Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
.pdf
118
COUGH IN CHILDREN
The GP overview
e symptom GPs love to hate because it can appear so trivial. Reassurance and explanation
are oen all that is required, and this can build a bond with parents and children. Take parents
seriously and sympathetically: Nocturnal cough is a destroyer of sleep and family peace.
Differential diagnosis
COMMON
URTI
bronchiolitis (usually aged under two)
post-nasal drip (e.g. post URTI, allergic rhinitis)
asthma
pneumonia
OCCASIONAL
pertussis
recurrent viral wheeze
multi-trigger wheeze
croup
inhaled foreign body
GORD
psychogenic
RARE
TB
cystic brosis
earwax or foreign body in the ear canal
immune deciency
interstitial lung disease
congenital (e.g. trachea-oesophageal stula)
https://t.me/med1917
COUGH IN CHILDREN 119
Ready reckoner
URTI Bronchiolitis PN drip Asthma Pneumonia
Child unwell No Possible No Possible Ye s
Chest signs No Ye s No Possible Possible
Spring/summer exacerbation No No Possible Possible No
Marked nasal catarrh Yes Possible Yes Possible No
Cough >3 weeks
No Possible Possible Ye s Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, CXR, serial peak ow or spirometry.
SMALL PRINT: Pertussis serology, sweat test, secondary care investigations (e.g. for interstitial
lung disease or immune deciency).
FBC, ESR /CRP: WCC raised in infection – marked lymphocytosis in pertussis; ESR/CRP
elevated in any inammatory process.
CXR: May be helpful in LRTI, TB, inhaled foreign body, cystic brosis.
Serial pea k ow or spirometry: To help conrm a dia gnosis of asthma (gu idance recommends,
in children over the age of 5, testing fractional exhaled nitric oxide in suspected asthma but
this may not be practical, or available).
Pertussis serology: If a clinical suspicion of pertussis needs conrming.
Sweat test: For cystic brosis.
Other secondary care investigations: May be required aer referral (e.g. for interstitial lung
disease or immune deciency).
TOP TIPS
ink pertussis in any paroxysmal cough lasting more than 3 weeks – it is much more
common than most people, and many doctors, realise.
Educate parents about the likely duration of URTI-related coughs and simple measures to
take. Avoid prescribing, as this simply reinforces the tendency to attend the doctor for minor,
self-limiting illness.
In the asthmatic child, a cough may be a sign of poor control – check treatment, compliance
and inhaler technique.
Many parents panic that a cough might harm their child. An explanation that a cough is
oen simply a way of ‘keeping the lungs clear’ can defuse the situation.
An aural foreign body is an unusual but remediable cause of childhood cough.
https://t.me/med1917
120 SYMPTOM SORTER
Many parents wonder why their pre-school wheezy child has not been given a denitive
diagnosis of asthma, particularly aer treatment with bronchodilators. It is therefore worth
broaching this by explaining the current way wheezy pre-school children are labelled, and
why.
Psychogenic cough typically does not occur at night.
Parents tend to focus on the cough. In the acute situation, rather more important are
symptoms and signs of respiratory distress – the NICE trac light system for febrile children
is useful in the acutely coughing febrile child and will help guide the need for admission.
A dramatic and abrupt onset of coughing in a child without an URTI should make you
consider an inhaled foreign body.
Beware the ‘poorly controlled asthmatic’ who isn’t thriving – this could be cystic brosis.
It can be dicult to distinguish between pneumonia and bronchiolitis in the unwell child.
Children with pneumonia will tend to have a high fever and focal crepitations; children with
bronchiolitis will be under 2 years old (most common in the rst year of life), have a milder
fever and more generalised sounds on auscultation. Whatever the diagnosis, if the child is
unwell with respiratory distress, it needs admission.
In a child with croup, admit if stridor or sternal/intercostal recession at rest, or if agitation
or lethargy, pallor or cyanosis, or raised pulse or respiratory rate.
NOTES:
https://t.me/med1917
121
COUGHING UP BLOOD
The GP overview
Patients invariably view this relatively uncommon symptom as representing something serious –
this is rarely the case in primary care. In practice, the origin of the blood may not be immediately
obvious: uite oen, blood from the nose or throat may be coughed out with saliva (spurious
haemoptysis) and described as ‘coughing up blood’.
Differential diagnosis
COMMON
chest infection
pulmonary embolism (PE)
bronchogenic carcinoma
pulmonary oedema
prolonged coughing
OCCASIONAL
bronchiectasis
mitral stenosis
polyarteritis nodosa
tuberculosis
tumour of larynx or trachea
RARE
associated with SLE
aspergillosis
Goodpasture’s syndrome
contusion due to trauma
pulmonary arteriovenous malformations (50% associated with hereditary haemorrhagic
telangiectasia)
https://t.me/med1917
122 SYMPTOM SORTER
Ready reckoner
Chest infection PE Bronchogenic carcinoma Pulmonary oedema Prolonged coughing
Purulent sputum Ye s No Possible No Possible
Pink frothy sputum No No No Ye s No
Chest signs Ye s Possible Possible Possible No
SOB Ye s Ye s Possible Ye s No
Fever Ye s Possible Possible No No
Possible investigations
LI KE LY: CXR.
POSSIBLE: FBC, ESR/CRP, autoantibody screen, sputum, pulse oximetry.
SMALL PRINT: Bronchoscopy, secondary care investigations for pulmonary embolism,
echocardiogram, other chest imaging (e.g. CT scan).
CXR: is is the single most valuable investigation for detecting many of the causes listed.
Sputum microbiology: May be needed to look for acid-fast bacilli of TB.
FBC and ESR/CRP: For anaemia (LVF and malignant disease); WCC raised in infection,
ESR/CRP raised in malignancy, infection and inammatory conditions.
Autoantibody screen: For assessing possible connective tissue disease.
Pulse oximetry: Hypoxia points to signicant acute lung pathology.
Hospital-based tests: Various other investigations may be considered according to the
likely aetiology and would usually be arranged by the hospital specialist aer referral, e.g.
bronchoscopy, investigations for pulmonary embolism, CT scan and echocardiography.
TOP TIPS
In younger patients, the symptom is most commonly caused by vigorous coughing. If this
is clearly the case, and the haemoptysis was minor, do not engender unnecessary anxiety by
arranging a CXR.
Take a careful history. e terminology used by some patients can confuse the doctor as to
whether blood was coughed or vomited up.
Don’t forget that most patients – and smokers in particular – will be worried that the
symptom represents cancer. Reassure rmly when appropriate, but investigate early those
cases that concern you, providing an adequate explanation as to why you are arranging a
CXR and making rm arrangements for follow-up.
https://t.me/med1917
COUGHING UP BLOOD 123
Any smoker with signicant haemoptysis should have a CXR – particularly if there are
other sinister features such as shortness of breath, weight loss, persistent cough or clubbing.
PE causes sudden onset of shortness of breath with pleuritic pain. Consider this diagnosis
if there is no other obvious explanation for the symptoms, especially if the patient has a
tachycardia. Signs of DVT may only appear later, or sometimes never at all.
TB is on the increase in the UK. Consider this possibility in the elderly, immigrants and
vagrants. It oen mimics malignancy.
If haemoptysis persists, arrange referral even if the CXR is clear – some lesions may not
appear on the X-ray, or may only develop aer some time has elapsed. Other investigations
may be required.
NOTES:
https://t.me/med1917
124
PALPITATIO N S
The GP overview
Palpitations are presented fairly frequently to the GP, sometimes in isolation but more oen
immersed in other symptoms. Patients use the word ‘palpitations’ to describe a remarkable
variety of sensations, and it is important to establish exactly what is meant. Cardiac causes are
relatively rare; anxiety about a cardiac problem, and anxiety as a cause of the symptom, are
common.
Differential diagnosis
COMMON
anxiety (increased awareness of normal heartbeat)
sinus tachycardia (e.g. stress, fever, exercise)
atrial ectopics
ventricular ectopics
supraventricular tachycardia (SVT)
OCCASIONAL
structural heart disease (e.g. valvular problem, cardiomyopathy)
thyrotoxicosis (combination of sinus tachycardia and increased awareness even if ventricular
ectopics are absent)
menopause (due to sudden vasodilation)
atrial brillation (AF – various causes, e.g. IHD, mitral valve disease, alcohol)
iatrogenic (e.g. digoxin, nifedipine)
atrial utter
dumping syndrome (e.g. aer bariatric surgery)
RARE
heart block (especially with changes in block)
sick sinus syndrome
drug abuse
ventricular tachycardia (VT)
phaeochromocytoma
carcinoid syndrome
https://t.me/med1917
PALPITATIONS 125
Ready reckoner
Anxiety Sinus
tachycardia
Atrial
ectopics
Ventricular
ectopics
SVT
Sudden onset Possible No Possible Possible Ye s
‘Heart racing’ Ye s Ye s No No Yes
‘Heart misses a beat’ Possible No Ye s Yes No
Underlying heart disease No No No Possible Possible
Rate/rhythm abnormal during episode No Ye s Ye s Ye s Ye s
Possible investigations
LI KE LY: ECG, TFT.
POSSIBLE: U&E, 24 h ECG or event monitor.
SMALL PRINT: Echocardiography, further secondary care cardiac investigations, 24 h urinary
5-HIAA, 24 h urinary-free catecholamines and VMAs.
ECG: May show arrhythmia itself or evidence of ischaemic heart disease or Wol–
Parkinson–White syndrome.
TFT: yrotoxicosis can cause palpitations or exacerbate other causes.
U&E: Electrolyte disturbance can precipitate or aggravate some arrhythmias.
24 h ECG or event monitor: To provide ECG evidence of the arrhythmia.
Echocardiography: To investigate possible structural lesions such as valvular problems or
cardiomyopathy.
Further secondary care investigations: Might include investigation for underlying ischaemic
heart disease.
24 h urinary 5-HIAA: If carcinoid syndrome suspected.
24 h urinary-free catecholamines and VMAs: If phaeochromocytoma suspected.
TOP TIPS
Take time to obtain a clear history, as the patient’s perception of a ‘palpitation’ may dier
markedly from yours.
In paroxysmal cases, suggest that the patient attends the surgery or casualty urgently during
an attack to obtain an ECG.
Patients can easily be taught to take their own pulse. Self-reported pulse rates can help
considerably in establishing a diagnosis or they can measure their pulse using one of the
various pieces of electronic gadgetry available for domestic use, though beware of fuelling
neurosis.
Most patients with palpitations fear heart disease, and this anx iety exacerbates the symptoms.
Ensure this fear is resolved whenever possible.
https://t.me/med1917
126 SYMPTOM SORTER
Multiple, or multifocal, ventricular ectopics suggest signicant ischaemic heart disease – and
may herald VT or brillation if they follow an infarct.
Sudden onset of tachycardia in a young adult with breathlessness, dizziness, chest pain and
polyuria suggests signicant SVT.
Take very seriously patients with palpitations which are linked with syncope, or which come
on aer exercise, or who have an existing cardiac history, or who have a family history of
sudden death in under 40s. All need referral.
Remember that digoxin can aggravate as well as resolve some arrhythmias.
NOTES:
https://t.me/med1917
127
EAR
Deafness 128
Earache 131
Ear discharge 134
Tinnitus 137
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана