physical examination is necessary to determine the cause of patients' symptoms.     

Musculoskeletal pain syndromes that affect adolescents

Musculoskeletal pain is one of the most common pains of adolescence, along with headache and abdominal pain, and arthralgia is the single most common reason for referral to the pediatric rheumatologist. Not surprisingly, the pediatric rheumatologist is frequently called to distinguish organic from functional symptoms. During the past decade, the pediatric rheumatology community has been evaluating increasing numbers of adolescents and preadolescents who experience musculoskeletal symptoms presumably as a defense against emotional stress from achievement either in academic work or in sports. To complicate the challenge further, coexistent organic and psychologic disturbance is not rare. Clearly, organic illness does not protect a patient from emotional plan, and it may be most difficult to differentiate nonorganic pain in a patient with a known organic illness. Conversely, adolescents with organic illness may use their disease for secondary gain. Fear of misdiagnosis of physical illness as psychiatric and the notion that all of the patient's complaints should be explained by a unifying diagnosis cause diagnostic error in both psychogenic illness with physical manifestations and physical illness with psychogenic symptoms.     

The differential diagnosis of Meniere's disease

The diagnosis of "classic" Meniere's disease is easy to make. Unfortunately, Meniere's disease is a diagnosis of exclusion and many disease entities can mimic Meniere's disease. Thus, it is essential to eliminate other possible etiologic agents for complaints that could be related to Meniere's disease before making this diagnosis. This article evaluates the differential diagnosis in Meniere's disease.     

Rehabilitation of injuries in competitive swimmers

Competitive swimmers perform highly repetitive motions, therefore characteristic overuse injuries of the shoulder, back, and knee can occur. A thorough history and examination should be performed by both physician and physical therapist. The combination of hypovascularity, fatigue, poor stroke mechanics, and the progressive instability of a hypermobile joint results in shoulder impingement. Medical evaluation should determine the existence of any glenohumeral joint instability or signs of impingement. Back injuries are most commonly due to disc degeneration, hyperextension, or myofascial involvement. Medial knee pain is most common in breaststroke swimmers and may be due to excessive valgus and rotatory stress. Frequently seen diagnosis includes patellofemoral pain, medial collateral ligament stress syndrome, and medial synovitis. Treatment will focus on elimination of inflammation. Rehabilitation should focus on stabilisation exercises for hypermobile joints, postural correction, strengthening and flexibility.     

First evidence of Trypanosoma rangeli in the southeast of Brazil, an endemic region for Chagas'' disease

Coccidiomycosis is a fungal infection that primarily causes pulmonary disease. Extrapulmonary dissemination can occur to the musculoskeletal system with the knee joint most frequently involved. This case report describes a patient with coccidiomycosis whose initial presentation was of a popliteal cyst. The need for aggressive surgical and antibiotic treatment to eradicate this infection is discussed. Coccidiomycosis should be considered in a differential diagnosis of patients with popliteal cysts without other obvious etiologies.     

Mucinous cystadenoma of the pancreas as a cause of acute pancreatitis

Acute pancreatitis is only rarely the first presentation of a cystic neoplasm of the pancreas. Mucinous cystadenomas have not been reported to be a cause of acute pancreatitis; however, we present two cases of mucinous cystadenoma of the pancreas which have caused acute pancreatitis. Both patients (female) presented acute abdominal pain, with serum amylase elevation and ultrasound scan (US) and computed tomography (CT) evidence of moderate pancreatitis, which resolved with medical treatment; fluid collection in the distal pancreas had been misinterpreted as a pseudocyst. There was no history of alcohol abuse or gallstone disease. After distal pancreatectomy the diagnosis of mucinous cystadenoma was confirmed; in one case a large pseudocyst was associated with this diagnosis. Pre-operative differential diagnosis between inflammatory and neoplastic cysts is difficult, especially when the patient's first presentation is due to an episode of acute pancreatitis. A neoplastic cyst should be considered when acute pancreatitis attacks occur in non-alcoholic women, who do not have gallstone disease.     

Focal infarction of the testis. Report of a case simulating a gonadal mass

Series of comments on the clinical history of one patient diagnosed "a posteriori" with a focal infarction of the testis. The case was pre-operatively handled as a tumour, as a result of which the patient underwent radial orchiectomy. The only notable feature in the patient's background was a vasectomy, performed two years earlier. The rationale for this communication is the rarity of this entity and the differential diagnosis to be practised. Reference is made to some complementary diagnostic tests that may be requested. It includes a number of considerations on testis vascularization. After reviewing some studies contributed by the Spanish literature, several complications to be taken into consideration when performing a vasectomy are explained.