Once the patient’s condition is stabilized, obtain a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection, or trauma? Does the patient smoke or have a history of smoking? Obtain a drug history.

♦ Acute respiratory distress syndrome (ARDS). ARDS causes increased respiratory difficulty and hypoxemia, with nasal flaring, dyspnea, tachypnea, diaphoresis, cyanosis, scattered crackles, and rhonchi. It also produces tachycardia, anxiety, and decreased level of consciousness.

♦ Airway obstruction. Complete obstruction above the tracheal bifurcation causes sudden nasal flaring, absent breath sounds despite intercostal retractions and marked accessory muscle use, tachycardia, diaphoresis, cyanosis, decreasing level of consciousness and, eventually, respiratory arrest.

Partial obstruction causes nasal flaring with inspiratory stridor, gagging, wheezing, violent cough, marked accessory muscle use, agitation, cyanosis, and hoarseness.

♦ Anaphylaxis. Severe reactions can produce respiratory distress with nasal flaring, stridor, wheezing, accessory muscle use, intercostal retractions, and dyspnea. Associated signs and symptoms include nasal congestion, sneezing, pruritus, urticaria, erythema, diaphoresis, angioedema, weakness, hoarseness, dysphagia and, rarely, vomiting, nausea, diarrhea, urinary urgency, and incontinence. Cardiac arrhythmias and signs of shock may occur late.

♦ Asthma (acute). An asthma attack can cause nasal flaring, dyspnea, tachypnea, prolonged expiratory wheezing, accessory muscle use, cyanosis, and a dry or productive cough. Auscultation may reveal rhonchi, crackles, and decreased or absent breath sounds. Other
findings include anxiety, tachycardia, and increased blood pressure.

♦ Chronic obstructive pulmonary disease. This disorder can lead to acute respiratory failure secondary to pulmonary infection or edema. Nasal flaring is accompanied by prolonged pursed-lip expiration; accessory muscle use; loose, rattling, productive cough; cyanosis; reduced chest expansion; crackles; rhonchi; wheezing; and dyspnea.

♦ Pneumonia (bacterial). With this condition, nasal flaring occurs with dyspnea, tachypnea, high fever, and sudden shaking chills. An initially dry and hacking cough later becomes productive. Stabbing chest pain worsens with movement and respirations. Auscultation reveals decreased or absent breath sounds, fine crackles, and pleural friction rub. Percussion reveals dullness.

♦ Pneumothorax. This acute disorder can result in respiratory distress with nasal flaring, dyspnea, tachypnea, shallow respirations, hyperresonance or tympany on percussion, agitation, distended jugular veins, tracheal deviation, and cyanosis. Other findings typically include sharp chest pain, tachycardia, hypotension, cold and clammy skin, diaphoresis, subcutaneous crepitation, and anxiety. Breath sounds may be decreased or absent on the affected side; similarly, chest-wall motion may be decreased on the affected side.

Similar findings can occur with hydrothorax, chylothorax, or hemothorax, depending on the amount of fluid accumulation.

♦ Pulmonary edema. This disorder typically produces nasal flaring, severe dyspnea, wheezing, and a cough that produces frothy, pink sputum. Increased accessory muscle use may occur with tachycardia, cyanosis, hypotension, crackles, jugular vein distention, peripheral edema, and decreased level of consciousness.

♦ Pulmonary embolus. Signs of this potentially life-threatening disorder may include nasal flaring, dyspnea, tachypnea, wheezing, cyanosis, pleural friction rub, and productive cough (possibly hemoptysis). Its other effects include sudden chest tightness or pleuritic pain, tachycardia, atrial arrhythmias, hypotension, low-grade fever, syncope, marked anxiety, and restlessness.

♦ Diagnostic tests. Pulmonary function tests, such as vital capacity testing, can produce nasal flaring with forced inspiration or expiration.

♦ Treatments. Certain respiratory treatments, such as deep breathing, can cause nasal flaring.

To help ease breathing, place the patient in a high Fowler’s position. If he’s at risk for aspirating secretions, place him in a modified Trendelenburg’s or side-lying position. If necessary, suction frequently to remove oropharyngeal secretions. Administer humidified oxygen to thin secretions and decrease airway drying and irritation. Provide adequate hydration to liquefy secretions. Reposition the patient every hour, and encourage coughing and deep breathing and incentive spirometry use. Avoid administering sedatives or opiates, which can depress the cough reflex or respirations. Continually assess the patient’s respiratory status, and check his vital signs and oxygen saturation every 30 minutes, or as necessary.

Prepare the patient for diagnostic tests, such as chest X-rays, lung scan, pulmonary arteriography, sputum culture, complete blood count, arterial blood gas analysis, and 12-lead electrocardiogram.

Nasal flaring is an important sign of respiratory distress in infants and very young children, who can’t verbalize their discomfort. Common causes include airway obstruction, hyaline membrane disease, croup, and acute epiglottiditis. Use oxygen and cool humidifiers to help improve oxygenation.

Begin the history by asking the patient about the duration and frequency of the obstruction. Did it begin suddenly or gradually? Is it intermittent
or persistent? Unilateral or bilateral? Inquire about the presence and character of drainage. Is it watery, purulent, or bloody? Does the patient have nasal or sinus pain or headaches? Ask about recent travel, the use of drugs or alcohol, and previous trauma or surgery.

Examine the patient’s nose; assess airflow and the condition of the turbinates and nasal septum. Evaluate the orbits for any evidence of dystopia, decreased vision, excess tearing, or abnormal appearance of the eye. Palpate over the frontal and maxillary sinuses for tenderness. Examine the ears for signs of middle ear effusions. Inspect the oral cavity, pharynx, nasopharynx, and larynx to detect inflammation, ulceration, excessive mucosal dryness, and neurologic deficits. Lastly, palpate the neck for adenopathy.

♦ Basilar skull fracture. A tear in the dura can lead to cerebrospinal rhinorrhea, which increases when the patient lowers his head. Associated findings may include epistaxis, otorrhea, and a bulging tympanic membrane from blood or fluid. A fracture may also cause headache, facial paralysis, nausea, vomiting, impaired eye movement, ocular deviation, vision and hearing loss, depressed level of consciousness, Battle’s sign, and raccoon eyes.

♦ Common cold. Onset of the common cold is typified by a watery discharge along with sneezing and nasal obstruction. Edema of the nasal mucosa may lead to sinus pain and infection as well as loss of smell and taste. Related findings include sore throat, malaise, myalgia, arthralgia, and mild headache.

♦ Hypothyroidism. An underactive thyroid gland may lead to a generalized hypoactive state. This can lead to vascular dilation in the nasal mucosa, resulting in nasal obstruction. Associated findings include fatigue, weight gain despite anorexia, cold intolerance, facial edema, impaired memory, brittle hair, thick skin and tongue, bradycardia, and a hoarse voice.

♦ Nasal deformities. Deviation of the nasal septum may cause unilateral or bilateral nasal obstruction, snoring, and postnasal drip. Perforation of the nasal septum may result in a sensation of nasal congestion due to altered air flow.

♦ Nasal fracture. Nasal obstruction develops because of trauma that results in nasal mucosal swelling, epistaxis, abscess, or a septal deviation. Periorbital ecchymoses and edema, nasal deformity and pain, and crepitation of the nasal bones may occur as well.

♦ Nasal polyps. The most common signs and symptoms are nasal obstruction, anosmia, and clear, watery drainage. The patient may have a history of allergies, chronic sinusitis, trauma, cystic fibrosis, or asthma. Translucent, pearshaped polyps that are unilateral or bilateral occur.

♦ Nasal tumors. Benign and malignant nasal tumors may cause unilateral or bilateral nasal obstruction, rhinorrhea, epistaxis, pain, foul discharge, and cheek swelling. Most of these tumors are benign papillomas and minor salivary gland tumors; malignant ones are rare. Kaposi’s sarcoma of the nose may occur in acquired immunodeficiency syndrome.

♦ Nasopharyngeal tumors. Benign and malignant tumors of the nasopharynx may cause nasal obstruction, rhinorrhea, epistaxis, otitis media, and nasal speech. Tumors usually reach a considerable size before symptoms develop. Cancer of the nasopharynx is the most common malignancy of the nasopharynx and may present first with a neck mass or conductive hearing loss.

♦ Pregnancy. High levels of estrogen during pregnancy may cause vascular engorgement of the nasal mucosa, resulting in nasal obstruction. Associated findings include clear or bloodtinged drainage, sneezing, and edematous and bluish turbinates.

♦ Rhinitis. Allergic rhinitis produces intermittent watery discharge and nasal obstruction. Common signs and symptoms include sneezing, increased lacrimation, decreased sense of smell, postnasal drip, and itching of the eyes, nose, or ears. The mucosa is edematous and pale.

Vasomotor rhinitis produces a profuse watery nasal discharge in addition to nasal obstruction. Sneezing, postnasal drip, and swollen turbinates occur as well.

With atrophic rhinitis, nasal obstruction is chronic and continuous. Associated findings include intermittent, purulent drainage, foul drainage odor, and nasal crusts that bleed on removal. The mucosa is pale pink and shiny.

♦ Sarcoidosis. This systemic granulomatous disease occasionally affects the nasal tissues. Nasal membranes appear firm, woody, and erythematous, and their surfaces may be covered by foul-smelling, crusty secretions. These features may occur with a nonproductive cough, substernal pain, malaise, and weight loss.
Related findings include tachycardia, arrhythmias, parotid enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and arthritis in the ankles, knees, and wrist.

♦ Sinusitis. With acute sinusitis, the usual findings are marked nasal obstruction along with thick, purulent drainage and severe pain over the involved sinuses. Fever, inflamed nasal mucosa with purulent mucus, and facial tenderness and pressure occur.

With chronic sinusitis, nasal obstruction can be persistent or recurrent. Thick, intermittently purulent rhinorrhea and low-grade discomfort over the involved sinuses are also seen.

Chronic fungal sinusitis is clinically similar to chronic bacterial sinusitis. However, in immunocompromised patients the disease may rapidly progress to proptosis, blindness, and death.

♦ Wegener’s granulomatosis. Besides nasal obstruction, other nasal findings include crusting, epistaxis, mucopurulent discharge, and cartilaginous necrosis of the septum and bridge of the nose.

♦ Drugs. Topical nasal vasoconstrictors may cause rebound rhinorrhea and nasal obstruction if used longer than 5 days. Antihypertensives may cause nasal congestion as well.

♦ Surgery. Nasal obstruction may occur after sinus or cranial surgery, or even after rhinoplasty.

Prepare the patient for X-rays or computed tomography scans of the nose, sinuses, or skull. Promote fluid intake to thin secretions, as needed. Give an antihistamine, a decongestant, an analgesic, or an antipyretic.

Acute nasal obstruction in children commonly results from the common cold. In infants and children, especially between ages 3 and 6, chronic nasal obstruction typically results from large adenoids. In neonates, choanal atresia is the most common congenital cause of nasal obstruction and can be unilateral or bilateral. Cystic fibrosis may cause nasal polyps in children, resulting in nasal obstruction. However, if the child has unilateral nasal obstruction and rhinorrhea, you should assume that a foreign body is in the nose until proven otherwise.

Tell the patient not to use over-the-counter nasal vasoconstrictor sprays for more than 5 days.

Begin by obtaining a complete medical history. Focus on GI, endocrine, and metabolic disorders; recent infections; and cancer and its treatment. Ask about drug use and alcohol consumption. If the patient is a female of childbearing age, ask if she is or could be pregnant. Have the patient describe the onset, duration, and intensity of the nausea, as well as what causes or relieves it. Ask about related complaints, particularly vomiting (color, amount), abdominal pain, anorexia and weight loss, changes in bowel habits or stool character, excessive belching or flatus, and a sensation of bloating.

Inspect the skin for jaundice, bruises, and spider angiomas, and assess skin turgor. Next, inspect the abdomen for distention, auscultate for bowel sounds and bruits, palpate for rigidity and tenderness, and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess other body systems as appropriate.

♦ Adrenal insufficiency. Common GI findings in this endocrine disorder include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze skin; hypotension; a weak, irregular pulse; vitiligo; and depression.

♦ Anthrax (GI). Initial signs and symptoms include nausea, vomiting, loss of appetite, and fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.

♦ Appendicitis. With acute appendicitis, a brief period of nausea may accompany onset of abdominal pain. Pain typically begins as vague epigastric or periumbilical discomfort and rapidly progresses to severe stabbing pain localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, fever, constipation or diarrhea, tachycardia, anorexia, moderate malaise, and positive psoas (increased abdominal pain occurs when the examiner places his hand above the patient’s right knee and the patient flexes his right hip against resistance) and obturator signs (internal rotation of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting tightening of the internal obturator muscle that causes abdominal discomfort).

♦ Cholecystitis (acute). With this disease, nausea often follows severe right-upper-quadrant pain that may radiate to the back or shoulders, often following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention, fever with chills, diaphoresis, and a positive Murphy’s sign.

♦ Cholelithiasis. With this disease, nausea accompanies attacks of severe right-upper-quadrant or epigastric pain after ingestion of fatty foods. Other associated findings include vomiting, abdominal tenderness and guarding, flatulence, belching, epigastric burning, tachycardia, and restlessness. Occlusion of the common bile duct may cause jaundice, clay-colored stools, fever, and chills.

♦ Cirrhosis. Insidious early signs and symptoms of cirrhosis typically include nausea and vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses, jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.

♦ Diverticulitis. Besides nausea, diverticulitis causes intermittent crampy abdominal pain, constipation or diarrhea, low-grade fever, and often a palpable, tender, firm, fixed mass.

♦ Ectopic pregnancy. Nausea, vomiting, vaginal bleeding, and lower abdominal pain occur in this potentially life-threatening disorder. Suspect ectopic pregnancy in a female of childbearing age with a 1- to 2-month history of amenorrhea.

♦ Electrolyte imbalances. Such disturbances as hyponatremia or hypernatremia, hypokalemia, and hypercalcemia commonly cause nausea and vomiting. Other effects include cardiac arrhythmias, tremors or seizures, anorexia, malaise, and weakness.

♦ Escherichia coli O157:H7. Signs and symptoms include nausea, watery or bloody diarrhea, vomiting, fever, and abdominal cramps. In children younger than age 5 and in the elderly, hemolytic uremic syndrome may develop in which red blood cells are destroyed, which may ultimately lead to acute renal failure.

♦ Gastric cancer. This rare cancer may produce vague GI symptoms—mild nausea, anorexia, upper abdominal discomfort, and chronic dyspepsia. Fatigue, weight loss, weakness, hematemesis, melena, and altered bowel habits are also common.

♦ Gastritis. Nausea is common with this disorder, especially after ingestion of alcohol, aspirin, spicy foods, or caffeine. Vomiting of mucus or blood, epigastric pain, belching, fever, and malaise may also occur.

♦ Gastroenteritis. Usually viral, this disorder causes nausea, vomiting, diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel sounds, abdominal pain and tenderness, and possible dehydration and electrolyte imbalances may also develop.

♦ Heart failure. This disorder may produce nausea and vomiting, particularly with rightsided heart failure. Associated findings include tachycardia, ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema, jugular vein distention, ascites, nocturia, and diastolic hypertension.

♦ Hepatitis. Nausea is an insidious early symptom of viral hepatitis. Vomiting, fatigue, myalgia and arthralgia, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur early in the preicteric phase.

♦ Hyperemesis gravidarum. Unremitting nausea and vomiting that persist beyond the first trimester are characteristic of this pregnancy disorder. Vomitus ranges from undigested food, mucus, and bile early in the disorder to a coffeeground appearance in later stages. Associated
findings include weight loss, signs of dehydration, headache, and delirium.

♦ Infection. Acute localized or systemic infection typically produces nausea. Other common findings include fever, headache, fatigue, and malaise.

♦ Inflammatory bowel disease. The most common symptom is recurrent diarrhea with blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur.

♦ Intestinal obstruction. Nausea commonly occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky but can become severe and steady with strangulation. Constipation occurs early in large-intestinal obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction, and hypoactive or absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal mass.

♦ Irritable bowel syndrome. Nausea, dyspepsia, and abdominal distention may occur with this syndrome especially during periods of increased stress. Other findings include lower abdominal pain and abdominal tenderness, which is generally relieved by moving the bowels; diurnal diarrhea alternating with constipation or normal bowel function; and small stools with visible mucus and a feeling of incomplete evacuation.

♦ Labyrinthitis. Nausea and vomiting commonly occur with this acute inner ear inflammation. More significant findings include severe vertigo, progressive hearing loss, nystagmus, tinnitus and, possibly, otorrhea.

♦ Lactose intolerance. Depending on the individual, signs and symptoms may include nausea, diarrhea, cramps, bloating, and gas, and they occur after eating dairy products.

♦ Listeriosis. Signs and symptoms include nausea, vomiting, diarrhea, fever, myalgias, and abdominal pain. If the infection spreads to the nervous system and causes meningitis, signs and symptoms include fever, headache, nuchal rigidity, and change in level of consciousness.

♦ Ménière’s disease. This disease causes sudden, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear fullness.

♦ Mesenteric artery ischemia. With this condition, nausea and vomiting may accompany severe cramping abdominal pain, especially after meals. Other findings include diarrhea or constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal bruits.

♦ Mesenteric venous thrombosis. Insidious or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation, abdominal distention, hematemesis, and melena.

♦ Metabolic acidosis. This acid-base imbalance may produce nausea and vomiting, anorexia, diarrhea, Kussmaul’s respirations, and decreased level of consciousness.

♦ Migraine headache. Nausea and vomiting may occur in the prodromal stage, along with photophobia, light flashes, increased sensitivity to noise, light-headedness and, possibly, partial vision loss and paresthesia of the lips, face, and hands.

♦ Motion sickness. With this disorder, nausea and vomiting are brought on by motion or rhythmic movement. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea may also occur.

♦ Myocardial infarction. Nausea and vomiting may occur, but the cardinal symptom is severe substernal chest pain that may radiate to the left arm, jaw, or neck. Dyspnea, pallor, clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.

♦ Norovirus infection. Acute gastroenteritis from noroviruses commonly causes infected individuals to experience nausea. Frequent accompanying symptoms include vomiting, diarrhea, and abdominal pain or cramping. Less commonly, individuals may develop low-grade fever, headache, chills, muscle aches, and generalized tiredness. These viruses are carried in the stool or vomit of infected individuals, and are often spread through contaminated food or water. Duration of illness is brief, with healthy individuals recovering in 24 to 60 hours.

♦ Pancreatitis (acute). Nausea, usually followed by vomiting, is an early symptom of pancreatitis. Other common findings include steady, severe pain in the epigastrium or left upper quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and fever. Tachycardia, restlessness, hypotension, skin mottling, and
cold, sweaty extremities may occur in severe cases.

♦ Peptic ulcer. With this disorder, nausea and vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically occur when the stomach is empty, or after ingestion of alcohol, caffeine, or aspirin; they’re relieved by eating food or taking an antacid or an antisecretory. Hematemesis or melena may also occur.

♦ Peritonitis. Nausea and vomiting usually accompany acute abdominal pain localized to the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal distention, rigidity, and tenderness (including rebound tenderness); positive obturator sign and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations; and hiccups.

♦ Preeclampsia. Nausea and vomiting commonly occur with this disorder of pregnancy, along with rapid weight gain, epigastric pain, oliguria, severe frontal headache, hyperreflexia, and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.

♦ Q Fever. Signs and symptoms include nausea, vomiting, diarrhea, fever, chills, severe headache, malaise, and chest pain. Fever may last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

♦ Renal and urologic disorders. Cystitis, pyelonephritis, calculi, uremia, and other disorders of the renal system can cause nausea. Related findings reflect the specific disorder.

♦ Rhabdomyolysis. Signs and symptoms include nausea, vomiting, muscle weakness or pain, fever, malaise, and dark urine. Acute renal failure is the most commonly reported complication of the disorder. It results from renal structure obstruction and injury during the kidneys’ attempt to filter the myoglobin from the bloodstream.

♦ Thyrotoxicosis. With this disorder, nausea and vomiting may accompany the classic findings of severe anxiety, heat intolerance, weight loss despite increased appetite, diaphoresis, diarrhea, tremor, tachycardia, and palpitations. Other signs include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.

♦ Typhus. An abrupt onset of nausea, vomiting, fever, and chills follows the initial symptoms of headache, myalgia, arthralgia, and malaise.

♦ Drugs. Common nausea-producing drugs include antineoplastics, opiates, ferrous sulfate, levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics, quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal antiinflammatories.

Herbal remedies, such as ginkgo biloba and St. John’s wort, can produce adverse reactions, including nausea.

♦ Radiation and surgery. Radiation therapy can cause nausea and vomiting. Postoperative nausea and vomiting are common, especially after abdominal surgery.

If your patient is experiencing severe nausea, prepare him for blood tests to determine fluid and electrolyte status, and acid-base balance. Have him breathe deeply to ease his nausea; keep his room air fresh and clean-smelling by removing bedpans and emesis basins promptly after use and by providing adequate ventilation. Because he could easily aspirate vomitus when in a supine position, elevate his head or position him on his side.

Because pain can precipitate or intensify nausea, administer pain medications promptly, as needed. If possible, give medications by injection or suppository to prevent exacerbating nausea. Be alert for abdominal distention and hypoactive bowel sounds when you administer an antiemetic: These signs may indicate gastric retention. If you detect these, immediately insert a nasogastric tube, as required.

Prepare the patient for such procedures as computed tomography scan, ultrasound, endoscopy, and colonoscopy. Consult the nutritionist to determine the patient’s metabolic demands such as total or partial parenteral nutrition.

Nausea, commonly described as stomachache, is one of the most common childhood complaints. Often the result of overeating, it can also occur as part of diverse disorders, ranging from acute infections to a conversion reaction caused by fear.

Elderly patients have increased dental caries; tooth loss; decreased salivary gland function, which causes mouth dryness; reduced gastric acid output and motility; and decreased senses of taste and smell—any of which can contribute to nonpathologic nausea.

If the patient hasn’t sustained trauma, find out the severity and onset of his neck pain. Where specifically in the neck does he feel pain? Does anything relieve or worsen the pain? Is there any particular event that precipitates the pain? Also, ask about the development of other symptoms such as headaches. Next, focus on the patient’s current and past illnesses and injuries, diet, drug history, and family health history.

Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses, erythema, and ecchymoses. Assess active range of motion in his neck by having him perform flexion, extension, rotation, and lateral side bending. Note the degree of pain produced by these movements. Examine his posture, and test and compare bilateral muscle strength. Check the sensation in his arms, and assess his hand grasp and arm reflexes. Attempt to elicit Brudzinski’s and Kernig’s signs if there is not a history of neck trauma, and palpate the cervical lymph nodes for enlargement. (See Neck pain: Causes and associated findings, pages 480 to 483.)

♦ Ankylosing spondylitis. Intermittent, moderate to severe neck pain and stiffness with severely restricted range of motion is characteristic of this disorder. Intermittent low back pain and stiffness and arm pain are generally worse in the morning or after periods of inactivity and are usually relieved after exercise. Related findings also include low-grade fever, limited chest expansion, malaise, anorexia, fatigue and, occasionally, iritis.

♦ Cervical extension injury. Anterior or posterior neck pain may develop within hours or days following a whiplash injury. Anterior pain usually diminishes within several days, but posterior pain persists and may even intensify. Associated findings include tenderness, swelling and nuchal rigidity, arm or back pain, occipital headache, muscle spasms, visual blurring, and unilateral miosis on the affected side.

♦ Cervical fibrositis. This disorder may produce anterior neck pain that radiates to one or both shoulders. Pain is intermittent and variable, often changing with weather patterns. Other findings are nonspecific but commonly include point tenderness over involved muscles.

♦ Cervical spine fracture. Fracture at C1 to C4 can cause sudden death; survivors may experience severe neck pain that restricts all movement, intense occipital headache, quadriplegia, deformity, and respiratory paralysis.

♦ Cervical spine infection (acute). This infection can cause neck pain that restricts motion. Other findings include fever, possible deformity, muscle spasms, local tenderness, dysphagia, paresthesia, and muscle weakness.

♦ Cervical spine tumor. Metastatic tumors typically produce persistent neck pain that increases with movement and isn’t relieved by rest; primary tumors cause mild to severe pain along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to
atrophy and paralysis, and bladder and bowel incontinence.

♦ Cervical spondylosis. This degenerative process produces posterior neck pain that restricts movement and is aggravated by it. Pain may radiate down either arm and may accompany paresthesia, weakness, and stiffness.

♦ Cervical stenosis. This progressive disorder, commonly asymptomatic, may cause nonspecific neck and arm pain, paresthesia, muscle weakness or paralysis, and decreased range of motion.

♦ Esophageal trauma. An esophageal mucosal tear or a pulsion diverticulum may produce mild neck pain, chest pain, edema, hemoptysis, and dysphagia.

♦ Herniated cervical disk. This disorder characteristically causes variable neck pain that restricts movement and is aggravated by it. It also causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.

♦ Hodgkin’s lymphoma. This disorder may eventually result in generalized pain that may affect the neck. Lymphadenopathy, the classic sign, may accompany paresthesia, muscle weakness, fever, fatigue, weight loss, malaise, and hepatomegaly.

♦ Laryngeal cancer. Neck pain that radiates to the ear develops late in this disorder. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.

♦ Lymphadenitis. With this disorder, enlarged and inflamed cervical lymph nodes cause acute pain and tenderness. Fever, chills, and malaise may also occur.

♦ Meningitis. Neck pain may accompany characteristic nuchal rigidity. Related findings include fever, headache, photophobia, positive Brudzinski’s and Kernig’s signs, and decreased level of consciousness.

♦ Neck sprain. Minor sprains typically produce pain, slight swelling, stiffness, and restricted range of motion. Ligament rupture causes pain, marked swelling, ecchymosis, muscle spasms, and nuchal rigidity with head tilt.

♦ Osteoporosis. Neck pain is rare with this disorder, which usually affects the thoracic or lumbar vertebrae. Cervical vertebrae involvement produces tenderness and deformity.

♦ Paget’s disease. This slowly developing disease is commonly asymptomatic in its early stages. As it progresses, cervical vertebrae deformity may produce severe, persistent neck pain, along with paresthesia and arm weakness or paralysis.

♦ Rheumatoid arthritis. This disorder usually affects peripheral joints, but it can also involve the cervical vertebrae. Acute inflammation may cause moderate to severe pain that radiates along a specific nerve root; increased warmth, swelling, and tenderness in involved joints; stiffness, restricting range of motion; paresthesia and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the acute phase.

♦ Spinous process fracture. Fracture near the cervicothoracic junction produces acute pain radiating to the shoulders. Associated findings include swelling, exquisite tenderness, restricted range of motion, muscle spasms, and deformity.

♦ Subarachnoid hemorrhage. This life-threatening condition may cause moderate to severe neck pain and rigidity, headache, and a decreased level of consciousness. Kernig’s and Brudzinski’s signs are present. The patient may describe the headache as “the worst headache of my life.”

♦ Thyroid trauma. Besides mild to moderate neck pain, thyroid trauma may cause local swelling and ecchymosis. If a hematoma forms, it can cause dyspnea.

♦ Torticollis. With this neck deformity, severe neck pain accompanies recurrent unilateral stiffness and muscle spasms that produce a characteristic head tilt.

♦ Tracheal trauma. Fracture of the tracheal cartilage, a life-threatening condition, produces moderate to severe neck pain and respiratory difficulty.

Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion, hemoptysis, hoarseness, and dysphagia.

Promote patient comfort by giving an anti-inflammatory and an analgesic, as needed. Prepare him for diagnostic tests, such as X-rays, computed tomography scan, blood tests, and cerebrospinal fluid analysis.

The most common causes of neck pain in children are meningitis and trauma. A rare cause of neck pain is congenital torticollis.

Often difficult to identify, night blindness refers to impaired vision in the dark, especially after entering a darkened room or while driving at night. A symptom of choroidal and retinal degeneration, night blindness occurs in various ocular disorders and as an early indicator of vitamin A deficiency. In some patients, however, night blindness occurs without underlying pathology, simply reflecting poor adaptation to the dark. In these patients, it’s commonly accompanied by myopia.