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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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x ABBREVIATIONS
GORD gastro-oesophageal reux
disease
GUM genito-urinary medicine
Hb haemoglobin
HCG hum an chorioni c gonadotroph in
5HIAA 5-hydroxy-indole-acetic acid
HIV human immunodeciency virus
HLA human leucocyte antigen
HRT hormone-replacement therapy
HSV herpes simplex virus
HVS high vaginal swab
IBD inammatory bowel disease
IBS irritable bowel syndrome
IC intermittent claudication
IGTN ingrowing toenail
IHD ischaemic heart disease
INR international normalised ratio
ITP idiopathic thrombocytopenia
purpura
IUCD intrauterine contraceptive
device
IVP intravenous pyelogram
IVU intravenous urogram
JCA juvenile chronic arthritis
LFT liver function tests
LGV lymphogranuloma venereum
LH luteinising hormone
LMP last menstrual period
LN lymph node
LRTI lower respiratory tract infection
LSD lysergic acid diethylamide
LUTS lower urinary tract symptoms
LVF le ventricular failure
MAOI monoamine oxidase inhibitor
MC&S microscopy, culture and
sensitivity
MCV mean cell volume
MI myocardial infarction
MMR measles, mumps, rubella
MRI magnetic resonance imaging
MS multiple sclerosis
MSU mid-stream urine (sample)
NAI non-accidental injury
NICE National Institute for Health
and Care Excellence
NSAID non-steroidal anti-inammatory
drug
OA osteoarthritis
OE otitis externa
O/E on examination
OG onychogryphosis
OGD oesopha go-gas tro duodenoscopy
OM otitis media
OTC over the counter
PAN polyarteritis nodosa
PCOS polycystic ovary syndrome
PCR protein creatinine ratio
PCV packed cell volume
PE pulmonary embolism
PEFR peak expiratory ow rate
PF proctalgia fugax
PID pelvic inammatory disease
PMR polymyalgia rheumatica
PMT pre-menstrual tension
PR per rectum
PRIST paper radioimmunosorbent disc
test
PSA prostate-specic antigen
PTH parathyroid hormone
PU peptic ulcer
PUO pyrexia of unknown origin
PV per vagina
PVE per vaginal examination
PVD peripheral vascular disease
RA rheumatoid arthritis
RAST radioallergosorbent test
RAU recurrent aphthous ulceration
RLS restless legs syndrome
RUQ right upper quadrant
SA septic arthritis
SCC squamous cell carcinoma
SHBG serum hormone binding
globulin
SLE systemic lupus erythematosus
SOB shortness of breath
STD sexually transmitted disease
SVT supraventricular tachycardia
TAH total abdominal hysterectomy
TATT ‘tired all the time’
TB tuberculosis
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ABBREVIATIONS xi
TCA tricyclic antidepressant
TFT thyroid function tests
TIA transient ischaemic attack
TMJ temporomandibular joint
TN trigeminal neuralgia
TSH thyroid-stimulating hormone
TURP transurethral resection of
prostate
TV trichomonal vaginosis
U&E urea and electrolytes
URTI upper respiratory tract infection
UTI urinary tract infection
UV ultraviolet
VMA vanillyl-mandelic acid
VT ventricular tachycardia
WCC white cell count
WRULD work-related upper limb
disorder
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1
INTRODUCTION
Life would be much simpler for GPs if patients presented with diagnoses. Unfortunately, they
do not: they present with symptoms, which are frequently vague, sometimes multiple and
occasionally obscure. It is up to the GP to create some order from this chaos. However, the vast
majority of clinical texts adopt a diagnosis, rather than symptom-based, approach, and the few
which do reect the reality of patient presentations are inevitably orientated towards hospital
medicine and so are irrelevant to GPs.
is book aims to redress the balance. It analyses a multitude of symptoms commonly seen in
primary care and, for each, presents dierentials, distinguishing features, possible investigations
and key points. e only omissions are presentations for which there are so few dierentials that
diagnosis is really quite simple (e.g. ‘lump on elbow’); those which rarely present in isolation (e.g.
nausea, anorexia); and those which are so rare that the reader would be sure to require specialist
advice (our personal favourite being ‘pilimiction’).
Written by two full-time GP principals, its perspective is very much grass roots primary
care – though informed by the latest evidence and guidance where possible or appropriate –
and its appeal is therefore wide. GP registrars and young principals, relatively unfamiliar with
the protean presentations possible in general practice, will be able to check their diagnostic
hypotheses against the information in the book; the more experienced GP might use it as a
refresher or as a pointer to a more exotic diagnosis in an unusual case; and the nurse practitioner,
taking increasing responsibility as a rst port of call in primary care for many patients, will nd
the contents unique and essential.
e popularity of the rst edition and the need for multiple subsequent editions emphasises
the fact that, while general practice may experience many reorganisations and restructurings,
the bread and butter business of making sense of symptoms remains. is new edition adds a
number of extra chapters and signicant updates of existing chapters.
Each symptom is analysed in a uniform, accessible way, as follows.
The GP overview
is denes the symptom and its key characteristics, and gives some idea of the frequency of
presentation.
Differential diagnosis
is lists the likely diagnoses, subdivided ‘Common’, ‘Occasional’ and ‘Rare’. (It should be
noted that these headings are relative to the symptom in question.) Restrictions of space and
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2 SYMPTOM SORTER
imagination mean that such a dierential can never claim to be exhaustive, and a lack of accurate
prevalence data renders the allocation of the diagnoses to these subdivisions somewhat arbitrary,
based on our experience rather than hard evidence. ese are minor limitations, however; this
section will invariably provide clear guidance as to the likely cause of any symptom.
Ready reckoner
is provides a quick guide to the key distinguishing features of the ve most likely diagnoses
listed in the preceding section.
Possible investigations
is section outlines those investigations likely to assist the reader in making a diagnosis.
e emphasis is upon tests performed in primary care or usually arranged by the GP. Where
appropriate, more complex, hospital-initiated investigations are outlined – partly because
GPs may wish to let their patients know the type of tests they might anticipate aer referral
and also because GP access to traditionally hospital-organised investigation is increasing. All
investigations discussed are categorised according to the likelihood that they will be performed,
the three categories being, ‘Likely’, ‘Possible’ and ‘Small print’.
TOP TIPS
is provides a potpourri of management nuggets appropriate to each symptom, which the
authors have accumulated over the years. Such hints from experience are dicult to analyse
or quantify and so most are unashamedly anecdotal rather than evidence based – this should
not detract from their usefulness or occasional elegance. Some might appear to stretch the
scope of the book in that they cross the boundary between symptom assessment and symptom
management – but the reader should bear in mind that the diagnostic process, particularly in
primary care, involves hypothesis testing, and so these boundaries are, in reality, blurred.
Most symptoms presented in primary care are benign, minor and self-limiting. is can
occasionally lull the unwary into a false sense of security: for each presentation there exist
pointers which should set alarm bells ringing. ‘Red ags’ highlight aspects of symptoms which
suggest signicant pathology and which therefore should not be missed or neglected.
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INTRODUCTION 3
How to use this book
is Symptom Sorter is designed to act as a rapid reference. It has deliberately been written in
a note and list format so that, unlike weightier tomes, it is quick and easy to use. For the sake
of brevity, common and well-recognised abbreviations have been used whenever possible. Its
consistent style will soon breed familiarity and allow the reader to know where and how to
retrieve information painlessly. To help achieve this, the symptoms are arranged in sections,
each section corresponding to a system or anatomical region. In these sections, the symptoms
are arranged alphabetically and, for the most part, are labelled in patient, rather than doctor,
vernacular (e.g. shortness of breath rather than dyspnoea) – the exceptions being where there is
no acceptable or concise ‘patientspeak’ version. However, as many symptoms can have a variety of
descriptions (e.g. shortness of breath, dyspnoea, breathlessness, wheeziness, diculty breathing
and so on) the index is deliberately expansive and cross-referenced, and will quickly guide the
reader to the appropriate pages.
e categorisation of symptoms and their arrangement in sections is a complex task which
can be approached in a number of ways – for example, rashes might be divided according
to distribution, size of lesion, morphology, itch and so on. roughout, we have chosen the
approach which seems most logical to us and which, whenever possible, avoids unnecessary
omission or repetition; again, the index should rapidly point the reader in the right direction.
Assigning symptoms to certain sections may sometimes seem arbitrary, especially when they
can have such disparate causes, but this approach provides the book with a clear, understandable
structure.
As GPs, we are aware that patients oen present polysymptomatically. Our book, neatly
dividing complaints into individual symptoms, might therefore be criticised for not accurately
reecting real primary care life. In fact, such presentations can usually be distilled down to
one or two predominant symptoms; more minor symptoms oen act as pointers to the actual
diagnosis, a fact our ‘Ready reckoners’ in each chapter exploits. In the truly polysymptomatic,
the book may help to dene a common thread among the symptoms, thereby revealing the real
diagnosis – usually, in such cases, anxiety or depression.
e book should be kept to hand for use during surgery to conrm the likelihood of a certain
diagnosis or raise the possibility of others. Being comprehensive, relevant and accessible, retrieval
of information will be speedy and helpful during the consultation itself (you may wish to wait
until the patient is undressing behind the curtain: there should be time).
e book may be used in other ways. GP trainers could use the analysis of a certain symptom
provided in the text as the basis for a tutorial. Indeed, the book could itself form part of the
GP registrar’s curriculum. By ‘sorting’ two or three symptoms a week, using the text as a guide,
the registrar could, over the course of his or her time in practice, cover the vast majority of
presentations seen in primary care. Trainers of undergraduates, too, will nd that the contents
provide useful material for teaching sessions.
Others might simply like to browse, refreshing or rening their diagnostic skills and mulling
over the ‘Red ags’ and ‘Top tips’.
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4 SYMPTOM SORTER
Feedback received by the authors indicates that previous editions are now included in many
undergraduate curricula as recommended reading, and the book is proving very popular among
primary care nurses and nurse practitioners.
However the reader uses this book, we are convinced that it will prove an essential resource.
Making sense of symptoms is the essence of general practice, and any tool designed by and for
GPs which contributes to this art is likely to benet doctors and patients alike.
Keith Hopcro
Vincent Forte
October 2019
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5
ABDOMEN
Abdominal swelling 6
Acute abdominal pain in adults 9
Acute abdominal pain in children 12
Acute abdominal pain in pregnancy 15
Chronic/recurrent abdominal pain in adults 18
Constipation 21
Diarrhoea in adults 24
Diarrhoea in children 27
Epigastric pain 30
Loin pain 33
Recurrent childhood abdominal pain 36
Vomiting 39
Vomiting blood 42
Vomiting in infants 45
For ‘Difculty swallowing’, see ‘Neck’ chapter
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6
ABDOMINAL SWELLING
The GP overview
is presentation covers both abdominal and pelvic masses, and general abdominal swelling. e
patient may complain of a general increase in girth or of a discrete mass discovered accidentally;
alternatively the GP might nd the swelling while performing a physical examination.
Differential diagnosis
COMMON
pregnancy
irritable bowel syndrome (IBS)
constipation
broid uterus
enlarged bladder
OCCASIONAL
coeliac disease
ascites (itself has many causes)
intestinal obstruction
ovarian mass (cyst or malignant tumour)
carcinoma of stomach or colon
hepatomegaly (various causes)
RARE
splenomegaly (various causes)
pancreatic carcinoma
aortic aneurysm
massive para-aortic lymphadenopathy
hydronephrosis, renal cysts and renal malignancy
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ABDOMINAL SWELLING 7
Ready reckoner
Pregnancy IBS Constipation Fibroid uterus Bladder
Size varies No Ye s Possible No Possible
Amenorrhoea Ye s No No No No
Poor urinary stream No No No No Ye s
Diarrhoea No Ye s Possible No No
Cannot get below Ye s No Possible Ye s Yes
Possible investigations
LI KE LY: Pregnancy test, ultrasound.
POSSIBLE: Urinalysis, FBC, U&E, LFT, CA-125, anti-endomysial and anti-gliadin antibodies,
plain abdomen X-ray.
SMALL PRINT: Hospital-based lower GI investigations, paracentesis, CT scan.
Pregnancy test essential in amenorrhoeic women.
Urinalysis may reveal microscopic haematuria in renal or bladder tumours.
Abdominal ultrasound is the quickest and most ecient way to dene the source of most
abdominal swellings or masses. Ultrasound of pelvis/abdomen may also be indicated
according to an elevated CA-125 (see below).
Full blood count (FBC): Anaemia l ikely in malignancy, possible in broids with menorrhag ia;
also will reveal blood dyscrasias.
Urea and electrolytes (U&E) may be deranged in gross renal disease. Liver function tests
(LFTs) may give a clue to alcoholic hepatomegaly or malignancy. Low albumin in ascites.
CA-125: May be indicated in women, especially those aged 50 or more, to help exclude
ovarian cancer.
Anti-endomysial and anti-gliadin antibodies: For possible coeliac disease.
Hospital-based lower GI investigations: Useful to conrm or exclude colonic disease.
Plain abdominal X-ray: May show constipation or obstruction (in the latter case, likely to be
arranged aer admission).
Other tests are likely to be arranged aer specialist referral, e.g. paracentesis (to investigate
and relieve ascites), CT scanning (to establish nature of mass and its eects on surrounding
structures).
TOP TIPS
Take care in the history to distinguish between intermittent or variable swelling, and
progressive swelling. e former will probably not be caused by serious pathology, whereas
the latter may well be.
Pregnancy can catch out the unwary, particularly when dealing with perimenopausal women
or teenage girls. Do not accept the claim that ‘I can’t be pregnant’.
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