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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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88 SYMPTOM SORTER
Hallucinations caused by drugs, or by drug and alcohol withdrawal, can be terrifying and
dangerous for the patient and carers, so admission is likely to be required.
Genuine auditory hal lucinations strongly suggest ps ychotic ill ness, par ticularly schizophrenia
and depression; visual hallucinations are almost always organic in nature.
Purely olfactory hallucinations are pathognomic of temporal lobe pathology and require
urgent investigation.
Tactile hallucinations are very suggestive of acute alcohol withdrawal and occasionally
cocaine abuse.
NOTES:
https://t.me/med1917
89
HEADACHE
The GP overview
ere are almost as many causes for headache in medicine as there are disorders. is universal
symptom presents a challenge to all GPs because it is common, very oen non-organic, but
seriously pathological just oen enough to merit a thorough and usually negative examination.
e chance of a sinister hidden problem is always there, but the known vast majority of benign
headaches can put the clinician o guard.
Differential diagnosis
COMMON
tension headache (underlying anxiety or depression)
frontal sinusitis
migraine
cervical spondylosis
eye strain
OCCASIONAL
any acute febrile illness (common cause of headache but usually presents with other
symptoms)
iatrogenic (e.g. analgesic abuse, calcium antagonists, nitrates)
chronic daily headache
fatigue/sleep deprivation (especially in parents)
trigeminal, sphenopalatine and occipital neuralgias
temporal arteritis
post-concussional syndrome
menstrual migraines (10%–14% of women)
sleep apnoea (causes morning headaches)
orgasm headache
other specic headache syndromes (e.g. hemicrania continua, ice-pick headache)
RARE
cluster headache
intracranial lesion (e.g. carcinoma, abscess, haematoma, benign intracranial hypertension)
meningitis
intracerebral haemorrhage
https://t.me/med1917
90 SYMPTOM SORTER
carbon monoxide poisoning (blocked boiler ue)
Paget’s disease of skull
severe hypertension
pre-eclampsia
Ready reckoner
Tension Frontal sinusitis Migraine Cervical spondylosis Eye strain
Worse on lying down No Ye s No Possible No
Congested nose No Ye s Possible No No
Worse on neck
movement
No No Possible Ye s No
Tender at point of pain Possible Ye s No No No
Unilateral No Possible Possible No Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR /CRP.
S MA L L P RI N T: U&E, alkaline phosphatase, x-ray of sinuses, cervical spine or skull, CT scan, sleep
studies, lumbar puncture.
FBC: WCC raised in abscess and sinusitis. ESR/CRP essential if arteritis suspected.
U&E: Na
+
/K
+
derangement in pituitar y tumours, alkaline phosphatase raised in Pag et’s d isease.
X-ray: May see uid levels in sinusitis (rarely useful in diagnosis). May conrm cervical
spondylosis and Paget’s disease.
CT scan: To exclude intracranial lesion.
Sleep studies: If sleep apnoea suspected.
Lumbar puncture: In suspected meningitis; may also help in diagnosis of benign intracranial
hypertension.
TOP TIPS
Explore the patient’s fears: e majority are worried about serious pathology, such as a brain
tumour, and may leave the consultation dissatised unless this specic worry is addressed.
Another common concern is hypertension. Patients will expect to have their blood pressure
checked, even though this is almost never the cause of the symptom.
Analgesics may paradoxically exacerbate tension headache. It is more constructive to adopt
alternative approaches, such as relaxation techniques or antidepressants, as appropriate.
Headache caused by an intracranial lesion usually produces other neurological symptoms
or signs.
https://t.me/med1917
HEADACHE 91
Suspect subarachnoid haemorrhage given a history of sudden explosive headache. It is
frequently described as ‘like a blow to the head’.
If temporal arteritis is suspected, treat immediately. e ESR provides retrospective
conrmation only.
Beware of the pregnant woman complaining of headache in the third trimester – check the
blood pressure, ankles and urinalysis. Headache, particularly with visual disturbance, may
be a symptom of impending eclampsia.
A new and increasing headache present on waking and increased by stooping or straining
may be due to raised intracranial pressure. Check for other symptoms and signs and refer
urgently if in doubt.
If a headache feels and smells like migraine, then it’s a migraine regardless of age. However,
beware of making this the diagnosis in the elderly without systematically ruling out more
sinister causes rst.
NOTES:
https://t.me/med1917
92
INSOMNIA
The GP overview
is problem is commoner in women, and commonest in the elderly. Normal sleep requirement
varies widely. A few people need only 3–4 h per night and the average amount of sleep needed
declines with age. Self-reporting of time taken to get to sleep and hours slept are said to be
inaccurate, but it is the change from the individual’s normal pattern that is signi cant in practice.
Differential diagnosis
COMMON
anxiety from excess psychological stress (work, relationships, nance)
clinical depression
chronic alcohol excess
poor sleep hygiene: hyperstimulation (e.g. caeine, nicotine, drugs, exciting television lms)
and daytime naps
pain of chronic physical illness (e.g. osteoarthritis)
OCCASIONAL
menopausal ushes and sweats
nocturia
external problems (e.g. snoring partner, children who disturb parental sleep)
biorhythm disruption: jet lag and shi work
respiratory problems: asthma, chronic obstructive pulmonary disease (COPD), le
ventricular failure (LVF) commonest
benzodiazepine withdrawal
other medical problem, e.g. restless legs syndrome or GORD
RARE
malnutrition and low body weight
post-traumatic stress disorder
parasomnias: nightmares, night terrors and sleepwalking
hyperthyroidism
mania
sleep apnoea (usually presents as ‘tired all the time’ [TATT]; only 30% aware of waking)
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INSOMNIA 93
Ready reckoner
Stress Depression Alcohol Poor sleep hygiene Pain
Slow to go off Ye s Possible Possible Ye s Possible
Early morning waking Possible Ye s No No Possible
Low mood Possible Ye s Possible No Possible
Physical illness too No No Possible No Ye s
Weight loss Possible Possible No No Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, LFT, TFT.
SMALL PRINT: Investigation of primary symptom leading to insomnia (see below).
FBC (MCV), LFT and γGT may show evidence of chronic alcohol misuse.
TSH will dierentiate non-organic anxiety state from thyrotoxicosis.
NOTE: Pain, nocturia, respiratory problems and sleep apnoea may require investigating in their
own right.
TOP TIPS
Uncover any underlying physical problem such as pain or nocturia and manage as
appropriate – it is pointless adopting a ‘sleep hygiene’ approach when the problem is
primarily physical.
Don’t forget the role of alcohol; this is oen an u nderlying or contributory cause, p aradoxically
taken by the patient to relieve the insomnia.
If the diagnosis seems likely to be tension or poor sleep hygiene, establish the patient’s agenda
early. Patients who simply want sleeping pills are unlikely to listen to well-intentioned advice
until this issue has been discussed and resolved.
Explain to elderly patients that sleep requirements fall with increasing age and that daytime
naps are to be discouraged.
https://t.me/med1917
94 SYMPTOM SORTER
Shi workers are signicantly at risk of developing clinical depression. Be sure to assess
carefully for this pathology in the insomniac shi worker.
Beware of young male temporary residents presenting ‘urgently’ with insomnia. ey may
well be drug addicts trying to obtain a prescription for benzodiazepines.
Bone or joint pain waking an elderly patient at night is highly signicant. In the patient with
known arthritis, joint replacement may be indicated; in others, it may indicate serious bony
pathology such as secondaries.
Take the problem seriously even if the cause seems trivial or obvious (e.g. a patient’s snoring)
– insomnia can be extremely debilitating, and by the time patients attend, they may be
desperate for help.
Anxiety and severe weight loss with sweating and tachycardia suggests hyperthyroidism. Be
sure to check TSH before deciding this is non-organic.
NOTES:
https://t.me/med1917
95
LOSS OF SEX-DRIVE
The GP overview
Loss of sex-drive can be a daunting presentation for established GP and registrar alike. is
universal problem spans adulthood in both sexes. Conventional medical school teaching seems
to fail to prepare the generalist; however, the didactically taught approach of systematic enquiry
and examination is the key to successful management.
Differential diagnosis
COMMON
depression
relationship problems
perimenopause
excess alcohol intake (and cirrhosis in men)
ageing
OCCASIONAL
low testosterone in men
hypothyroidism
antihypertensive treatment in men
hyperprolactinaemic drugs in men (e.g. phenothiazines, haloperidol)
anti-androgenic drugs in men (e.g. cimetidine, nasteride)
anti-androgenic drugs in women (e.g. cyproterone)
RARE
hypothalamic/pituitary disease
renal failure
primary testicular disease or damage
adrenal disease (Cushing’s and Addison’s diseases)
feminising tumours in men: testis or adrenal gland
https://t.me/med1917
96 SYMPTOM SORTER
Ready reckoner
Depression Relationship problem Perimenopause Alcohol Ageing
Excessive fatigue Ye s Possible Ye s Possible Possible
Irrational mood swings Ye s Possible Ye s Possible No
Facial ushing No No Ye s Possible No
Alters with different partner Possible Ye s No No No
Otherwise well No Ye s Possible Possible Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, U&E, LFT, TFT.
SMALL PRINT: Hormone prole.
FBC: May show evidence of general disease; MCV raised with signicant excess alcohol.
U&E: Check for renal failure. Na
+
and K
+
deranged in adrenal disease.
LFT and γGT: Should reveal hard evidence of excess alcohol.
TFT: Will demonstrate hypothyroidism.
Hormone prole: FSH/LH, prolactin, oestradiol and testosterone may be useful in both
sexes. Altered by primary endocrine disease, drugs and alcohol.
TOP TIPS
is is oen a ‘by the way’ or ‘while I’m here’ symptom. It may be tempting to ask the patient
to return for a further appointment, but bear in mind that this may mean a lost opportunity
to help the patient.
General examination is important to detect rare causes. is also demonstrates that the
problem is being taken seriously.
Avoid over-medicalising the situation if it is clearly a relationship problem.
Be prepared to revise or augment your diagnosis – the problem is oen multifactorial.
Don’t forget iatrogenic causes and be prepared to undertake a trial without treatment.
https://t.me/med1917
LOSS OF SEXDRIVE 97
Loss of sex drive may be the tip of the iceberg of signicant pathology, such as depression or
alcoholism – don’t be distracted into a supercial approach.
Depression and relationship diculties can cause each other and coexist. A careful history
will reveal whether antidepressants and/or psychosexual counselling is appropriate
Investigations don’t oen help – but lower your threshold for blood tests if the patient seems
generally unwell and isn’t obviously depressed.
Early hypothyroidism closely mimics depressive illness.
NOTES:
https://t.me/med1917
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