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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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308 SYMPTOM SORTER
Deep ulcers involving deep fascia, tendon, periosteum or bone may well have an arterial
component.
Mixed ulcer aetiology may confuse the clinical picture and make treatment choices harder.
Refer for a specialist opinion if in any doubt.
More than 50% of leg ulcer patients are sensitive to one or more allergens, including lanolin,
topical antibiotics, cetyl stearyl alcohols, balsam of Peru and parabens. ese may contribute
to non-healing and cause discomfort to the patient. Refer the patient for patch testing if
dermatitis is associated with a leg ulcer.
Topical antibiotics do not contribute to healing and are frequent sensitisers – avoid using
them.
Pain from an ulcer is most frequently associated with an arterial aetiology.
Beware neoplastic change in an existing ulcer. is is rare, but not to be missed. Consider
referral for biopsy if the ulcer has an atypical appearance or fails to improve with treatment.
Compression bandaging is dangerous in diabetes and arterial insuciency. Do not prescribe
it until they are ruled out. If in doubt about ABPI, refer for a vascular opinion.
NOTES:
https://t.me/med1917
309
LIMP IN A CHILD
The GP overview
is is an infrequent but alarming presentation, as it may herald signicant pathology and may
be dicult to manage properly in an uncooperative toddler. Assessment should be methodical
and patient, and follow-up arranged unless the diagnosis is obvious at the outset.
Differential diagnosis
COMMON
trauma, including foreign body in foot (especially toddlers)
irritable hip (transient synovitis)
acute viral infection with arthralgia
pauciarticular juvenile chronic arthritis (JCA: 1 in 1000)
slipped femoral epiphysis (usually over 10 years old)
OCCASIONAL
Perthes’s disease (1 in 2000 between 4 and 10 years old)
septic arthritis
idiopathic scoliosis
congenital dislocation of the hip
acute lower abdominal pain: especially appendicitis
unequal leg length
neurological (e.g. cerebral palsy)
RARE
acute osteomyelitis
rheumatic fever
autoimmune disorders (e.g. SLE, dermatomyositis)
rickets
genuine juvenile rheumatoid arthritis
malignancy aecting bone
Duchenne’s muscular dystrophy
https://t.me/med1917
310 SYMPTOM SORTER
Ready reckoner
Trauma Irritable hip Viral infection JCA Slipped epiphysis
Fever No Possible Ye s Possible No
Sudden onset Ye s Possible Possible No Ye s
Stiff in early morning No No No Ye s No
Usually over 10 years old No No No No Yes
Many joints affected No No Yes Possible No
Possible investigations
LI KE LY: FBC, ESR/CRP, X-ray.
POSSIBLE: Autoimmune screen.
SMALL PRINT: Calcium, phosphate, alkaline phosphatase, creatine kinase, ASO titre, blood
culture.
FBC and ESR/CRP: WCC and ESR/CRP elevated in an underlying inammatory or
infective cause.
Hip X-ray: May reveal fracture, slipped femoral epiphysis, congenital dislocation, Perthes’s
and other signicant disorders – but may be normal in the presence of serious pathology.
Rheumatoid factor and autoimmune screen may be helpful if a connective tissue disorder
is suspected.
Serum calcium, phosphate and alkaline phosphatase: Calcium and phosphate low, alkaline
phosphatase high in rickets.
Creatine kinase: Markedly elevated in muscular dystrophy.
ASO titre is raised in 80% of cases of rheumatic fever.
In hospital, blood culture may identify the infecting organism in osteomyelitis and septic
arthritis.
TOP TIPS
Never forget to examine the soles of the feet and between the toes for obvious and potentially
simple to treat, non-serious causes of limp.
It’s worth investing some time gaining the child’s condence – this will enable you to make
a proper assessment and feel positive about your management.
Parents may try to rationalise the symptom by recalling a recent minor episode of trauma
which is likely to be purely coincidental.
Don’t forget referred pain. Hip pathology can cause pain in the knee.
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LIMP IN A CHILD 311
Marked restriction of movement and/or dramatic bony tenderness suggests a signicant
problem – especially fracture, septic arthritis and osteomyelitis.
Fever with a limp requires an urgent specialist opinion. Admit to exclude osteomyelitis or
septic arthritis.
Beware the obese pubertal boy with groin pain and a limp – slipped femoral epiphysis is
likely.
Do not conne your assessment to the hip – for example, abdominal pain, especially
appendicitis, can make a child limp.
NOTES:
https://t.me/med1917
312
MULTIPLE JOINT PAIN
The GP overview
e range of causes of multiple joint pain spans acute, chronic and chronic relapsing conditions.
e diculty for the GP is siing through the wide dierential and spotting early signicant
disease that requires prompt referral.
Differential diagnosis
COMMON
rheumatoid arthritis (RA)
psoriatic arthropathy
viral polyarthritis (e.g. hepatitis, rubella)
connective tissue diseases (e.g. SLE, systemic sclerosis, polyarteritis nodosa, giant cell
arteritis)
multiple osteoarthritis (OA)
OCCASIONAL
the spondoarthritides: ankylosing spondylitis, Reiter’s disease, enteropathic arthritis,
Behçet’s syndrome, juvenile chronic arthritis
Henoch–Schönlein syndrome
malignancy (usually secondary)
iatrogenic: corticosteroid therapy, isoniazid, hydralazine
hypertrophic pulmonary osteoarthropathy (due to lung cancer)
sarcoidosis
RARE
sickle-cell crisis
amyloidosis
rheumatic fever
atypical systemic infections (e.g. Lyme disease, Weil’s disease, brucellosis, syphi lis [secondary])
decompression sickness (the bends)
https://t.me/med1917
MULTIPLE JOINT PAIN 313
Ready reckoner
RA Psoriasis Viral Connective tissue OA
Symmetrical Ye s Possible Possible Possible Possible
Rash No Ye s Possible Possible No
Fever, malaise Possible No Ye s Possible No
Young patient Possible Possible Possible Possible No
Self-limiting No No Ye s No No
Possible investigations
LI KE LY: FBC, ESR/CRP, autoantibodies.
POSSIBLE: Urinalysis, U&E, HLA-B27, joint X-rays, synovial uid aspiration.
SMALL PRINT: Blood lm, serology, CXR, bone scan, bronchoscopic biopsy or nodal aspiration.
FBC, ESR/CRP, blood lm: WCC and ESR/CRP raised in acute inammation and
infection. Anaemia of chronic disease may be seen, and blood lm will reveal sickle cell.
Autoantibodies: Rheumatoid factor is positive in most cases of RA (if negative, consider
measuring anti-CCP), but is also positive in many autoimmune diseases and chronic
infections; antinuclear factor is positive in 98% of cases of SLE but a similar result is obtained
in 30% of cases of RA and also in many other diseases.
Urinalysis: May reveal proteinuria or haematuria if there is renal involvement in connective
tissue disease.
U&E: To check for renal failure via renal involvement in multisystem connective tissue
disease.
HLA-B27: A high prevalence in spondoarthritides.
Serology: May be useful to diagnose viral, or atypical systemic, infections. ASO titres, if
rising, suggest recent streptococcal infection (e.g. in rheumatic fever).
Joint X-rays: Hand X-rays may show characteristic features helping to distinguish between
RA and psoriatic arthritis; pelvic and lumbar spine X-rays may show the typical changes of
ankylosing spondylitis (if negative, and clinical suspicion high, a bone scan may be helpful);
X-rays of aected joints may conrm clinical diagnosis of OA.
CXR: May reveal lung malignancy.
Synovial uid analysis: Helps distinguish inammatory from infective and crystal
arthropathies.
Bronchoscopic biopsy or nodal aspiration: For sarcoidosis.
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314 SYMPTOM SORTER
TOP TIPS
e connective tissue diseases can all aect almost every organ system. Take a full history so
as not to miss a clue or complication.
Check the skin as this may contribute to the diagnosis (e.g. scaly rash in psoriasis, buttery
rash in SLE, thickening of skin in sclerosis ).
Don’t overvalue autoimmune blood tests. Most diagnoses of arthritis are clinical, blood tests
simply providing conrmatory or prognostic information.
Suspect Reiter’s syndrome in a young male with an inammatory oligoarthritis of the lower
limbs.
An insidious onset of symmetrical polyarthritis in the 30–50 age range, with early morning
stiness, pain and swelling of hands and feet, suggests RA.
Pain in the wrists and ankles of a middle-aged or elderly smoker with clubbing and chest
symptoms strongly suggests hypertrophic pulmonary osteoarthropathy caused by underlying
lung cancer.
Don’t overlook the patient’s occupation as this may be relevant in certain cases – for example,
in vets and farm workers, brucellosis and Weil’s disease are possible infective causes.
NOTES:
https://t.me/med1917
315
PAINFUL MUSCLES
The GP overview
is symptom has a multitude of causes. A careful history is required to distinguish between
muscle and joint pain, and between muscle pain and weakness. In some of the underlying
pathologies, these symptoms may coexist. Cramp, causing very transient muscle pain, is covered
elsewhere (see Calf pain, p. 292).
Differential diagnosis
COMMON
overuse (including strain injury)
acute viral illness
depression
polymyalgia rheumatica (PMR)
side eects of statins (myalgia much more common than myositis)
OCCASIONAL
vitamin D deciency
referred joint pain (e.g. from hip to thigh, neck to shoulder, shoulder to arm)
bromyalgia
chronic fatigue syndrome
connective tissue disease (e.g. RA, SLE, polyarteritis nodosa [PAN], scleroderma)
peripheral vascular disease: intermittent claudication
neuropathy: diabetic, alcoholic
Bornholm disease (epidemic myalgia, devil’s grip)
hypothyroidism
drugs other than statins: clobrate, street drug withdrawal, chemotherapy, lithium,
cimetidine
RARE
HIV infection
polymyositis (usually more weakness than pain)
adult and childhood dermatomyositis
underlying malignancy
porphyria
Guillain–Barré syndrome and poliomyelitis
Lyme disease
https://t.me/med1917
316 SYMPTOM SORTER
Ready reckoner
Overuse Viral illness Depression PMR Statin side effect
Sudden onset Ye s Ye s No Possible Possible
Morning stiffness Ye s Possible No Ye s No
Vague generalised No Possible Ye s No Possible
Persistent No No Ye s Yes Ye s
Muscle tenderness Ye s Possible No Possible Possible
Possible investigations
LI KE LY: FBC, E SR/CRP.
POSSIBLE: Urinalysis, autoimmune blood tests, TFT, LFT, blood sugar or HbA1c, creatine
phosphokinase (CPK), vitamin D levels.
SMALL PRINT: Joint and chest X-rays, HIV test, Lyme disease serology; in secondary care,
angiography, electromyography, muscle biopsy, lumbar puncture, urinary porphyrins.
Urinalysis: Glycosuria in undiagnosed diabetes Proteinuria and/or haematuria may be
present in connective tissue disease.
FBC and ESR/CRP: Hb may be depressed in connective tissue disease and PMR. WCC
and ESR/CRP raised in any inammatory disorder (ESR more useful than CRP in PMR);
MCV elevated in hypothyroidism and alcohol abuse.
Autoimmune blood tests: May be helpful if connective tissue disorder suspected.
TFT: Will conrm hypothyroidism.
Blood sugar or HbA1c, LFT: e former to conrm diabetes; the latter may help in
conrming an alcohol problem. Both may cause a neuropathy resulting in muscle pain.
CPK: Raised in acute inammatory and viral myopathies.
Vitamin D levels: Vitamin D deciency is increasingly being recognised and may present
with muscle pain and/or weakness.
HIV test or Lyme disease serology: For HIV infection or Lyme disease.
Joint X-rays: If referred pain from primary joint pathology suspected.
Angiography: For peripheral vascular disease.
Electromyography and muscle biopsy (both in secondary care): To conrm diagnosis of
polymyositis or dermatomyositis.
Lumbar puncture: To examine CSF in hospital in suspected Guillain–Barré syndrome or
poliomyelitis.
Urinary porphyrins: To exclude porphyria.
Other investigations for suspected underlying malignancy (e.g. CXR).
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PAINFUL MUSCLES 317
TOP TIPS
In polysymptomatic patients with muscle pain but no objective signs and normal blood tests,
consider bromyalgia, depression and chronic fatigue (Note: ese problems may coexist).
e diagnosis of PMR is clinched by a trial of prednisolone (15 mg/day). In PMR, this
treatment should lead to total resolution of symptoms within a few days.
Muscle pain is more likely to be associated with signicant pathology in the very young and
old than the middle-aged, when psychological causes and overuse are the most likely.
Always remember PMR in the older patient complaining of aching pain and stiness in the
hip and shoulder girdle muscles which is worse in the mornings.
If considering PMR, or initiating treatment in this condition, enquire aer symptoms
of temporal arteritis. About 30% of patients develop this complication, and are at risk of
blindness.
Muscle pain with signicant and progressive weakness (e.g. diculty climbing stairs or
getting out of a chair) suggests polymyositis, hypothyroidism, vitamin D deciency or
malignancy.
Signicant underlying disease (e.g. PMR, polymyositis, dermatomyositis or connective tissue
disease) is likely if there is an arthritis associated with the muscle pain.
NOTES:
https://t.me/med1917
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