Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
.pdf
38 SYMPTOM SORTER
Explore the parents’ concerns – a child’s anxiety may be fed by parents unnecessarily
worryingabout sinister and unlikely diagnoses.
Talk to children alone – this may reveal relevant problems at home or school which they
would not have been able to admit in front of parents.
If recurrent UTI is a possibility, provide the parents with the necessary bottle and lab form
so that an MSU can be taken during the next episode of pain.
Infants with perceived abdominal pain are oen ta ken to various doctors and/or A&E. ey
may well end up with diagnoses of GORD, cow’s milk protein intolerance, infant colic or
some combination of these. It may take trials of treatment to ease the problem (which is
likely to resolve on its own given time anyway). But if the infant is otherwise unwell or not
thriving, it should be referred promptly for a paediatric opinion.
Organic disease is suggested by pain distant from the umbilicus which wakes the child and
which is associated with loss of appetite or weight, or a change in bowel habit.
Beware the unlikely event of an acute cause for the pain supervening, e.g. appendicitis,
torsion of the testis – ensure that parents know that a dierent, acute pain should not be
dismissed as ‘the same old problem’, but should be presented urgently.
Children proven to have a UTI should be managed according to NICE guidelines.
Avoid colluding in pa rental somatisation and overlooking the existence of fami ly dysfunction
or other causes of unhappiness.
Don’t forget the rare possibility of sickling in the appropriate ethnic groups.
NOTES:
https://t.me/med1917
39
VOMITING
The GP overview
Vomiting is one of the commonest reasons for an out-of-hours call – especial ly for children. While
most cases are self-limiting and benign, the possible causes are numerous and the symptoms can
herald serious pathology. Careful assessment is required, together with a willingness to review
and admit if the diagnosis remains unclear.
NOTE: Vomiting in infants is covered in a separate section.
Differential diagnosis
COMMON
gastroenteritis
acute vestibular neuronitis (and some other causes of acute vertigo)
upper respiratory tract infection (URTI) (in children, especially with marked coughing)
pregnancy
appendicitis and other causes of the acute abdomen
OCCASIONAL
hyper- and hypoglycaemia
intestinal obstruction
pyelonephritis
ureteric calculus
migraine
medication (e.g. antibiotics and cytotoxics)
RARE
gastroduodenal disease (e.g. pyloric stricture or stenosis, DU, carcinoma)
meningitis
cerebral haemorrhage
bulimia nervosa
severe constipation
raised intracranial pressure (e.g. tumour)
renal failure
acute glaucoma
https://t.me/med1917
40 SYMPTOM SORTER
Ready reckoner
Gastroenteritis Vestibular neuronitis URTI (child) Pregnancy Acute abdomen
Mainly mornings No No No Ye s No
With diarrhoea Ye s No Possible No Possible
Nystagmus No Ye s No No No
Bowel sounds increased? Ye s No No No Possible
Tender abdomen? Possible No Possible No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Urinalysis, MSU, pregnancy test, blood glucose, FBC, U&E.
SMALL PRINT: Lumbar puncture, abdominal X-rays, renal imaging, OGD, CT scan.
Urinalysis: High specic gravity suggests dehydration; glucose and ketones indicate
hyperglycaemia; blood, pus cells and nitrites suggest UTI (conrm with MSU); blood alone
might indicate a renal stone.
Pregnancy test: To conrm or reveal pregnancy.
Blood glucose: Will conrm hypo- or hyperglycaemia.
U&E: May be deranged by vomiting; may also reveal underlying renal failure.
FBC: Raised WCC suggests underlying infection or inammation. Haemoglobin (Hb) may
be reduced in malignancy. Raised platelets associated with oesophageal or stomach cancer.
Lumbar puncture, renal imaging, abdominal X-rays, OGD and CT scans: Required in a few
cases depending on the clinical picture and invariably arranged by the relevant specialist.
TOP TIPS
Vomiting in children tends to be presented early, when it may be dicult to give a denite
diagnosis. Be honest about this and make sure that parents know to call you again if the
symptom doesn’t settle or other ‘alarm’ symptoms develop – or arrange a denite time for
follow-up.
Remember to look for both the cause (i.e. the aetiology) and the eect (i.e. possible
dehydration) – especially in the very young and the very old, when the history may be
dicult to obtain and the eects of uid loss more marked.
Check to see if the patient is on any medication. is may be causing the vomiting, or it may
have serious implications for management (e.g. steroids).
Don’t forget pregnancy as a cause – the patient may be ‘ignoring’ the possibility.
https://t.me/med1917
VOMITING 41
Unless the diagnosis is obviously migraine, beware the patient with vomiting and a headache –
think of meningitis, subarachnoid haemorrhage or raised intracranial pressure.
Do not treat empirically with anti-emetics – these may mask the true diagnosis or cause
diagnostic confusion via side eects.
Have a low threshold for admitting diabetics. Whatever the cause of the vomiting, their
diabetes is liable to become uncontrolled.
Look for acid dental erosion as a clue to bulimia in recurrent vomiting.
Gastroenteritis should cause increased bowel sounds. In the patient with abdominal pa in and
vomiting, if bowel sounds are absent or scanty, the diagnosis is likely to be an acute abdomen.
NOTES:
https://t.me/med1917
42
VOMITING BLOOD
The GP overview
is presentation may vary from a few red streaks in gastric uid to copious quantities of bright
red blood. Blood static in the stomach for a few hours will change to look dark and granular,
like coee grounds. Always do a full urgent assessment, and be prepared for the sudden need
for resuscitation.
Differential diagnosis
COMMON
peptic ulcer (PU)/acute gastritis
Mallory–Weiss (M–W) tear
oesophageal varices (cirrhosis, usually alcoholic)
malignancy: oesophagus or stomach
GORD
OCCASIONAL
swallowed blood (nose bleeds obvious, haemoptysis less so)
foreign body or mediastinal tumour perforating oesophag us and aorta (including aneurysm)
haemobilia (blood in bile)
ingested poisons: corrosive acid and alkali, arsenic
blood dyscrasias (e.g. thrombocytopenia, leukaemia, haemophilia, aplastic anaemia)
RARE
ruptured oesophagus (acute vomiting or trauma)
spurious: deliberate swallowing and vomiting of blood (Munchausen’s syndrome)
gallstone perforation of duodenum
scurvy
polyarteritis nodosa, systemic lupus erythematosus (SLE)
https://t.me/med1917
VOMITING BLOOD 43
Ready reckoner
PU M–W tear Varices Cancer Oesophagitis
History of weight loss Possible No Possible Ye s No
Preceded by vomiting Possible Ye s No No No
Preceded by melaena Possible No Possible Possible Possible
Severe pain Ye s Possible No Possible Ye s
Signs of shock likely Ye s No Ye s Possible No
Possible investigations
ese will be done acutely in hospital, or in general practice aer an episode of haematemesis
when urgent admission is not indicated.
FBC: Essential for assessment of the degree of blood loss. A normal Hb does not exclude
a serious bleed as haemodilution may take several hours. Will also reveal blood dyscrasias.
Raised platelets associated with oesophageal or stomach cancer.
Upper gastrointestinal (GI) endoscopy is the gold standard for nding the cause of the bleed
and biopsy of suspicious lesions.
Helicobacter testing: In the presence of peptic ulceration.
LFT and γGT to assess liver function. Alcohol is a signicant contributory factor in many
cases.
Plain erect abdominal X-ray (in hospital) useful to look for signs of viscus perforation (air
under diaphragm) and, rarely, an ectopic gallstone.
TOP TIPS
Take a careful history – patients oen confuse vomiting up and coughing up blood.
If about to visit, ask the patient not to dispose of the evidence – viewing the vomit is worth
a thousand words of history.
Don’t forget the relevance of the patient’s drug history – non-steroidal anti-inammatory
drugs (NSAIDs), steroids and warfarin may all be associated with acute gastric erosions.
https://t.me/med1917
44 SYMPTOM SORTER
Tachycardia may be the only physical sign of a signicant GI bleed.
In all acute cases, admit unless the patient is perfectly well and the cause obvious and
insignicant (e.g. swallowed blood or very minor Mallory–Weiss tear).
e patient may not realise the signicance of coee-ground vomit or melaena – enquire
specically about these symptoms.
Troisier’s sign (enlargement of the le supraclavicular node) strongly suggests malignancy.
Oesophageal varices account for only 5% of cases, but 80% of mortality. Call for an
ambulance immediately and secure intravenous (IV) access if possible.
NOTES:
https://t.me/med1917
45
VOMITING IN INFANTS
The GP overview
is is not a problem that GPs anticipate with relish. And it is not only the potential impact on
clothes or carpet that they are worried about – in the acute scenario, the dierential is wide and
encompasses some serious illnesses. Ongoing vomiting is less of an urgent worry, with a narrower
range of possibilities.
Differential diagnosis
COMMON
URTI (vomiting secondary to coughing)
gastro-oesophageal reux/GORD
gastroenteritis
any acute febrile illness (e.g. otitis media, tonsillitis, UTI, meningitis, pneumonia)
cow’s milk protein intolerance
OCCASIONAL
feeding mismanagement (overfeeding)
pyloric stenosis
intussusception
other causes of bowel obstruction
RARE
metabolic
raised intracranial pressure
other causes of the acute surgical abdomen
diabetes
https://t.me/med1917
46 SYMPTOM SORTER
Ready reckoner
URTI Gastro-oesophageal
reux/GORD
Gastroenteritis Acute febrile
illness
CMPI
Recurrent No Ye s No No Ye s
Fever Possible No Possible Yes No
Diarrhoea Possible No Ye s Possible Possible
Positional No Ye s No No No
Infant off feeds Possible No Ye s Ye s No
Possible investigations
It is highly unlikely that the GP would arrange any investigations in this scenario. If the level
of concern or diagnostic uncertainty is such that the child needs investigating, then it would
need referral (usually urgently). Even if a UTI is suspected as the cause, then investigations in
primary care become academic – if the child is unwell enough to be vomiting with a UTI, then
it needs hospital assessment.
TOP TIPS
Take time to clarify the clinical picture. Many parents will describe orid vomiting when
they actually mean retching aer bouts of coughing. ey also have a tendency to call many
episodes of vomiting ‘projectile’, so take time to get them to describe what they mean.
In the acute situation, a precise diagnosis may be dicult and the consultation is more
about whether observation or admission is required. Work through the most relevant issues
systematically. Is the child dehydrated? Is this sepsis? Is it an acute abdomen? And, if all the
above are negative, is the child ill enough to require admission anyway?
Bear in mind that gastro-oesophageal reux and GOR D are not the same thing. e former
can be considered normal and self-limiting; the latter shares some features with simple reux
but also causes distress or other symptoms.
In ongoing vomiting in an otherwise well child, the likely diagnoses are feeding
mismanagement, GORD or CMPI.
https://t.me/med1917
VOMITING IN INFANTS 47
In the acutely ill child, use the NICE trac light system and sepsis screens early in your
assessment – if the child is seriously ill then it needs admission regardless of precise diagnosis.
Genuinely projectile vomiting in infants up to 2 or 3 months of age should be taken
seriously– pyloric stenosis needs excluding.
Bile stained vomiting , particularly with abdominal swelling, suggests intestinal obstruction.
Beware the vomiting infant with screaming episodes associated with pallor – this could be
intussusception.
Recurrent vomiting with failure to thrive requires a specialist opinion.
A bulging fontanelle, decreased responsiveness or rapidly increasing head circumference
associated with vomiting suggests raised intracranial pressure – this needs urgent assessment.
NOTES:
https://t.me/med1917
Соседние файлы в папке Библиотека им академика М.И. Перельмана