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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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228 SYMPTOM SORTER
Ready reckoner
Diabetes
mellitus
Dehydration Medication Mouth
breathing
Anxiety
Polyuria/frequency Ye s No No No Possible
Generally unwell Possible Ye s Possible No Possible
Difculty breathing through nose No No No Ye s No
Symptom intermittent No No Possible Possible Possible
Clinically dehydrated Possible Ye s No No No
Possible investigations
LI KE LY: Urinalysis, fasting blood glucose or HbA1c.
POSSIBLE: FBC, ESR/CRP, U&E, calcium, R A factor/anti-CCP and other autoantibody screen.
SMALL PRINT: Serum and urine osmolality, sickle-cell screen.
Urinalysis: Glycosuria in diabetes, specic gravity raised in dehydration and reduced in
diabetes insipidus and compulsive water drinking, may be proteinuria and/or microscopic
haematuria in CKD.
Fasting blood glucose or HbA1c: To denitively diagnose diabetes.
FBC/ESR: Hb may be reduced and ESR elevated in Sjögren’s linked to connective tissue
disorder; Hb may also be reduced in CKD.
U&E: May suggest dehydration or CKD.
Calcium: Elevated in hypercalcaemia.
RA factor/anti-CCP and other autoantibodies: Sjögren’s may be linked to rheumatoid
arthritis, SLE or other connective tissue disease.
Serum and urine osmolality: Serum osmolality raised and urine osmolality low in diabetes
insipidus; in compulsive water drinking, serum osmolality low.
Sickle-cell screen: To detect sickle-cell anaemia.
TOP TIPS
e assessment of thirst does not stop at the exclusion of diabetes mellitus – consider other
causes.
Intermittent dry mouth in an anxious individual also reporting episodic perioral
paraesthesiae is likely to be caused by anxiety – perhaps aggravated by certain medications
the patient might be taking for the problem.
Do not underestimate the complaint of dry mouth, especially in the elderly – it can cause
signicant distress.
Remember hypercalcaemia, particularly in palliative care patients – this is a potentially
remediable cause of troublesome thirst.
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THIRST OR DRY MOUTH 229
Children who are ‘always thirsty’, have been like that for as long as the parents can remember
and are otherwise well will not have diabetes – though the parents may feel short-changed
if this isn’t tested for.
In the acute presentation of thirst, it is essential to exclude diabetes immediately – a very high
glucose level with ketonuria will require admission.
Beware the thirsty elderly patient with an acute illness, particularly if the patient is on ACE
inhibitors – he or she may be signicantly dehydrated and developing renal failure.
Dry eyes and joint swellings in association with a dry mouth may indicate Sjögren’s.
Beware that the elderly with diabetes may complain of dry mouth rather than thirst.
NOTES:
https://t.me/med1917
230
TIREDNESS
The GP overview
Feeling tired all the time is such a common presenting symptom that ‘TATT’ has become the
universal GP acronym. In around 85% of rst consultations the cause is apparent by the end.
Although the vast majority turn out to have a non-organic cause, it is clearly important not to
get lulled into ignoring important physical illness. A structured approach can turn this heartsink
calling card into a rewarding and successful consultation.
Differential diagnosis
COMMON
true depressive illness
stress (overwork, young children, boredom, etc.)
anaemia
acute post-viral fatigue
hypothyroidism
OCCASIONAL
diabetes mellitus
sleep apnoea (though usually presents with sleepiness rather than tiredness)
iron deciency (in the absence of anaemia)
coeliac disease
any cause of insomnia (see p. 92)
chronic post-viral fatigue syndrome (‘ME’)
major organ failure (heart, liver, kidney)
hyperthyroidism
substance misuse
drug therapy (β-blockers, diuretics)
RARE
malignant disease
chronic infection (e.g. TB, hepatitis, HIV, Lyme disease)
chronic neurological disorders (Parkinson’s disease, myasthenia gravis, MS, motor neurone
disease)
other endocrine disorders and deficiency states (e.g. Addison’s disease, hypo- or
hypercalcaemia, hyponatraemia, hypokalaemia)
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TIREDNESS 231
connective tissue diseases (RA, polymyalgia rheumatica [PMR], SLE)
carbon monoxide poisoning
Ready reckoner
Depression Stress Anaemia Post-viral Hypothyroidism
Diurnal variation Ye s Possible No No No
Identiable life event triggers Possible Ye s No No No
Recent illness Possible Possible Possible Ye s No
Mucosal/nailbed pallor No No Ye s No Possible
Cold, dry skin No No Possible No Ye s
Possible investigations
LI KE LY: Urinalysis, FBC, blood glucose or HbA1c, TFT.
POSSIBLE: ESR/CRP, U&E, LFT, ferritin, calcium, anti-endomysial and anti-gliadin antibodies.
SMALL PRINT: CXR, autoantibody screen, sleep studies, further blood tests as indicated such as
HIV, glandular fever test, hepatitis or Lyme disease serology.
Urinalysis: Simple screen for diabetes and renal disease.
Blood glucose or HbA1c: For diabetes.
TFT for hypo- or hyperthyroidism.
FBC: e anaemias, infection and alcohol abuse.
ESR/CRP: Raised in a host of causes; not diagnostic but suggests a possible underlying
physical cause.
U&E: Deranged in renal failure, hyponatraemia, hypokalaemia and Addison’s disease.
LFT: For liver disease (malignancy, alcohol abuse and hepatitis).
Ferritin: Iron deciency may cause tiredness in the absence of anaemia.
Calcium: Hyper- or hypocalcaemia may cause tiredness.
Anti-endomysial and anti-gliadin antibodies: Will suggest a diagnosis of coeliac disease.
Autoantibody screen: For connective tissue disease.
Sleep studies: To explore the possibility of sleep apnoea.
Further blood tests: ese will be dictated by the clinical picture and might include HIV,
glandular fever or hepatitis or Lyme disease testing.
CXR: May reveal malignancy, cardiac failure or TB.
TOP TIPS
Tiredness as a presenting symptom, in the absence of other signicant volunteered symptoms
– particularly weight loss or gain – is unlikely to have a physical cause.
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232 SYMPTOM SORTER
e longer tiredness has been a problem, the less likely you will nd any remediable cause.
Make eye contact with the patient and shake hands – your rst impressions as to whether
or not the patient is actually ‘ill’ are likely to prove correct, and may give early clues to easily
overlooked causes such as Parkinson’s disease.
If you suspect depression, enquire directly about relevant symptoms – you do not have to
‘exclude’ physical illness before making a presumptive diagnosis of this sort.
Investigations ordered are oen more therapeutic than diagnostic.
Ask about other household members’ health and well-being. Carbon monoxide poisoning
would be likely to aect them too.
Do not be too trigger-happy with the usual ‘blood screen’. Many patients ‘promised’ blood
tests if their symptoms persist another month do not return. Also, checking blood quite oen
raises irrelevant abnormalities which concern the patient and confuse the issue.
Take tiredness associated with weight loss seriously – this combination suggests malignant
disease or hyperthyroidism.
Don’t miss depressive illness by being coy in enquiry or colluding with patient denial.
Don’t miss easy-to-nd signs when physical illness seems a real possibility – check pulse rate,
mucous membranes for pallor, lymph nodes, chest and abdomen.
Consider a rare cause if the symptoms progress and the patient starts to look unwell.
Beware the very rare attender. Although the overall pick-up rate for signicant physical
disease is low when tiredness is presented in the absence of other signicant symptoms, this
does not hold for rare attenders, in whom any symptom, no matter how vague, should be
taken very seriously.
NOTES:
https://t.me/med1917
233
TREMOR
The GP overview
is is rhythmic movement of parts of the body. ere are three clinica l types: Rest tremor (worst
at rest), postural tremor (worst in a xed posture, e.g. outstretched arms) and intention tremor
(worst during voluntary movement). Tremor may be noticed by the GP during an assessment for
some other problem, or it may be the presenting symptom. In the latter case, the patient may be
embarrassed by the lack of ‘self-control’, so a sympathetic approach is important.
Differential diagnosis
COMMON
anxiety
thyrotoxicosis
drug withdrawal (e.g. opiates, benzodiazepines, alcohol)
benign essential tremor (familial)
Parkinson’s disease
OCCASIONAL
adverse drug reaction (e.g. phenothiazines, β-agonists)
carbon dioxide retention (e.g. COPD)
multiple sclerosis (MS)
cerebellar ataxia: many causes, including tumour, acoustic neuroma, Friedreich’s ataxia,
CVA , ab sces s
RARE
fulminant hepatic failure
Wilson’s disease
tertiary syphilis
hysterical: usually restricted to one limb and is very gross
meningoencephalitis
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234 SYMPTOM SORTER
Ready reckoner
Anxiety Thyrotoxicosis Drug
withdrawal
Benign
essential
Parkinson’s
disease
Rest tremor No No No No Ye s
Suppressed by alcohol Possible No Possible Ye s No
Otherwise well Possible No No Ye s No
Tachycardia Ye s Ye s Possible No No
Bradykinesia No No No No Ye s
Possible investigations
LI KE LY: TFT.
POSSIBLE: FBC, LFT.
SMALL PRINT: Syphilis serology and, in secondary care, MRI scan, lumbar puncture, visual
evoked response, serum caeruloplasmin/blood copper, blood gases.
FBC: Macrocytosis in chronic alcohol excess.
LFT: For evidence of alcohol abuse or liver failure.
TFT: If hyperthyroidism suspected.
MRI most sensitive test for picking up CNS demyelination and tumours (e.g. cerebellar).
Lumbar puncture: CSF electrophoresis may show oligoclonal bands in MS, or evidence of
meningoencephalitis.
Visual evoked response: Prolonged in MS.
Syphilis serology: In suspected syphilis.
Blood gases: Will reveal carbon dioxide retention.
Serum caeruloplasmin/blood copper: To diagnose Wilson’s disease.
TOP TIPS
Patients who present with their tremor are invariably worried about signicant disease,
especial ly Parkinson’s diseas e. Ensure that these an xieties are resolved during the consultation.
Essential tremor is characteristically suppressed by a small dose of alcohol. is can be a
useful pointer from the history.
A tremor can have more than one cause and may not necessarily follow the neat patterns
described, especially in the elderly.
e tremor of early Parkinson’s disease usually causes the patient few problems. It may
therefore be noticed by the doctor when the patient presents with other symptoms, or be
presented by concerned relatives or friends.
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TREMOR 235
Have a low threshold for arranging TFT: Anxiety can closely mimic thyrotoxicosis and vice
versa.
Parkinson’s disease may well present with a consultation for frequent falls. Look for other
signs such as mask face, small handwriting, slow movement, festinant gait and diculty
rising from chair.
ink of alcohol problems in isolated middle-aged and elderly men developing postural
tremor.
Intention tremor with nystagmus or dysarthria suggests signicant cerebellar pathology.
NOTES:
https://t.me/med1917
236
WEIGHT GAIN
The GP overview
By far the commonest cause of this problem is simple obesity. is is 50% commoner in women,
who also present more oen than men. It may be the primary problem presented or it may be a
‘while I’m here’ symptom – either way, it tends to be viewed as a ‘heartsink’ symptom, as such
patients may have unrealistic expectations of what the doctor can achieve.
Differential diagnosis
COMMON
simple obesity (usually hereditary component with poor diet and lack of exercise)
hypothyroidism
pregnancy
oedema of any cause (e.g. cardiac failure, renal failure, hepatic failure)
alcohol excess
OCCASIONAL
menopause
iatrogenic (e.g. steroids, insulin, sulphonylureas, oestrogen, pizotifen)
polycystic ovary syndrome
large single ovarian cyst
physical or mental disability restricting activity (e.g. CVA, Down’s syndrome)
RARE
anabolic steroid abuse
Cushing’s syndrome
hypothalamic lesion or hypopituitarism
insulinoma
rare genetic syndromes such as Prader–Willi syndrome
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WEIGHT GAIN 237
Ready reckoner
Simple obesity Hypothyroidism Pregnancy Oedema Alcohol
Pitting oedema Possible No Possible Ye s Possible
Only abdominal girth
increased
No No Ye s No Possible
Long history Ye s Possible No Possible Possible
Palpable liver No No No Possible Possible
Otherwise well Ye s Possible Possible No No
Possible investigations
LI KE LY: TFT.
POSSIBLE: Urinalysis, FBC, LFT, U&E, pregnancy test, total testosterone, SHBG, cardiac
investigations if the cause is possible cardiac failure, pelvic ultrasound.
SMALL PRINT: Secondary care investigations for endocrine dysfunction.
Urinalysis: Proteinuria may be present in oedema caused by underlying renal disease.
FBC: Anaemia may precipitate cardiac failure; MCV raised in hypothyroidism and alcohol
excess.
TFT: Will reveal hypothyroidism.
U&E: Deranged in renal failure and Cushing’s syndrome.
LFT: To check for liver failure, evidence of alcohol abuse and hypoproteinaemic states.
Total testosterone normal or moderately elevated, and SHBG normal or low in PCOS.
Pregnancy test: To exclude pregnancy if this is a possibility.
Pelvic ultrasound: Will conrm ascites, ovarian cysts and pregnancy.
Cardiac investigations: CXR, ECG, BNP and echocardiography if the underlying cause is
possible cardiac failure.
Secondary care investigations for endocrine dysfunction: For insulinoma, hypopituitarism,
Cushing’s syndrome.
TOP TIPS
Patients presenting with weight gain, especially if it is a long-term or uctuating problem,
usually have a clear agenda of their own – such as wanting a blood test or drug treatment.
Much time can be wasted giving unwanted advice about diet and exercise which the patient
will have heard before. Establish the patient’s agenda early in the consultation.
Parents anxious about weight gain in their children oen want to be reassured that the
child’s ‘glands’ are normal. If the child’s height is in proportion to its weight, or the parents
have a similar physiognomy, and the child is otherwise well, it is highly unlikely that there
is an underlying cause.
https://t.me/med1917
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