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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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268 SYMPTOM SORTER
Ready reckoner
Thrush Trichomonas Chemical Trauma Atrophic vaginitis
Itching prominent Ye s Possible Ye s Possible No
Soreness prominent Possible Ye s Ye s Ye s Ye s
White discharge Ye s No No No No
Fishy, smelly discharge No Ye s No No No
Thin, dry, red mucosa No No No No Ye s
Possible investigations
LI KE LY: HVS (if discharge present).
POSSIBLE: Urinalysis.
SMALL PRINT: FBC, LFT, U&E, fasting sugar or HbA1c, vulval biopsy.
Urinalysis for sugar: Diabetes predisposes to thrush and glycosuria in itself can cause vulvitis.
FBC, LFT, U&E: If vulvitis is part of a generalised pruritus, or if the patient is generally
unwell, these blood tests may reveal blood dyscrasias or renal or hepatic dysfunction.
Fasting sugar or HbA1c to diagnose or rule out underlying diabetes.
HVS: Identifying the pathogen if discharge is present will help management in puzzling or
recurrent cases.
Vulval biopsy (secondary care): Multiple biopsies are required if vulval dysplasia or carcinoma
is suspected.
TOP TIPS
It is easy to make an erroneous diagnosis of UTI in a patient with vulvitis – external dysuria
and contamination of urine with pus cells and blood (especially if there is an associated
discharge) may mislead the unwary. Helpful pointers are the presence of external vulval
irritation and the absence of frequency or urgency.
In obscure cases, check the skin elsewhere. Vulval irritation may be a manifestation of a
primary skin disorder, such as eczema or psoriasis.
e aetiology may be multifactorial with, for example, some primary cause leading to
secondary chemical irritation from over-washing or the use of douches. A careful history is
needed to unravel the underlying cause and exacerbating factors.
Recurrent candidal infection is a particular problem. Various therapeutic strategies are
available, but it is important to take time to explore the woman’s perception of the cause,
explain the diagnosis and resolve any exacerbating factors.
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VULVAL IRRITATION 269
Post-menopausal atrophic vaginitis causes soreness rather than itch. Dysplasias and some
carcinomas produce intense irritation. Examine these patients and, if in doubt, refer for
biopsy.
Consider diabetes in orid or refractory cases of Candida infection.
Signicant psychosexual problems may present with vulval irritation. Adopt a sympathetic,
open approach. Take particular note of any comments made during the physical examination
as this sometimes prompts the patient to reveal the true problem.
Persistent vulval irritation may rarely be a symptom of signicant systemic disease. Consider
this if the patient has generalised pruritus elsewhere and seems unwell in herself.
If the cause is sexually transmitted (e.g. genital herpes or warts), exclude other infections by
referring to a GUM clinic.
NOTES:
https://t.me/med1917
270
VU LVAL SWE LLI NG
The GP overview
Vulval swellings may originate in the vulva, or appear there aer displacement from their origin.
ey oen present as ‘a lump down below’ – an expression which belies the variety of possible
causes. ey generate a lot of anxiety but are rarely sinister.
Differential diagnosis
COMMON
boils
sebaceous cysts
viral warts (condylomata acuminata)
Bartholin’s cyst
inguinal hernia (may extend down to labium major)
OCCASIONAL
varicose vein, varicocoele of vulva
Bartholin’s abscess (infected Bartholin’s cyst)
broma, lipoma, hidradenoma
uterine prolapse, cystocoele, rectocoele, enterocoele (hernia of the pouch of Douglas)
urethral caruncle (meatal prolapse)
RARE
cervical polyp
carcinoma (95% are squamous)
endometrioma
hydrocoele of the canal of Nuck
traumatic haematoma
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VULVAL SWELLING 271
Ready reckoner
Boil Sebaceous cyst Viral warts Bartholin’s cyst Inguinal hernia
Tender Ye s No No No No
Reducible No No No No Ye s
Multiple Possible Possible Ye s No No
Epidermal Ye s Yes Ye s No No
Central punctum No Ye s No No No
Possible investigations
ere are no investigations likely to be performed in primary care: e diagnosis is a lmost always
established by history and examination. If it isn’t, then referral is usually required.
TOP TIPS
Remember that, to many patients, a lump means cancer until proven otherwise. You may
only require a cursory glance to reassure yourself that the problem is insignicant – but the
patient may interpret your approach as dismissive or inadequate. Ensure that the patient’s
anxieties are resolved by adequate examination and explanation.
If the lump is not obviously apparent, or is poorly dened, examine the patient standing –
this may reveal a hernia, varicocoele or prolapse.
A varicocoele of the vulva has a characteristic ‘bag of worms’ feel. It oen appears and gets
worse during pregnancy.
A persistent, ulcerating lump in the vulva must always be referred for biopsy to exclude
carcinoma, even though some benign lumps can ulcerate (e.g. hidradenoma).
Check for lymphadenopathy: Hard inguinal nodes with a painless lump are highly suggestive
of malignancy. e lump can occasionally be a metastasis itself.
Women with genital warts may have coexisting sexually transmitted infection – refer to the
local GUM clinic for appropriate investigation and, if necessary, contact tracing.
NOTES:
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272
VULVAL ULCERATION/
SORES
The GP overview
is oen unpleasant symptom is uncommon, but very important, as many causes are signicant
and require specialist investigation, treatment and follow-up. Patients oen have diculty
visualising or describing these types of lesions, so adequate examination is vital in establishing
the diagnosis.
Differential diagnosis
COMMON
herpes simplex virus (HSV)
thrush (particularly if very excoriated)
vulval dysplasia
squamous cell carcinoma (SCC): 95% of vulval malignancies
excoriated scabies
OCCASIONAL
allergic contact eczema
chancroid: H. ducreyi (tropical)
granuloma inguinale: K. granulomatis (tropical)
lymphogranuloma venereum: Chlamydia trachomatis (tropical)
other malignancies (e.g. BCC, melanoma, adenocarcinoma, sarcoma)
herpes zoster
RARE
syphilis and yaws
Behçet’s syndrome
tuberculosis
xed drug eruption
dermatological disorders (e.g. pemphigus and pemphigoid)
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VULVAL ULCERATION/SORES 273
Ready reckoner
HSV Thrush Vulval dysplasia SCC Excoriated scabies
Fever, malaise Yes No No No No
Prodromal tingling Yes No No No No
Itchy No Ye s Ye s Possible Ye s
Vaginal discharge Possible Ye s No No No
Inguinal lymphadenopathy Ye s No No Possible No
Possible investigations
LI KE LY: Urinalysis, swab.
POSSIBLE: Fasting sugar or HbA1c, and (in secondary care) biopsy.
SMALL PRINT: Syphilis serology, patch testing.
Urinalysis: Glycosuria may be present in undiagnosed diabetes presenting with severe or
recurrent Candida infection. Fasting sugar or HbA1c to rule out or diagnose undiagnosed
diabetes.
Swab for microscopy and culture: May help in the diagnosis of various infections such
as HSV, Candida, chancroid, granuloma inguinale and lymphogranuloma venereum (if
STD suspected, then other relevant swabs and blood tests for coexistent infection will be
performed at GUM clinic).
Syphilis serology: If syphilis a possibility (Note: Serology may not become positive for up to
3 months aer infection).
Patch testing: May help in the diagnosis of allergic contact eczema.
Biopsy (in secondary care): For any persistent ulcer to conrm diagnosis – may reveal
carcinoma, vulval dysplasia or underlying skin disorder.
TOP TIPS
A diagnosis of HSV can be traumatic for a woman. Spend time discussing the nature of
the problem and its recurrent nature, including implications for sexual partners and future
pregnancies.
If the patient suers recurrent vulval ulceration, oer to see her as an ‘urgent’ during the next
attack to visualise the lesions and arrange microbiological testing.
In obscure cases do not conne the history and examination to the vulva. Lesions elsewhere
(e.g. with pemphigus or Behçet’s syndrome) may give the clue needed to make the diagnosis.
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274 SYMPTOM SORTER
History of travel and sexual contact with travellers is very important as there are a number
of ‘tropical’ causes.
e more straightforward causes (HSV and severe excoriated thrush) usually result in
multiple ulcers, with the diagnosis being obvious from the history and examination. Take
very seriously any single persistent vulval sore – signicant disease is likely.
If you suspect a sexually transmitted disease, refer urgently to the local GUM clinic for
appropriate investigations and contact tracing.
Remember the possibility of undiagnosed diabetes in severe Candida infection.
e pregnant woman near term with primary HSV is in danger of transmitting the virus
to her newborn – a situation with a signicant mortality and morbidity. Contact the
obstetrician urgently to arrange probable elective Caesarian section.
NOTES:
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275
HAIR AND NAILS
Abnormal nails 276
Excess body hair 279
Hair loss 282
Itchy scalp 285
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276
ABNORMAL NAILS
The GP overview
Women are far more likely to present with this symptom than men, oen for cosmetic
reasons. e likeliest queries relate to normal nails that break easily or are not smooth. Other
abnormalities may be detected during physical examination rather than being volunteered by
the patient, and may indicate signicant pathology.
Differential diagnosis
COMMON
psoriasis
fungal infection: onychomycosis
trauma to nail bed
trauma due to biting (also hang nail)
onychogryphosis (OG)
OCCASIONAL
trophic changes (Beau’s lines): appear 2–3 months aer severe illness
hand eczema
longitudinal ridging (onychorrhexis)
chronic paronychia
clubbing (various causes)
autoimmune disease (e.g. alopecia areata, lichen planus)
koilonychia (spoon nails): iron deciency anaemia and Plummer–Vinson syndrome
RARE
subungual melanoma
leuconychia (e.g. liver disease, diabetes)
lamellar nail dystrophy
yellow nail syndrome (may be accompanied by chronic bronchitis, bronchiectasis or pleural
eusion)
exfoliative dermatitis: nail shedding
nail dystrophy due to poor circulation (e.g. Raynaud’s disease)
epidermolysis bullosa
https://t.me/med1917
ABNORMAL NAILS 277
Ready reckoner
Trauma Psoriasis Fungal Biting OG
Pitting on nails No Ye s No No No
Nails symmetrically affected No Ye s No Possible No
Ragged edges No No No Ye s No
Increased thickness Possible Possible Ye s No Ye s
Friable and crumbly No Possible Ye s No No
Possible investigations
LI KE LY: Nail clippings for mycology.
POSSIBLE: Urinalysis, FBC.
SMALL PRINT: LF T, CXR .
Nail clippings for mycology may be the only way to dierentiate psoriatic nail dystrophy
and onychomycosis.
Urinalysis worthwhile if nails are unusually white: is can occur in diabetes.
FBC may conrm iron deciency anaemia in koilonychia.
LFT: To assess liver function in leuconychia.
CXR worthwhile if chest symptoms with clubbing or yellow nails.
TOP TIPS
Don’t conne your examination to the nails – useful clues may be found elsewhere, e.g.
patches of psoriasis or coexisting tinea corporis.
e commonest dierentials are psoriasis and fungal infections. e latter are usually
asymmetrical.
Patients usually worry about vitamin or calcium deciencies – these are never the real cause.
By the time Beau’s lines are obvious to the patient, 3 months or so will have passed from the
precipitating event – look back in the records for aetiological clues.
https://t.me/med1917
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