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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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198 SYMPTOM SORTER
diabetic autonomic neuropathy
aortic stenosis
painless (‘silent’) myocardial infarction
Ready reckoner
Orthostatic
hypotension
Parkinson’s
disease
Iatrogenic Postural
instability
Acute illness
Joint stiffness No No No Possible No
On standing up Ye s Possible Possible Possible Ye s
Confused No No Possible No Possible
Polypharmacy Possible Possible Possible No No
On turning head No No No No Possible
Possible investigations
LI KE LY: Urinalysis, FBC.
POSSIBLE: TFT, U&E, B
12
and folate, fasting glucose or HbA1c, serum electrophoresis, vitamin
D, LFT, ECG (or 24 h ECG/event monitor).
SMALL PRINT: CT scan, echocardiography.
Urinalysis for glucose may reveal underlying diabetes: A major cause of autonomic or
peripheral neuropathy – or evidence of UTI.
FBC: Anaemia will exacerbate any cause of postural hypotension, or may itself cause
dizziness. Sepsis is suggested by a raised WCC. A high MCV may be a useful pointer to
alcohol misuse, B
12
or folate deciency, or hypothyroidism.
TFT: Hypothyroidism is common in the elderly and develops insidiously.
Fasting glucose or HbA1c: To conrm or detect diabetes.
U&E, B
12
and folate, serum electrophroresis: Renal failure, B
12
/folate deciency or myeloma
may cause a peripheral neuropathy.
Vitamin D: Deciency may cause muscular weakness.
LFT: For evidence (γGT) of alcohol misuse.
ECG or 24 h ECG/event monitor is useful to identify an arrhythmia, conduction defect
orMI.
CT scanning (e.g. for tumours or hydrocephalus) or echocardiography (for aortic stenosis)
may be arranged by the specialist aer referral.
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FALLS WITH NO LOSS OF CONSCIOUSNESS 199
TOP TIPS
Failure to observe the patient’s gait may mean that signicant diagnoses, such as Parkinson’s
disease, are missed.
Recurrent falls in the elderly are oen caused by a combination of factors, such as failing
vision, poor lighting and trip hazards at home. A home assessment may give valuable clues.
In the acute situation, management may depend more upon the ability of the patient to
remain safely at home (e.g. social support) rather than the precise diagnosis.
Don’t underestimate the importance of what you prescribe in causing morbidity. Attempt
to reduce polypharmacy and review therapy regularly.
Recurrent falls in the frail elderly are a real concern with the prospect of signicant injury
and recurrent admission. ey can also be endishly dicult to pin down and resolve – so
use your local multidisciplinary falls team if you have one.
In dealing with this problem, don’t forget to look for cause and eect – the aetiology of the
falls and any signicant injuries sustained.
Sudden onset of falls in the previously well elderly patient is likely to represent acute
pathology – have a low threshold for investigation or admission.
Gradual onset of recurrent falls is oen multifactorial in the elderly; in younger patients,
specic underlying disease is more likely, so refer for investigation.
Evidence of injury (e.g. bruises or fractures) and multiple attendance slips from A&E
department indicate either a very frail, vulnerable elderly person or signicant underlying
illness.
NOTES:
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200
THE FEBRILE CHILD
The GP overview
is symptom probably generates more GP advice calls and parental anxiety than any other. It
is nearly always caused by an infection of some kind. e list of culprits is so vast that we have
concentrated on the common and occasional ones more likely to be seen in general practice in
the UK.
Differential diagnosis
COMMON
non-specic viral URTI (e.g. colds, u-type illness, pharyngitis, tracheitis)
gastroenteritis
otitis media
tonsillitis
chest infection
OCCASIONAL
urinary tract infection
bronchiolitis
croup
common viral exanthems (e.g. chickenpox, roseola, hand, foot and mouth, h disease)
appendicitis
cellulitis (especially orbital) and other signicant skin infections (e.g. abscess, scalded skin)
glandular fever
post-immunisation
giardiasis
RARE
meningitis/meningococcal septicaemia
encephalitis
hepatitis
AIDS
rare exanthems (e.g. measles, rubella)
mumps
acute epiglottitis
atypical infections (e.g. brucellosis, listeriosis, Lyme disease, cat scratch fever)
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THE FEBRILE CHILD 201
tuberculosis
protozoal diseases (e.g. cryptosporidium, leishmaniasis, toxoplasmosis, malaria)
septic arthritis, osteomyelitis
Kawasaki’s disease
Ready reckoner
URTI Gastroenteritis OM Tonsillitis Chest infection
Prominent neck nodes Possible No Possible Ye s Possible
Signicant pain No Possible Ye s Yes Possible
Localising chest signs No No No No Ye s
Diarrhoea Possible Ye s Possible Possible Possible
Cough Ye s No Possible No Ye s
Possible investigations
Usually none are necessary in practice. If a febrile child is ill enough to require investigation, the
problem will usually be suciently urgent to need management by acute admission. Urinalysis,
as a pointer to UTI (assuming obtaining a urine sample is feasible), is sometimes helpful in
avoiding or facilitating admission. If possible, extend this to an MSU for bacteriological analysis.
TOP TIPS
Many clinical markers (see Ready reckoner) are non-specic and are present in many
dierent infections. It is oen a matter of degree as to how likely they are a pointer to a
specic pathology. For example, many infections cause mesenteric adenitis with abdominal
pain, but the tenderness of appendicitis, for example, is usually far greater on examination.
Respiratory rate is raised in all fevers, but a chest problem will increase it further along with
the presence of chest signs. A good policy is to be as thorough as possible in an examination
so as to be able to cross-reference the maximum clinical information.
Remember that parents will be worried about their child, and no matter how simple the
management of this common problem appears to you, to the parent it may be the harbinger
of a serious illness. Practise a calm and polite demeanour, empathy and sensitivity.
In telephone advice calls, always do three things: First, check that the parent is satised with
your advice; second, put a robust safety net/plan B in place with easily identiable guidelines
for the parent, e.g. ‘if by X hours Y has not happened, then call back’; third, record your
clinical assessment and the last two points in detail.
If in doubt, always see a child in person. Be sensitive to your intuition. If something nags
you aer an advice call, ring back and arrange a consultation. You will never look stupid for
doing this – only careful.
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202 SYMPTOM SORTER
Remember to follow up with children in whom you’ve diagnosed UTI according to NICE
guidelines, which recommend further investigation, var ying according to the age of the chi ld.
It is very easy to print computerised clinical notes immediately aer writing them. Handing
a consultation note to a parent can be invaluable to the parent (and the clinician) if the child
is seen later on out of hours, when clinical records are oen unavailable. e baseline ndings
from earlier in the day can be priceless information in the dark hours later on.
Spend time explaining the nature of fever and that the key issue is the cause of the fever rather
than the fever itself – many parents are ‘fever phobic’.
It’s oen more important to be able to distinguish between ‘well’ and ‘ill ’ babies and children
than it is to make a clever, precise diagnosis – the NICE ‘trac light’ and sepsis guidance
may help.
It’s easy to be tempted into complacency in the telephone or consultation management of
this problem – fever is just so common. Never forget that uncommon very serious illnesses
may all begin with a fever. Always be diligent and systematic in assessment, no matter how
busy your winter on-call day is turning out to be.
Dehydration can kill a baby quickly. Ensure you have satised yourself about the state of
hydration of a child. e colour and quantity of urine passed, or frequency of nappy changes
are useful practical guides, together with the general ‘look’ of the child and the capillary
rell time.
A febrile baby or child who is oppy or drowsy should be admitted immediately.
Be suspicious of the irritable and inconsolable infant. Even without other hard evidence,
suspect a serious problem and arrange urgent paediatric assessment.
e petechial rash of meningococcal septicaemia is a late phenomenon. Do not be reassured
by its absence. Its presence should prompt a 999 call and administration of immediate
parenteral antibiotics according to local protocols.
In most cases, the height of a fever is no guide to the severity of the illness – the exception
being babies, where a temperature of 38°C or more in those under 3 months is seen as a ‘red’
and one of 39°C or more in those between 3 and 6 months is viewed as ‘amber’ according
to NICE.
Don’t forget malaria as a possibility, especially if there is otherwise no clear explanation for
a fever – enquire about recent foreign travel.
NOTES:
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203
FEELING TENSE
AND ANXIOUS
The GP overview
e patient complaining of feeling tense and anxious may induce similar feelings in the GP –
because there are many possible underlying and contributory causes, the consultation may be
lengthy, and the patient may well present in a crisis. A calm, methodical approach, possibly
stretching over more than one consultation, will pay dividends.
Differential diagnosis
COMMON
life events (may be underlying ‘anxious personality’)
pre-menstrual tension
generalised anxiety disorder
panic disorder
depression
OCCASIONAL
obsessive–compulsive disorder
phobias
drug side eect (e.g. in the early stages of SSRI treatment)
hyperthyroidism
drug/alcohol use or withdrawal
somatisation disorder
post-traumatic stress disorder
RARE
psychotic illness
any cause of palpitations (may be ‘misinterpreted’ by the patient or others as anxiety)
organic brain disease (e.g. tumour)
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204 SYMPTOM SORTER
Ready reckoner
Life events PMT GAD Panic disorder Depression
Clear causative event Yes No No No Possible
Related to menstrual
cycle in women
No Ye s Possible No Possible
Persistent low mood Possible No No No Ye s
Feeling of tension is
short-lived
Possible Possible No Ye s Possible
Sleep disturbed Ye s Possible Possible No Ye s
Possible investigations
It would be very unusual for the GP to require any investigations when dealing with this
symptom. yroid function tests would be indicated in suspected hyperthyroidism, and a blood
screen, to include LFT, if alcohol was thought to be playing a signicant part. Investigations in
the rare event of suspected organic brain disease would usually be le to the specialist.
TOP TIPS
It is tempting to lump many of these scenarios under a catch-all label of ‘tension’ or ‘anxiety’.
But attempts at making a more precise diagnosis are worthwhile, as this may signicantly
alter the management.
Do not overlook an alcohol or drug history – abuse or withdrawal may be the cause of the
symptoms, or a signicant contributor.
It may be worthwhile carefully reviewing the patient’s old records to establish patterns of
symptoms or attendance, and to check previous response to treatment.
Whenever possible, life events should not be ‘medicalised’ – otherwise this may, in the
future, encourage re-attendance and foster dependence on treatment.
Apparent pre-menstrual tension may be a sign of some other underlying disorder – the
patient may be suering generalised anxiety disorder, for example, but may tend to focus on
the pre-menstrual phase, when the symptoms are at their worst.
Do not accept a self-diagnosis of ‘panic attacks’ at face value – the patient may actually mean
any one of a number of possible symptoms.
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FEELING TENSE AND ANXIOUS 205
If the underlying diagnosis turns out to be depression, assess for any suicidal ideas or intent.
Check for any psychotic features – anxiety can occasionally be a presenting feature of serious
psychotic illness.
New onset of tension or anxiety without any obvious explanation – especially in the context
of personality change, neurological features or new headaches – could, rarely, reect organic
brain disease.
It’s important to make diagnoses such as somatisation disorder when appropriate – otherwise
the patient may suer years of unnecessary tests and treatment.
NOTES:
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206
FLUSHING
The GP overview
is symptom presents more oen in women than in men, not only because of its cosmetic
importance, but also because the menopause accounts for the vast majority of presentations. It
is dierent from emotional blushing in its context, severity, duration and extent.
Differential diagnosis
COMMON
menopause
chronic alcohol misuse
rosacea
iatrogenic (e.g. calcium antagonists)
anxiety
OCCASIONAL
polycythaemia rubra vera
hyperthyroidism
drug/alcohol interaction: metronidazole, disulram
mitral valve disease (malar ush)
hyperglycaemia and hypoglycaemia
epilepsy (aura)
dumping syndrome (e.g. aer bariatric surgery)
RARE
carcinoid tumour
phaeochromocytoma
Zollinger–Ellison syndrome
systemic mastocytosis
ACTH-secreting bronchogenic carcinoma and Cushing’s syndrome
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FLUSHING 207
Ready reckoner
Menopause Alcohol Rosacea Iatrogenic Anxiety
Continuous No Possible Possible Possible No
Weight loss No Possible No No Possible
Facial papules No No Ye s No No
Tremor No Possible No No Ye s
Long history Possible Ye s Possible No Possible
Possible investigations
LI KE LY: None.
POSSIBLE: FBC, LFT, TFT, blood sugar, FSH/LH.
SMALL PRINT: Echocardiogram, EEG, urinary 5HIAA and VMA, gastrin level, further
specialised endocrine tests.
FBC: Raised haemoglobin and PCV in polycythaemia (may also be elevated platelets and
WCC), raised MCV in chronic alcohol misuse.
Biochemistry: LFT and γGT abnormal in alcohol misuse. TFT will reveal hyperthyroidism.
Blood sugar: To reveal hypo- or hyperglycaemia.
FSH/LH of limited use as does not correlate well with symptoms (useful only if premature
menopause suspected).
Echocardiography: If mitral stenosis suspected.
EEG: For possible epilepsy.
Specialist tests might include 24 h urinary 5-HIAA if carcinoid syndrome suspected, 24 h
urinary-free catecholamines and VMAs if phaeochromocytoma suspected and further
endocrine tests (e.g. for Cushing’s syndrome).
TOP TIPS
Many women complaining of ushing will suspect the cause is the menopause. Address this
possibility in the consultation, especially in young women fearing ‘an early change’.
A constantly ushed face in older men is li kely to be due to alcohol, polycythaemia or rosacea.
Anxiety is likely if the circumstances t – but bear in mind that hyperthyroidism can
produce a very similar clinical picture.
It can be dicult to distinguish anxiety from menopausal symptoms in a woman of
menopausal age. Flushes with sweats waking the woman at night are more likely to be caused
by the menopause – but a trial of treatment is the acid test (though beware of an initial
placebo response).
https://t.me/med1917
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