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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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238 SYMPTOM SORTER
Patients with Down’s syndrome have a relatively high prevalence of hypothyroidism –
consider this possibility if a patient with Down’s syndrome experiences inexplicable weight
gain.
Investigation is usually clinically unnecessary, but may be useful to clear the way to dealing
with the real cause.
Correction of hypothyroidism may not solve a weight gain problem, merely unmask an
underlying simple obesity. Don’t falsely raise expectations.
Establish whether the weight gain is diuse or whether there is predominantly abdominal
swelling. e latter may indicate pregnancy, ascites or a large ovarian cyst.
Recent onset of weight gain in an elderly patient suggests probable congestive cardiac failure
or possible hypothyroidism.
Young women may not consider, or accept, a diagnosis of pregnancy as a cause of their weight
gain. Arrange a pregnancy test if in any doubt.
e yield from routine blood tests is low – but consider investigation if the patient is unwell
or the history atypical.
NOTES:
https://t.me/med1917
239
WEIGHT LOSS
The GP overview
e signicance of weight loss should not be underestimated: In about one-third of patients,
there is no specic cause, but in the rest, a serious underlying pathology is found. e minority
of these are psychiatric; 90% have organic illness. orough assessment from the start is the rule.
Differential diagnosis
COMMON
‘normal’ stressful life events without psychiatric illness (e.g. changing job, divorce,
redundancy, bereavement, exam pressure)
clinical depressive illness
eating disorders: anorexia nervosa and bulimia nervosa
hyperthyroidism: thyrotoxicosis and iatrogenic (excess thyroid replacement)
malignancy anywhere
OCCASIONAL
anxiety (of whatever cause)
any terminal illness (e.g. malignancy, motor neurone disease)
substance misuse: alcohol, opiates, amphetamines, laxatives
organ failure: cardiac, renal and hepatic
undiagnosed diabetes mellitus
chronic inammatory conditions (e.g. RA, SLE)
gastrointestinal disease (e.g. peptic ulcer, inammatory bowel disease, coeliac disease,
parasites)
RARE
any chronic infection (especially tuberculosis)
endocrine: Addison’s disease, phaeochromocytoma
AIDS
malnutrition (rare in developed countries, common worldwide)
https://t.me/med1917
240 SYMPTOM SORTER
Ready reckoner
Normal stress Depression Eating disorders Hyper thyroidism Malignancy
Mild anxiety Ye s Possible No No No
Loss of appetite Possible Ye s No No Ye s
Distorted body image No No Yes No No
Recurrent problem Ye s Possible Possible Possible No
Severe malaise No Ye s Possible Possible Ye s
Possible investigations
LI KE LY: Urinalysis, FBC, ESR/CRP, TFT, U&E, LFT, CXR, blood glucose or HbA1c.
POSSIBLE: Autoimmune screen, HIV test, CA-125, bowel investigations such as FIT,
faecal calprotectin or antiendomysial and anti-gliadin antibodies, other hospital-based
investigations.
SMALL PRINT: None.
Urinalysis: For possible undiagnosed diabetes; proteinuria in renal failure.
FBC and ESR/CRP: Hb may be reduced and ESR/CRP elevated in malignancy and any
chronic disorder. Raised platelets associated with oesophageal or stomach cancer.
U&E: Abnormal in renal failure and sometimes in eating disorders; sodium reduced,
potassium and urea elevated in Addison’s disease.
TFT: Will conrm hyperthyroidism.
LFT: Deranged in alcoholism and liver disease.
Blood glucose or HbA1c: To conrm diabetes.
Autoimmune screen: May be helpful in suspected connective tissue disorder.
HIV test: If AIDS suspected.
CA-125: If ovarian cancer is a possibility.
Bowel investigations such as FIT, faecal calprotectin or anti-endomysial and anti-gliadin
antibodies: If carcinoma, IBD or coeliac disease suspected.
CXR: May reveal carcinoma, TB, lymphadenopathy or cardiac failure.
Other investigations (usually hospital-based) may be required according to the symptoms
accompanying the weight loss and the results of preliminary investigations.
TOP TIPS
Weight loss needs to be taken seriously but can be complex and time-consuming to assess. If
presented as a ‘by the way’ at the end of a consultation for some other matter, it is reasonable
to reverse the normal approach by arranging basic blood tests and urinalysis rst, and
booking a follow-up appointment, with the results, for a more complete assessment.
https://t.me/med1917
WEIGHT LOSS 241
Establish whether episodes of weight loss have happened before. Patients, or their records,
may indicate, for example, that they always lose weight when stressed.
Check that the patient really has lost weight. e history may not be clear, and there is oen
a record available (e.g. new patient check or health promotion data) of previous weight.
Look at the patient. e obviously cachectic will have signicant disease and require urgent
and thorough investigation.
Rapid weight loss with malaise and respiratory or gastrointestinal symptoms strongly suggest
a physical cause.
ink of eating disorders in young females – look for acid dental erosion on palatal surfaces
of upper teeth as a giveaway sign of recurrent vomiting.
Weight loss in a child is caused either by signicant organic pathology or emotional abuse.
Look out for signs of non-accidental injury (NAI) during physical examination.
Depression with weight loss is a dicult problem; it may be the primary cause or the
change in mood may be secondary to some physical illness. Either way, don’t overlook
signicant depression while you arrange investigations; there is nothing to be lost in starting
antidepressants while you continue to exclude a physical cause, so long as you explain your
strategy to the patient.
NOTES:
https://t.me/med1917
https://t.me/med1917
243
GENITAL
Erectile dysfunction 244
Haemospermia 247
Painful intercourse 250
Penile pain 253
Penile ulceration/sores 256
Scrotal swelling 259
Testicular pain 262
Vaginal discharge 264
Vulval irritation 267
Vulval swelling 270
Vulval ulceration/sores 272
https://t.me/med1917
244
ERECTILE DYSFUNCTION
The GP overview
is is the partial or complete failure to achieve a satisfactory erection. e inability to ejaculate
(ejaculatory erectile dysfunction) is not dealt with here. Erectile dysfunction presents fairly oen
to GPs and will probably do so increasingly frequently as new treatments are developed and
publicised.
Differential diagnosis
COMMON
depression/anxiety
excessive alcohol intake
relationship dysfunction
vascular: arterial insuciency (arteriopathy) or excessive venous drainage
iatrogenic (e.g. prostatic cancer treatments, hypotensives, some antidepressants)
OCCASIONAL
testosterone deciency (may be primary or secondary)
diabetic autonomic neuropathy
trauma: pelvic or spinal fracture, trauma to penis, post-TURP
anatomical: phimosis, tight frenulum
excessive cigarette smoking
Peyronie’s disease
drug abuse (e.g. heroin, amphetamines)
RARE
fetishism (erection only possible with unusual stimuli)
spinal cord compression: tumour
thrombosis of a corpus cavernosum
neurological: tabes dorsalis, multiple sclerosis
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ERECTILE DYSFUNCTION 245
Ready reckoner
Depression/
anxiety
Alcohol Relationship
dysfunction
Vascular Drugs
TATT/sleep problem Ye s Possible Possible No No
Occasional only Possible No Ye s No No
Full morning erection Ye s No Ye s No No
Reduced foot pulses No No No Ye s No
Taking medication Possible No No No Ye s
Possible investigations
LI KE LY: Urinalysis.
POSSIBLE: Blood sugar or HbA1c, FBC, LFT, endocrine assays (testosterone, prolactin, FSH/
LH, TSH), cholesterol, PSA.
SMALL PRINT: Doppler ow studies, angiography, intracorporeal prostaglandin injection test,
MRI scanning – all likely to be specialist initiated.
Urinalysis: An essential easy screen for undiagnosed diabetes.
Blood sugar or HbA1c: To conrm diabetes.
FBC and LFT pos sibly helpful in a lcohol excess (raised MCV and po ssible LFT abnormalities).
Testosterone levels reduced in primary or secondar y hypogonadism. Prolactin, FSH/LH and
TSH check pituitary function. Erectile dysfunction may be a sign of cardiovascular disease –
so in certain patients a cholesterol level would be warranted.
e link between prostate cancer and erectile dysfunction is far from clear. Some guidelines
recommend PSA in this situation to assess for possible prostate cancer; judge each case on
its merits and according to other symptoms and the man’s wishes.
Doppler ow studies of supercial and deep penile arterial ow assess arterial suciency.
Angiography may be necessary if symptoms suggest signicant lower limb arterial
insuciency associated with impotence.
Intracorporeal prostaglandin injection test: Immediate and prolonged response indicates
neurological problems. Good initial response with rapid failure indicates excessive venous
drainage.
Possible neurological causes will occasionally require further investigation (e.g. MRI
scanning for cord lesions or MS).
TOP TIPS
Establish whether the patient can get an erection at any time (e.g. early morning). If he can,
then the cause is unlikely to be organic. Take a positive approach – many psychological causes
are transient.
https://t.me/med1917
246 SYMPTOM SORTER
Don’t be too quick to diagnose anxiety as the underlying problem. is may be the eect,
rather than the cause, of the impotence.
Erectile dysfunction is oen presented as a ‘by the way’ or ‘while I’m here’ symptom. e
temptation is to invite the patient to book a further appointment, but bear in mind that this
may represent a lost opportunity to help, as he may not return.
Demonstrate that you are taking the problem seriously – for example, by performing
an appropriate examination or by inviting the patient’s partner to attend a subsequent
appointment.
Sudden onset of erectile dysfunction with saddle anaesthesia and sphincter disturbance
indicates a cauda equina lesion. Refer urgently.
An erection which is consistently lost aer a predictable period is likely to be organic –
probably vascular – in origin.
Do not forget that alcohol and drug abuse are possible causes. Look in the notes for clues and
make specic enquiry, as these problems are unlikely to be volunteered.
Erectile dysfunction may well be a marker for vascular disease elsewhere. Extend your
assessment as appropriate.
NOTES:
https://t.me/med1917
247
HAEMOSPERMIA
The GP overview
is is an uncommon presentation – but one we may see increasingly frequently as men become
less reticent about coming to the doctor. As with any symptom involving leakage of blood,
anxiety levels tend to run high. is shouldn’t transfer to the GP, though – it is unusual for the
symptom to have a sinister cause.
Differential diagnosis
COMMON
unknown (at least 50%; the majority are probably secondary to forgotten or unnoticed
trauma)
prostatitis
post-operative (prostate surgery, biopsy or extracorporeal shock wave lithotripsy)
genito-urinary infection (epididymo-orchitis, urethritis, UTI)
trauma (to testicles or perineum)
OCCASIONAL
blood clotting disorder or anticoagulation
calculi in the prostate
carcinoma: prostate, testicles, bladder or seminal vesicles
RARE
tuberculosis
schistosomiasis
malignant hypertension
structural problems (such as urethral strictures or polyps)
https://t.me/med1917
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