Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
.pdf
218
NUMBNESS AND
PARAESTHESIAE
The GP overview
Paraesthesiae and numbness are taken here to mean sensations of tingling, pins-and-needles,
subjective numbness, and feelings of cold and heat. ey may appear spontaneously or be a result
of touching the area of skin concerned. Patients are oen alarmed and may make an immediate
association with serious disease. e dierential is huge but most cases in primary care involve
anxiety, nerve entrapment or cerebrovascular disease.
Differential diagnosis
COMMON
anxiety with hyperventilation
carpal tunnel (CT) syndrome
sciatica
diabetic neuropathy
cervical spondylosis
OCCASIONAL
multiple sclerosis and dorsal myelitis
peripheral polyneuropathy (especially alcohol; also vitamin B
12
and folate deciency,
iatrogenic, metabolic, connective tissue disorder, malignancy and rare causes such as
Guillain–Barré, leprosy)
stroke and TIA
trauma/compression involving a peripheral nerve or spinal cord
migraine with focal neurological signs
RARE
intramedullary spinal cord tumour
syringomyelia
trauma, brain tumour and epilepsy aecting sensory cortex
hysteria
vascular: ischaemic heart disease, peripheral vascular disease
https://t.me/med1917
NUMBNESS AND PARAESTHESIAE 219
Ready reckoner
Anxiety CT syndrome Sciatica Diabetes Cervical spondylosis
Associated dizziness Ye s No No No No
Episodic Ye s Possible Possible Possible Possible
Associated pain No Ye s Ye s Possible Ye s
Worse at night No Ye s No Possible Possible
Associated weakness No Possible Possible No Possible
Possible investigations
LI KE LY: Urinalysis, blood sugar or HbA1c.
POSSIBLE: FBC, LFT, γGT, U&E, serum calcium, B
12
and folate, TFT, serum electrophoresis,
nerve conduction studies.
SMALL PRINT: Autoimmune screen, cervical spine X-ray, secondary care investigations (MRI/
CT scan, lumbar puncture, carotid imaging, angiography, myelography).
Urinalysis: To pick up glycosuria in undiagnosed diabetes.
Blood sugar or HbA1c: To conrm diabetes.
FBC: To look for macrocytosis (sign of alcohol excess or B
12
/folate deciency). May be
anaemia of chronic illness or malignancy.
LFT and γGT if alcoholic neuropathy suspected.
Metabolic screen (including U&E, calcium, LFT, B
12
and folate).
TFT: Hypothyroidism can cause a polyneuropathy or precipitate carpal tunnel syndrome.
Serum electrophoresis: To exclude myeloma.
Autoimmune screen: To help diagnose a connective tissue disorder.
Nerve conduction studies: To conrm a diagnosis of nerve compression prior to surgical
treatment.
X-ray cervical spine: Conrms clinical diagnosis of cervical spondylosis, but not real ly helpful
as positive ndings common and don’t correlate well with symptoms, and the investigation
is unlikely to alter the management.
Secondary care investigations might include: Lumbar puncture (MS, Guillain–Barré
syndrome), carotid imaging (TIA), CT or MRI scan (spinal pathology or compression,
MS, cerebral tumour, syringomyelia), angiography (vascular causes), myelography (cord
compression).
TOP TIPS
Intermittent perioral paraesthesiae are pathognomic of hyperventilation.
Use a logical approach: A careful history will oen reveal the likely underlying problem. For
example: Well-demarcated area in anatomically explicable distribution – peripheral nerve
entrapment; larger area, one limb – root compression; whole side of body – cerebral lesion;
hands and feet – peripheral neuropathy; legs alone – possible cord lesion.
https://t.me/med1917
220 SYMPTOM SORTER
Wasting of the thenar eminence suggests signicant CT syndrome which will require
decompression.
Remember to tell women taking the combined oral contraceptive who develop migraine with
focal symptoms to use an alternative method of contraception.
Sudden and progressive bilateral leg symptoms with sphincter disturbance suggest cord
compression – admit immediately.
Intermittent paraesthesiae in varying distributions – especially with other features, such as
vertigo or optic neuritis – suggest MS.
A patient with a TIA within the preceding week should be given aspirin 300 mg immediately
and referred for a specialist assessment to take place within 24 hours.
e borders of sensory loss in hysteria are oen sharply demarcated and do not correspond
to an anatomical pattern.
Constant, progressive paraesthesiae, especially with other neurological symptoms or signs,
suggest signicant pathology. Refer urgently.
NOTES:
https://t.me/med1917
221
PROLONGED FEVER
The GP overview
GPs deal with fevers on a daily basis – the vast majority are caused by viruses and are self-limiting.
is section deals with a dierent and much less common scenario: A temperature above normal
for 3 weeks or more. It may be continuous or swinging. Many more causes exist than can be
named here, but those likeliest in general practice are listed.
Differential diagnosis
COMMON
glandular fever (GF)
abscess (anywhere)
chronic pyelonephritis (recurrent UTI)
carcinoma (especially bronchial)
rheumatoid arthritis (RA)
OCCASIONAL
lymphoma and leukaemia
systemic lupus erythematosus, polyarteritis nodosa, polymyositis
Crohn’s disease and ulcerative colitis
drug idiosyncrasies
RARE
malaria and other tropical diseases
Lyme disease
tuberculosis, syphilis
actinomycosis
HIV infection: AIDS
infective endocarditis
factitious
https://t.me/med1917
222 SYMPTOM SORTER
Ready reckoner
GF Abscess UTI Carcinoma RA
Generalised lymphadenopathy Possible No No Possible Possible
Local lymphadenopathy Possible Ye s No Possible No
Frequency of micturition No No Ye s No No
Rapid weight loss Possible Possible No Ye s Possible
Joint swelling No No No Possible Ye s
Possible investigations
LI KE LY: FBC, ESR/CRP, LFT, U&E, Paul–Bunnell test, urinalysis, MSU.
POSSIBLE: CXR, autoimmune screen.
SMALL PRINT: Faecal calprotectin, blood cultures, malaria lms, syphilis serology, HIV test and
a variety of other secondary care-based tests.
FBC, ESR/CRP, U&E, LFT: Anaemia will be revealed in a variety of disorders (e.g.
malignancy, connective tissue disorders); WCC raised in many inammatory or infective
processes and also some blood dyscrasias. Elevated ESR/CRP is a non-specic nding in
many of the illnesses listed. Abnormal U&E or LFT may point to an underlying renal or
hepatic problem.
Paul–Bunnell test: May be positive in glandular fever.
Urinalysis, MSU: May be proteinuria, haematuria and evidence of infection in chronic
pyelonephritis.
CXR: Will show signs of malignancy (e.g. lung, lymphoma), occult infection and TB.
Autoimmune screen: May suggest a connective tissue disorder.
Faecal calprotectin: If symptoms suggest possible IBD.
Secondary care-based tests: A number of tests may be performed aer referral to the specialist
in cases which remain obscure aer initial assessment and investigation. ese include
further microbiological tests (e.g. stool, blood cultures), blood tests (e.g. for malaria, syphilis
and HIV), isotope scans, ultrasound and CT scans (for occult infection or malignancy),
tuberculin testing (for possible TB) and esoteric tests for tropical diseases.
TOP TIPS
Prolonged fever is usually an uncommon presentation of a common disorder (unless there
has been recent travel), so review the situation regularly and encourage the patient to report
new symptoms, which may help reveal the diagnosis.
Refer early if the patient is unwell or has lost weight; if not, arrange initial investigations
yourself.
https://t.me/med1917
PROLONGED FEVER 223
Don’t always accept self-reporting of this symptom at face value. Flushing or sweating may
be misreported as ‘fever’. If in doubt, get the patient to record the temperature over a period
of time.
Always take a travel history, and specically enquire about insect bites and compliance with
antimalarial therapy. Remember, too, occupation and recent contact with infectious illness.
Tuberculosis is rare but on the increase in the UK. Consider this diagnosis, particularly in
Asian immigrants and vagrants.
Itching with prolonged pyrexia suggests leukaemia or lymphoma.
Refer to a tropical medicine centre a patient with PUO who has recently been abroad
somewhere exotic – in such a case, the dierential is much wider and the possibility of an
obscure pathology therefore much greater.
Factitious prolonged fever is rare, but possibly more common among health sta; beware the
health worker with apparent fever but who never feels hot and who never appears unwell,
especially if basic investigations are all normal.
Don’t forget the possibility of infective endocarditis in a patient with a cardiac murmur.
NOTES:
https://t.me/med1917
224
SWOLLEN GLANDS
The GP overview
ere are very many causes of swollen glands (lymphadenopathy), but in general it is possible to
narrow the list of possible causes down to a manageable few by careful history and examination.
Age, geography (or travel history) and distribution of enlarged glands have a considerable
inuence on the dierential diagnosis.
Differential diagnosis
COMMON
local infection (e.g. URTI, tonsillitis)
generalised viral infection (e.g. glandular fever, rubella)
malignancy: secondary metastasis
white cell malignancy: lymphoma, leukaemia, myeloma
septicaemia
OCCASIONAL
sarcoid
cat scratch fever (especially in children)
rubella/measles
SLE
rheumatoid arthritis
tropical/subtropical sexually transmitted infection: lymphogranuloma venereum (LGV),
granuloma inguinale (GI)
RARE
syphilis (primary or secondary)
HIV: AIDS and AIDS-related complex (ARC)
tuberculosis
tropical infections: leprosy, lariasis, trypanosomiasis, tularaemia
drug reactions (e.g. phenytoin, penicillins, sulphonamides)
Lyme disease
https://t.me/med1917
SWOLLEN GLANDS 225
Ready reckoner
Local infection General viral Metastases WC malignancy Septicaemia
Tender nodes Ye s Ye s No Possible Possible
Persistent (>6 weeks)
No No Yes Yes No
Regional nodes only Ye s No Ye s Possible No
Firm splenomegaly No Possible No Possible No
Night sweats No Possible Possible Ye s Possible
Possible investigations
LI KE LY: None if localised; FBC and ESR/CRP if generalised.
POSSIBLE: Paul–Bunnell test, CXR, acute and convalescent sera, HIV testing, lymph node
biopsy.
SMALL PRINT: Autoimmune blood tests, syphilis and Lyme disease serology, cultures and
scrapings for LGV and GI, bronchoscopic biopsy or nodal aspiration, CT scan, indirect
uorescent antibody blood test for Bartonella henselae.
FBC: Atypical lymphocytes reect acute viral infection; many of the causes listed will result
in a raised WCC and ESR/CRP. Hb may be low in malignancy and connective tissue disea se;
WCC and lm may show evidence of lymphoma or leukaemia.
Paul–Bunnell test: To conrm glandular fever.
CXR: May reveal carcinoma, TB, lymphoma, sarcoid and the source of septicaemia.
Serology: Acute and convalescent sera may conrm specic viral infection.
Bronchoscopic biopsy or nodal aspiration: For possible sarcoid.
Abdominal and chest CT scan is a sensitive test to detect pelvic, para-aortic, mesenteric, hilar
or paratracheal node enlargement (e.g. in lymphoma).
Autoimmune blood tests: May help in diagnosis of connective tissue disorder.
Culture/scrapings (GUM clinic): For LGV and GI.
Syphilis and Lyme disease serology, HIV testing: For syphilis, Lyme disease and AIDS.
Indirect uorescent antibody test for B. henselae: is is the causative organism in cat scratch
disease.
Lymph node biopsy may be necessary to reach a denitive diagnosis.
TOP TIPS
Normal cervica l lymph nodes are oen palpable in children; they swell with URTIs and may
be presented by anxious parents fearing signicant disease.
Remember geography: A young adult from the UK with persistent cervical nodes is likely to
have Epstein–Barr virus (EBV) infection while, in Africa, the likeliest diagnosis would be
tuberculosis. Swollen groin glands in the latter group might be caused by LGV or GI.
https://t.me/med1917
226 SYMPTOM SORTER
Patients oen attach great signicance to swollen glands. It is worth explaining that
lymphadenopathy usually represents a normal part of the immune system’s defence against
infection and does not in itself require attention from the doctor unless there are unusual
features.
Unexplained and persistent cervical lymphadenopathy in the middle-aged and elderly should
prompt urgent ENT assessment to exclude nasopharyngeal carcinoma.
An enlarged le supraclavicular node (Troisier’s) in a patient with weight loss suggests
gastrointestinal carcinoma.
Generalised, persistent lymph nodes with weight loss and sweats in a young adult suggest
glandular fever, lymphoma or AIDS.
A slowly enlarging, non-tender cervical node in an unusual site is likely to be malignant.
NOTES:
https://t.me/med1917
227
THIRST OR DRY MOUTH
The GP overview
e complaint of thirst rings alarm bells in doctor and patient alike. Diabetes clearly needs to be
excluded but the dierential may need to be extended beyond this in the light of negative initial
tests. Dry mouth tends to create less concern but can sometimes herald signicant pathology
and may be a serious nuisance to the patient.
Differential diagnosis
COMMON
diabetes mellitus
dehydration
medication (e.g. tricyclic antidepressants, antihistamines)
mouth breathing (usually through nasal blockage)
anxiety
OCCASIONAL
normality (children sometimes presented because ‘they are always thirsty’)
smoking
excess alcohol
Sjögren’s syndrome
hypercalcaemia
chronic kidney disease (CKD)
RARE
diabetes insipidus
pregnancy (common condition but rarely causes signicant thirst)
compulsive water drinking
sickle-cell disease
previous head/neck irradiation
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана