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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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328 SYMPTOM SORTER
Ready reckoner
Cellulitis Swollen ankles Muscular Baker’s cyst DVT
Fever Ye s No No No Possible
Bilateral Possible Possible No No Possible
Sudden pain No No Yes Possible Possible
Previous swelling behind knee No No No Ye s No
Skin red Ye s Possible No No Possible
Possible investigations
LI KE LY: None (unless sent to hospital).
POSSIBLE: FBC, ESR/CRP and other investigations for swollen ankles (see p. 322); usually in
hospital – D-dimer, ultrasound, venography.
SMALL PRINT: None.
FBC, ESR/CRP: Elevated white cell count and ESR/CRP in cellulitis.
D-dimer: Raised level suggests DVT but is not conclusive.
Ultrasound: May help diagnose DVT and useful in conrming ruptured Baker’s cyst as the
cause. Venography necessary to conrm DVT in some cases.
TOP TIPS
e swelling resulting from a muscle rupture can be impressive – but a typical history with
pain (described as ‘like being shot in the calf’) preceding the swelling should clinch the
correct diagnosis.
Varicose eczema is oen misdiagnosed as cellulitis. Clues are that it is commonly bilateral,
itches more than hurts and is not accompanied by fever. To complicate matters, varicose
eczema can become infected, causing cellulitis.
Anxiety about possible DVT may cloud the presentation – careful questioning may reveal
that swelling is, in fact, long-standing and/or bilateral, making DVT very unlikely.
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SWOLLEN CALF 329
Patients with unexplained DVT are three to four times more likely than controls to have
an underlying malignancy – so, once the DVT has been dealt with, consider appropriate
investigation.
In high-risk patients – such as those who have just returned from a long haul ight – your
index of suspicion for DVT should be raised.
When the history suggests muscular rupture, ensure that the Achilles tendon is intact.
NOTES:
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331
NECK
Difculty swallowing 332
Hoarseness 335
Neck lumps 338
Sore throat 341
Stiff neck 344
Stridor in children 347
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332
DIFFICULTY
SWALLOWING
The GP overview
is symptom can mean several things, and a careful history is necessary to tease out the precise
problem: Diculty in initiating swallowing; a sensation of food sticking somewhere; painful
swallowing; also included here is the sensation of ‘something in the throat’ even when not trying
to swallow anything.
Differential diagnosis
COMMON
globus hystericus
any painful pharyngeal condition, e.g. pharyngitis
GORD
benign stricture
oesophageal carcinoma
OCCASIONAL
pharyngeal pouch
pharyngeal carcinoma
compression by mediastinal tumours (e.g. lymphoma, bronchial carcinoma)
oesophageal achalasia
gastric carcinoma
xerostomia (the elderly, post-parotidectomy and Sjögren’s syndrome)
foreign body
drugs: NSAID-associated oesophagitis, failure to take bisphosphonate tablets correctly
RARE
Plummer–Vinson syndrome
Chagas’s disease (South American trypanosomal infection)
scleroderma (CREST syndrome), polymyositis and dermatomyositis
neurological disorders (e.g. myasthenia gravis, bulbar palsy)
motor neurone disease
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DIFFICULTY SWALLOWING 333
Ready reckoner
Globus GORD Stricture Oesophageal
carcinoma
Painful
pharynx
Weight loss No No Possible Ye s No
Intermittent Ye s Yes No No No
Progressive No No Ye s Ye s No
Reux of unchanged food No No Possible Ye s No
Retrosternal pain No Yes Possible Possible No
Possible investigations
LI KE LY: (Unless obvious globus or local pharyngeal cause) FBC, ESR/CRP, barium swallow or
endoscopy.
POSSIBLE: CXR, LFT.
SMALL PRINT: Pharyngea l swab, CT scan thorax, videouoroscopy, oesophageal motility studies.
FBC and ESR/CRP: May reveal evidence of malignancy or iron-deciency anaemia.
LFT if malignancy suspected: Abnormality suggests hepatic spread.
Barium swallow useful in the frail and to safely demonstrate stricture or motility problems
if no absolute dysphagia for liquids (risk of aspiration).
Flexible upper GI endoscopy allows visualisation and biopsy of suspicious lesions.
roat swab occasionally helpful in painful pharyngeal lesions.
CXR if suspicion of mediastinal tumour of any cause.
CT scan or further imaging may be arranged by the specialist to further dene mediastinal
tumours.
Videouoroscopy and oesophageal motility studies: Hospital-based tests which may be
required, particularly if a neurological or muscular cause is suspected.
TOP TIPS
A young patient under stress who can swallow food and drink without problems but who
feels there is ‘something stuck ’ almost certainly has globus. Reassurance usually resolves the
situation.
Remember to ask about medication – recent onset of painful dysphagia may be caused
by severe oesophagitis secondary to drugs such as alendronate, NSAIDs and slow-release
potassium supplements.
Take time with the history – diculty in swallowing can mean a number of dierent
things, and the diagnosis is much more likely to be revealed by careful questioning than by
examination.
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334 SYMPTOM SORTER
Recent onset of progressive dysphagia with weight loss in an elderly patient is caused by
oesophageal carcinoma until proved otherwise.
A palpable hard lymph node in the le supraclavicular fossa (Troisier’s sign) is strongly
associated with gastric carcinoma.
Beware of patients who have a long history of oesophagitis but who complain of increasing
or unusual dysphagia – they may have developed a stricture, or even a carcinoma.
If endoscopy does not reveal a cause but the symptom continues, remember rarer causes, such
as extrinsic compression on the oesophagus or a neurological problem. Consider a barium
swallow, or referral to a neurologist if there are other neurological symptoms or signs.
NOTES:
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335
HOARSENESS
The GP overview
Hoarseness may start suddenly and last a few days (acute), or arise gradually and continue for
weeks or months (chronic). e history wil l clarify t his and point the way forward in manag ement.
Acute hoarseness rarely causes any diagnostic problem or concern; the less common chronic case
raises more worrying possibilities and usually requires referral.
Differential diagnosis
COMMON
acute viral laryngitis
voice overuse (shouting, screaming)
hypothyroidism
smoking
sinusitis
OCCASIONAL
GORD
benign tumours: singer’s nodes, polyps
crico-arytenoid rheumatoid arthritis
functional (hysterical) aphonia
RARE
acute epiglottitis
laryngeal carcinoma
recurrent laryngeal nerve palsy
physical trauma (e.g. aer intubation)
chemical inhalation trauma
rare inammatory lesions (e.g. TB, syphilis)
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336 SYMPTOM SORTER
Ready reckoner
Acute laryngitis Overuse Hypothyroidism Smoking Sinusitis
Recent illness Ye s No Possible No Ye s
Tired, cold and slowed up No No Yes No No
Fever and malaise Possible No No No Ye s
Symptoms chronic No Possible Ye s Ye s No
Facial pain and catarrh No No No No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: TFT, CXR, direct or indirect laryngoscopy.
SMALL PRINT: roat swab.
TFT: In chronic hoarseness to exclude hypothyroidism.
CXR: To check for thoracic lesions causing recurrent laryngeal nerve palsy.
Indirect laryngoscopy: Useful for a GP with the necessary skills; most will refer to an ENT
specialist.
Direct laryngoscopy: Using a exible bre-optic endoscope. is is a specialist investigation
allowing close-up views and biopsy of suspicious lesions.
roat swab: Useful, very rarely, if hoarseness is associated with a persisting pharyngitis.
TOP TIPS
In acute laryngitis, don’t forget to tell the patient to rest the voice, and remember that
occupational factors are important – use of voice (e.g. by telephonists) or working in smoky
environment (e.g. a pub) will aggravate and prolong symptoms, causing diagnostic confusion.
If you suspect a malignancy, arrange an urgent CXR immediately prior to referral. e
referral can then be made to the correct specialist (chest rather than ENT) if a lung lesion is
present, thus expediting appropriate management.
Don’t forget transient hoarseness caused by intubation – GPs are seeing this increasingly
oen as patients spend less post-operative time in hospital.
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HOARSENESS 337
Every adult patient with persistent, unexplained hoarseness has carcinoma of the larynx
until proved otherwise.
GORD is a common cause in the elderly, but beware of making this diagnosis without
specialist investigation rst.
Epiglottitis is rare but if you suspect it in any patient, admit immediately – and don’t examine
the throat.
Hypothyroidism is easily overlooked – prompt diagnosis can save unnecessary anxiety and
investigation.
NOTES:
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