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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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278 SYMPTOM SORTER
Subungual melanoma is rare and is easily confused with the much more common subungual
haematoma. Possible pointers include nail destruction, extension of pigment onto the nail
fold and longitudinal bands of pigment. If in doubt, refer.
Clubbing is really an abnormality of the ngertips; if noted, be alert to signs of major
pulmonary or cardiac disease. Carcinoma of the lung is the commonest cause.
Don’t assume crumbly white nails are caused by fungus. Before embarking on lengthy
antifungal treatment, try to conrm the diagnosis with nail clippings.
Severely bitten nails may be a minor symptom of a major anxiety disorder. Be aware of the
possible need to explore psychological issues.
NOTES:
https://t.me/med1917
279
EXCESS BODY HAIR
The GP overview
is is dened as excess growth of terminal hair in women in male distribution sites (i.e. chin,
cheeks, upper lip, lower abdomen and thighs). It presents as a cosmetic problem. Ethnic origin
must be taken into account: Mediterraneans and Indians grow more than Nordics. Japanese,
Chinese and American Indians grow the least. In the UK, according to surveys, up to 15% of
women believe they have excess body hair, although only a minority present to the GP.
Differential diagnosis
COMMON
constitutional (physiological)
polycystic ovary syndrome (PCOS): 50% of cases
anorexia nervosa
menopause
iatrogenic (e.g. phenytoin, minoxidil, danazol, glucocorticoids)
OCCASIONAL
congenital adrenal hyperplasia (1 in 5000)
anabolic steroid abuse
ovarian tumours: arrhenoblastoma, hilus cell tumour, luteoma
adrenal tumours: carcinoma and adenoma
congenital (1 in 5000 live births) and juvenile hypothyroidism
RARE
acromegaly (incidence 3 per million)
porphyria cutanea tarda
Cushing’s syndrome (incidence 1–2 per million)
hypertrichosis lanuginosa
Cornelia de Lange syndrome (Amsterdam dwarsm)
https://t.me/med1917
280 SYMPTOM SORTER
Ready reckoner
Constitutional PCOS Anorexia Menopause Drugs
Excess vellous hair No No Ye s No Possible
Facial hirsutism Possible Possible No Ye s Possible
Oligo/amenorrhoea No Ye s Ye s Yes No
Otherwise well Ye s Ye s No Possible Possible
Weight loss No No Ye s No No
Possible investigations
LI KE LY: None.
POSSIBLE: Serum testosterone, SHBG, pelvic ultrasound, FBC, U&E, TFT.
SMALL PRINT: FSH/LH, other tests of endocrine function and specialised imaging techniques
(for adrenal/pituitary disorders), urinary porphyrins.
Serum testosterone and SHBG: Probably the most useful investigation. Mild elevation (up to
three times the normal value) and normal or low SHBG suggests PCOS; testosterone levels
above this indicate a possible tumour.
FBC, U&E: Possible iron deciency anaemia and electrolyte disturbance in anorexia; U&E
may be deranged in adrenal disorders.
FSH/LH and TFT: e former may help to conrm menopause and may point towards
PCOS (elevated LH, normal FSH); the latter reveals hypothyroidism.
Other tests of endocrine function and imaging techniques: To investigate possible adrenal
and pituitary disorders (usually undertaken in secondary care).
Pelvic ultrasound: Multiple ovarian cysts characteristic of PCOS; may also reveal ovarian
tumour.
Urinary porphyrins: For porphyria.
TOP TIPS
Mild, long-standing hirsutism does not require investigation.
Enquire about self-medication, especially in athletes – anabolic steroids may occasionally
be the cause.
Take the problem seriously and be prepared for questions about cosmetic treatments such as
bleaching, depilatory creams and electrolysis.
https://t.me/med1917
EXCESS BODY HAIR 281
Sudden and severe hirsutism is the most important marker for serious underlying pathology.
Other clues suggesting a possible hormone-secreting tumour include amenorrhoea, onset of
baldness at the same time as hirsutism and a patient who seems generally unwell.
Consider psychological factors: Hirsutism can cause – or be the presenting complaint in –
signicant depression.
Recent onset of signicant headache and visual eld defect raise the possibility of a pituitary
adenoma.
NOTES:
https://t.me/med1917
282
HAIR LOSS
The GP overview
A distressing symptom for both genders: Young men may fret about self-image, and women are
horried at the cosmetic disaster unfolding. e psychological signicance of increased hairfall
is all too easy to overlook in a typical busy surgery. Take care to acknowledge that the problem
is being taken seriously.
Differential diagnosis
COMMON
androgenic alopecia (male pattern baldness)
seborrhoeic dermatitis
alopecia areata
contact allergic dermatitis
tinea capitis
OCCASIONAL
bacterial folliculitis
telogen euvium
endocrine: myxoedema, hypopituitarism and hypoparathyroidism
traction alopecia
lupus erythematosus
iatrogenic (e.g. chemotherapy, anticoagulants)
RARE
secondary syphilis
trichotillomania
morphoea
malnutrition
https://t.me/med1917
HAIR LOSS 283
Ready reckoner
Androgenic Seborrhoeic dermatitis Alopecia areata Allergic dermatitis Tinea capitis
Normal scalp Yes No Yes No No
Abnormal skin on body No Possible No Possible Possible
Exclamation mark hairs No No Yes No No
Patchy hair thinning Yes (M) Ye s Ye s Ye s Ye s
No (F)
Scaling and weeping No Ye s No Possible Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Wood’s light test, hair and scales for mycology.
SMALL PRINT: FBC, ESR/CRP, U&E, TFT, FSH/LH, prolactin, autoimmune tests, syphilis
serology.
Microsporum infections will uoresce green under a Wood’s (UV) light.
Send scrapings and hair for mycology if the scalp looks abnormal.
FBC, ESR/CRP and autoimmune tests may help identify autoimmune causes, e.g. SLE.
Syphilis serology: Old-fashioned, but syphilis is on the increase.
U&E, TFT, FSH/LH, prolactin will eectively screen for endocrinopathy.
TOP TIPS
Alopecia areata is occasionally associated with other autoimmune diseases. Further
assessment is sensible, even at a later consultation.
Remember that in telogen euvium, the traumatic event – such as a signicant illness
or childbirth – will have taken place about 4 months before the onset of hair loss, so the
connection is unlikely to be made by the patient.
e patient invariably fears total hair loss – ensure that this is broached and that a realistic
prognosis is given.
Lymphadenopathy in association with alopecia may suggest an infective process – consider
bacterial folliculitis.
https://t.me/med1917
284 SYMPTOM SORTER
Alopecia areata has a particularly poor prognosis if there are several patches, there is loss of
eyebrows or eyelashes, or if it begins in childhood.
Scarring a lopecia should prompt the clin ician to look for general signs of lupus erythematosu s.
Trichotillomania in children is usually simply due to habit; in adults, though, it is more oen
a sign of signicant psychological disturbance.
NOTES:
https://t.me/med1917
285
ITCHY SCALP
The GP overview
is might appear a mundane symptom to the GP, but it can cause the patient signicant
distress. It’s usually a welcome presentation, as it’s perceived as a quickie – one of those problems
in which a brief examination can be performed at the same time as an equally brief history. is
approach generally pays dividends, but the problem can sometimes be more complicated than
it might at rst appear.
Differential diagnosis
COMMON
head lice
seborrhoeic eczema
psoriasis
lichen simplex
impetigo (may be underlying head lice or eczema)
OCCASIONAL
allergic/contact eczema
other fungal infections
RARE
stress/depression
viral infection (e.g. chickenpox – a common problem but only rarely presents with scalp itch)
https://t.me/med1917
286 SYMPTOM SORTER
Ready reckoner
Head lice Seborrhoeic eczema Psoriasis Lichen simplex Impetigo
Scaly scalp No Yes Ye s Possible No
Pustular lesions Possible No No No Ye s
Skin lesions elsewhere No Possible Possible Possible Possible
Visible egg cases Ye s No No No No
Chronic problem No Possible Ye s Possible No
Possible investigations
It is highly unlikely that any investigations will be required at all. Conrmation of a fungal
infection may be obtained via uorescence under a Wood’s light or by microscopy and culture
of scalp and hair samples.
TOP TIPS
Whatever the actual diagnosis, scratching will perpetuate or complicate the problem and so
should be discouraged.
Consider examining the skin and nails, as these may provide useful additional clues.
e diagnosis in a child is very likely to be head lice; the list of dierentials increases the
older the patient.
Scalp impetigo in a child – particularly if it relapses rapidly – suggests an underlying problem
such as head lice or eczema. is needs treating too, or the symptom will persist.
In an otherwise puzzling case, consider psychological causes – stress and depression can
sometimes present with scalp itching.
NOTES:
https://t.me/med1917
287
LIMBS
Acute single joint pain 288
Arm and shoulder pain 291
Calf pain 294
Foot pain 297
Hand and wrist pain 300
Hand and wrist swellings 303
Leg ulcers 306
Limp in a child 309
Multiple joint pain 312
Painful muscles 315
Recurrent hip area pain in an adult 318
Recurrent knee pain 321
Swollen ankles 324
Swollen calf 327
https://t.me/med1917
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