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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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138 SYMPTOM SORTER
Ready reckoner
Earwax Hearing loss Otitis media Otosclerosis Ménière’s disease
Sudden onset Ye s No Ye s No Possible
Pain in ear Possible No Ye s No No
Rinne’s test
positive
No Ye s Possible No Ye s
Vertigo Possible No Possible No Ye s
High-pitched No Possible No No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Tympanogram, audiogram, MRI scan (all usually in secondary care).
SMALL PRINT: FBC, U&E, skull X-ray, angiography (the latter two in secondary care).
FBC and U&E: If anaemia or renal failure suspected.
Tympanogram for middle-ear function and stapedial reex threshold. Audiogram to assess
hearing loss objectively.
Cerebral angiography: If vascular pathology suspected.
MRI scan: e most sensitive way to examine the inner ear and skull for structural lesions.
Skull X-ray: If associated with signicant head injury.
TOP TIPS
Most patients are afraid of the diagnosis of tinnitus because of its potentially debilitating
nature. If the cause is clearly self-limiting or remediable, take time to reassure the patient.
Have a low threshold for referral in persistent tinnitus. While no specic treatment may
be available, this shows that you are taking the problem seriously, ensures that remediable
problems won’t be missed and may give the patient access to masking devices.
Be prepared to reassess ongoing tinnitus, as new symptoms may develop. For example,
tinnitus may precede other symptoms in Ménière’s disease by months or even years.
https://t.me/med1917
TINNITUS 139
Depression in tinnitus ha s been severe enough to cause suicide. Ma ke a thorough psychologica l
assessment and consider a trial of antidepressants.
ink of otosclerosis in younger patients (15–30) with persistent conductive deafness –
especially if there is a family history. Early diagnosis is important.
Progressive unilateral deafness with tinnitus could be caused by an acoustic neuroma.
Exclude by referring for an MRI scan.
NOTES:
https://t.me/med1917
https://t.me/med1917
141
EYE
Acutely red and painful eye 142
Double vision 145
Eyelid problems 148
Flashes, oaters and transient visual disturbance 151
Gradual loss of vision 154
Itchy or irritating eyes or eyelids 157
Sudden loss of vision 160
https://t.me/med1917
142
ACUTELY RED AND
PAINFUL EYE
The GP overview
is is a common reason for an urgent surgery appointment. If a visit request is made, try to
negotiate consultation in surgery, where optimal examination conditions and equipment are to
hand. Carefully examine to assess acuity, state of the cornea and pupillary reexes.
Differential diagnosis
COMMON
acute conjunctivitis (allergic or infective)
acute iritis
acute glaucoma
keratitis/corneal ulcer
corneal abrasion or supercial foreign body (FB)
OCCASIONAL
episcleritis
scleritis
keratoconjunctivitis sicca
trauma: contusion and penetrating wound, burns (arc eye and chemical)
orbital cellulitis
RARE
carotico-cavernous stula (rupture of carotid aneurysm)
gout (urate deposits in conjunctiva or sclera)
granulomatous disorders: TB, sarcoid, toxoplasmosis
onchocerciasis (transmitted by Simulium black y in Africa)
tumour: primary eye tumour, invasion from nasopharyngeal tumour
https://t.me/med1917
ACUTELY RED AND PAINFUL EYE 143
Ready reckoner
Conjunctivitis Iritis Glaucoma Keratitis/ulcer Abrasion/FB
Discharge Ye s No No Possible Possible
Visual disturbance No Yes Yes Possible Possible
Circumcorneal injection No Ye s Possible Possible No
Poor pupil reex No Ye s Ye s No Possible
Hazy cornea No Possible Ye s Possible No
Possible investigations
In practice, the problem is either easily treated by the GP (e.g. conjunctivitis or foreign body)
or usually requires urgent referral. e GP’s role in investigating the painful red eye is therefore
very limited.
Swab of discharge for microbiology: Very occasionally helpful in conjunctivitis not settling
with usual treatment.
Blood: Raised WCC and ESR/CRP may support diagnosis of inammatory disorders.
Rheumatoid factor in suspected rheumatoid arthritis (RA); HLA-B27 usually positive in
ankylosing spondylitis. e latter investigations would normally be performed at leisure
rather than in the acute situation, when an underlying collagen disease is suspected (e.g.
iritis).
Intraocular pressure measurement is essential if acute glaucoma is suspected. Usually done
by a specialist.
TOP TIPS
If in serious doubt about the diagnosis, refer for urgent assessment – this is one scenario
where a delay in treatment can have devastating consequences.
Don’t rely on the patient’s subjective assessment of blurring of vision – check the visual
acuity.
Remember to evert the upper lid to check for a concealed foreign body.
Review the patient 24–48 hours aer removing a foreign body to ensure that the cornea
has healed.
https://t.me/med1917
144 SYMPTOM SORTER
Never use mydriatics when examining the red eye: You may precipitate acute glaucoma.
Bilateral red eye is usually caused by conjunctivitis. If unilateral, consider other causes.
Failure to recognise herpetic corneal ulcer or acute glaucoma may lead to permanent visual
loss. If in doubt, refer for urgent specialist opinion.
Never instil steroid drops unless you are absolutely sure you are managing the problem
correctly and have excluded herpetic ulceration.
Take a careful history when dealing with foreign bodies. Any possibility of a high-speed
impact (e.g. grinding metal) requires urgent specialist assessment to exclude intraocular
foreign body.
Contact lens wearers are at risk of a number of signicant ocular problems – refer any
unilateral red eye in a contact lens wearer for same day specialist assessment.
NOTES:
https://t.me/med1917
145
DOUBLE VISION
The GP overview
Diplopia is nearly always binocular, with movement of one eye being limited for a number of
possible reasons. A lthough relatively uncommon as a presenting symptom, the majority of causes
are signicant and therefore careful assessment is essential.
Differential diagnosis
COMMON
physiological (focusing too near, or perceiving objects nearer than those focused on)
intoxication: prescribed sedation, non-prescribed drugs, especially excess alcohol, opiates,
benzodiazepines
stroke
mild head injury, causing temporary diplopia
facial bone trauma: Orbital and zygomatic fracture
OCCASIONAL
mononeuropathy (e.g. diabetes, MS)
orbital disease (usually associated with pain and proptosis) and aer surgery (scarring
limiting globe movement)
Guillain–Barré syndrome
palsy of third, fourth or sixth cranial nerves due to intracranial space-occupying lesion
(haemorrhage, tumour, aneurysm, abscess, cavernous sinus thrombosis)
myasthenia gravis
monocular diplopia: early cataract, irregularity of corneal surface (e.g. post trauma or
inammation)
RARE
ophthalmoplegic migraine
Tolosa–Hunt syndrome: granulomatous or inammatory process in anterior portion of
cavernous sinus or superior orbital ssure
pseudoparalysis of ocular muscles: dysthyroid disease; Duane’s syndrome (congenital brosis
of lateral rectus)
orbital myositis
pituitary exophthalmos
https://t.me/med1917
146 SYMPTOM SORTER
Ready reckoner
Physiological Intoxication Stroke Head injury Facial bone trauma
History of trauma No No No Ye s Ye s
Unequal pupils No No Possible Possible No
Unilateral limb paresis No No Possible Possible No
Impaired consciousness No Ye s Possible Possible No
Facial bone deformity No No No No Ye s
Possible investigations
LI KE LY: none; FBC, ESR/CRP, lipid studies, urinalysis, fasting glucose or HbA1c.
POSSIBLE: TFT, X-rays, CT/MRI scan.
SMALL PRINT: Edrophonium test, EMG, CSF studies, angiography.
No investigation is indicated in primary care for the most common causes – referral is the
likeliest course of action.
FBC, ESR/CRP, lipid studies: If stroke suspected and admission not required. FBC and
ESR/CRP will also provide evidence of inammatory conditions.
Urinalysis for glucose/fasting glucose or HbA1c: To investigate possible diabetes.
TFT will reveal hyperthyroidism.
Other investigations (and possibly some of the above) are likely to be carried out in secondary
care: Skull and facial bone x-rays in trauma cases; CT or MRI scan (head injury, stroke, MS,
space-occupying lesion); specialist neurological investigations (edrophonium test, single-
bre EMG studies, CSF examination, angiography).
TOP TIPS
Establish if the diplopia is binocular or not. Uniocular double vision has a much narrower
dierential diagnosis.
Take time to clarify the symptom. Sometimes, patients complain of ‘double vision’ when they
really mean blurring – and vice versa.
e cover test is a reliable way to nd out which eye is aected.
Fourth cranial nerve palsy produces diplopia on looking downwards and inwards, oen
noticed when descending stairs. e patient may try to compensate by tilting the head –
so-called ocular torticollis.
https://t.me/med1917
DOUBLE VISION 147
Intoxication in conjunction with a head injury is commonly seen in custody medicine and
A&E departments. Admission for neurological observation is strongly recommended.
Diplopia of acute onset may well reect serious pathology – refer for urgent assessment.
Intermittent diplopia should not be dismissed too readily as insignicant – remember that
myasthenia gravis and multiple sclerosis are possibilities.
NOTES:
https://t.me/med1917
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