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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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368
MOUTH ULCERS
The GP overview
is symptom may oen make a GP feel baed – largely because it tends to be overlooked, or
dealt with only briey, during medical training. In fact common causes are simple to detect
and treat, and it is clearly important to spot the occasional serious problem at an early stage.
Examination could hardly be simpler, and a dentist may well have a clearer idea if referral is
necessary in more obscure cases.
Differential diagnosis
COMMON
trauma
recurrent aphthous ulceration (RAU)
acute necrotising ulcerative gingivitis (ANUG)
thrush
deciency states (iron, B
12
and folate)
OCCASIONAL
Coxsackie virus: herpangina, hand, foot and mouth
inammatory bowel disease: ulcerative colitis and Crohn’s disease
coeliac disease
herpes simplex and zoster
glandular fever (EBV): infectious mononucleosis
erosive lichen planus
RARE
carcinoma: squamous cell, salivary gland
autoimmune: Behçet’s syndrome, pemphigoid, pemphigus, bullous erythema multiforme
syphilitic chancre or gumma
leukaemia, agranulocytosis (may be iatrogenic)
tuberculosis
HIV infection
https://t.me/med1917
MOUTH ULCERS 369
Ready reckoner
Trauma RAU ANUG Thrush Deciency states
Usually in crops No Ye s Possible Ye s Ye s
White buccal plaques No No No Ye s No
Bleeding gums No No Yes No No
Mucosal pallor No No No No Ye s
Recurrent Yes Ye s No No Possible
Possible investigations
LI KE LY: FBC, ferritin.
POSSIBLE: Urinalysis, vitamin B
12
and folate, coeliac screen.
SMALL PRINT: Swab, autoantibody screen, syphilis and HIV serology, biopsy.
FBC: Essential basic investigation for anaemia and rarer blood dyscrasias. Ferritin for iron
deciency.
Urinalysis: Check for glycosuria. Underlying diabetes may predispose to infective causes
(especially Candida).
Vitamin B
12
and folate: To establish underlying vitamin deciency (especially if MCV raised).
Coeliac screen: Anti-endomysial and anti-gliadin antibod ies suggest coeliac disease if positive.
Swab: May help conrm doubtful diagnosis of ANUG – conrms presence of Vincent’s
organisms.
Autoantibody screens and HLA tests may be useful if autoimmune causes are suspected.
Syphilis or HIV serology: If syphilis or HIV are suspected.
Biopsy: Required in persistent ulcer of uncertain aetiology (secondary care investigation).
TOP TIPS
Consider vitamin or iron deciency, especially if the patient has glossitis and ang ular cheilitis
as well as oral ulceration.
e patient with sore, ulcerated gums and foul halitosis has ANUG; the smell is sometimes
apparent as soon as the patient walks in.
Patients with RAU oen believe they are suering from a vitamin deciency; in fact, this
is rarely the case, but be sure to broach this with them and consider a blood test as this may
reinforce your reassurance.
Enquire about skin problems elsewhere in an obscure case – this may give a clue to the precise
diagnosis.
Faucial ulceration and petechial haemorrhages of the so palate and pharynx are likely to
be caused by glandular fever.
https://t.me/med1917
370 SYMPTOM SORTER
A solitary, persistent and oen painless ulcer could be malignant – especially in smokers.
Refer urgently to the oral surgeon for biopsy.
Ask about bowel function – diarrhoea, abdominal pain and bloodstained stools with mucus
suggest associated inammatory bowel disease.
Don’t forget to enquire about medication – blood dyscrasias are a rare but signicant side
eect of some treatments (e.g. carbimazole), and oral ulceration may be the rst sign.
Oral candidiasis is common in the debilitated and those with dentures, but much less so
in the otherwise apparently t. In the latter cases consider underlying problems such as
immunosuppression or diabetes.
NOTES:
https://t.me/med1917
371
PAINFUL TONGUE
The GP overview
Pain in the tongue is usually caused by something immediately apparent on examination, but
there are a few less obvious causes. is is something much more likely to be seen by a dentist,
but is not strictly dental and therefore a working knowledge of the symptom is rmly within
the GP remit.
Differential diagnosis
COMMON
geographic tongue (benign migratory glossitis): painful in some cases
candidal infection (e.g. post-antibiotic, steroids and uncontrolled diabetes)
trauma (bitten, burnt from hot food or drink)
anaemia: iron, vitamins B
6
and B
12
, and folate deciency
aphthous ulceration
OCCASIONAL
viral infection (e.g. herpes simplex, hand, foot and mouth)
median rhomboid glossitis (supercial midline glossitis)
burning mouth syndrome (also known as glossodynia)
ssured tongue (doesn’t commonly cause pain)
glossopharyngeal neuralgia
lichen planus
RARE
carcinoma of the tongue
Behçet’s disease
pemphigus vulgaris
drugs (e.g. mouthwashes, aspirin burns)
Moeller’s glossitis
https://t.me/med1917
372 SYMPTOM SORTER
Ready reckoner
Geographic Candida Trauma Anaemia Aphthous ulcer
Depapillation Ye s Possible No Possible No
White plaques No Possible No No No
Localised pain No No Ye s No Ye s
Pale mucosae No No No Ye s No
Recurrent Ye s Possible No Possible Ye s
Possible investigations
LI KE LY: FBC.
POSSIBLE: Vitamin B
12
, folate and ferritin assays, swab.
SMALL PRINT: Biopsy.
FBC initially to screen for anaemia.
Vitamin B
12
, folate and ferritin assays: If indicated by FBC.
Swab of tongue may be helpful if appearance not obviously candidal.
Biopsy of suspicious lesion to determine diagnosis (especially if possible carcinoma or
pemphigus).
TOP TIPS
Take note of self-medication. Aspirin sucked for toothache can cause a mucosal burn.
A long history of soreness with spicy or bitter foods suggests geographic tongue or median
rhomboid glossitis.
A miserable, mildly febrile child with a painful tongue caused by numerous ulcers is likely to
have a viral infection such as herpes simplex or hand, foot and mouth disease.
Check the skin for other lesions in obscure cases – this may reveal the diagnosis (e.g.
pemphigus, lichen planus).
Patients with recurrent aphthous ulcers oen erroneously believe they are decient in
vitamins – broach this concern with them.
https://t.me/med1917
PAINFUL TONGUE 373
If an ulcer in an adult fails to heal within a few weeks of presentation, refer urgently (though
most oral neoplastic lesions are initially painless).
e border of geographic tongue changes shape within weeks. is is not the case with more
serious pathology.
In candidal infections without an obvious cause, consider underlying diabetes or
immunosuppression.
Glossodynia characteristically produces burning pain on the tip of the tongue – a ‘burner’ is
a dentist’s heartsink and the symptom may signify underlying depression.
NOTES:
https://t.me/med1917
https://t.me/med1917
375
PELVIC
Acute pelvic pain 376
Chronic pelvic pain 379
Groin swellings 382
https://t.me/med1917
376
ACUTE PELVIC PAIN
The GP overview
is is nearly always seen in women rather than men. In its mildest form it is experienced
universally at some time or other associated with periods, ovulation or sexual intercourse. In
its severest form it is the commonest reason for urgent laparoscopic examination in the UK.
Differential diagnosis
COMMON
acute pelvic inammatory disease (PID)
urinary tract infection (UTI)
miscarriage
ectopic pregnancy
ovarian cysts: torsion, rupture
OCCASIONAL
pelvic abscess (appendix, PID)
endometriosis
pelvic congestion (exacerbation of pelvic pain syndrome)
prostatitis (men)
functional (psychosexual origin)
RARE
misplaced IUCD (perforated uterus)
referred (e.g. spinal tumour, bowel spasm)
proctitis
invasive carcinoma of ovaries or cervix
broid degeneration
strangulated femoral or inguinal hernia
https://t.me/med1917
ACUTE PELVIC PAIN 377
Ready reckoner
PID UTI Miscarriage Ectopic Ovarian cyst
Abnormal vaginal bleeding Possible No Ye s Possible No
Purulent discharge PV Ye s No No No No
Fever Ye s Ye s No No No
Palpable mass No No Possible No Possible
Tender uterus PV Ye s No Possible No No
Possible investigations
LI KE LY: HVS, cervical swab, urinalysis, MSU.
POSSIBLE: FBC, ESR/CRP, pregnancy test, ultrasound, laparoscopy (all usually arranged by
hospital admitting team).
SMALL PRINT: None.
Urinalysis: Look for nitrites and pus cells to make diagnosis of UTI.
MSU will conrm UTI and guide antibiotic treatment.
HVS for bacteria including gonococcus and endocervical swab for Chlamydia if purulent
discharge present.
ESR/CRP: Elevated in PID.
Pregnancy test: Positive in ectopic and miscarriage.
FBC: Raised WCC helps conrm PID and UTI if not being admitted. Also elevated in
pelvic abscess.
Urgent ultrasound helpful if miscarriage or ectopic pregnancy suspected.
Cases referred to hospital are likely to undergo laparoscopy.
TOP TIPS
In miscarriage, pain follows bleeding. In ectopic pregnancy, the sequence is usually reversed.
Remember that there may be no bleeding with an ectopic pregnancy – or that the vaginal
loss may be a light, blackish discharge.
PV bleeding will cause haematuria on urinalysis. Only diagnose UTI if the symptoms are
suggestive and urinalysis also shows nitrites and pus cells.
https://t.me/med1917
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