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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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https://t.me/med1917
79
CEREBRAL
Acute confusion 80
Dizziness 83
Hallucinations 86
Headache 89
Insomnia 92
Loss of sex-drive 95
Memory loss 98
Vertigo 101
https://t.me/med1917
80
ACUTE CONFUSION
The GP overview
ere are hundreds of possible individual causes of confusion. Patients with acute confusion are
usually elderly and oen present out of hours via a call from an anxious relative or neighbour.
e dementias constitute the chronic confusional states, which are not considered here.
Differential diagnosis
COMMON
hypoxia (respiratory and cardiac)
systemic infection
cerebrovascular accident (CVA: stroke and transient ischaemic attack [TIA])
hypoglycaemia
diabetic ketoacidosis (DKA)
OCCASIONAL
alcohol withdrawal or intoxication
cerebral infection
electrolyte imbalance and uraemia
iatrogenic (e.g. digoxin, diuretics, steroids and opiates)
myxoedema
drug abuse
RARE
Wernicke’s encephalopathy
cerebral tumour
hypo- and hyperparathyroidism
Cushing’s disease
postictal state
carbon monoxide poisoning
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ACUTE CONFUSION 81
Ready reckoner
Hypoxia Infection CVA Hypoglycaemia DKA
Central cyanosis Ye s Possible No No No
Fever Possible Ye s No No Possible
Focal weakness No No Possible Possible No
Ketohalitosis No No No No Ye s
Tachypnoea Ye s Possible No No Ye s
Possible investigations
Acute confusion has so many causes and possible presentations that it is dicult to provide a
denitive guide of investigations for the GP. A number of investigations might be considered
according to the clinical picture and social circumstances; in the majority of cases, the patient
will be admitted and necessary tests arranged by the hospital.
LI KE LY: Urinalysis, blood sugar (usually glucometer), pulse oximetry.
POSSIBLE: FBC, CXR, ECG, cardiac biomarkers, TFT.
SMALL PRINT: Calcium, digoxin levels, CT scan.
Urinalysis is very helpful if possible: Look for glucose and ketones (DKA), specic gravity
(dehydration), pus, blood and nitrite in UTI. Ketones alone in starvation.
A blood glucometer reading is more practical than a formal blood glucose in the acute
situation to diagnose hypo- and hyperglycaemia.
Pulse oximetry: To detect hypoxia.
FBC: Raised WCC in infections. Raised MCV helpful pointer to excess alcohol and
myxoedema.
U&E important, especially if any signs of dehydration or on diuretics.
LFT and TFT: Alcohol, disseminated malignancy and hypothyroidism should always be
considered.
CXR: May reveal a cause of hypoxaemia (e.g. pneumonia, cardiac failure).
ECG, cardiac biomarkers: If silent infarct suspected as cause.
Calcium: To detect possible hypo- or hyperparathyroidism.
Digoxin levels: For digoxin toxicity.
CT scan: Invariably a hospital-based investigation in acute confusion – may reveal space-
occupying lesion, bleed or infarct.
https://t.me/med1917
82 SYMPTOM SORTER
TOP TIPS
e key to management is establishing that the confusion really is acute rather than a gradual
deterioration of cognition. is requires a careful history from someone who knows the
patient well.
Don’t forget a drug history – if little information is available on a visit, check the patient’s
medication cupboard.
In acute confusional states, it can be dicult to obtain useful clinical pointers from the
patient’s history. e examination therefore assumes greater importance than usual.
It is virtually impossible to reach a rm diagnosis and treat safely in the home. Be very sure
of yourself if you choose not to admit.
Central cyanosis is an ominous sign. Give oxygen, if possible, and dial 999.
In a diabetic on treatment, always check the blood sugar – remember that hypoglycaemia
can produce confusion with neurological signs, mimicking a CVA.
Altered physiological responses in the elderly may result in a normal pulse and temperature
even in the presence of signicant infection. Don’t be misled by this.
Ask if any other household members have been unwell – carbon monoxide poisoning could
aect others too.
NOTES:
https://t.me/med1917
83
DIZZINESS
The GP overview
is common and vag ue symptom can mean dierent things to dierent people. It is treated here
as being a sense of light-headedness without the illusion of movement characteristic of vertigo. is
is a useful distinction in practice as the causes of true vertigo are dierent – see p. 101. Dizziness
tends to be a heartsink symptom as it is so common, has so many diag nostic possibilities, is so oen
linked with anxiety and other symptoms – and very oen the exact cause remains obscure.
NOTE: We no longer list the diagnosis ‘vertebrobasilar insuciency’ as this is an ill-dened term
which is falling out of use.
Differential diagnosis
COMMON
viral illness
anxiety (and hyperventilation)
hypoglycaemia
postural hypotension (e.g. elderly and pregnancy)
iatrogenic: drug therapy (e.g. antihypertensives, antidepressants – may cause dizziness in
their own right or via postural hypotension)
OCCASIONAL
acute intoxication: drugs/alcohol
eects of chronic alcohol misuse
cardiac arrhythmia
any severe systemic disease
anaemia
dumping syndrome (e.g. aer bariatric surgery)
RARE
carotid sinus syndrome
aortic stenosis
subclavian steal syndrome
partial seizures
Addison’s disease
carbon monoxide poisoning (blocked ue)
signicant acute illness (e.g. silent infarct, gastrointestinal haemorrhage – can present with
sudden onset dizziness)
https://t.me/med1917
84 SYMPTOM SORTER
Ready reckoner
Viral infection Hypoglycaemia Postural hypotension Iatrogenic Anxiety
Sudden onset No Ye s Yes Possible No
Irritable mood No Possible No No Possible
Episodic No Ye s Ye s Possible Possible
Coincides with start of medication No Possible Possible Possible No
Relief on lying down No No Ye s Ye s No
Possible investigations
LI KE LY: None.
POSSIBLE: Urinalysis, FBC, U&E, LFT, glucometer blood glucose.
SMALL PRINT: EEG, ECG/24-h ECG, echocardiography, CT scan, hospital-based investigations.
Urinalysis for glucose: Underlying diabetes may cause dizziness, either through general
malaise or because of an autonomic neuropathy.
FBC: Underlying anaemia can cause or exacerbate light-headedness; raised MCV may
indicate alcohol abuse.
U&E and LFT may be worth measuring if systemic disease suspected; in particular, sodium
low, and potassium and urea both high in Addison’s disease; LFT may be abnormal in
alcohol abuse.
Glucometer blood glucose: Blood glucose measurement will provide a diagnosis of
hypoglycaemia only if done during an episode.
EEG: If partial epilepsy a possibility (would also then require CT scan) – both arranged by
specialist.
ECG/24 h ECG: For possible arrhythmia.
Echocardiography: For suspected aortic stenosis.
Hospital-based investigations: In acute onset/unwell patient to rule out possibilities such as
silent infarct or gastrointestinal haemorrhage.
TOP TIPS
e rst step in the history is to establish what the patient means by dizziness, and, in
particular, to distinguish it from true vertigo.
Dizziness is oen multifactorial, especially in the elderly – so do not necessarily expect to
nd a single underlying pathology.
If no clear diagnosis is obvious from the history, the dizziness is long standing, and the
patient presents a list of other vague symptoms yet is objectively quite well (e.g. no weight
loss), the likely diagnosis is anxiety.
Don’t forget that commonly prescribed drugs can cause or aggravate postural hypotension –
review the patient’s medication.
https://t.me/med1917
DIZZINESS 85
If the patient has episodic loss of consciousness as well as dizziness, then the chances of
signicant pathology are much greater – investigate or refer.
In puzzling cases, ask about other family members and type of domestic heating used.
Carbon monoxide poisoning is a completely avoidable but regular killer.
If an aortic murmur is heard, refer urgently. Signicant aortic stenosis can cause sudden
death.
Remember denial is very strong in alcoholics. If in doubt, check MCV and LFT.
An acute presentation of dizziness is unusual. Beware this in the older infrequent attender,
especially if the patient seems unwell – consider a silent infarct or gastrointestinal
haemorrhage.
NOTES:
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86
HALLUCINATIONS
The GP overview
A hallucination is a sensory perception occurring without any external stimulus. is
distinguishes it from an illusion, which is a distortion of a sensory perception. Hallucinations
can occur in any sensory modality and may present in isolation or as part of a larger clinical
problem (particularly an acute confusional state). A hallucination is oen a very frightening
experience for the suerer.
Differential diagnosis
COMMON
drugs (such as amphetamine, cocaine, LSD, ecstasy, solvents and tricyclic overdose) and drug
withdrawal
extreme fatigue
alcoholic hallucinosis (delirium tremens of acute alcohol withdrawal)
febrile delirium
schizophrenia
OCCASIONAL
severe metabolic disturbance of any cause
temporal lobe epilepsy
cerebral space-occupying lesion
psychotic depression
bereavement reaction
hypoxia
RARE
narcolepsy
mania
post-concussional state
iatrogenic: idiosyncratic adverse drug reaction
near-death experience
https://t.me/med1917
HALLUCINATIONS 87
Ready reckoner
Drugs Fatigue Alcohol withdrawal Febrile delirium Schizophrenia
Sudden onset Ye s Possible Ye s Yes No
Tremor Possible No Yes Possible No
Mainly auditory hallucination No No Possible No Ye s
Tachycardia Possible No Yes Ye s No
Cognition impaired Ye s Possible Ye s Yes No
Possible investigations
e GP’s use of investigations will depend on the clinical situation. If hallucinations are part
of an acute confusional state, particularly in adults, admission is likely to be required and will
result in a battery of tests to check, for example, for sources of fever, hypoxia and metabolic
disturbance. e following are investigations the GP might use in patients who do not require
admission or who are not presenting acutely.
Urinalysis: Very useful in the acute situation, particularly in the elderly. May suggest UTI
or hyperglycaemic ketotic state or severe dehydration.
Pulse oximeter: To detect hypoxia.
Glucometer blood glucose: In a known diabetic or if any glycosuria.
FBC and LFT: Raised MCV and abnormal LFT suggest chronic alcohol excess.
U&E: May reveal electrolyte disturbance as underlying cause.
EEG: May suggest diagnosis of temporal lobe epilepsy or narcolepsy.
CT scan: e denitive test for a cerebral space-occupying lesion.
TOP TIPS
Delirium in children with a fever is quite common, especially at night and is not in itself a
sinister sign; assess possible causes of the fever in the usual way, and if the cause is not serious,
reassure the parents as they may be quite frightened by the child’s hallucinations.
Patients with anxiety, personality disorder and borderline mental illness may sometimes
complain of auditory hallucinations, occasionally because experience has told them that
this generates action from health professionals. Genuine auditory hallucinations are
usually distressing and oen in the second person (psychotic depression) or third person
(schizophrenia) – and are accompanied by other hard evidence of mental illness.
Minor and transient auditory and visual hallucinations are normal in the recently bereaved –
but the patient will need reassurance that he or she isn’t ‘going mad’.
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