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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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178
Thirst or dry mouth 227
Tiredness 230
Tremor 233
Weight gain 236
Weight loss 239
https://t.me/med1917
179
ABNORMAL GAIT
IN ADULTS
The GP overview
Very few patients present with abnormal gait. It is more oen noticed by the GP, while the
patient’s complaint is usually a manifestation of the gait (e.g. unsteadiness in Parkinson’s disease)
or of its cause (e.g. pain in arthritis). Congenital causes are not considered here as patients are
most unlikely to present such problems to the GP.
Differential diagnosis
COMMON
trauma (back and leg)
osteoarthritis (OA) or other painful joint problem
vestibular ataxia (vestibular neuritis, Ménière’s disease, CVA)
Parkinson’s disease
intermittent claudication (IC)
OCCASIONAL
foot drop (peroneal nerve atrophy)
multiple sclerosis
spinal nerve root pain (especially L5 and S1)
cauda equina lesions
myasthenia gravis
RARE
tabes dorsalis (syphilis)
dystrophia myotonica
motor neurone disease
cerebellar ataxia
hysteria
https://t.me/med1917
180 SYMPTOM SORTER
Ready reckoner
Trauma OA/other Vestibular Parkinson’s IC
Sudden onset Ye s Possible Ye s No Possible
Painful unilateral limp Ye s Ye s No No Ye s
Worse with exercise Ye s Ye s No No Yes
Shufing gait No Possible No Ye s No
Staggering gait No No Ye s No No
Possible investigations
Most cases requiring tests will need referral to a specialist. e role of the GP in investigating
these patients is therefore very limited.
LI KE LY: None.
POSSIBLE: X-ray, FBC, ESR/CRP, RA factor/anti-CCP, uric acid.
SMALL PRINT: Syphilis serology, scans, lumbar puncture, angiography.
FBC, ESR/CRP, RA factor/anti-CCP, uric acid: Some forms of arthritis will result in an
anaemia of chronic disorder. ESR/CRP may also be raised. Depending on the pattern of joint
pain, RA factor/anti-CCP and uric acid may provide useful information in the diagnosis of
rheumatoid arthritis and gout.
X-rays useful in bony trauma. Limited value in OA except to exclude other bony pathology.
Syphilis serology: If tabes dorsalis suspected.
If neurological signs of incoordination, consider CT/MRI scan and lumbar puncture –
usually arranged by the specialist.
Angiography: Arranged by the vascular surgeon if surgery contemplated in claudication.
TOP TIPS
Look up from the notes or computer as the patient walks in – otherwise you may miss a
useful clue in the patient’s gait.
If the patient actually complains of problems walking, take your time in assessing the
symptom – in particular, give the patient the opportunity to demonstrate the problem by
walking him or her up and down the corridor.
If the cause is not immediately apparent from the history, perform a careful neurological
examination – this is a situation where there may be hard signs which contribute signicantly
to diagnosis.
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ABNORMAL GAIT IN ADULTS 181
Vestibular neuritis usually settles within a few days. If patient remains ataxic, especially with
persistent nystagmus, consider a central lesion and refer urgently.
Numbness in both legs (saddle pattern) with back pain and incontinence suggests a cauda
equina lesion. Admit urgently.
If the patient is ataxic and has a past history of neurological symptoms, such as paraesthesia
or optic neuritis, consider multiple sclerosis.
Beware of labelling the patient as hysterical – apparently bizarre gaits may signify obscure
but signicant neurological pathology.
NOTES:
https://t.me/med1917
182
ABNORMAL MOVEMENTS
The GP overview
is is an infrequent cause for attendance – though the public is becoming increasing ly aware of
conditions such as restless legs syndrome (RLS) and Tourette’s, and their treatments. Obvious
generalised seizures and tremors are not considered in this chapter but are covered elsewhere.
Differential diagnosis
COMMON
RLS
myokymia (aecting orbicularis oculi muscles)
drug induced: including choreoathetosis, dystonias, tardive dyskinesias and akathisia (drugs
include -dopa, tricyclic antidepressants, metoclopramide and antipsychotics)
Tou ret te ’s
simple partial seizures
OCCASIONAL
anxiety/nervous tic (common, but rarely presented to the GP)
muscle fasciculation (e.g. benign fasciculation, motor neurone disease)
simple childhood tics (common, but infrequently presented)
dystonias (e.g. writer’s cramp, blepharospasm, spasmodic torticollis)
periodic leg movements during sleep
RARE
hemifacial spasm
myoclonus
chorea (Sydenham’s, Huntington’s)
Wilson’s disease
hemiballismus (e.g. post stroke)
hysterical
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ABNORMAL MOVEMENTS 183
Ready reckoner
RLS Myokymia Drug induced Tourette’s Simple partial
seizures
Worse at rest Yes Possible No No No
Patient on medication Possible Possible Ye s Possible Possible
Whole limb affected Ye s No Possible Possible Possible
Other neurological signs No No No No Possible
Childhood onset No No Possible Ye s Possible
Possible investigations
LI KE LY: FBC, U&E, ferritin, B
12
, folate, TFT, fasting glucose or HbA1c, calcium.
POSSIBLE: CT/MRI of brain or spinal cord, EEG, EMG, nerve conduction studies.
SMALL PRINT: Other specialised tests (e.g. for myoclonus and Huntington’s).
FBC, ferritin: To assess for iron deciency in RLS.
U&E: Renal failure is a potential cause of RLS and can be implicated in partial seizures.
B
12
, folate: Deciencies may cause or mimic RLS.
TFT: Hypothyroidism may cause RLS.
Fasting glucose or HbA1c: Diabetes may cause RLS or partial seizures.
Calcium: Hypocalcaemia may be implicated in seizures.
CT/MRI of brain or spinal cord: May be required in investigation of fasciculation and
seizures (usually arranged aer specialist referral).
EEG: For investigation of seizures.
Other specialised tests: Usually arranged by neurologist to explore the more obscure
diagnoses such as Huntington’s chorea and Wilson’s disease.
TOP TIPS
When faced with odd and otherwise inexplicable movements of recent onset in a patient,
remember to take a drug history.
Bear in mind that abnormal movements can be caused by a drug that the patient has been
taking for some time (e.g. tardive dyskinesias).
Patients with myokymia sometimes become disproportionately anxious about the symptom,
imagining all sorts of possible neurological catastrophes – they may need a lot of reassurance.
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184 SYMPTOM SORTER
Childhood tics tend to be single; the patient with the much more signicant Tourette’s will
probably have multiple tics.
Drug-induced dystonias may cause odd posturing and require prompt treatment. e
diagnosis is easily overlooked – antipsychotics are common culprits, so it is easy to erroneously
attribute the dystonia to psychiatric pathology.
Beware of the combination of personality changes a nd odd movements such as facial g rimaces
– this could be Huntington’s chorea. Also, don’t be misled by the lack of a positive family
history – this background may have been concealed from the patient.
NOTES:
https://t.me/med1917
185
BACK PAIN
The GP overview
Ongoing backache is a familiar presentation to all GPs, and acute back pain is one of the most
common reasons for an emergency appointment in primary care. e average GP can expect
about 120 consultations for this problem each year. Eighty percent of the Western population
suer back pain at some stage in their lives: It is the largest single cause of lost working hours
among both manual and sedentary workers; in the former it is an important cause of disability.
Remember that many non-orthopaedic causes of back pain lie in wait, so be systematic.
Differential diagnosis
COMMON
mechanical (muscular) back pain
prolapsed lumbar disc: nerve root pain
spondylosis (exacerbation)
pyelonephritis and renal stones
pelvic infection
OCCASIONAL
the spondyloarthritides (e.g. ankylosing spondylitis, Reiter’s syndrome)
neoplastic disease of the spine (usually secondaries), myeloma
duodenal ulcer/acute pancreatitis
depression and anxiety states
vertebral fracture (oen compression fracture associated with osteoporosis)
RARE
spinal stenosis
osteomalacia
aortic aneurysm
pancreatic cancer
spondylolisthesis
osteomyelitis
malingering
https://t.me/med1917
186 SYMPTOM SORTER
Ready reckoner
Mechanical pain Disc prolapse Spondylosis Pyelonephritis/
renal stones
Pelvic infection
Leg pain or numbness
present
Possible Ye s Possible No No
Unilateral symptoms Possible Ye s Possible Ye s Possible
Depressed reexes No Possible Possible No No
Abdominal tenderness No No No Possible Ye s
Fever No No No Possible Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Urinalysis, MSU, FBC, ESR/CRP, plasma electrophoresis, blood calcium, PSA.
SMALL PRINT: Lumbar spine X-ray, renal investigations, HLA-B27, CT or MRI scan, bone scan,
investigations for GI cause, ultrasound, DXA scan.
Urinalysis useful if UTI suspected: Look for blood, pus and nitrite as markers of infection;
conrm with MSU; blood alone suggests possible stone.
ESR/CRP elevated in malignant and inammatory disorders.
FBC: Hb may be reduced in malignancy; a high WCC raises the possibility of osteomyelitis.
Plasma electrophoresis: Paraprotein band in myeloma.
Blood calcium: Elevated in myeloma and bony secondaries; reduced in osteomalacia.
PSA: If disseminated prostate cancer suspected.
Lumbar spine X-ray usually unhelpful in mechanical pain. Consider if no resolution by 6
weeks to investigate possible underlying pathology. In younger patients, it may help diagnose
sacroiliitis or spondylolisthesis; in older people, it is useful to check for vertebral collapse.
Generally, if imaging is required, CT or MRI may be more helpful.
Bone scan: Will detect bony secondaries and bone infection.
CT or MRI scan usually a specialist’s request: Good for spotting spinal stenosis, signicant
prolapsed disc and discrete bony lesions.
Investigations for GI cause might include endoscopy (for DU), serum amylase (for
pancreatitis) and CT scan (for carcinoma of pancreas).
Ultrasound: For aortic aneurysm.
Renal investigations: For recurrent pyelonephritis and possible renal or ureteric stones.
DEXA scan: May be required to conrm suspicion of osteoporosis.
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BACK PAIN 187
TOP TIPS
e vast majority are ‘mechanical’, and most of these improve regardless of treatment
modality in 6–8 weeks; a positive and optimistic approach is important.
Patients oen expect an X-ray or scan. Resist requests unless appropriate – and explain why.
Even if the patient doesn’t make this request, consider volunteering why you’re not ordering
any investigations, as this can help maintain condence in the doctor–patient relationship,
especially if the symptoms take some time to settle.
If the problem is recurrent, exclude signicant pathology then explore the patient’s concerns.
In simple recurrent mechanical back pain, it is worth discussing preventive measures and
educating the patient for self-management of future episodes.
True malingering is not common, but back pain is favoured among malingerers because of its
subjectivity. Beware of patients who apparently cannot straight-leg raise, yet have no problem
sitting up on the couch.
e traditional ‘red ags’ in back pain are thought to be of very limited use because of poor
specicity and sensitivity. e only ones regarded as genuinely helpful are, for spinal fracture,
older age, trauma, the presence of contusions or abrasions and steroid use, and, for spinal
malignancy, a past history of cancer. Current consensus is that slavish adherence to red ags
should be avoided and instead the overall clinical picture and progress assessed – although
an ESR/CRP may be useful in ruling out signicant disease.
Bilateral sciatica, saddle anaesthesia and bowel and/or bladder dysfunction suggests central
disc protrusion – this is a neurosurgical emergency.
Consider prostatic cancer in men over 55 with atypical low back pain. Do a PR exam,
together with PSA and bone assay.
Back pain without any restriction of spinal movement, or which is not exacerbated by back
movement, suggests that the source of the problem lies elsewhere – consider renal, aortic or
gastrointestinal disease, or pelvic pathology in women.
Tearing interscapular or lower pain in a known arteriopath suggests dissecting aortic
aneurysm – admit straight away.
NOTES:
https://t.me/med1917
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