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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2716_Библиотеки_им_академика_М_И_Перельмана
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76
Conjunctival rim pallor
Reddish color
Entire lid is pale
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3—GENERAL APPEARANCE OF THE PATIENT
Pull down lower lid
Conjunctival rim pallor
ABSENT
PRESENT
Everted lower lid:
Pale color
Fig. 10.1 Conjunctival rim pallor. After gently pulling down the patient’s lower lid (top), the clinician observes
the lid’s inner surface, comparing the color of the lid margin (its rim) with that of the conjunctival surface nearer
the globe. In patients without anemia (bottom left), there are two zones of color: a reddish color at the rim
(due to its prominent vascular supply) and a contrasting paler color nearer the globe (from prominent lymphoid
tissue.) In patients with anemia (bottom right), the entire inner surface of the lower lid has a pale color (i.e.,
conjunctival rim pallor.)
III. Clinical Significance
EBM Box 10.1 presents the diagnostic accuracy of physical signs for chronic anemia as applied
to hundreds of patients. ese studies excluded patients with acute bleeding or those who had
recently received transfusions. As much as possible, the color of skin and conjunctiva was determined using natural lighting.
According to EBM Box 10.1, the finding of conjunctival rim pallor (likelihood ratio
[LR] = 16.7), increases the probability of anemia the most, followed by palmar crease pallor
(LR = 7.9), palmar pallor (LR = 5.6), conjunctival pallor (i.e., not specifically conjunctival rim
pallor, LR = 4.7), nailbed pallor (LR = 4.3), facial pallor (light-skinned persons only, LR = 3.8),
and tongue pallor (LR = 3.7). Importantly, no physical sign convincingly decreases the probability
of anemia (i.e., no LR <0.4).
EBM BOX 10.1 Anemia*
Finding (Reference)
Pallor at any site
Facial pallor
Nailbed pallor
Palmar pallor
Palmar crease pallor
Conjunctival pallor
Likelihood Ratio‡
if Finding Is
†
3–9
4
4,5,8
4,5
4
4,5,10,11
Sensitivity (%) Specificity (%)
22–77 66–92 3.8 0.5
46 88 3.8 0.6
41–60 66–93 4.3 0.5
58–64 74–96 5.6 0.4
8 99 7.9 NS
31–62 82–97 4.7 0.6
Present Absent
Continued
10—ANEMIA
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EBM BOX 10.1 Anemia*—Con’td
Likelihood Ratio‡
if Finding Is
Finding (Reference)
Tongue pallor
Conjunctival rim pallor
Pallor present 10 99 16.7 …
Pallor borderline 36 … 2.3 …
Pallor absent 53 16 0.6 …
†
12
2
Sensitivity (%) Specificity (%)
Present Absent
48 87 3.7 0.6
77
*Diagnostic standard: for anemia, hematocrit less than 35%,4 hemoglobin (Hb) less than 7 g/dL,9 Hb less
than 9 g/dl,12 Hb less than 10,6 Hb less than 11 g/dl,
than 13 g/dl in men.
†
Definition of findings: for pallor at any site, examination of skin, nailbeds, and conjunctiva
pallor, the study excluded black patients; for palmar crease pallor, examination after gentle extension of
the patient’s fingers; for conjunctival rim pallor, see Fig. 10.1.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
3,8
2,5,7,10,11
or Hb less than 11 g/dl in women and less
3–5,8
; for facial
ANEMIA
Probability
Decrease Increase
45%
–
LRs
0.1 0.2 0.5 12510
Absence of palmar pallor
–
–
+45%+30%+15%
LRs
Conjunctival rim pallor
15%
30%
Palmar crease pallor
Palmar pallor
Pallor at any site
Facial pallor
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
References
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1. Lewis T. e Blood Vessels of the Human Skin and their Responses. Shaw & Sons; 1927.
2. Sheth TN, Choudhry NK, Bowes M, Detsky AS. e relation of conjunctival pallor to the presence of
anemia. J Gen Intern Med. 1997;12(2):102–106.
3. Gjørup T, Bugge PM, Hendriksen C, Jensen AM. A critical evaluation of the clinical diagnosis of
anemia. Am J Epidemiol. 1986;124(4):657–665.
4. Nardone DA, Roth KM, Mazur DJ, McAfee JH. Usefulness of physical examination in detecting the
presence or absence of anemia. Arch Intern Med. 1990;150(1):201–204.
5. Stoltzfus RJ, Edward-Raj A, Dreyfuss ML, etal. Clinical pallor is useful to detect severe anemia in
populations where anemia is prevalent and severe. J Nutr. 1999;129(9):1675–1681.
6. Bergsjø P, Evjen-Olsen B, Hinderaker SG, Oleking’ori N, Klepp KI. Validity of non-invasive assessment
of anaemia in pregnancy. Trop Med Int Health. 2008;13(2):272–277.
7. Chowdhury MK, Chongsuvivatwong V, Geater AF, Akhter HH, Winn T. Taking a medical history and
using a colour scale during clinical examination of pallor improves detection of anemia. Trop Med Int
Health. 2002;7(2):133–139.
8. Butt Z, Ashfaq U, Sherazi SF, Jan NU, Shahbaz U. Diagnostic accuracy of “pallor” for detecting mild and
severe anaemia in hospitalized patients. J Pak Med Assoc. 2010;60(9):762–765.
9. Sawe HR, Mfinanga JA, Mwafongo V, Reynolds TA, Runyon MS. e test characteristics of physician
clinical gestalt for determining the presence and severity of anaemia in patients seen at the emergency
department of a tertiary referral hospital in Tanzania. Emerg Med J. 2015;33(5):338–344.
10. Kent AR, Elsing SH, Hebert RL. Conjunctival vasculature in the assessment of anemia. Ophthalmology.
2000;107(2):274–277.
11. van den Broek NR, Ntonya C, Mhango E, White SA. Diagnosing anaemia in pregnancy in rural clinics:
assessing the potential of the haemoglobin colour scale. Bull World Health Organ. 1999;77(1):15–21.
12. Kalantri A, Karambelkar M, Joshi R, Kalantri S, Jajoo U. Accuracy and reliability of pallor for detecting
anaemia: a hospital-based diagnostic accuracy study. PLoS One. 2010;5(1):1–6.
78.e1
CHAPTER
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11
Hypovolemia
KEY TEACHING POINTS
• In elderly patients with acute illness, four physical findings accurately detect hypovolemia:
dry axilla, sunken eyes, dry tongue, and abnormal skin turgor (subclavicular space).
• The absence of tongue furrows and presence of normal skin turgor decrease probability
of hypovolemia.
Introduction
I.
e term hypovolemia refers collectively to two distinct disorders: (1) volume depletion, which
describes
fluid) that occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and (2)
dehydration,
mately causes cellular desiccation and elevates the plasma sodium concentration and osmolality.
Chapter 17 discusses the accuracy of abnormal vital signs in patients with volume depletion; this
chapter discusses assorted additional findings.
II.
Many of the traditional signs of hypovolemia—dry mucous membranes, sunken eyes, shriveled
skin, poor skin turgor, and confusion—were originally described in patients with cholera near vascular collapse.
contribute to these signs.
between the examiner’s thumb and forefinger.
seconds after 3 seconds of pinching was defined as abnormal.
for the recoil of skin, and in vitro experiments show that its recoil time increases forty-fold after
loss of as little as 3.4% of its wet weight.
that the specificity of poor skin turgor diminishes as patients age.
III. Clinical Significance
EBM Box 11.1 presents clinical studies comparing traditional signs to laboratory tests of hypovo-
lemia (i.e., increased serum urea-to-creatinine, serum osmolarity, or serum sodium levels). ese
studies enrolled mostly elderly patients presenting to emergency departments with vomiting,
decreased oral intake, or diarrhea. Few if any were as desperately hypovolemic as patients with
classic cholera.
the loss of sodium from the extracellular space (i.e., intravascular and interstitial
which refers to the loss of intracellular water (and total body water) that ulti
The Findings and Their Pathogenesis
2
Presumably, cellular dehydration, interstitial space dehydration, and poor perfusion
Poor skin turgor refers to the slow return of skin to its normal position after being pinched
3,4
In one study, persistence of skin tenting 3 or more
3
Elastin also deteriorates with age, however, suggesting
5
e protein elastin is responsible
-
1
79
80
LRs
HYPOVOLEMIA
Abnormal skin turgor (subclavicular area)
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3—GENERAL APPEARANCE OF THE PATIENT
EBM BOX 11.1 Hypovolemia*
Likelihood Ratio‡
if Finding Is
Present Absent
+45%+30%+15%–15%–30%–45%
Finding (Reference)
Skin, eyes, and mucous membranes
6–8
Dry axilla
Dry mucous membranes of mouth and
5,8,9
nose
Dry tongue
8,9
Longitudinal furrows on tongue
Sunken eyes
†
9
7,9
Sensitivity
(%)
40–57 82–93 3.8 0.5
49–85 58–88 2.8 0.4
59–73 73–85 3.6 0.4
85 58 NS 0.3
33–62 82–93 3.7 0.6
Specificity
(%)
Abnormal skin turgor (subclavicular area)573 79 3.5 0.3
Neurologic findings
Confusion
Weakness
Speech unclear or rambling
*Diagnostic standard: for hypovolemia, serum urea nitrogen-creatinine ratio >25, osmolarity
>295-300 mOsm/L, or serum sodium >145-150 mEq/L.
†
Definition of findings: for abnormal skin turgor, see text.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
5,9
9
9
49–57 73–99 NS 0.5
43 82 NS NS
56 82 NS 0.5
Probability
Decrease Increase
0.1 0.2 0.5 12510
LRs
Absence of tongue furrows
ese studies indicate that the presence of dry axilla (likelihood ratio [LR] = 3.8, EBM
Box 11.1), sunken eyes (LR = 3.7), dry tongue (LR = 3.6), abnormal skin turgor (tested in the
subclavicular area, LR = 3.5), and dry mucous membranes (LR = 2.8) increase the probability of
hypovolemia. Testing skin turgor over the thighs, sternum, or subclavicular area was more accurate than testing skin over the forearms.5 e absence of tongue furrows and presence of normal
skin turgor decrease the probability of hypovolemia (LR = 0.3 for both findings). e presence or
absence of confusion, weakness, or abnormal speech had little diagnostic value in these studies.
Although poor capillary refill time has been advanced as a reliable sign of hypovolemia, it
lacked diagnostic value in one study9 (see Chapters 54 and 70).
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
Dry axillaNormal skin turgor
Sunken eyes
Dry tongue
References
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1. Mange K, Matsuura D, Cizman B, etal. Language guiding therapy: the case of dehydration versus vol-
ume depletion. Ann Intern Med. 1997;127(9):848–853.
2. Osler W. e Principles and Practice of Medicine. D. Appleton and Co.; 1892.
3. Dorrington KL. Skin turgor: do we understand the clinical sign? Lancet. 1981;1(8214):264–266.
4. Aguilar OM, Albertal M. Images in clinical medicine. Poor skin turgor. N Engl J Med. 1998;338(1):25.
5. Chassagne P, Druesne L, Capet C, Ménard JF, Bercoff E. Clinical presentation of hypernatremia in
elderly patients: a case control study. J Am Geriatr Soc. 2006;54(8):1225–1230.
6. Eaton D, Bannister P, Mulley GP, Connolly MJ. Axillary sweating in clinical assessment of dehydration
in ill elderly patients. Br Med J. 1994;308(6939):1271.
7. Kinoshita K, Hattori K, Ota Y, etal. e measurement of axillary moisture for the assessment of dehydra-
tion among older patients: a pilot study. Exp Gerontol. 2013;48(2):255–258.
8. Guastaferro R, Rosi IM, Milos R, Messina E, Cerra A, Bonetti L. Development of a screening tool
to assess dehydration in hospitalized older population: a diagnostic, observational study. Prof Inferm.
2018;71(3):178–187.
9. Gross CR, Lindquist RD, Woolley AC, Granieri R, Allard K, Webster B. Clinical indicators of dehydra-
tion severity in elderly patients. J Emerg Med. 1992;10(3):267–274.
80.e1
CHAPTER
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12
Protein-Energy Malnutrition and
Weight Loss
KEY TEACHING POINTS
• Classic findings of malnutrition (marasmus and kwashiorkor) are uncommon in
malnourished patients from the industrialized world. Instead, hospitalized patients with
malnutrition present with decreased muscle mass (evident from limb circumference
measurements) and decreased grip strength.
• Decreased muscle mass and grip strength accurately predict increased morbidity and
mortality after major surgery.
• In patients with involuntary weight loss, 65% have a responsible organic disorder, which
is usually evident during the initial history, physical examination, and laboratory testing.
• Significant underestimation of weight loss by the patient increases probability of organic
disease; significant overestimation increases probability of nonorganic disease.
PROTEIN-ENERGY MALNUTRITION
Introduction
I.
e
most common cause of malnutrition worldwide is inadequate food supply, although in
industrialized countries malnutrition usually reflects increased nutrient loss (e.g., malabsorption,
diarrhea, nephrotic syndrome), increased nutrient requirements (e.g., fever, cancer, infection, or
surgery), or both. Among patients admitted to surgical services in industrialized nations, 9% to
27% have signs of severe malnutrition.
II.
The Findings
In
children of developing nations, there are two distinct syndromes of protein-energy malnu
trition: marasmus (profound
(abdominal distention, edema, and hypopigmented hair). In industrialized countries, however,
most malnourished patients have less dramatic findings and present instead with combinations
of low body weight, atrophy of muscle and subcutaneous fat, weakness, and various laboratory
abnormalities (e.g., low albumin or other serum proteins).
A. ARM MUSCLE CIRCUMFERENCE
Arm muscle circumference is a decades-old anthropometric measurement of the amount of muscle in
the arm, which theoretically reflects the total amount of muscle or protein in the body. e clinician
1,2
weight loss, muscle wasting, and fat wasting) and
kwashiorkor
81
-
82
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3—GENERAL APPEARANCE OF THE PATIENT
measures the upper arm circumference (Ca, using a flexible tape measure) and the triceps skinfold thickness (h, using calipers) and estimates arm muscle circumference (AMC) with the following formula:
AMC = Ca−πh
Age- and sex-standardized values of the normal AMC have been published.3 e technique
for forearm muscle circumference is similar.
B. GRIP STRENGTH
Based on the hypothesis that malnutrition influences the outcome of surgical patients and that
muscle weakness is an important sign of malnutrition, Klidjian in 1980 investigated 102 surgical
patients and demonstrated that hand grip strength accurately predicts postoperative complications.4 In his method the patient squeezes a simple handheld spring dynamometer three times,
resting 10 seconds between each attempt, and the clinician records the highest value obtained
(patients with arthritis, stroke, or other obvious causes of weakness are excluded).
Age- and sex-standardized values of normal grip strength have been published.5 Clinical stud-
ies of grip strength usually test the nondominant arm, but this may be unnecessary because studies
show both arms are similar.
Historically, clinicians measured grip strength by rolling up an adult aneroid blood pressure
cuff (making a cylinder of about 2 inches in diameter with rubber bands on each end), inflating the
cuff to 20 mm Hg, and then asking the patient to squeeze the cuff. e subsequent sphygmomanometer reading (in mm Hg) is a measure of grip strength; formulas for converting these readings
to dynamometer readings (in kilograms or pounds) have been published.
5
6
III. Clinical Significance
EBM Box 12.1 addresses the accuracy of physical examination in predicting significant postop-
erative complications among patients undergoing major surgery. In these studies, complications
are significant if they prolong hospital stay, threaten the patient’s life, or cause death (e.g., sepsis,
wound infections, myocardial infarction, or stroke).
In these studies, the findings of reduced arm or forearm muscle circumference (likelihood
ratio [LRs] = 2.5 to 3.2), reduced grip strength (LR = 2.6), and low body weight (LR = 2) all
modestly increase the probability of postoperative complications. Normal grip strength decreases
the probability of complications (LR = 0.4). Interestingly, the presence of recent weight loss has
little diagnostic value in predicting complications, possibly because this finding not only identifies
patients with weight loss from malnutrition (which should increase complications) but also overweight patients who voluntarily lose weight before surgery (which should decrease complications).
WEIGHT LOSS
I. Introduction
Involuntary weight loss reflects either diuresis, decreased caloric intake, or the increased caloric
requirements of malabsorption, glucosuria, or a hypermetabolic state. In series of patients
*is formula assumes that the arm is a cylinder of only skin and muscle (i.e., it disregards the humerus). To
derive this formula: (1) AMC=πd
of arm; h=skinfold thickness, which, since the skin is pinched, actually includes a double layer of skin and
subcutaneous tissue); (3) erefore AMC=πd1=π(d2–h)=πd2-πh=Ca-πh. If the clinician desires to directly
enter the skinfold thickness in mm (as it is measured), 0.314 is substituted for π in the formula (i.e., AMC
and C are measured in centimeters).
a
(d1=diameter of muscle component of the arm); (2) d1=d2–h (d2=diameter
1
12—PROTEIN-ENERGY MALNUTRITION AND WEIGHT LOSS
LRs
PROTEIN-ENERGY MALNUTRITION
Forearm circumference <85% predicted
Low body weight
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83
EBM BOX 12.1 Protein-Energy Malnutrition and Major Surgical Complications
Likelihood Ratio‡
if Finding Is
Present Absent
8,9,14,15
for predicted arm muscle
LRs
Finding (Reference)
Body weight
Weight loss >10%
Low body weight
4,7–10
4,8,9,11
†
Sensitivity
(%)
15–75 47–88 1.4 NS
11–35 83–97 2.0 NS
Specificity
(%)
Anthropometry
Upper arm muscle circumference
<85% predicted
Forearm muscle circumference
<85% predicted
Muscle strength
Reduced grip strength
*
Diagnostic standard: in each of these studies, disease is defined as a major postoperative complication,
including those prolonging hospital stay, threatening the patient’s life, or causing death.
†
Definition of findings (all findings from preoperative physical examination): for weight loss >10%, (recalled
usual weight – measured weight)/(recalled usual weight) >10%; for low body weight, weight-for-height
less than normal lower limit,11 <90% of predicted,4 or <85% of predicted;
circumference, published standardized values;3 for forearm muscle circumference <85%, <20 cm in men
and <16/3 cm in women;
closely to published age- and sex-standardized abnormal values based upon reference 5.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
4,8,9
4,8,9
4,5,8,9,12–16
4,9
and for reduced grip strength, specific thresholds differ but all correspond
26–38 83–91 2.5 0.8
14–42 85–97 3.2 0.8
33–90 46–93 2.6 0.4
Probability
Decrease Increase
–
45%
–
–
+45%+30%+15%
15%
30%
0.1 0.2 0.5 12510
*
Normal grip strength
presenting with involuntary weight loss (exceeding 5% of their usual weight), organic disease is
diagnosed in 65% of patients (most commonly cancer and gastrointestinal disorders, although virtually any chronic disease may cause weight loss) and psychiatric disorders are diagnosed in 10%
of patients (depression, anorexia nervosa, schizophrenia). In 25% of patients, the cause remains
unknown despite at least 1 year of follow-up.
II. Clinical Significance
Weight loss is rarely due to occult disease, and most diagnoses are made during the initial evaluation, including the patient interview, physical examination, and basic laboratory testing.
Reduced grip strength
Upper arm circumference <85% predicted
17–21
17,18,20,21
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3—GENERAL APPEARANCE OF THE PATIENT
In patients with involuntary weight loss, the presence of alcoholism (LR = 4.5) and cigarette
smoking (LR = 2.2) increase the probability that an organic cause will be discovered during
6 months follow-up, whereas prior psychiatric disease (LR = 0.2) and a normal initial physical examination (LR = 0.4) decrease the probability of discovering organic disease.22 Also, the
patient’s perceptions of the weight loss—whether he or she significantly underestimates or overestimates it—helps predict the final diagnosis. e patient is asked to estimate his or her weight
before the illness (W ) and the amount of weight lost (E). e observed weight loss (O) is the former weight (W ) minus the current measured weight. Significant underestimation of weight loss,
defined as (O – E) greater than 0.5 kg, predicts an organic cause of weight loss with a sensitivity of
40%, specificity of 92%, positive LR of 5.4, and negative LR of 0.6.23 Significant overestimation of
weight loss, defined as (E – O) greater than 0.5 kg, predicts a nonorganic cause of weight loss with
a sensitivity of 70%, specificity of 81%, positive LR of 3.6, and negative LR of 0.4.
23
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
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