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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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98
MEMORY LOSS
The GP overview
Memory loss is a distressing and perilous symptom for both suerers and caring relatives. It
may be due to organic or non-organic causes. Memory is classied into immediate, short-term
(or recent) and long-term (or remote) memory. e type of loss varies according to the cause.
Memory loss is also a feature of any cause of acute confusion; this problem is covered elsewhere
(see Acute confusion, p. 80).
Differential diagnosis
COMMON
anxiety/stress
depressive illness
dementia (multi-infarct, Alzheimer’s disease and dementia with underlying cause, such as
tumour, neurosyphilis, hypothyroidism, vitamin B
12
and folate deciency)
trauma: head injury
CVA (infarct in posterior cerebral artery territory)
OCCASIONAL
chronic excess alcohol intake (thiamine deciency: Korsako ’s syndrome)
subarachnoid haemorrhage
other thiamine deciency: malabsorption, carcinoma stomach, hyperemesis gravidarum
transient global amnesia
fugue states and psychogenic amnesia
tumour of third ventricle or hypothalamus
RARE
personality disorder
malingering
intractable epilepsy
carbon monoxide poisoning
herpes simplex encephalitis
https://t.me/med1917
MEMORY LOSS 99
Ready reckoner
Trauma Dementia CVA Depression Anxiety
Aware of problem Possible No Possible Possible Ye s
Memory loss recent events Ye s Ye s Possible Ye s Ye s
Memory loss remote events Possible No Possible No No
Neurological signs Possible Possible Possible No No
Sudden onset Ye s No Ye s No No
Possible investigations
LI KE LY: (Unless obvious depression or anxiety) FBC, TFT, LFT, calcium.
POSSIBLE: B
12
and folate levels, CT/MRI scan.
SMALL PRINT: Syphilis serology.
FBC may show raised MCV, suggesting either alcohol abuse or B
12
/folate deciency. Check
B
12
and folate levels if MCV raised.
TFT: Hypothyroidism is an important remediable cause of dementia.
LFT and γGT will give useful clues to alcohol intake (history likely to be unreliable).
Calcium level: May show hypo- or hypercalcaemia.
Syphilis serology: For possible neurosyphilis as underlying cause of dementia.
CT scan/MRI: Will detect space-occupying lesions, cerebrovascular disease, atrophy and
subarachnoid haemorrhage.
TOP TIPS
Patients with dementia are oen unaware of, or deny, their memory loss; the problem is more
oen brought to the GP’s attention by a concerned friend or relative.
Patients who present themselves to the GP complaining of memory loss are most likely to be
suering from anxiety or depression.
Even if a diagnosis of anxiety or depression seems obvious, patients are likely to be concerned
about the possibility of dementia, which will exacerbate the situation; explaining that the
problem is more to do with poor concentration than failing memory will help reassure them.
Establishing the onset gives valuable clues to the problem – a dementia pattern progressing
slowly over a year or two is likely to be Alzheimer’s or multi-infarct dementia; with a shorter
history, an underlying cause is possible; and sudden onset of memory loss is likely to be caused
by a vascular event or trauma.
It can be very dicult to distinguish between depression and dementia – and the two may
coexist. Consider a trial of antidepressants.
https://t.me/med1917
100 SYMPTOM SORTER
Rapid onset of apparent dementia over 3–6 months or less suggests a possible underlying
cause.
True memory loss aer a head injury suggests signicant trauma.
Depression in the elderly may mimic dementia (pseudodementia) with behavioural changes
like hoarding and bad temper. Do not miss this treatable condition.
NOTES:
https://t.me/med1917
101
VERTIGO
The GP overview
Vertigo is an illusion of movement of either the patient or his or her environment. is is both
visual and positional. Associated nausea or vomiting are common and, in its acute form, it is
a severe and completely disabling symptom. It must be distinguished from ‘light-headedness’
(seep. 83).
Differential diagnosis
COMMON
benign positional vertigo
vestibular migraine
Ménière’s disease
vestibular neuritis
Eustachian tube (ET) dysfunction (causes mild vertigo)
OCCASIONAL
chronic otitis media
drugs: salicylates, quinine, aminoglycosides
acute alcohol intoxication (common, but unlikely to present to the GP)
neurological conditions (e.g. CVA, multiple sclerosis [MS], syringobulbia, cerebellar
tumours)
epilepsy
RARE
earwax (common problem but rare cause of vertigo)
syphilis
acoustic neuroma
nasopharyngeal carcinoma
post-traumatic
https://t.me/med1917
102 SYMPTOM SORTER
Ready reckoner
Benign positional Vestibular migraine Ménière’s Vestibular neuritis ET dysfunction
Tinnitus No No Ye s Possible Possible
Rapid onset, severe Possible Possible Ye s Possible No
Momentary Ye s No No No Possible
Associated viral illness No No No Ye s Possible
Recurrent Ye s Ye s Ye s No No
Possible investigations
ere are no investigations likely to be performed in primary care. Referral might lead to a
number of secondary ca re tests, such as audiometry for coch lear function; electronystagmog raphy,
calorimetry and brainstem-evoked responses to assess vestibular function; CT or MRI scan for
possible neurological conditions; EEG for suspected epilepsy; lumbar puncture in possible MS;
and syphilis serology if syphilis is suspected.
TOP TIPS
Take a careful history – the patient may use the term ‘vertigo’ inaccurately, or describe true
‘vertigo’ as light-headedness. e diagnostic possibilities for vag ue dizziness and true vertigo
are quite dierent.
e vast majority of cases seen in primary care are benign positional vertigo, vestibular
migraine, Ménière’s disease or viral neuritis.
Ménière’s disease tends to be over-diagnosed. It comprises violent paroxysms of vertigo
lasting for several hours, associated with deafness and tinnitus, oen necessitating urgent
attention because of prostration and vomiting.
Benign positional vertigo is usually easily diagnosed by the history – the patient experiences
vertigo lasting only for a few seconds, classically on turning over in bed.
Vestibular migraine is under-diagnosed. Consider it in any case of recurrent vertigo – enquire
about headache before, during or aer the vertigo.
https://t.me/med1917
VERTIGO 103
e patient who has chronic otitis media and then develops vertigo probably has signicant
disease – especially if the stula sign is positive (putting pressure on the external ear cana l by
forcibly occluding the external auditory meatus with a nger causes vertigo). Refer urgently.
Young or middle-aged patients with atypical, episodic vertigo who have other, diuse and
transient neurological symptoms may have MS.
Loss of consciousness with vertigo suggests epilepsy.
An acoustic neuroma can cause quite mild vertigo. Consider this possibility if the patient
also has a unilateral sensorineural deafness and tinnitus.
A neurological cause such as a stroke is suggested by any CNS symptoms or signs; a new
type of headache, especially occipital; acute deafness (otherwise unexplained); or vertical
nystagmus.
NOTES:
https://t.me/med1917
https://t.me/med1917
105
CHEST
Acute shortness of breath 106
Chest pain 109
Chronic shortness of breath 112
Cough in adults 115
Cough in children 118
Coughing up blood 121
Palpitations 124
https://t.me/med1917
106
ACUTE SHORTNESS
OF BR E ATH
The GP overview
is is a terrifying symptom for the patient, and the subjective feeling of shortness of breath is not
predictably related to the t ype or degree of pathology. is , combined with the fa ct that the cause is
oen organic, means that a careful and urgent assessment is mandatory.
Differential diagnosis
COMMON
asthma
pneumonia
acute LVF
acute exacerbation of COPD
hyperventilation
OCCASIONAL
pneumothorax
pulmonary embolism
pleural eusion
diabetic ketoacidosis (DKA)
lobar collapse (tumour)
RARE
aspiration pneumonitis
Guillain–Barré syndrome
hypovolaemic shock
shock lung (adult respiratory distress syndrome)
laryngeal obstruction
https://t.me/med1917
ACUTE SHORTNESS OF BREATH 107
Ready reckoner
Asthma Pneumonia LVF Exacerbation of COPD Hyperventilation
Purulent phlegm Possible Ye s No Ye s No
Coarse crackles No Ye s No Ye s No
Bilateral wheeze Ye s No Possible Ye s No
Bilateral ne crackles No No Yes Possible No
Focal reduced air entry No Ye s No No No
Possible investigations
e GP is highly unlikely to initiate any investigations at all. If the patient with acute shortness
of breath is ill enough – or the diagnosis obscure enough – to warrant investigation, then
the patient probably requires admission. e following therefore refers to those few cases in
which the patient is reasonably well, the diagnosis unclear and the scenario not so urgent that
immediate referral is required.
Urinalysis: Glucose and ketones in DKA. Conrm with a glucometer reading.
Sputum culture: Very occasionally helpful in infective processes not settling with rst-line
empirical treatment.
FBC: WCC raised in infection. Anaemia may be signicant incidental nding.
Pulse oximetry: Hypoxia suggests a signicant problem.
CXR an essential part of assessment but usually done aer admission/referral.
Other investigations such as blood gases and investigations for pulmonary embolus might be
required to clinch a diagnosis but would be arranged by the admitting team.
TOP TIPS
If the diagnosis is likely to be hyperventilation, instruct the patient to rebreathe from a paper
bag while waiting for you. is action may curtail the attack by the time you arrive.
Spacer devices can be as eective as nebulisers when managing acute exacerbations of asthma ,
and are more practical to use when on call.
Sudden onset of breathlessness in an elderly patient in the middle of the night is likely to be
LVF. Remember that it may be have been precipitated by an infarct.
https://t.me/med1917
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