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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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168 SYMPTOM SORTER
Ready reckoner
Acne Rosacea Seborrhoeic eczema Impetigo Perioral dermatitis
Mainly around mouth Possible No No Possible Ye s
Rash elsewhere Possible No Possible Possible No
Age >40
No Ye s Possible Possible Possible
Papules and pustules Ye s Ye s No Possible Ye s
Rapid response to antibiotics No Ye s No Yes Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, ESR/CRP, autoantibody screen, CPK.
SMALL PRINT: Viral or bacterial swabs, skin biopsy, muscle biopsy.
FBC: WCC raised in any infection; may be normochromic, normocytic anaemia in SLE.
ESR/CRP, autoantibody screen: ESR/CRP likely to be raised in infection and SLE;
autoantibodies may be positive in the latter.
CPK: Elevated in dermatomyositis.
Viral or bacteria l swabs: To help diagnosis in obscu re cases or if secondary i nfection suspected.
Skin biopsy; muscle biopsy: e former for suspected lupus vulgaris or sarcoidosis; the latter
to conrm dermatomyositis.
TOP TIPS
Do not underestimate the possible impact of a facial rash on a patient’s life. e cosmetic
eect may be devastating.
A therapeutic trial of antibiotics in acne may take up to 3 months to take eect – ensure the
patient is aware of this.
Remember that impetigo may simply represent superinfection of an underlying skin problem,
such as eczema, which will require treatment in its own right.
Check on OTC medication usage. In particular, remember that hydrocortisone 1% cream
is available over the counter – inappropriate use might aggravate rosacea and perioral
dermatitis.
Parents are sensitised to non blanching rashes. ey can be reassured that such a rash
restricted to the face (indeed, restricted to the entire distribution of the superior vena cava)
is not due to meningitis.
https://t.me/med1917
FACIAL RASH 169
A complaint of dramatic facial ‘sunburn’ in the elderly may well represent a phototoxic
reaction – check the drug history.
Beware the acute onset of unilateral unexplained facial erythema with mild oedema,
especially in an elderly patient. is may well be the start of cellulitis or herpes zoster.
Warn patients with facial zoster or herpes simplex infection near the eye to report any ocular
problems.
Acne excoriée may be a marker of signicant psychiatric pathology.
NOTES:
https://t.me/med1917
170
FACIAL SWELLING
The GP overview
is section looks at ‘internal’ causes of facial swelling rather than supercial skin conditions
which are dealt with elsewhere (see p. 395). is problem is usual ly a major concern to the patient
because of the disgurement, which it is impossible to hide. e causal conditions are oen very
painful too.
Differential diagnosis
COMMON
mumps (viral parotitis)
angioneurotic oedema (allergy)
dental abscess
trauma (especially fractured zygoma)
salivary gland stone
OCCASIONAL
bacterial parotitis
cellulitis (including orbital)
masseteric hypertrophy (caused by bruxism)
dental cyst
myxoedema
herpes zoster (may be swelling rather than blistering initially)
RARE
parotid tumour
maxillary or mandibular sarcoma
Cushing’s syndrome
nasopharyngeal carcinoma
Burkitt’s lymphoma
https://t.me/med1917
FACIAL SWELLING 171
Ready reckoner
Mumps Angioneurotic Dental abscess Trauma Parotid stone
Bilateral Yes Ye s No Possible No
Swells when eating No No No No Ye s
Skin erythema No Ye s Possible Possible No
Tapping tooth painful No No Ye s No No
Fever Yes No Possible No No
Possible investigations
LI KE LY: Facial X-ray (if trauma).
POSSIBLE: TFT (if patient looks myxoedematous).
SMALL PRINT: FBC, ESR/CRP, sialogram.
Plain facial X-ray important in trauma (view may depend on site). Also may reveal rare cases
of bony tumour.
TFT, FBC, ESR/CRP: TFT will reveal hypothyroidism; WCC raised in infective process;
ESR/CRP raised in infection and tumour.
Parotid sialogram will show obstruction of duct (stone, tumour).
TOP TIPS
New gru voice with diuse facial swelling should prompt investigation for likely
hypothyroidism.
Don’t over-diagnose mumps in children – since the advent of MMR vaccination, this is
becoming more uncommon; cervical adenitis is much more likely.
Whenever possible, direct patients with dental problems directly to the dentist, who will be
able to prescribe any necessary antibiotics and analgesics.
https://t.me/med1917
172 SYMPTOM SORTER
Painless, progressive facial swelling suggests tumour or dental cyst. Urgent oral surgical
referral is indicated.
Bloodstained nasal discharge in association with a unilateral facial swelling is an ominous
sign suggesting malignancy.
Severe angioedema may cause respiratory tract obstruction – treat vigorously as for
anaphylactic shock.
Orbital cellulitis requires urgent assessment and intravenous antibiotics.
Parotid swelling with a facial palsy suggests parotid tumour with involvement of the facial
nerve.
Suspected herpes zoster in the ophthalmic division of the trigeminal nerve requires urgent
antiviral treatment and ophthalmological referral.
NOTES:
https://t.me/med1917
173
FACIAL ULCERS
AND BLISTERS
The GP overview
Facial ulcers and blisters present much earlier than similar lesions elsewhere on the body because
of the cosmetic disgurement. Smaller lesions, especially basal cell carcinomas, are oen picked
up coincidentally by the doctor when the patient attends for some unrelated matter. (NB: For
rashes conned, or largely conned, to the face, see Facial rash, p. 165.)
Differential diagnosis
COMMON
impetigo
herpes simplex virus (HSV)
herpes zoster
basal cell carcinoma (BCC)
keratoacanthoma
OCCASIONAL
squamous cell carcinoma (SCC)
ulcerating malignant melanoma and lentigo maligna (Hutchinson’s freckle)
drugs (e.g. barbiturates)
acne excoriée
ulcerating dental sinus
RARE
dermatitis artefacta
tuberculosis
pemphigus
Actinomyces
primary syphilitic chancre or tertiary syphilitic gumma
cutaneous leishmaniasis
cancrum oris
https://t.me/med1917
174 SYMPTOM SORTER
Ready reckoner
BCC Herpes zoster Keratoacanthoma Impetigo HSV
Feverish and unwell No Yes No No Possible
Rapid development No Ye s Ye s Yes Ye s
Recurrent Possible No No Possible Ye s
Occurs in children No Possible No Yes Ye s
Multiple lesions No Yes No Ye s Yes
Possible investigations
Acute lesions very rarely require investigation; chronic lesions pose more of a diagnostic problem.
In such cases, biopsy, or excision biopsy, is the gold standard test. Cytology aer scraping the
lesion with a scalpel blade may be helpful in diagnosing basal cell carcinoma. Syphilis serology
may very rarely be useful if primary or tertiary syphilis is suspected.
TOP TIPS
Remember that herpes simplex can occ ur on the face at sites other than the lip. e appeara nce
of the lesions and their recurrent nature should provide the diagnosis.
‘Rodent ulcer’ is a kinder term than basal cell carcinoma, especially for small lesions, as
it is less likely to arouse unnecessary anxiety. Nonetheless, impress upon the patient the
importance of attending the appointment with the specialist.
Patients with herpes zoster are at risk of a number of anxieties because of the existence of
various ‘old wives’ tales’ about shingles. Establish any fears and take time to explain the
natural history of the condition, including the possibility of post-herpetic neuralgia.
In children with recurrent impetigo, consider an underlying condition – particularly eczema .
https://t.me/med1917
FACIAL ULCERS AND BLISTERS 175
If in any doubt about the diag nosis, urgent dermatologica l referral for skin biopsy is indicated.
Remember that chronic facial ulceration is rarely benign.
Ulceration in a previously abnormally pigmented area of skin suggests advanced local
malignancy.
Beware attempting excision biopsy of facia l lesions unless specially trained. A reas of cosmetic
importance can be medico-legal mineelds.
Ask about foreign travel – leishmaniasis develops from the bite of a Mediterranean or South
American sandy.
Beware of herpes zoster or simplex developing around the eye – signi cant complications may
follow, so treat and follow up carefully and obtain an ophthalmological opinion if necessary.
NOTES:
https://t.me/med1917
https://t.me/med1917
177
GENERAL PHYSICAL
Abnormal gait in adults 179
Abnormal movements 182
Back pain 185
Crying baby 188
Episodic loss of consciousness 191
Excessive sweating 194
Falls with no loss of consciousness 197
The febrile child 200
Feeling tense and anxious 203
Flushing 206
Infertility 209
Itching 212
Jaundice in adults 215
Numbness and paraesthesiae 218
Prolonged fever 221
Swollen glands 224
https://t.me/med1917
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