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with Rod Moser, PA, PhD

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Thursday, April 22, 2010

A Closer Exam of Soft Signs

How is a diagnosis usually made? A careful analysis of symptoms, the presence of physical signs, and of course, a careful examination to determine the significance of those signs. In medicine, there are hard signs – classic or definite signs that indicate a specific disease or condition, and soft signs – non-specific signs that may be present in many different disease or conditions.

Girl Holding Ear

Photo: Rod Moser

Perhaps one of the most common soft signs that I see on a daily basis is pulling on the ears. Anytime that a parent (especially a new, inexperienced parent) sees a child pulling or tugging on the ear, they worry that there is a middle ear infection present. Sometimes, the parent is correct and a middle ear infection is found on examination, but often, this random ear-pulling is just that – random, ear pulling.

Dylan's ear

Photo: Rod Moser

Children tend to pull things. For instance, if you have a little boy, you know they will occasionally pull their penis. This does not mean they have a penis infection, so why do parents tend to believe that all ear-pulling is an infection? Ears can be annoying, such as being stuffy or popping. This could call a child’s attention to the ear, making him or her tug on it. Dental issues, from normal teething to dental infections/cavities, can be mistaken for an ear-related issue. The upper molars are only located about an inch from the ear. Because of nerve pathways, swollen lymph nodes from a sore throat can also be referred to the ear. In older adults, a muscle spasm or an issue with the cervical spine can cause ear discomfort.

A recent study published by Pediatrics, proved the obvious:

1. Acute otitis media cannot be diagnosed over the phone, based on symptoms alone.
2. Restless sleep – the most common parental suspicion of an ear infection – has no predictive value.
3. Fever has no predictive value in determining if a child has an ear infection.
4. A child’s verbal or non-verbal expression of ear pain is also not predictive.

The only way a child can be accurately diagnosed is with an ear examination – not something that can be done over the phone or the internet.

Another soft sign could be a rash. Basically, the skin can only react in one-way – the creation of a skin eruption or rash. Certain skin lesions are classic diagnostic signs. For instance, a line of itchy, clear blisters on the arms or legs tends to be rhus dermatitis; also known as poison oak or ivy. If those same clear blisters are painful and located just on one side of the body, following a nerve distribution route, than this may be herpes zoster (shingles). A round skin lesion with raised borders and a clearing center area is classic for tinea corporis (ringworm).

Many things can cause rashes, however, such as hives, viral infections, chicken pox, measles or impetigo. All of these diseases with skin eruptions tend to have characteristic appearances. Children tend to be excluded from school or daycare until it is determined if the rash is a hallmark of a contagious disease or not. Measles and even chicken pox is uncommon now due to vaccination efforts, but people are still worried about them. I may see chicken pox (varicella) a dozen times a year now, but in the past, I used to see a dozen cases a week. I haven’t seen a live, laboratory-confirmed case of measles (roseola) in over thirty years. I see a lot of rashes in my practice, but not all of them can be easily diagnosed by their appearance, if at all.

People tend to get tummy aches from time to time – another soft sign. A tummy ache can simply be gas, intestinal cramps, constipation, impending diarrhea or just too many cookies. A tummy ache could also mean appendicitis, a kidney infection or a gastrointestinal infection, just to name a few. When a young woman comes in with right lower quadrant abdominal pain, we tend to immediately think about appendicitis, but she could just as easily have a pelvic infection, an ectopic (tubal) pregnancy or a kidney stone. Diagnostic tests, like an abdominal CT scan, are used routinely now in emergency rooms to quickly make that diagnosis. In times past, it was up to the skilled hands of the clinician to make that important, diagnostic call.

Headaches can be another soft sign. There are a few hundred different types of headaches, the most common being a muscle tension headache. Our brains do not really feel pain, but our skull is surrounded by muscles that do feel pain. Migraines, cluster headaches, aneurysms and the dreaded brain tumor are all listed as possibilities. Thank goodness that not all headaches are brain tumors or aneurysms, so deciding when to do an MRI of the brain to rule them out is always an important clinical decision your medical provider needs to make.

Other soft signs include fatigue, malaise, body aches or just feeling “yucky,” whatever that means. Today, I felt yucky, but went to work anyway. I would like to blame it on seasonal allergies, but my self-diagnosis tells me that I am getting a sinus infection (again). I had one a few months ago, so I am certainly familiar with the signs and symptoms. Of course, a person can have allergies AND a secondary viral or bacterial infection going on at the same time. Dealing with sick people every day, I certainly get exposed.

When someone posts a question on the Cold and Flu Exchange, they will often list some of these soft signs. As much as I would like to help them sort out this array of symptoms, a list of non-specific symptoms and signs is rarely sufficient to narrow down the field of possibilities. Do I have pneumonia? I don’t know… I can’t examine your lungs or get a chest x-ray. Do I have strep? Maybe, but I can’t look at your throat or do a strep test. Most people do understand that I cannot accurately diagnose anyone over the internet based solely on symptoms and a few (usually soft and non-specific) signs. It would be a wonderful world if we could.

What soft signs do you worry most about? Comment on this blog post and talk with Dr. Moser on the Cold and Flu Exchange.

Posted by: Rod Moser, PA, PhD at 9:06 am

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