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2 History and examination
Dysphasia
BOX
LMN
CNIX/ X
MND
UMN
MND
MRI
https://t.me/med1917
A disorder that aects the ability to produce and understand spoken language.
It is one of the most debilitating neurological conditions, especially when cogni-
tive function is intact.
Assessment
Dysphasia is unlikely when speech is fluent, grammatically correct, and meaningful.
1
Comprehension: test capacity to follow one- , two- , and several- step commands,
eg ‘Touch your ear, stand up, then close the door’.
2
Articulation: test repetition of complex words/ phrases, eg ‘British constitution’,
‘No ifs, ands, or buts’, ‘baby hippopotamus’.
3
Naming: test ability to name common and uncommon things, eg parts of a
watch/ clock/ pen.
4
Reading and writing: usually aected like speech in dysphasia. If normal, consider
other pathology, eg psychogenic, developmental. Remember to check hearing.
Classification (See
• Broca’s (expressive) anterior dysphasia: non- fluent speech, eort and frustration
‘Problems with classifying dysphasias’.)
with malformed words (eg ‘spoot’ for ‘spoon’), or impaired recall of words (eg ‘That
thing’). Comprehension is relatively intact: patients understand questions and attempt
to convey meaningful answers. Site of lesion: inf erolat eral do minan t front al lob e.
• Wernicke’s (receptive) posterior dysphasia: empty, fluent speech with phonemic
(‘flush’ for ‘brush’) and semantic (‘comb’ for ‘brush’) paraphasias/ neologisms. May
be mistaken for psychotic speech. The patient is unaware of errors. Comprehension
may be impaired. Site of lesion: posterior superior dominant temporal lobe.
• Conduction aphasia: repetition is impaired, comprehension and fluency less so.
Site of lesion: communication between Broca’s and Wernicke’s areas.
• Nominal dysphasia: objects cannot be named but other aspects of speech are
normal. Site of lesion: posterior dominant temporoparietal lesions.
Mixed dysphasia is common. Discriminating features may take time to emerge
after acute brain injury. Speech therapy is oered, though it may not help.
Problems with classifying dysphasias
The classical model of language comprehension occurring in Wernicke’s area and
language expression in Broca’s area is too simple. Functional
simplistic teaching that the processing of abstract words is confined to the left
studies defy
hemisphere and concrete words are processed on the right. Consider instead
a mosaic of language centres in the brain with more and less specialized functions. There is evidence that tool- naming is handled dierently and in a dierent
area to fruit- naming. There is also inter- individual variation in the anatomy of
these mosaics. This is depressing for those who want a rigid classification of dysphasia, but a source of hope to those who have had a stroke: recovery may be
better than teaching and non- functional imaging lead us to believe.
Dysarthria
Diculty with articulation due to incoordination/ weakness of muscles needed for
speech. Language is normal. Detected with assessment of articulation. Causes:
• Cerebellar disease Ataxic speech muscles lead to slurring (as if drunk). Speech
may be irregular in volume and staccato in quality.
• Extrapyramidal disease Soft, indistinct, monotonous speech.
• Bulbar palsy
• Pseudobulbar pa lsy
, p
502
fortful speech (eg
lesion causing palatal weakness (eg
). Speech may have a nasal character.
, p
lesion; Guillain– Barré;
les ion c ause s spa stic d ysar thria: s low, indi stin ct, n asal, ef-
502
; MS). A ‘hot potato voice’ occurs with bilateral lesions.
Dysphonia
Wea knes s o f re spi rator y m uscl es and / or vocal cords (eg myasthenia, p
p
500
Barré,
counting to
) leads to abnormal voice/ volume. It may be precipitated in myasthenia by
100
. Parkinson’s disease can produce a mix of dysarthria and dysphonia.
508
; Guillain–
71
2 History and examination
Mental state examination
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72
Psychiatric symptoms reflect dysfunction of the brain.
Just because a presentation is odd does not mean it is psychiatric.
Physical, neurological, and cognitive examination are needed before a psychiatric
diagnosis is made.
If psychiatric symptoms are due to medical/ neurological conditions there may
be other evidence of nervous system dysfunction, eg dysarthria (
disturbance (
If rapid onset, altered conscious level and/ or fluctuating presentation consider
delirium.
p71), altered gait (p64), sensory deficit.
Psychiatric symptoms
Consider all symptoms in their cultural and religious context.
• Negative symptoms: the absence of a behaviour, thought, feeling, or sensation,
eg lack of appetite, apathy, blunted emotion.
• Positive symptoms: the presence of symptoms that are not normally expected,
eg hallucinations.
Mood
• Lost of interest/ pleasure (anhedonia) in usual activities, feeling sad, hopeless,
decreased energy, social withdrawal.
• Anxiety.
• Mania: non- contextualized elevated mood and/ or disinhibition. Hypomania:
milder than mania.
Always ask, ‘Have you ever felt so low that you thought of harming yourself?’
Sensory
• Hallucinations: ‘Have you ever heard voices or seen things when there hasn’t
been anyone or anything there?’
Thoughts
• Delusion: a fixed, false, idiosyncratic belief. ‘What thoughts have you had?’,
‘Have you ever had any thoughts or beliefs that have struck you afterwards as
strange?’
• Thought insertion: delusion that thoughts belong to someone else and have
been inserted.
• Thought broadcasting: delusion that thoughts are heard or known by others.
• Obsessions: repeated unwanted/ unpleasant thoughts that cause anxiety, dis-
gust, or unease.
• Flight of ideas: speech races through themes, switching whimsically or through
associations, eg ‘clang’ association: ‘Yesterday I went to the shop. I didn’t hop
(clang), but I walked. Kangaroos hop, don’t they? My friend Joey wasn’t there.’
• Knight’s move: an unexpected change in the direction of thinking (akin to the
lateral component of the move of the knight’s piece in chess).
Language
• Pressure of speech: rapid and frenzied speech, inappropriate to the situation.
• Neologism (new words), echolalia (repeating others’ words), paralalia (repeti-
tion of own words).
Behaviour
• Avoidance: due to anxiety/ phobia.
• Compulsions: performing an action persistently and repetitively.
• Eating disorders.
• Altered sleep.
• Distractibility.
• Increased goal- directed activity.
• Excessive involvement in risky activity. Alcohol/ drug misuse (p
Somatic
Physical symptoms for which no physiological basis can be found. Include: fatigue,
dizziness, insomnia, reduced appetite, weight loss, breathlessness, chest pain,
headache, nausea, abdominal/ muscular pain.
p71), language
276
).
2 History and examination
Mental state examination
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Tips
• Explain the reason for meeting. Help to make the patient feel comfortable.
• Respect concerns and distress.
• Take into account culture, ethnicity, language, and comprehension.
• Consider whether physical health is impacting mental health, particularly pain and
cognition.
• Write down the patient’s exact words including the order in which they are ex-
pressed. This may be important for diagnosis.
Aims
• To achieve a snapshot of thoughts and behaviour at the time of examination.
• Identify the presence and severity of mental health conditions.
• Identify risk to self and to others.
Appearance
• Is dress appropriate for the setting?
• Do clothes reflect mood, ie bright/ dark?
• Is personal hygiene maintained?
• Signs of possible withdrawal: tremor, agitation, perspiration.
• Signs of neurological disease: ataxia, dysarthria, motor asymmetry.
Behaviour
An examination of non- verbal communication. Avoid stigmatization and pejorative
terminology.
• Attitude: cooperative, defensive, hostile, apathetic, distracted, agitated, anxious.
• Eye contact: able to maintain or not? Appropriate?
• Facial expression: expressive, relaxed, smiling/ laughing, sad, distrustful, slow.
• Mannerisms: repetition, compulsions, rituals.
• Psychomotor activity: pacing, tremors, foot tapping, psychomotor slowing, pauses.
If taking antipsychotic medication, observe for possible
oro- buccal dyskinesia, tremor, choreiform movements, dystonia.
effects:
• Arousal: level of attention/ distraction. Signs of hyperarousal, delirium?
• Disinhibited behaviour: a disregard of social conventions aecting emotion, cogni-
tion, or motor function/ response.
• Engagement and rapport: a key component of the examination. Note if rapport
established, if easy, easier over time, tenuous, poor, or dicult.
Speech
• Quantity: spontaneous, talkative, expansive, paucity/ poverty.
• Rate: rapid/ pressure (mania), slow (depression, negative symptom in psychosis).
• Flow and route: tangential (mania), circumstantial (anxiety/ obsession).
• Specific pathology: neologism, echolalia, paralalia (p72).
Mood (Sustained emotional state.); Aect (Expression of emotion, may fluctuate.)
• Assess subjective and objective: elated, euthymic, dysthymic, depressed, anxious.
Fluctuation, range, and congruence.
Thoughts
• Stream: pressure/ poverty, blocking of thoughts.
• Form: logical? Linked or tangential?
• Possession: insertion/ withdrawal/ broadcasting (p72).
• Content: delusions (eg persecutory, grandiose), obsession, phobia.
Suicidal ideation, self- harm, plans to violence/ harm/ abscond.
Perception
• Hallucination (visual/ auditory).
• Phenomenology: the patient’s perception and understanding of thoughts/
phenomena.
Cognition
• Attention, memory, alertness, functioning (p61).
Insight
• Do they recognize their symptoms?
• Are they willing to work with healthcare professionals on treatment/ recovery?
73
extrapyramidal side
2 History and examination
Signs of systemic disease in the hands
PDGF
VEGF
PDGF
VEGF
TB.
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74
The hands can give you a wealth of diagnostic information:
• Thyroid disease: warm, sweaty, tremor.
• Heart/ lung disease: cold, cyanosis.
• Neurological disease: diculty relaxing grip in myotonia, weak grip in myopathy/
peripheral neuropathy.
Clubbing
Clubbed fingernails (± toenails) have:
• Soft tissue swelling of the terminal phalanx.
• Increased curvature in all directions.
• Loss of angle between nail and nail fold (figs
Hypothesized pathogenesis:
1
Disruption to normal pulmonary circulation means that megakaryocytes,
which are usually fragmented in the lung, enter the systemic circulation.
2
Megakaryocytes become lodged in the capillaries of the fingers and toes, re-
leasing platelet- derived growth factor (
factor (
3
Other hypothesized pathogenic signalling proteins include prostaglandins,
). Release of
bradykinin, ferritin, adenosine nucleotides, interleukinfactor, serum transforming growth factor-
epidermal growth factor. These are altered by disruption to production/
metabolism, eg in the liver/ bowel.
4
An altered growth factor/ signalling profile leads to increased vascularity,
permeability, and connective tissue damage.
Unilateral clubbing remains unexplained.
Causes
Respiratory
• Bronchial cancer (women>men), usually not small cell cancer.
• Chronic lung suppuration: empyema, ab-
scess, bronchiectasis, cystic fibrosis.
• Fibrosing alveolitis.
• Mesothelioma.
•
Gastrointestinal
• Inflammatory bowel disease.
• Cirrhosis.
• GI lymphoma.
• Malabsorption, eg coeliac disease.
Cardiovascular
• Cyanotic congenital heart disease.
• Endocarditis.
• Atrial myxoma.
• Aneurysms.
• Infected grafts.
Rare
• Familial.
• Thyroid acropachy (p
Unilateral clubbing
• Hemiplegia.
• Vascular lesions:
• Upper limb artery aneurysm.
• Takayasu’s arteritis.
• Brachial arteriovenous malfor-
mations (including iatrogenic:
haemodialysis fistulas).
560
).
2.32, 2.33
).
and
) and vascular endothelial growth
may also be enhanced by hypoxia.
1
, tumour necrosis factor, and
Fig 2.
32
Finger clubbing.
Fig 2.
33
Testing for finger clubbing.
6
, von Willebrand
2 History and examination
Nail abnormalities
CT
ACTH
DIP
https://t.me/med1917
• Koilonychia : spoon- shaped nails (fig
ficiency, haemochromatosis, infection (eg fungal),
endocrine disorders (eg acromegaly, hypothyroidism), malnutrition.
• Leuconychia: whitening of nails (fig
tate due to trauma, alopecia, psoriasis, fungal infection. See also Beau’s lines and Terry’s nails below.
• Onycholysis: detachment of the nail from the nailbed:
hyperthyroidism, fungal infection, psoriasis.
• Beau’s lines: transverse furrows from temporary ar-
rest of nail growth (
fig
of physiological stress, eg severe infection, chemotherapy. The furrow’s distance from the cuticle allows
dating of the stress:
• Mees’ lines: single white transverse bands: arsenic
70.1
mm/ day.
poisoning, chronic kidney disease, carbon monoxide
poisoning.
• Muehrcke’s lines: paired white parallel transverse
bands (without furrowing of the nail itself, distinguishing them from Beau’s lines) seen in chronic hypoalbuminaemia, Hodgkin’s disease, pellagra (
chronic kidney disease.
• Ter ry ’ s n a il s : proximal portion of nail is white/ pink,
nail tip is red/ brown. Causes include cirrhosis, chronic
kidney disease, congestive cardiac failure.
• Pitting: see n in ps orias is, al opeci a areat a.
• Splinter haemorrhages: fine longitudinal haem-
orrhagic streaks under the nails (
microemboli or trauma. In the febrile patient, look
for infective endocarditis. In the well gardener, look
no further.
• Nail- fold infarcts: vasculitis, connective tissue (CT)
disease, eg scleroderma, mixed
• Chronic paronychia: chronic infection of the nail
fig
2.37
fold (
). Presents as a painful swollen nail with
intermittent discharge.
Skin changes
• Palmar erythema (fig
nancy, hyperthyroidism, rheumatoid arthritis, polycythaemia, chemotherapy- induced palmar/ plantar
erythrodysaesthesia. Also chronic liver disease/
cirrhosis via dinactivation of vasoactive endotoxins.
• Pallor of the palmar creases suggests anaemia.
• Pigmentation: normal pigmentation in dark skin.
Also Addison’s disease and Nelson’s syndrome
after removal of the adrenal glands in
(i
Cushing’s disease).
Nodules and contractures
• Dupuytren’s contracture: fibrosis and contracture
of palmar fascia (
fig
2.24
ageing.
• Heberden’s (distal interphalangeal joint, fig
Bouchard’s (fig
2.44
, proximal interphalangeal joint)
‘nodes’ are osteophytes (bone over- growth at a joint)
seen in osteoarthritis.
• Gottron’s papules: purple rash on the knuckles. Look
for with dilated nail- fold end- capillary loops. Seen in
dermatomyositis (
p
549
).
2.34
): iron de-
2.42
, p76): punc-
2.35
). Corresponds to times
p
240
fig
2.36
). Due to
disease.
2.38
): associated with preg-
, p58): liver disease, trauma,
2.39
) and
Fig 2.
34
Koilonychia.
Fig 2.
35
Beau’s lines. Here due to
chemotherapy, a new line is seen
with each cycle. See
p
525
),
Fig 2.
36
Splinter haemorrhages.
Fig 2.
37
Paronychia.
Reproduc ed from Burg e et al., Oxford
Handbook of Medical Dermatology
(
2016
), with permission from Oxford
Fig 2.
38
Fig 2.
39
Reproduced from Watts et al. (eds)
Oxford Textbook of Rheumatology
(
2013
), with permission from Oxford
University Press.
Palmar erythema.
Heberden’s nodes (
University Press.
75
.
).
2 History and examination
Musculoskeletal hand examination
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76
Expose the arms and hands. Ask the patient to rest their hands on a pillow. Start
by examining the dorsal surface and then turn the hands over. Always ask about
pain or tender areas. Follow the ‘look, move, feel’ approach to avoid causing pain.
On both the palm and the dorsum start by inspecting the skin for:
1
Colour Pigmentation of creases (p75), pallor, palmar erythema (p75, fig
2
Consistency Tight (sclerodactyly, fig
3
Characteristic lesion Pulp infarcts, rashes, purpura, spider naevi, telangiecta-
fig
sia, tophi (
replacement).
Fig 2.
40
Sclerosis.
2.41
), tendon xanthomata, scars (eg carpal tunnel release, joint
Look: skin
2.40
), thick (DM, acromegaly).
Fig 2.
41
Gouty tophi.
2.38
).
See pp74– 5.
• Clubbing (p74, figs 2.32, 2.33).
• Koilonychia (p75, fig 2.34).
• Leuconychia (fig 2.42).
• Pitting and onycholysis.
• Splinter haemorrhages (p75, fig
• Nail fold infarcts.
Wasting and fasciculations
• Palmar surface: look particularly at the
thenar (median nerve,
thenar eminences.
• Dorsal surface: look for wasting of dorsal
interossei. Generalized wasting, particularly of the interossei on the dorsum, but
sparing of the thenar eminence suggests
an ulnar nerve lesion.
Dupuytren's contracture (fig
fig
2.43
2.24
Look: nails
2.36
).
Fig 2.
Look: muscles
) and hypo-
, p58).
42
Fig 2.
Leuconychia.
43
Thenar wasting.
2 History and examination
1 Look for signs of acute inflammation:
DIP
PIP
DIP
PIP
DIP
PIP
https://t.me/med1917
Look: joints
swelling/ erythema of joints.
2
Characteristic deformities of rheumatoid
arthritis:
• Ulnar deviation at the wrist.
• Z deformity of the thumb.
• Swan- neck: flexed
fig
12.2
(
• Boutonnière: hyperextended
3
Characteristic deformities of osteoarthritis:
• Heberden’s nodes (
• Bouchard’s nodes (
, p
, hyperextended
536
).
joi nt, figs
joi nt, fig
, flexed
2.39, 2.44
2.44
).
.
).
Fig 2.
44
Bouchard’s nodes.
Reproduc ed from Jol ly et al. (eds)
Tra in in g in M ed ic in e (
permission from Oxford University Press.
2016
), with
Fee l
1 Using the dorsum of your hand, gently feel for warmth (and tenderness)
over each joint (don’t forget scaphoid: ‘snubox’ tenderness). Once pain excluded, palpate for joint eusions.
2
Palpate thenar and hypothenar muscle bulk.
3
Palpate for palmar thickening of Dupuytren’s contracture (fig
4
Palpate radial and ulnar pulse to confirm blood supply to hand.
5
Sensation:
• Median nerve: index finger, thenar eminence.
• Ulnar nerve: little finger, hypothenar eminence.
• Radial: first dorsal webspace.
6
Tinel's test (percuss over the distal skin crease of the wrist), Phalen's test
(patient holds dorsal surfaces of both hands together for
2.24
, p58).
60
seconds). Tests
are positive if tingling is reported, suggesting carpal tunnel syndrome.
77
Wrist and forearm
• Extension: prayer po sition.
• Flexion: reverse prayer.
• Supination and pronation.
Small muscles
• Pincer grip: finger and thumb.
• Power grip: ‘ Squeeze my fi ngers. ’
• Thumb abduction: with palm facing ceiling ask patient to, ‘Point your thumb to the
ceiling and don’t let me push down’.
• Finger abduction (‘Spread your fingers’) and adduction (‘Grip this piece of paper
between your fingers’). Fro ment' s si gn = flexion of the thumb during grip as ulnar
nerve lesion prevents adduction (
Functional assessment
• Wri te a sen tence, und o a but ton, pi ck up a coin .
• Examine the elbows: psor iatic pla que, rheu matoid nodule, surgi cal scar.
• Neurological examination of the upper limb (p62).
• Examination of th e face for si gns of conn ective tissue disea se.
Top tips
• Cross your fingers before the patient grips them, it hurts less!
• Don’t forget to palpate the radial and ulnar pulses.
• Don’t forget to look at the elbows for plaques of psoriasis and rheumatoid nodules.
Move
p
449
).
Other
2 History and examination
Thyroid examination
NB
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78
For symptoms of thyroid disease see p29, p
If clinical examination suggests that a lump is not arising from the thyroid then
examine lump like any other (
p
586
212
, p
214
.
; lump in the neck, pp
1
Inspect
590– 592
).
Position patient sitting on a chair (with space behind), adequately expose neck.
Inspect from front and sides:
1
Is there a goitre?
• The normal thyroid is usually neither visible nor palpable. A midline swelling
should raise your suspicion of thyroid pathology. Look for scars (eg collar incision from previous thyroid surgery).
2
What is the thyroid status?
• Hypothyroidism: puness, pallor, dry flaky skin, xanthelasma, corneal arcus,
balding, loss of the lateral third of eyebrow, slowness, lethargy, weight gain.
• Hyperthyroidism: an xious , nervo us, ag itate d, fidg ety, trem or, we ight l oss.
Proptosis is better seen from above and behind so is inspected for when you
move behind the patient for palpation.
2
Swallow test
Stand in front of the patient. Ask them to, ‘Sip water... hold it in your mouth. . . and
swallow’ to see if any midline swelling moves up on swallowing. Goitres (
thyroglossal cysts (
p
590
) (and rarely lymph nodes) move up on swallowing.
3
Ton g ue p ro tr u si o n t e st
Ask patient to ‘stick out your tongue’. Does the lump move up? A thyroglossal
cyst will move up on tongue protrusion.
4
Palpat ion
Stand behind the patient.
• Proptosis (p
213
) May be best seen from above and behind, so can be examined for
at this stage. Ask the patient to tilt their head back slightly; this will give you a
better view to assess protrusion of the eyeball anteriorly out of the orbit.
• Thyroid g land
• Excl ude pain prior to palp ation.
• Place middle
to thyroid,
largement/ nodules.
• Pal pate eac h lobe. Deter mine siz e, nodular (solitary or multiple) or smooth/
diffuse.
• Repeating the swallow test while palpating allows you to confirm the inspec-
tion finding, but also allows an attempt to ‘get below the lump’. If there is a
3
fingers of either hand along midline below chin and ‘walk down’
2
finger breadths below the cricoid on both sides. Assess any en-
distinct inferior border under which you can place your hand then the goitre is
unlikely to have retrosternal extension.
• Lymph nod es Exa mine l ymph n odes o f head and neck ( p58).
• Trac he a Palpat e for t rachea l devia tion f rom th e midl ine.
p
592
) and
2 History and examination
5
https://t.me/med1917
Percuss the sternum for the dullness of retrosternal extension of a goitre.
Listen over the goitre for a bruit (a continuous sound heard over the thyroid).
A bruit in a smooth thyroid goitre is suggestive of Graves’ disease (
curs due to a proliferation of the blood supply when the thyroid enlarges.
• Inspect Thyroid acropachy (clubbing) and palmar erythema in hyperthyroidism.
• Temperature Warm peripheries in hyperthyroidism, cool in hypothyroidism.
• Pulse Rate and rhythm. Tachycardia and atrial fibrillation may be seen in hyper-
thyroidism, while bradycardia may be seen in hypothyroidism.
• Fine tremor Ask patient to, ‘Hold hands out’. Place a sheet of paper over out-
stretched hands to help elicit tremor.
The ‘normal’ upper eyelid should always cover the upper eye such that the
white sclera is not visible between the lid and the iris. If visible,
is present.
Lid- lag = the upper eyelid is higher than normal with the globe in downgaze
and can be elicited with downward movement of the eye. Ask patient to, ‘Follow
my finger’ as you move your finger from a point above the eye to below horizontal gaze.
Proptosis and exophthalmos are often used interchangeably. Some stick to a
stricter definition:
Eye movements Ask the patient to follow your finger whilst gently holding their
head still, as you make an ‘H’ shape with your finger. Any double vision?
Lid retraction, lid- lag, exophthalmos and ophthalmoplegia are all signs of auto-
immune hyperthyroidism, most commonly due to Graves’ disease (
exophthalmos = proptosis + lid retraction/ lag.
Percus sion
6
Auscultation
7
Hands
8
Eyes
p
212
) and oc-
lid retraction
p
213
).
79
1 Proximal myopathy Ask patient to stand up from the chair without using
their arms to assess for proximal myopathy (can occur due to both hyper-
and hypothyroidism).
2
Pretibial myxoedema Swelling and discolouration of the lower leg above
the lateral malleoli in Graves’ disease.
3
Ankle reflexes Delayed relaxation in hypothyroidism.
9
Other
2 History and examination
HRT/
USS
FNA)
SOCRATES
B
ALGrawany
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Breast examination
80
Breast symptoms
Symptoms that require exclusion of breast cancer include:
Lump or swelling in breast/ upper chest/ axilla.
Breast skin changes, eg dimpling/ puckering.
Change in skin colour, erythema.
Nipple change, eg inversion.
Nipple rash or crusting/ discharge.
Change in size or shape of breast.
Lump
• Site (fig
2.45
• Associated symptoms: pain, overlying skin change, nipple change/ inversion/ discharge?
• Drugs (eg
• Systemic symptoms: weight loss, breathlessness, back/ bone pain?
• History: previous lumps? Family history of breast/ ovarian cancer (p
menstrual history. Previous mammograms, clinical examinations of the breast,
fine- needle aspirate (
• Social support.
Nipple changes
• Shape change: unilateral/ bilateral, fixed, associated skin changes/ discharge?
• Discharge: amount, nature, colour? Any blood? Associated symptoms: pain, skin
changes, headache, visual loss, amenorrhoea/ infertility.
• Causes: du ct ec tasi a (gre en/ brown/ red, often multiple ducts and bilateral), intraductal
papilloma/ adenoma/ carcinoma (bloody discharge, often single duct), lactation/
galactorrhoea.
• Management: diagnose the cause (mammogram, ultrasound, ductogram, biopsy,
serum prolactin) then treat appropriately. Cessation of smoking may reduce discharge
from duct ectasia.
Breast pain
•
• Associated symptoms: mass, nipple/ skin changes.
• Exclude breast ca ncer (rare if isol ated pain).
• Rule out cardiac chest pain (p86, p
• If non- malignant and non- cyclical, consider:
) and size. Change in size related to menstrual cycle?
oestrogens)?
516
)? Obstetric and
/ core biopsy.
(p26), bilateral/ unilateral, history of trauma, related to menstrual cycle?
764
).
• Ti etze’s syndro me: c osto chond riti s plus swel ling o f the costa l car tila ge.
• Bornholm disease/ Devil’s grip: coxsackie
which may be mistaken for cardiac pain or an acute surgical abdomen. It resolves
72
wee ks.
within
• Angina.
• Gallstones.
• Lung disease.
• Tho racic o utlet syndro me.
virus causing chest/ abdominal pain,
,
Fig 2.
45
The quadrants of the breast with the
axillary tail of Spence.
Reproduced from Thomas J, et al. (eds) Oxford
Handbook of Clinical Examination and Practical
Skills (
2014
), with permission from Oxford
University Press.
Соседние файлы в папке Библиотека им академика М.И. Перельмана