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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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158 SYMPTOM SORTER
Ready reckoner
Allergic conjunctivitis Infective conjunctivitis Dry eyes Blepharitis Blocked tear duct
Bilateral Yes Possible Ye s Ye s Possible
Eyes red Ye s Ye s Possible No No
Eyelids red Possible No No Ye s No
Seasonal Possible No No No No
Discharge Ye s Ye s Possible No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Swab, Schirmer’s test.
SMALL PRINT: TFT, thyroid autoantibodies, MRI orbits, biopsy.
Swab: May be necessary in persistent discharge; essential in neonates who’ve had sticky eyes
since birth.
Schirmer’s test: To assess for dry eye – may be performed by the optician.
TFT, thyroid autoantibodies, MRI orbits – may be required in suspected thyroid eye disease.
Biopsy: Rarely, if sebaceous gland carcinoma suspected.
TOP TIPS
Diagnosis can be dicult and an optician’s input may be invaluable.
Enquire about the use of OTC drops and their eect: is may give clues to the underlying
problem. Sometimes, the drops themselves may be the cause.
It can be easy to overlook entropion – ask the patient to squeeze the eyes shut, then suddenly
open them, in which case a subtle entropion should be revealed.
Bear in mind that patients with dry eyes sometimes paradoxically complain of a stringy
discharge.
https://t.me/med1917
ITCHY OR IRRITATING EYES OR EYELIDS 159
Remember that thyroid eye disease can present before biochemical dysfunction – if in doubt,
refer.
Do not overlook a foreign body as a possible cause, especially if the history is vague and the
symptoms unilateral.
Chlamydia and gonorrhoea must be excluded in the neonate with a sticky eye or eyes from
birth.
e rare sebaceous gland carcinoma causes blepharitis-type symptoms, but with localised
inammation and localised loss of lashes.
NOTES:
https://t.me/med1917
160
SUDDEN LOSS
OF VISION
The GP overview
Sudden loss of vision is a genuine GP emergency. Most causes require an urgent ophthalmological
opinion as there is little that the GP can do. is particular symptom is not oen encountered
in general practice – a prompt appointment or visit and a careful examination are necessary to
assess the situation and exclude the causes not requiring urgent specialist treatment. Blurring,
such as that found in some cases of the acute red and painful eye, is not covered here.
Differential diagnosis
COMMON
acute glaucoma (may cause blurring but can rapidly progress to complete loss of vision)
vitreous haemorrhage
central retinal artery occlusion
migraine
CVA or TIA
OCCASIONAL
central retinal vein occlusion
retrobulbar (optic) neuritis
retinal detachment
temporal arteritis
posterior uveitis
RARE
hysteria
cortical blindness (non-vascular)
optic nerve injury
quinine poisoning
https://t.me/med1917
SUDDEN LOSS OF VISION 161
Ready reckoner
Acute
glaucoma
Vitreous
haemorrhage
Retinal artery
occlusion
Migraine TIA/CVA
Preceded by spots and ashing lights No Possible No Ye s Possible
Followed by headache Possible No No Yes Possible
Painful eye Ye s No No No No
Absent red reex No Ye s No No No
Affected pupil dilated and xed Yes No Ye s No No
Possible investigations
In practice, there are none worth doing at the time, as the vast majority of cases will be referred
urgently. Virtually all tests will therefore be arranged by the specialist, usually aer the event, to
look for underlying causes. Such investigations include the following.
Screening for diabetes: Undetected retinopathy may have preceded vitreous haemorrhage.
FBC: PCV may be raised in central retinal vein occlusion.
ESR: Raised in temporal arteritis.
Multiple microbiological investigations are needed for posterior uveitis.
Posterior pole ultrasound may be useful in vitreous haemorrhage to identify treatable causes.
CT scan only useful to investigate cerebral causes (CVA or cortical blindness).
TOP TIPS
Acute visual disturbance is oen dicult to diagnose accurately and very alarming for the
patient. If in doubt, refer urgently, or, at the very least, review in a few hours.
e patient’s assessment of visual loss, and its severity, is highly subjective – if at all possible,
test it with a Snellen chart.
Always keep spare batteries handy for your ophthalmoscope!
https://t.me/med1917
162 SYMPTOM SORTER
Don’t forget that the visual disturbance may be the presenting symptom of some other
pathology, such as hypertension, temporal arteritis or diabetes.
Don’t miss a heart murmur or carotid bruit. ese may be present in retinal artery occlusion
and T IA/C VA.
A cherry red spot on the fovea is pathognomic of retinal artery occlusion.
Never use mydriatics to aid examination at the bedside – these will cloud the clinical picture
and may even precipitate acute glaucoma.
NOTES:
https://t.me/med1917
163
FACE
Facial pain 164
Facial rash 167
Facial swelling 170
Facial ulcers and blisters 173
https://t.me/med1917
164
FACIAL PAIN
The GP overview
Pain in the face may either be due to local disease of any of the major structures of the face, or
conditions aecting the innervation. e latter can occur anywhere between the posterior fossa
and the ends of the trigeminal nerve. A good examination is not dicult, and quicker than most
as undressing is not usually required.
Differential diagnosis
COMMON
maxillary/frontal sinusitis
trigeminal neuralgia (TN)
dental abscess
temporomandibular joint (TMJ) dysfunction
shingles (herpes zoster)
OCCASIONAL
cluster headache (periodic migrainous neuralgia)
temporal arteritis
parotid: mumps, abscess and duct obstruction (stone/tumour)
upper cervical spondylosis
mandibular or maxillary osteitis or cyst
cellulitis
RARE
multiple sclerosis
atypical facial pain (may be linked with depression)
nasopharyngeal, sinus and lingual carcinoma
posterior fossa tumours
gummatous meningitis and tabes
glaucoma and iritis
https://t.me/med1917
FACIAL PAIN 165
Ready reckoner
Sinusitis TN Dental abscess TMJ Shingles
Fever and malaise Possible No Possible No Possible
Lymphadenopathy Possible No Yes No Yes
Pain worse on bending Ye s No Ye s No No
Pain on tapping teeth Possible No Yes No No
Lancinating pain No Ye s No No Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, sinus x-ray.
SMALL PRINT: X-ray of TMJ, temporal artery biopsy, sialogram, CT/MRI scan.
FBC: WCC and ESR/CRP raised in infection; ESR/CRP raised in temporal arteritis and
tumour (ESR more useful than CRP in suspected temporal arteritis).
X-rays: Sinus X-ray of little help in acute sinusitis but may help in chronic pain to assess for
possible chronic sinusitis or tumour; TMJ views and dental plain lm for abscess likely to
be arranged by dentist; parotid sialogram for stone/tumour.
Temporal artery biopsy: May be necessary to clinch diagnosis of temporal arteritis.
CT/MRI scan the only practical way to examine the posterior cranial fossa and Gasserian
ganglion – a specialist investigation.
TOP TIPS
Don’t over-diagnose sinusitis – many URTIs will produce mild facial ache through a vacuum
eect.
Remember that shingles can produce pain before the rash – in the acute onset of unexplained
unilateral facial pain, warn the patient to report back to the doctor should a blistering rash
develop.
Refer dental abscesses to a dentist without treating rst, to ensure proper investigation,
treatment and follow-up – and to encourage the patient to present to the correct agency in
future.
https://t.me/med1917
166 SYMPTOM SORTER
If no obvious cause is found for persistent facial pain, refer to exclude sinister pathology.
Trigemina l neuralg ia is usually idiopathic, but may have a serious underlying cause, especially
if there is associated motor disturbance or other neurological symptoms or signs.
Temporal arteritis is a clinical diagnosis. If suspected, treat immediately with high-dose
steroids to prevent blindness. ESR is for retrospective conrmation only.
If the eyeball is red and tender in frontal facial pain, consider glaucoma, iritis or orbital
cellulitis. Refer urgently.
Out-of-hours dental treatment can be very hard for patients to access in the UK. You may
nd yourself ethically obliged to provide some form of treatment, but be sure to give the
advice (and document it) that the patient should contact their own dentist as soon as the
dental surgery is open. Send a copy of your clinical notes to the dentist as you would any other
clinician. You should never feel pressured to work outside your areas of competence, so don’t
hesitate to refer to the local hospital facio-maxillar y team on call if you have any doubts about
diagnosis or emergency management.
NOTES:
https://t.me/med1917
167
FACIAL RASH
The GP overview
Unlike most of the other ‘skin’ chapters in this book, this section is presented according to the
rash’s distribution. is is because it is a common presentation, one with a wide dierential
and one which causes the patient signicant concern, largely because of the cosmetic impact.
Occasionally, it can be caused by, or represent, signicant pathology. Individual facial spots –
such as basal cell carcinoma – aren’t considered here.
Differential diagnosis
COMMON
acne
rosacea
seborrhoeic eczema
impetigo
perioral dermatitis
OCCASIONAL
chloasma
sycosis barbae
drug side eect: especially phototoxicity
infection (e.g. herpes zoster and simplex, cellulitis, chickenpox, slapped cheek)
allergic eczema
acne excoriée
post inammatory hypo- or hyperpigmentation
pityriasis alba
petechiae from coughing/vomiting/straining
other generalised skin diseases (e.g. psoriasis, vitiligo)
RARE
Stevens–Johnson syndrome
SLE
mitral ush
tuberous sclerosis
lupus vulgaris
sarcoidosis
dermatomyositis
https://t.me/med1917
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