Practice

The Review of Systems

Address correspondence to
Dr Peter H. Gorman,
Kernan Orthopaedics and
Rehabilitation Hospital,
2200 Kernan Drive,
Baltimore, MD 21207,
pgorman@kernan.umm.edu.
in Spinal Cord Injury
Relationship Disclosure:
Dr Gorman anticipates
receiving research support
and Dysfunction
for a clinical trial from
Geron and has served Peter H. Gorman, MD, FAAN
as an expert witness.
Dr Gorman has received
a grant from the US
Department of Defense
ABSTRACT
for a clinical trial on Individuals with spinal cord injury or dysfunction represent unique diagnostic chal-
aquatic therapy and lenges when they present with symptoms of generalized malaise or ‘‘feeling lousy.’’
Lokomat therapy in spinal
cord injury. Those individuals with injury or dysfunction at or above the T6 level are specifically
Unlabeled Use of at risk for the phenomenon known as autonomic dysreflexia, which is a medical
Products/Investigational emergency. The underlying cause of autonomic dysreflexia as well as other sec-
Use Disclosure:
Dr Gorman reports no
ondary complications in the patient with a spinal cord injury can best be uncovered
disclosure. through a comprehensive review of systems, which encompasses constitutional,
Copyright * 2011, head, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, respiratory,
American Academy of skin, neurologic, psychiatric, endocrinologic, hematologic, and immunologic issues.
Neurology. All rights
reserved.
Continuum Lifelong Learning Neurol 2011;17(3):630–634.

Case
A 44-year-old man with C4 complete tetraplegia presented to the
emergency department with a 3-hour history of an abrupt-onset headache
and ‘‘feeling lousy.’’
The patient was injured in a motor vehicle collision 15 years ago. He had
been living at home with caregiver assistance and had not required
ventilator support since inpatient rehabilitation. His past history included
sphincterotomy 10 years ago. He has been using an external condom
catheter for urine collection and bisacodyl suppositories every other day
for bowel management. He had a sacral decubitus ulcer requiring flap
surgery 8 years ago.
His medical history was also notable for nonYinsulin-dependent
diabetes mellitus, obstructive sleep apnea, and chronic midscapular pain.
His medications included morphine sulfate extended release 45 mg 2 times
daily, gabapentin 900 mg 3 times daily, diazepam 10 mg 4 times daily,
glyburide 5 mg daily, and docusate sodium 100 mg 2 times daily.
His review of systems was notable for a report of facial sweating
coincident with the headache. The patient reported that he had not had
a bowel movement in 3 days despite the use of a laxative. His urine
had become foul smelling. He also reported the presence of an
ingrown toenail.
His temperature was 37.4-C (99.3-F), pulse 88 beats/min, respirations
18, blood pressure 161/88 mm Hg, and oxygen saturation 96% on room
air. He had mild facial diaphoresis. Cardiopulmonary examination was
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 Continued from page 630
unremarkable. He had a protuberant abdomen with diminished but
present bowel sounds. Genital examination revealed an uncircumcised
man with no scrotal masses. He had a stage III right ischial decubitus
ulcer with minimal serous drainage. Rectal examination demonstrated
reflexive but not voluntary tone with moderately hard stool in the
vault. He had an ingrown right great toenail. Neurologic examination
revealed intact cranial nerves but no voluntary motor control in his
extremities. The patient had moderately increased tone on passive range
of motion at the elbows, wrists, hips, and knees (Modified Ashworth
scale 3) and sustained clonus at the ankles. Laboratory studies were
notable for a white blood cell count of 11,200. Fingerstick glucose
was 235 mg/dL.
A Foley catheter was inserted, and 1000 mL of cloudy urine were
drained. Urinalysis showed too-numerous-to-count white blood cells and a
positive leukocyte esterase. Five minutes after Foley catheter insertion his
blood pressure decreased to 98/60 mm Hg and his headache resolved. He
was then manually disimpacted with lidocaine lubricant and treated
presumptively for a urinary tract infection. The Foley catheter was kept in
place, and the patient was discharged home.

DISCUSSION
The review of systems is a required portion of a medical evaluation that may
sometimes be done in a perfunctory fashion in clinical practice. It is, however, an
important diagnostic tool leading to enhanced patient care. This case illustrates the
importance of performing a careful, thoughtful review of systems because it can
provide essential information to guide further evaluation, especially in those indi-
viduals with spinal cord injury (SCI) or spinal cord dysfunction (SCD).
Patients with SCI or SCD at or above the T6 level are at risk for a phenomenon
known as autonomic dysreflexia. This condition, defined as an exaggerated re-
sponse to a noxious stimulus below the level of spinal injury, represents a true
medical emergency.1 Episodes of dysreflexia can lead to intracerebral hemorrhage
and death. Fortunately, if rapidly diagnosed, it can be managed and treated. Diag-
nosing and managing autonomic dysreflexia requires attention to systemic issues
not always considered by neurologists. A systematic review of systems is presented
here. Performing such a review ensures effective management of secondary
complications in individuals with a history of traumatic SCI, such as the patient
in this case, as well as those with multiple sclerosis, transverse myelitis, and spinal
cord infarction.

Constitutional Symptoms
Generalized malaise, fevers, chills, sweats, and weight loss are nonspecific symp-
toms. This patient related that he ‘‘felt lousy,’’ a report that requires particular
attention in a patient with SCD because of the lack of specific localizing signs. For
example, patients with SCI with acute appendicitis will not have localized
tenderness at the McBurney point, and those with obstructing renal lithiasis will
not necessarily have back pain. In this case, the report of ‘‘feeling lousy’’ should

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 Review of Systems

engender an extensive differential diagnosis that considers acute abdomen, urinary

tract or other major infections, an occult fracture, thromboembolism, and a cardiac
event. Evaluation must be more comprehensive than in the population without
SCI or SCD. The diagnosis of fever from thermoregulatory dysfunction in this
population is one of exclusion.2

Head, Eye, Ear, Nose, and Throat

The patient had a sudden-onset headache, which can be the primary symptom in
autonomic dysreflexia. Associated symptoms can include diaphoresis above the
level of the spinal cord lesion (as in this patient’s case), piloerection, flushing,
blurred vision, and nasal congestion. The major sign is a sudden increase in blood
pressure, realizing a blood pressure of 160/90 mm Hg would be considered
dramatically high in an individual with tetraplegia. Those with spinal cord lesions at
or above T6 are at risk, as vasoconstriction of the uninhibited splanchnic circulation
sympathetically innervated below T6 produces the relative hypertension. Triggers
can be anything that irritates the body below the level of injury, such as bladder
obstruction or infection and bowel distension (the patient reported foul-smelling
urine, and he had not had a bowel movement in 3 days). Other possibilities include
deep vein thromboses (DVTs), pressure ulcers, ingrown toenails (as in this case),
ectopic pregnancy, and other abdominal pathologies. Treatment is aimed at the
underlying cause and (if necessary) managing the blood pressure acutely.3 In this
case, information about several of these conditions was provided in the review
of systems.

Cardiovascular
Resting blood pressure is generally low in patients with SCI because of reduced
sympathetic activity and subsequent reduced vasomotor tone. Orthostatic hypo-
tension can be a major problem, especially acutely.
Another cardiovascular issue is the increased risk factors for ischemia. Individuals
living with SCI tend to have lower serum high-density lipoprotein cholesterol (24%
to 40% abnormal compared to 10% in the US population).4 These individuals also
have a greater incidence of impaired glucose tolerance (the patient’s blood glu-
cose was elevated), asymptomatic coronary disease, and an increased percentage
of fat mass.5 Stress testing in these patients is more challenging, often requiring
dipyridamole studies. Some evidence exists that exercise can make a difference,
however, even in those with profound paralysis.6 A negative history of chest pain
or coronary heart disease does not exclude this condition.

Gastrointestinal
Individuals with SCD tend to have prolonged colonic transit times, increasing from
15T7 hours for the average individual to 42T12 hours after SCI.7 With SCI/SCD
above the conus, there is decreased sensation but intact reflex propulsion of
stool and a spastic, continent external anal sphincter. As illustrated in this case,
the patient indicated that he had not had a bowel movement in 3 days.

Genitourinary
SCI bladder dysfunction is complex. After upper motor neuron SCI, bladder filling
will cause dyssynergia or reflex co-contraction of both detrusor and sphincter,

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which can be a trigger for urinary reflux and autonomic dysreflexia. The goal of
management is to maintain a low pressure collection system so as to avoid these
phenomena. Approaches include chronic indwelling catheterization, reliable in-
termittent catheterization, or sphincterotomy.8 This patient’s history suggested a
urinary tract infection, and he also had urinary retention.

Musculoskeletal
Musculoskeletal issues after SCI include overuse syndromes and contracture de-
velopment. One particularly common condition is heterotopic ossification, which
occurs in 16% to 53% of patients with SCI9 and commonly affects the shoulders,
hips, and knees. Heterotopic ossification can lead to marked limitations in range of
motion and is also associated with DVT and unexplained fever. The patient had no
specific symptoms of DVT, but his presentation does not exclude the condition.

Respiratory
Pulmonary function after SCI is highly dependent on the level and completeness of
injury. Interestingly, vital capacity is less in the sitting position than in the supine
position after SCI. The patient did not report dyspnea, and his oxygen saturation
was normal. Patients with SCI, however, may still have respiratory compromise
based on diaphragmatic weakness, lack of accessory musculature, and infectious
processes.

Skin
Even in the best of circumstances, the incidence of decubitus ulcers during acute
rehabilitation for patients with new SCI is approximately 34%.10 This patient had a
past history of decubitus ulcers and had a recurrence that could have contributed
to the autonomic dysreflexia.

Neurologic
The most common neurologic symptoms associated with SCI/SCD, besides paralysis
and anesthesia, are spasticity and pain. These problems are familiar to the neuro-
logist. This patient was receiving a chronic narcotic and neuropathic pain medi-
cations that may have masked other symptoms.

Psychiatric
SCI is associated with a greater incidence of depression and suicide than in age-
matched controls, especially within the first 5 years postinjury.11 The high incidence
of depression is likely due to the extent of change in physical function and body
image. Identifying depression early and treating through counseling and pharma-
cology is critically important. Depression should be specifically assessed as part of
the review of systems.

Endocrinologic
The incidence of impaired glucose tolerance is high after SCI and can contrib-
ute to cardiovascular disease and autonomic dysfunction. Because this patient
had a history of diabetes, information on changes in his food consumption and
fluid intake should be sought.

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 Review of Systems

Hematologic
The incidence of DVT is up to 80% higher in the first 3 months after SCI than in any
other acute medical condition.12 DVT and subsequent pulmonary embolism (PE)
can contribute to a report of ‘‘feeling lousy,’’ as well as cardiovascular instability
and dyspnea. The patient or caregiver should be asked about any new leg swelling
and any history of DVT. It is noteworthy that the risk of DVT returns to baseline
after 3 months for reasons that are not completely understood. Therefore, lifelong
DVT prophylaxis is generally not necessary, but DVT or PE should be considered
in the differential diagnosis of patients with this acute presentation.

Allergic/Immune
Reduction in natural killer cells occurs after SCI. Additionally, neutrophil phagocy-
tosis is impaired and T-cell function is depressed. All of these changes predispose
those with SCD to infection. The system review should specifically address possible
occult infection.

CONCLUSION
As illustrated by this case, the review of systems often provides critical information.
Knowledge of the differential diagnosis and possible etiologies of a patient’s con-
dition is essential, especially in the care of people with SCI/SCD. As with other parts
of the clinical evaluation, obtaining a thorough review of systems will pay dividends
in improved patient safety and outcome.

REFERENCES
1. Krassioukov A, Warburton DE, Teasell R, Eng JJ; Spinal Cord Injury Rehabilitation Evidence
Research Team. A systematic review of the management of autonomic dysreflexia after spinal
cord injury. Arch Phys Med Rehabil 2009;90(4):682Y695.
2. Colachis SC 3rd, Otis SM. Occurrence of fever associated with thermoregulatory dysfunction
after acute traumatic spinal cord injury. Am J Phys Med Rehabil 1995;74(2):114Y119.
3. U.S. Department of Health and Human Services. Consortium for Spinal Cord Medicine. Acute
management of autonomic dysreflexia: individuals with spinal cord injury presenting to
health-care facilities. Washington, DC: Paralyzed Veterans of America, 2001.
4. Bauman WA, Spungen AM. Coronary heart disease in individuals with spinal cord injury:
assessment of risk factors. Spinal Cord 2008;46(7):466Y476.
5. Kocina P. Body composition of spinal cord injured adults. Sports Med 1997;23(1):48Y60.
6. Lavis TD, Scelza WM, Bockenek WL. Cardiovascular health and fitness in persons with spinal cord
injury. Phys Med Rehabil Clin N Am 2007;18(2):317Y331.
7. Krogh K, Mosdal C, Laurberg S. Gastrointestinal and segmental colonic transit times in patients
with acute and chronic spinal cord lesions. Spinal Cord 2000;38(10):615Y621.
8. U.S. Department of Health and Human Services. Consortium for Spinal Cord Medicine. Bladder
management for adults with spinal cord injury: a clinical practice guideline for health-care
providers. J Spinal Cord Med 2006;29(5):527Y573.
9. Silver JR. A systematic review of the therapeutic interventions for heterotopic ossification after
spinal cord injury. Spinal Cord 2011;49(3):482.
10. Yarkony GM, Heinemann AW. Pressure ulcers. In: Stover SL, Delisa JA, Whiteneck GG, eds. Spinal
cord injury: clinical outcomes from the model systems. Gaithersburg, MD: Aspen Publishing, 1995.
11. Hagen EM, Lie SA, Rekand T, et al. Mortality after traumatic spinal cord injury: 50 years of
follow-up. J Neurol Neurosurg Psychiatry 2010;81(4):368Y373.
12. U.S. Department of Health and Human Services. Consortium for Spinal Cord Medicine. Prevention
of thromboembolism in spinal cord injury. Washington, DC: Paralyzed Veterans of America, 1999.

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