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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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208 SYMPTOM SORTER
Diarrhoea and dyspnoea with ushing aer alcohol, food and exercise suggest possible
carcinoid syndrome.
Flushing followed by an episode of altered consciousness points to a signicant cause, such
as recurrent hypoglycaemia or epilepsy.
Do not be tempted to write this symptom o as the hot ushes of emotional blushing. While
common, this problem is unlikely to present in daily practice.
Recent onset of severe ushing which is not obviously menopausal or anxiety may have a
signicant cause, especially if the patient has other symptoms. Have a low threshold for
investigations or referral in such cases.
NOTES:
https://t.me/med1917
209
INFERTILITY
The GP overview
About 80% of couples conceive within the rst year of trying, and a further 5%–10% in the
second. e actua l denition of infertility is nowadays viewed as less about an arbitrary period of
being unsuccessful at falling pregnant and more about when it might be appropriate to intervene
– which, in turn, will depend on various factors such as age, any suggestion of an obvious
underlying cause, patient wishes and so on. e most signicant factor aecting investigation
and referral is prevailing local and national protocols and guidelines.
Differential diagnosis
COMMON
unexplained (27%)
defective sperm (24% – may be various underlying causes)
anovulatory cycles/defective ovulation (21%)
fallopian tube blockage (14%)
endometriosis (6%)
OCCASIONAL
hostile cervical mucus
PCOS
other causes of amenorrhoea or hypomenorrhoea (see Absent periods, p. 382)
uterine broids, polyp
cervical problems: inammation, polyps, stenosis
systemic illness, e.g. anaemia, thyroid disorders
RARE
congenital uterine, vaginal, fallopian or ovarian malformation or absence
sexual dysfunction
adrenocortical tumours
chromosomal abnormalities: Turner’s syndrome (XO), super-female (XXX)
endometrial tuberculosis
https://t.me/med1917
210 SYMPTOM SORTER
Ready reckoner
Unexplained Defective sperm Anovulation/
defective ovulation
Tubal blockage Endometriosis
Dysmenorrhoea No No No Possible Ye s
History of STD No Possible No Ye s No
Menorrhagia No No Possible Possible Possible
Abnormal pelvic
examination
No No No Possible Possible
Regular cycle Yes Ye s Possible Yes Yes
Possible investigations
NOTE: Amenorrhoea will need investigation in its own right – see Absent periods, p. 382. e
degree of investigation undertaken for infertility will depend very much on the particular
situation and local guidelines.
LI KE LY: Semen analysis, serum progesterone 7 days before anticipated onset of period.
POSSIBLE: If menstrual irregularity/amenorrhoea/unwell – FBC, FSH, LH, prolactin, TFT,
U&E, testosterone, SHBG. In secondary care: Ovarian/uterine ultrasound.
SMALL PRINT: Laparoscopy and dye, hysterosalpingogram. In the male: Further investigation of
sperm problems, e.g. FSH, LH, testosterone, testicular ultrasound.
Semen analysis: May need repeating if rst test sub-optimal.
Serum progesterone 7 days before anticipated onset of period: To check for ovulation.
FBC, FSH, LH, prolactin, TFT, U&E, testosterone, SHBG: To check for underlying
pathology if female is unwell or has menstrual problems.
Ovarian and uterine ultrasound: To exclude structural abnormalities. Can be extended to
visualise ovarian follicle development and ovulation.
Laparoscopy and dye, hysterosalpingogram: To check for tubal patency.
Male FSH, LH and testosterone: To check for endocrine causes of sperm production failure.
Testicular ultrasound: If anatomical abnormalities found on examination, e.g. varicocoele.
TOP TIPS
Adopt an optimistic approach whenever possible. A surprising number of couples conceive
successfully as soon as preliminary investigations are initiated!
Don’t overlook health promotion opportunities – especially female rubella status and advice
about taking folic acid.
Ensure you treat the couple rather than the individuals. Infertility management requires
much cooperation and motivation.
In primary care, hormone tests (other than progesterone) are not necessary if the periods
are normal.
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INFERTILITY 211
Infertility will only very rarely be the presenting symptom of serious pathology. However,
there are circumstances where it is important to act promptly in terms of investigation or
referral, such as:
if the female
– is over the age of 35
– has amenorrhoea
– has a history of previous pelvic surgery or PID
– has any abnormality on pelvic examination
or if the male
– has a history of urogenital problems or STD
– has a varicocele.
NOTES:
https://t.me/med1917
212
ITCHING
The GP overview
Itching is the commonest presenting dermatological symptom. It is frequently distressing,
and may interfere with the patient’s quality of life – for example, by preventing normal
sleep. erefore, it should be taken seriously. A good history alone will reveal the diagnosis
in the majority of cases. e remainder will yield to thorough examination and investigation.
Dermatological referral need only be a last resort to achieve diagnosis.
Differential diagnosis
COMMON
contact allergy (contact dermatitis)
scabies (and other pediculoses)
atopic eczema
pityriasis rosea
psoriasis
OCCASIONAL
urticaria (various causes)
liver disease
iron deciency, with or without anaemia
endocrine: diabetes mellitus, hypo- and hyperthyroidism
renal failure (uraemia)
lichen planus
prickly heat
drug side eect (with or without rash)
simple pruritus: no cause found (especially in elderly where it may simply be caused by dry
skin)
RARE
herpes gestationis
dermatitis herpetiformis
psychogenic (includes dermatitis artefacta)
leukaemia and myeloproliferative disorders
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ITCHING 213
Ready reckoner
Contact allergy Scabies Atopic eczema Pityriasis rosea Psoriasis
History of chemical exposure Yes No Possible No No
Widespread itch Possible Ye s Possible Yes No
Worse at night No Ye s Possible No No
Mainly on exures No No Ye s No No
Mainly on extensor surfaces Possible No No No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Urinalysis, blood glucose or HbA1c, FBC, ferritin, ESR, U&E, LFT, TFT.
SMALL PRINT: None.
Urine: Dipstick for glycosuria (blood glucose or HbA1c if positive).
FBC, ferritin: Will reveal iron-deciency anaemia and polycythaemia; eosinophil count may
be raised in allergic conditions; WCC may be very high in leukaemia; ESR may be elevated
in lymphoma; low ferritin will conrm iron deciency.
U&E: Will reveal uraemia.
LFT: Deranged liver enzymes and raised bilirubin in liver disease. Abnormalities here will
require further investigations or referral.
TFT: Both hypo- and hyperthyroidism can lead to skin changes which cause itching.
TOP TIPS
e key to sorting out this symptom is to identify whether or not there is an underlying rash.
Itching with a rash depends on identifying the rash; itching without a rash (other than that
caused by scratching) depends on identifying any systemic cause.
An itchy, unidentiable rash which is worse at night is likely to be scabies, particularly if any
contacts are aected.
Warn the patient that scabies treatment may take a week or two fully to relieve symptoms –
otherwise, the patient may apply the treatment repeatedly, causing a chemical irritation and
diagnostic confusion.
e books usually state that psoriasis doesn’t itch – but it certainly can, so don’t let this
symptom put you o the diagnosis.
It is usually very dicult to identify the allergen in a single episode of urticaria (and, indeed,
the cause may not be allergic at all). Tell the patient to keep a note of foods or medicines just
ingested so that, in the event of recurrence, any culprit can be identied.
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214 SYMPTOM SORTER
If no obvious cause, always examine the abdomen and lymph nodes – do not miss
lymphadenopathy, or enlarged liver, spleen or kidneys.
Don’t be tempted not to examine the itchy, malodorous self-neglected patient – poor personal
hygiene may deceptively mask some other identiable underlying cause.
Beware of apparently orid eczema appearing for the rst time in an elderly patient – this
may be a manifestation of serious underlying pathology.
Don’t forget iatrogenic causes – enquire about any drugs recently prescribed.
NOTES:
https://t.me/med1917
215
JAUNDICE IN ADULTS
The GP overview
Patients rarely present with the complaint of ‘turning yellow’; more oen – though still
infrequently – the GP notices jaundice during an examination of the patient. A systematic
clinical assessment together with relevant laboratory investigations will help pinpoint the cause.
Differential diagnosis
COMMON
gallstones in common bile duct
viral hepatitis (e.g. glandular fever, hepatitis A, B, C)
carcinoma of head of pancreas
hepatic carcinoma (usually metastases)
alcoholic cirrhosis
OCCASIONAL
alcoholic hepatitis
primary biliary cirrhosis
drugs: chlorpromazine, isoniazid, anabolic steroids, methyldopa, paracetamol overdose
haemolytic anaemia (many causes, such as autoimmune, malaria, drugs)
venous congestion: cardiac failure, constrictive pericarditis
cholangitis (and stricture in common bile duct aerwards)
pancreatitis
RARE
carcinoma of bile duct
leptospirosis
Rotor, Dubin–Johnson and Mirizzi syndromes
cholestasis or fatty liver of pregnancy
genetic: Gilbert’s syndrome, Wilson’s disease, α
1
-antitrypsin deciency, galactosaemia,
glycogen storage diseases, haemochromatosis
amyloidosis
https://t.me/med1917
216 SYMPTOM SORTER
Ready reckoner
Gallstones Hepatitis Carcinoma of
pancreas
Metastases Alcohol cirrhosis
Fever Possible Yes No No No
Colicky RUQ pain Ye s No No No No
Rapid weight loss No Possible Yes Ye s No
Pale stools/dark urine Ye s Possible Yes No No
Epigastric mass No No Ye s Possible No
Possible investigations
LI KE LY: Urinalysis, FBC, LFT, hepatitis serology.
POSSIBLE: Ultrasound, antimitochondrial antibody.
SMALL PRINT: Serum amylase, secondary care tests (e.g. ERCP, liver biopsy).
Urinalysis: If bilirubin is present in the urine, the jaundice is cholestatic. If present with
urobilinogen, it is hepatocellular. If not, it is obstructive.
LFT: Bilirubin very high in biliary obstruction. AST and ALT raised in hepatic causes.
Alkaline phosphatase rises moderately in hepatic causes and marked ly in biliary obstruction
and primary biliary cirrhosis.
FBC: Anaemia in chronic illness. Raised WCC in hepatitis. May be macrocytosis,
reticulocytosis and other red cell abnormalities in haemolytic anaemia. MCV raised by
alcohol.
Hepatitis serology: May reveal cause of viral hepatitis.
Serum amylase: Raised in pancreatitis.
Antimitochondrial antibody test: Positive in over 95% of patients with primary biliary
cirrhosis.
Ultrasound useful to assess liver, pancreas and gall bladder: May reveal stones, primary
tumours and metastases.
Referral may result in various other specialised tests including ERCP and liver biopsy, to
establish the underlying cause.
TOP TIPS
Remember to look at the patient – if signicant jaundice is present it will probably strike
you at rst glance.
In younger patients, the diagnosis is likely to be viral hepatitis. In older age groups, the
dierential is much wider.
Don’t forget iatrogenic causes. Remember too that the presence of jaundice implies liver
dysfunction, so take great care if prescribing any medication.
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JAUNDICE IN ADULTS 217
If the patient is well, with no pain and fever, it is reasonable to arrange initial investigations
– especially LFT – and arrange for review in a day or two. Most other cases will require
admission.
Remember to ask about foreign travel, contact with travellers, drug misuse and sexual history
if necessary in the suddenly jaundiced febrile patient.
Painless progressive jaundice suggests carcinoma of pancreas. Refer urgently.
An enlarged, knobbly, hard liver is nearly always caused by metastases.
Beware of restlessness, poor concentration and drowsiness. ese suggest fulminant hepatic
failure.
NOTES:
https://t.me/med1917
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