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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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108 SYMPTOM SORTER
Cyanosis is an ominous sign meriting a ‘blue light’ ambulance and oxygen as soon as possible.
e presence of intercostal recession and use of accessory muscles of respiration indicate
severe respiratory distress whatever the aetiology. Admit.
If a foreign body has been inhaled, astute telephone assessment and clear, calm advice may
be lifesaving.
Acute confusion with breathlessness indicates severe hypoxaemia, metabolic disturbance or
sepsis. Admit urgently.
Don’t forget that pneumothorax is commoner in asthmatics and patients with COPD –
consider this diagnosis if the patient suddenly becomes more short of breath especially if
there is no other obvious explanation, such as a supervening chest infection.
NOTES:
https://t.me/med1917
109
CHEST PAIN
The GP overview
Acute chest pain is a regular visitor to general practice: It may generate more adrenaline in the
physician than the patient. In spite of a constellation of causes, a good basic clinical approach will
determine the diagnosis in nearly all cases, long before any necessar y investigations are complete.
Differential diagnosis
COMMON
angina/MI
GORD
anxiety (Da Costa’s syndrome)
pulled muscle
Tietze’s syndrome (costochondritis)
OCCASIONAL
pleurisy (e.g. from pneumonia or pulmonary embolus)
peptic ulcer
biliary colic
shingles
mastitis
Bornholm disease
RARE
pulmonary infarct
hypertrophic obstructive cardiomyopathy
pericarditis
fractured ribs
myocarditis
pneumothorax
dissecting aortic aneurysm
https://t.me/med1917
110 SYMPTOM SORTER
Ready reckoner
Angina GORD Anxiety Pulled muscle Tietze’s syndrome
Worse on exertion Ye s Possible Possible Possible Possible
Worse lying down No Ye s Possible No No
Eased by rest Ye s Possible Possible Yes Possible
Chest tenderness No No Possible Ye s Ye s
Swelling at tender point No No No No Ye s
Possible investigations
LI KE LY: ECG.
POSSIBLE: FBC, CXR, pulse oximetry, secondary care cardiac investigations, OGD, ultrasound
of abdomen.
SMALL PRINT: Helicobacter tests, hospital-based investigations for pulmonary embolus.
ECG: May show evidence of cardiac ischaemia, pericarditis or pulmonary embolism.
FBC: WCC raised in pleurisy and may be raised in Tietze’s syndrome.
CXR: May reveal chest infection, rib fracture, heart disease, cardiomyopathy or
pneumothorax.
Pulse oximetry: Hypoxia a sign of signicant cardiac or respiratory problem in the acute
setting.
Secondary care cardiac investigations: To clarify whether a cardiac cause.
Ultrasound of abdomen: To check for gallstones.
OGD: To conrm peptic ulcer or oesophagitis.
Helicobacter tests useful in the presence of duodenal ulcer.
Hospital-based investigations for pulmonary embolus: If this diagnosis is suspected.
TOP TIPS
e history is all-important and will usually provide the diagnosis. Except in an obvious
emergency, take your time getting the facts straight.
If you feel worried enough to obtain an urgent ECG then you ought to consider whether the
patient really requires an urgent medical opinion or admission.
Watching the patient’s hand as the symptoms are being described can provide very helpful
clues. A clenched st on the chest is worrying; a single pointing nger much less so.
Musculoskeletal pain and pleurisy both cause pain on deep inspiration – but the former
usually also displays muscle or rib tenderness.
Tietze’s syndrome is distinguished from costochondritis by the presence of a palpable
swelling, caused by oedema, at the site of maximal tenderness. However, management is
largely the same.
Always encourage the patient to contact you if the problem persists or deteriorates.
https://t.me/med1917
CHEST PAIN 111
If in doubt, play safe: Give aspirin (if not allergic) and admit.
If the diagnosis remains unclear, examine the abdomen, especially for signicant epigastric
tenderness.
Don’t delay if the symptoms clearly suggest an infarct; admit the patient (via the telephone
if necessary).
A normal ECG does not exclude an infarct. Treat the patient, not the test.
Symptoms of genuine and signicant pathology may be clouded by various ensuing anxiety
symptoms. Take time to tease them out.
Performing unnecessary tests when the diagnosis is clearly anxiety is likely to exacerbate the
situation.
Be especially careful dealing with acute chest pain in patients with asthma or COPD,
especially if they are suddenly more short of breath than usual, too – remember, they are
more prone to developing a pneumothorax.
NOTES:
https://t.me/med1917
112
CHRONIC SHORTNESS
OF BR E ATH
The GP overview
Shortness of breath is dened as dicult, laboured breathing. Medica l teaching tends to focus on
individua l pathologies; however, in practice there is oen some overlap between several contributory
causes and sometimes the diagnosis can only be made aer therapeutic trials of treatment.
Differential diagnosis
COMMON
obesity/untness
COPD
anaemia
congestive cardiac failure (CCF)
asthma
OCCASIONAL
bronchiectasis
recurrent pulmonary emboli
bronchial carcinoma with lobar collapse
pleural eusion
aortic stenosis
chronic hyperventilation
RARE
pulmonary brosis
large hiatus hernia
brosing alveolitis
undiagnosed congenital heart disease
neurological: motor neurone disease and the muscular dystrophies
sarcoidosis
extrinsic allergic alveolitis (bird fancier’s lung, etc.)
https://t.me/med1917
CHRONIC SHORTNESS OF BREATH 113
Ready reckoner
Obesity/untness COPD Anaemia CCF Asthma
Worse lying down Possible No No Ye s No
Swelling of ankles No Possible No Ye s No
Cough No Ye s No Ye s Ye s
Copious sputum No Ye s No Ye s Possible
Pallor No No Ye s No No
Possible investigations
LI KE LY: CXR, FBC.
POSSIBLE: Peak ow, U&E, LFT, ESR/CRP, BNP, ECG, spirometry.
SMALL PRINT: Pulse oximetry, serum precipitins, CT scan, hospital-based tests for pulmonary
embolism, pleural tap, echocardiogram, bronchoscopic biopsy or nodal aspiration.
CXR : e single most useful i nvestigation. Wil l reveal or give clues to many of the causes liste d.
FBC essential to look for ana emia; ESR /CRP ra ised in carcinoma , inammation a nd infection.
U&E and LFT: Impaired renal function will contribute to CCF; LFT may show signs of
disseminated carcinoma.
Peak expiratory ow rate vari ability in a sthma (g uidance recommends testi ng fractional ex haled
nitric oxide in suspe cted asthma but this may not be pract ical, or available); more comprehensive
lung function tests (spirometry) are more helpful to diagnose COPD and other lung diseases.
ECG: Heart failure is unlikely if the ECG is normal.
BNP: Likely to be elevated in heart failure.
Pulse oxi metry: Helps g uide asses sment of severity and decisions about oxygen therapy but of little
help in making the diagnosis.
Serum precipitins: In suspected extrinsic allergic alveolitis.
Referral for more di cult cases may resu lt in CT (e.g. for bronchiecta sis), pleural tap (diagnostic
and therapeutic for pleural e usion), echocardiography (for heart valve lesions and asse ssment of
le ventric ul ar f unc tion), hospital-b ase d test s for pu lmona r y embol ism a nd bronchosc opic biopsy
or nodal aspiration (for sarcoidosis).
TOP TIPS
Cardiac fai lure may arise as a complication of COPD. Remember this possibil ity if a patient with
COPD complains of gradually increasing breathlessness unrelieved by standard treatment.
Do not forget to listen to the heart sounds , especially i f there is no clear respiratory cause and t he
patient is not in cardiac failure – aortic stenosis may cause signicant shortness of breath.
https://t.me/med1917
114 SYMPTOM SORTER
In the young and middle-a ged, sig hing speech a nd shortness of breath worse with stress or without
any clear pattern – espec ially if t he patient does not consistently have a problem with exercise – are
likely to be caused by hyperventilation.
Weight loss and clubbing with shortness of breath suggest bronchial carcinoma, though
bronchiectasis is possible – arrange an urgent CXR.
Wheeze may be present in cardiac failure – crepitations may not. Look for other signs of
CCF in the elderly and consider appropriate investigation and treatment.
Remember that acute causes ca n supervene at any time – for example, beware of pneumothorax
in the asthmatic.
Cardiac failure has a poor prognosis; look for an underlying cause (e.g. hypertension) and
arrange echocardiography with a view to starting ACE inhibitors.
Don’t forget anaemia as a possible cause – contrary to popular belief this tends to cause
shortness of breath rather than tiredness.
NOTES:
https://t.me/med1917
115
COUGH IN ADULTS
The GP overview
is is a symptom that patients seem to fear or value – as a signier of possible cancer or a justier
of antibiotics – far more than GPs. Most coughs are simply viral URTIs, but the GP should be
aware of the various other possibilities, especially when the symptom is persistent.
Differential diagnosis
COMMON
URTI
LRTI
asthma
COPD
ACE inhibitor side eect
OCCASIONAL
smoking (including passive smoking)
lung tumour (primary or secondary)
rhinitis
GORD
LVF
bronchiectasis
aspiration (e.g. post stroke)
RARE
TB
other medication side eect (e.g. methotrexate)
pulmonary brosis
brosing alveolitis
extrinsic allergic alveolitis
psychogenic
laryngeal carcinoma
inhaled foreign body
diaphragmatic irritation (e.g. abscess)
https://t.me/med1917
116 SYMPTOM SORTER
Ready reckoner
URTI LRTI Asthma COPD ACE inhibitor side effect
Associated shortness of breath No Possible Possible Ye s No
Productive cough Possible Ye s Possible Yes No
Persistent or recurrent cough No No Ye s Ye s Ye s
Audible wheeze No Possible Possible Possible No
On ACE inhibitor Possible Possible Possible Possible Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, spirometry, PEFR.
SMALL PRINT: Sputum, cardiac investigations, serum precipitins, hospital-based investigations
such as CT scan and bronchoscopy.
FBC: Hb may be reduced in malignancy and chronic illness; WCC raised in infections,
eosinophils raised in allergic conditions.
ESR/CRP: Raised in neoplasia, infective and inammatory conditions.
CXR: May show signs in a variet y of the relevant dierentials, such as LRTI, tumour and TB.
Spirometry: May show characteristic patterns particularly in asthma, COPD and pulmonary
brosis.
Serial peak ow: May be helpful in diagnosis of asthma (guidance recommends testing
fractional ex haled nitric oxide in suspected asthma but this may not be practical, or available).
Sputum: May be useful in diagnosing TB and occasionally helps guide antibiotic treatment
in LRTI or exacerbation of COPD.
Cardiac investigations: Such as BNP or echocardiogram if LVF suspected.
Serum precipitins: In suspected extrinsic allergic alveolitis.
Hospital-based investigations: Further investigations such as CT scan or bronchoscopy may
be required to clarify CXR abnormalities or pursue clinical suspicion.
TOP TIPS
Explain to patients that it is not unusual for the cough of a simple URTI to go on for 3 weeks –
this will reduce unnecessary re-attendances.
Take a careful history of provoking factors in the case of persistent cough – this is more likely
to reveal the diagnosis than is chest auscultation.
Have a low threshold for arranging a CXR in the middle-aged and elderly smoker with a
cough.
https://t.me/med1917
COUGH IN ADULTS 117
ACE inhibitor-associated cough may come on many months – or even longer – aer
initiating treatment. It starts to improve within 1–4 weeks of stopping treatment but may
take 3 months to settle completely.
In a persistent cough with a normal CXR and no chest signs, think asthma, GORD and
rhinitis – a therapeutic trial for each may be needed to clinch the diagnosis.
Remember to ask about foreign travel. Atypical pneumonias are infrequent, and TB rare,
but both can still present.
Beware of persistent cough, weight loss and voice change in a smoker – arrange an X-ray to
exclude malignancy.
Night sweats with persistent cough suggest signicant pathology such as TB or malignancy.
Beware the patient on immunosuppressants – these drugs may alter the clinical picture,
predispose to serious complications and in some cases (e.g. methotrexate) may be the cause
of the cough itself.
NOTES:
https://t.me/med1917
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