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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3156_Библиотеки_им_академика_М_И_Перельмана.pdf
8.5 Pleuritic Pain 158
8.6 Pneumothorax 160
8.7 Shortness of Breath 163
8.8 Stridor 167
8.9 Wheezing 170
Gastrointestinal Problems 173
Richard Fruehling
9.1 Abdominal Pain 173
9.2 Ascites 176
9.3 Constipation 179
9.4 Diarrhea 183
9.5 Dysphagia 189
9.6 Epigastric Distress 193
9.7 Upper Gastrointestinal Bleeding 197
9.8 Hepatitis 200
9.9 Hepatomegaly 204
9.10 Jaundice 208
9.11 Rectal Bleeding 210
9.12 Steatorrhea 213
Renal and Urologic Problems 216
David M. Quillen
10.1 Dysuria 216
10.2 Hematuria 217
10.3 Erectile Dysfunction 220
10.4 Urinary Incontinence 223
10.5 Nocturia 226
10.6 Oliguria and Anuria 228
10.7 Priapism 232
10.8 Scrotal Mass 233
10.9 Scrotal Pain 235
10.10 Urethral Discharge 238
Problems Related to the Female Reproductive System 242
Sanjeev Sharma
11.1 Amenorrhea 242
11.2 Breast Mass 243
11.3 Chronic Pelvic Pain 246
11.4 Dysmenorrhea 248
11.5 Dyspareunia 249
11.6 Menorrhagia 250
11.7 Nipple Discharge in Nonpregnant Females 254
11.8 Pap Smear Abnormality 256
11.9 Postmenopausal Bleeding 259
11.10 Vaginal Discharge 262
9
10
11
Contents
xxi
Musculoskeletal Problems 265
Allison M. Cullan
12.1 Arthralgia 265
12.2 Calf Pain 267
12.3 Hip Pain 270
12.4 Knee Pain 272
12.5 Low Back Pain 276
12.6 Monoarticular Joint Pain 279
12.7 Neck Pain 283
12.8 Polymyalgia 287
12.9 Shoulder Pain 290
Dermatologic Problems 294
Hassan Galadari
13.1 Alopecia 294
13.2 Erythema Multiforme 296
13.3 Maculopapular Rash 299
13.4 Pigmentation Disorders 301
13.5 Pruritus 305
13.6 Rash Accompanied byFever 307
13.7 Urticaria 309
13.8 Vesicular and Bullous Eruptions 310
Endocrine and Metabolic Problems 313
Arwa Abdulhaq Nasir
14.1 Diabetes Mellitus 313
14.2 Gynecomastia 316
14.3 Hirsutism 318
14.4 Hypothyroidism 320
14.5 Polydipsia 324
14.6 Thyroid Enlargement/Goiter 326
14.7 Thyroid Nodule 328
14.8 Hyperthyroidism/Thyrotoxicosis 330
14.9 Vitamin D Deficiency 333
Vascular and Lymphatic System Problems 335
Ashley Falk
15.1 Lymphadenopathy, Generalized 335
15.2 Lymphadenopathy, Localized 337
15.3 Petechiae and Purpura 339
15.4 Splenomegaly 341
12
13
14
15
xxii
Contents
Laboratory Abnormalities: Hematology and Urine Determinations 344
Carol A. LaCroix
16.1 Anemia 344
16.2 Eosinophilia 346
16.3 Erythrocyte Sedimentation Rate and C-Reactive Protein 348
16.4 Neutropenia 350
16.5 Polycythemia 352
16.6 Proteinuria 354
16.7 Thrombocytopenia 355
Laboratory Abnormalities: Blood Chemistry and Immunology 358
Nathan Falk
17.1 Alkaline Phosphatase, Elevated 358
17.2 Aminotransferase Levels, Elevated 363
17.3 Antinuclear Antibody Titer, Elevated 368
17.4 Brain Natriuretic Peptide 373
17.5 Elevated Creatinine 377
17.6 D-Dimer 382
17.7 Hypercalcemia 386
17.8 Hyperkalemia 390
17.9 Hypokalemia 394
Diagnostic Imaging Abnormalities 397
Enrique S. Fernandez
18.1 Abnormal Mammogram 397
18.2 Bone Cyst 400
18.3 Mediastinal Mass 402
18.4 Osteopenia 405
18.5 Solitary Pulmonary Nodule 409
INDEX 412
16
17
18
Contents
xxiii
Ten minutes for diagnosis? Really?
Yes, really!
If only we had 90 minutes to perform a diagnostic evaluation, as we did as third-year medi-
cal students on hospital rotations. Or, if we had even 30 minutes for diagnosis, as I recall from
internship. But those days are gone. Today—as clinicians practicing in the age of evidence-based,
cost-effective health care—office visits are of much shorter duration than in years past. For example,
in a recent study of 4,454 patients seeing 138 physicians in 84 practices, the mean visit duration
was 10 minutes (1). Another study of 19,192 visits to 686 primary care physicians estimated the
visit duration to be 16.3 minutes (2). Even when the total visit duration exceeds 10 minutes, the
time actually devoted to diagnosis—and not to greeting the patient, explaining treatment, doing
managed care paperwork, or even the patient’s dressing and undressing—is seldom more than
10 minutes.
So, if you and I generally have only 10 minutes per office visit for diagnosis, we need to be
focused, while remaining medically thorough and prudent. Actually, such an approach is possible
and is how experienced clinicians tend to practice. The following are some practice guidelines to
the 10-minute diagnosis (Dx10). And, to illustrate, let us consider a patient: Joan S., a 49-year-old
married woman, in your office for a first visit, whose chief complaint is severe, one-sided headaches that
have become worse over the past year. (For a more complete approach to the diagnosis of headache,
see Chapter 2.7.)
SEARCH FOR DIAGNOSTIC CUES THROUGHOUT THE CLINICAL ENCOUNTER
Note how the patient relates to the staff, takes off a jacket, and sits in the examination room. How
does the patient begin to describe the problem and what does he or she seem to want from the visit?
Who accompanies the patient to the office and who seems to do the talking?
Be sure to use “tell me about” open-ended questions. The inexperienced clinician moves early
to closed-ended “Yes” or “No” questions, but the veteran Dx10 clinician has learned that using nar-
row questions too early can lead to misleading conclusions, which are in the long run, at the least,
1.1
CHAPTER 1
Principles of the
10-Minute Diagnosis
Robert B. Taylor
Principles of the
10-Minute Diagnosis
Paul M. Paulman
This chapter appeared in the first volume of Taylor’s Diagnostic Manual. At that time, the title of the book was
The 10-Minute Diagnosis Manual. The editing team has elected to maintain Dr. Taylor’s chapter in the current
version of this book because its message is as pertinent now as it was when Dr. Taylor originally wrote it.
1
wasteful of time and, at worst, dangerous. An example would be attributing chest pain inappropri-
ately to gastroesophageal reflux disease because the patient has a past history of esophageal reflux
and responds affirmatively to questions about current heartburn and intolerance to spicy foods.
Watch the facial reaction to issues discussed. Tune in to hesitation and evasive answers and be
willing to follow these diagnostic paths, which may lead to otherwise hidden problems such as drug
abuse or domestic violence. In the case of Joan S., does she answer questions readily or does she seem
evasive when addressing some topics, such as family concerns or her home life?
THINK “MOST COMMON” FIRST
I remind medical students of the time-honored aphorism that “the most common problems occur
most commonly.” When working with a patient, the physician develops diagnostic hypotheses
early in the encounter. When faced with a patient with headache, we should initially consider
tension headache and migraine rather than temporal arteritis. Of course, the Dx10 clinician thinks
of special concerns, such as the possibility that the patient with headache might possibly have a
brain tumor. The initial history seeks the characteristics and chronology of the symptoms. Then
the clinician uses select questions that help rule in or out the diagnostic hypotheses: “What seems
to precede the headache pain?” “Has the nature or the severity of your pain changed in any way?”
The clinician also seeks important past medical, social, and family history: “What stress are you
experiencing that may be influencing your symptoms?” “Does anyone else in your family have a
headache problem?”
The physical examination should be limited to the body areas likely to contribute to the diag-
nosis, and a “full physical examination” is actually seldom needed. Therefore, for our patient with
recurrent headaches, Joan S., the Dx10 examination is likely to be limited to the vital signs, head, and
neck, with a screening of coordination, deep tendon reflexes, and cranial nerve function. Examination of
the chest, heart, and abdomen is unlikely to contribute to the diagnosis.
Tests should be limited to those that will help confirm or rule out a diagnostic hypothesis or,
later, those that would help make a therapeutic decision. For most patients with headache as a
presenting complaint, no laboratory test or diagnostic imaging is needed.
Of course, the uncommon problem occurs sometimes. Occasionally, you will encounter the
unexpected finding: the patient with headache having unanticipated unilateral deafness or the
fatigued individual with an enlarged spleen. Stop and think when you note a cluster of similar unex-
pected findings; such alertness helped clinicians identify the Muerto Canyon virus as the cause of the
1993 outbreak of the hantavirus pulmonary syndrome in southwestern United States and also the
occurrence of primary pulmonary hypertension in patients using dexfenfluramine for weight con-
trol. A few times in your career you will have the opportunity to experience a diagnostic epiphany;
the Dx10 clinician will seize this opportunity by staying alert for the unexpected diagnostic clue.
USE ALL AVAILABLE ASSISTANCE
In addition to your professional knowledge, experience, and time, your diagnostic resources include
your staff, the patient and his or her family, and the vast array of medical reference sources available.
Your office and hospital staff can be valuable allies in determining the diagnosis. Important
clues may be offered when the patient calls for an appointment or when being escorted to the
examination room. If a patient remarks to the receptionist or nurse that his chest pain is “just like
my father had before his heart attack” or if another wonders if her heartburn could be related to her
15-year-old daughter’s misbehavior, the staff member should ask the patient’s permission and then
share the information with the physician.
The patient and the family generally have some insight into the cause of symptoms such as
fatigue, diarrhea, or loss of appetite. In a study of patient’s differential diagnosis of cough, Bergh
found that while physicians considered a mean of 7.6 diagnostic possibilities, patients reported a
mean of 6.5 possibilities, with only 2.8 possibilities common to both (3). Joan S. and perhaps her
family may offer diagnostic suggestions that you have not strongly considered; also, these other hypotheses
represent concerns that should eventually be addressed to provide reassurance. For example, might Joan
be in the office today chiefly because an old friend has recently been diagnosed with brain cancer and she
has become concerned about the significance of her own headaches?
2
TAYLOR’S diffeRenTiAL diAGnOSiS MAnUAL
CONSIDER THE PSYCHOSOCIAL ASPECTS OF THE PROBLEM
To continue the case of the patient with headache, a migraine diagnosis is incomplete if it fails to
include the contribution of marital or job stress to the symptoms of family event cancellations, trips
to the emergency room, and large pharmacy bills for sumatriptan injections, as well as the impact
on others. No diagnosis of cancer or diabetes is complete without considering the impact on the
patient’s life and the lives of family members (4).
The Dx10 clinician will be especially wary of the International Classification of Diseases, Ninth
Edition (ICD-9) diagnostic categories, which facilitate statistical analysis and managed care pay-
ments, but lack the richness of narrative and also the personal and family context. For example,
compare “diabetes mellitus, uncomplicated, ICD-9 code 250.00” with “type 2 diabetes mellitus
in an elderly patient with poor diet, marginal retirement income, and isolation from the family.”
Failure to consider the psychosocial aspects of disease invites an incompletely understood or
even a missed diagnosis: how many instances of child abuse have been overlooked as busy emer-
gency room physicians care for childhood fractures without also exploring the cause of the injury
and the home environment?
When eliciting a medical history from Joan S., it will be important to learn the current stresses at
work and at home, and how she thinks her life would be different if the headaches were gone.
SEEK HELP WHEN NEEDED
Today, health care, including diagnosis, must be “evidence based” and not grounded in anecdote
or even in your “years of clinical experience.” The evidence is, of course, the vast body of medical
knowledge, including research reports and meta-analyses found in clinical journals (5), on the World
Wide Web (6), and in reference books such as The 10-Minute Diagnosis Manual. When thinking
about Joan S., you might search the literature for recent articles on the approach to migraine headaches.
Help is also available from colleagues. Consider a consultation when you have a diagnosis that
is somehow not “satisfying.” A personal physician in a long-term relationship with a patient can
develop a blind spot, and the diagnosis may be apparent only to someone taking a fresh look. What
may be needed at such a time is a rethinking of the problem—almost the antithesis of continuity.
Help can be available from the same-specialty colleague down the hall or from a subspecialist.
THINK IN TERMS OF A CONTINUALLY EVOLVING DIAGNOSIS
You do not always need to make the definitive diagnosis on the first visit; in fact, such an approach
tends to foster prolonged visits, excessive testing, overly biomedical diagnoses, and high-cost medi-
cine without adding quality. When faced with an elusive diagnosis, the best test is often the passage
of time and a follow-up visit. For example, we all know that headaches are often influenced by
stressful life events. Yet, a new patient may not be ready to share his or her personal, often embar-
rassing, burdens, and it is only when a trustful relationship has been established that the clinician
learns about the abusive spouse, the pregnant teenager, or the impending financial disaster.
It is often useful to use the descriptive, categorical diagnosis and seek the definitive diagnosis
over time. Examples include the teenage girl with chronic pelvic pain, the young adult with cough
for 3 months, the middle-aged person with loss of appetite, and the older person with fatigue or
insomnia. Sometimes, on an initial visit, this approach is the only reasonable option.
The Dx10 clinician will be careful not to “fall in love” with the initial diagnosis and realize that
the depressed patient losing weight might also have cancer and that it is too easy to attribute all
new symptoms to a known diagnosis of menopause or diabetes mellitus. If Joan’s headaches fail to
respond as expected over time, you may wish to reconsider your original diagnosis and perhaps seek further
testing that would have seemed excessive on the initial visit. For example, might the “1-year” duration of
increased severity merit imaging if a favorable response to initial therapy does not occur?
In your daily practice, use the time saved in the steps described here to consider and recon-
sider your diagnoses—as you review chart notes, read medical journals, search medical web sites,
and see the patient in follow-up visits. The Dx10 clinician will remain open to rethinking the
patient’s diagnostic problem list. In the end, patience and perseverance—often measured in
10-minute aliquots over time—will yield an insightful, biopsychosocially inclusive, and clinically
useful diagnosis.
Chapter 1 • Principles of the 10-Minute Diagnosis
3
RefeRences
1. Stange KC, Zyzanski SJ, Jaen CR. Illuminating the black box: a description of 4454 patient visits to
138 family physicians. J Fam Pract 1998;46:377–389.
2. Blumenthal D, Causino N, Chang YC. The duration of ambulatory visits to physicians. J Fam Pract
1999;48:264–271.
3. Bergh KD. The patient’s differential diagnosis: unpredictable concerns in visits for cough. J Fam Pract
1998;46:153–158.
4. Taylor RB. Family practice and the advancement of medical understanding: the first 50 years. J Fam
Pract 1999;48:53–57.
5. Richardson WS, Wilson MC, Guyatt GH, et al. User’s guide to the medical literature: how to use an
article about disease probability for differential diagnosis. JAMA 1999;281:1214–1219.
6. Hersh W. A world of knowledge at your fingertips: the promise, reality, and future directions of on-line
information retrieval. Acad Med 1999;74:240–243.
4
TAYLOR’S diffeRenTiAL diAGnOSiS MAnUAL
I. BACKGROUND. Anorexia is prolonged appetite loss. It is a common symptom of many
medical conditions and should be differentiated from the psychiatric disease “anorexia nervosa.”
II. PATHOPHYSIOLOGY
A. General Mechanisms.
It is not known exactly how the body regulates appetite stimula-
tion/suppression. It appears that both neural and humoral mechanisms interact. The hypo-
thalamus is believed to regulate both satiety and hunger, leading to homeostasis of body
weight in ideal situations. The hypothalamus interprets and integrates a number of neural
and humoral inputs to coordinate feeding and energy expenditure in response to conditions
of altered energy balance. Long-term signals communicating information about the body’s
energy stores, endocrine status, and general health are predominantly humoral. Short-term
signals, including gut hormones and neural signals from higher brain centers and the gut,
regulate meal initiation and termination. Hormones involved in this process include leptin,
insulin, cholecystokinin, ghrelin, polypeptide YY, pancreatic polypeptide, glucagonlike pep-
tide-1, and oxyntomodulin (1). Alterations in any of these humoral or neuronal processes
can lead to anorexia.
B. Etiology. Causes of anorexia can be divided into the following four categories:
1. Pathologic. These include malignancy (particularly gastrointestinal, lung, lymphoma,
renal, and prostate cancers); gastrointestinal diseases (including peptic ulcer disease,
malabsorption, diabetic enteropathy, dysphagia, inflammatory bowel disease, hepatitis,
Zenker’s diverticulum, and paraesophageal hernia); infectious diseases (human immuno-
deficiency virus [HIV], viral hepatitis, tuberculosis, chronic fungal or bacterial disease,
chronic parasitic infection, and lung abscess); endocrine disorders (uncontrolled diabetes
and adrenal insufficiency); severe heart, lung, and kidney diseases (heart failure; severe
obstructive or restrictive lung disease; and renal failure, nephritic syndrome, and chronic
glomerulonephritis); neurologic diseases (stroke, dementia, dysphagia, Parkinson disease,
and amyotrophic lateral sclerosis); and chronic inflammatory diseases (sarcoidosis, severe
rheumatoid arthritis, and giant cell vasculitis).
2. Psychiatric. Affective disorders (depression, bipolar disorder, and generalized anxiety
disorder) and food-related delusions from other psychiatric disorders (schizophrenia and
related conditions).
3. Pharmacologic. Decreased appetite may be a side effect of one of these medications:
topiramate, zonisamide, selective serotonin receptor inhibitors, levodopa, digoxin,
metformin, exenatide, liraglutide, nonsteroidal anti-inflammatory drugs, anticancer and
antiretroviral drugs, as well as alcohol, opiates, amphetamines, and cocaine. Withdrawal
2.1
CHAPTER 2
Undifferentiated Problems
Richard H. Hurd
Anorexia
Dorota Brilz
5
from chronic high-dose psychotropic medications and cannabis may cause anorexia.
Herbal and nonprescription preparations that cause appetite loss include 5-hydroxy-
tryptophan, aloe, caffeine, cascara, chitosan, chromium, dandelion, ephedra, garcinia,
glucomannan, guarana, guar gum, herbal diuretics, nicotine, pyruvate, and St. John’s
wort (2).
4. Social factors often cause anorexia. Bereavement, stress, and loneliness may decrease
appetite. Moving from one’s home, loss of ability to shop for food or to prepare meals,
and financial difficulties may also result in appetite changes.
III. EVALUATION
A. History.
Obtaining detailed history is essential in identifying potential causes of patient’s
anorexia.
1. History of Present Illness. How long has the problem been going on? Is it constant or
episodic? Does the patient associate it with anything? Are there are psychological stressors
present? How about difficulty or pain with swallowing?
2. Past Medical History. Any history of chronic medical problems, malignancies, or past
psychiatric problems, including eating disorders.
3. Medications and Habits. Use of illicit drugs or any of the above prescription medica-
tions that may cause anorexia.
4. Social History. Access to food, to include financial and mobility issues. Patients may
experience anorexia if their food is prepared in a manner different from their customary
fashion (e.g., patients entering an institution). Patients who may be restricted by their
medical professionals to a certain health-related diet may experience lack of appetite due
to taste preferences.
5. Review of Systems. Review of systems should focus on weight changes, as well as gastro-
intestinal, psychiatric, and neurologic systems. A food diary is often helpful to quantify
patient’s intake and analyze for the presence of any patterns.
B. Physical Examination.
1. General Appearance. Does the patient appear healthy or ill? Review the vital signs
for fever, tachycardia, tachypnea, or blood pressure abnormalities as signs of systemic
illness.
2. Head, Eyes, Ears, Nose, and Throat (HEENT). Examine the oral cavity for lesions
or poor dentition. Assess for dysphagia/odynophagia and for the presence of lymphade-
nopathy, thyromegaly, or cervical masses.
3. Cardiovascular System. Assess the patient for arrhythmias and signs of congestive heart
failure, such as rales, jugular venous distention, and lower extremity edema.
4. Respiratory System. Auscultate lungs for the presence of wheezes, crackles, or poor air
exchange indicating chronic obstructive pulmonary disease or restrictive lung disease.
5. Gastrointestinal System. Listen for abnormal bowel sounds. Examine for tenderness,
rigidity, ascites, and hepatomegaly. Rectal examination, including guaiac testing, should
be performed (3).
6. Skin. Jaundice, skin tracks, cyanosis, lanugo, hyperpigmentation, and turgor should be
noted.
7. Neurologic and Psychological Systems. Examine the functions of cranial nerves,
including smell and taste. Look for focal or generalized weakness, gait or balance dis-
turbances, or movement disorders. Assess the patient’s functional capacity and mental
status. Assess for anxiety, depression, dementia, delirium, and psychosis.
C. Testing. As in all areas of medicine, diagnostic studies should be guided by the history
and physical examination. Tests to consider in anorexia include a complete blood count,
electrolyte panel, hepatic panel, and albumin. When assessing nutritional status, measuring
prealbumin level may be preferred over albumin level in acute cases of anorexia because
prealbumin is the earliest marker of changes in nutritional status (4). Chest x-ray and
tuberculosis testing can be helpful in some cases, as might esophagogastroduodenoscopy,
colonoscopy, and abdominal computed tomography, or ultrasonography. Other tests to
6
Taylor’s DifferenTial Diagnosis Manual
include are HIV, thyroid-stimulating hormone and thyroid hormone, viral hepatitis panel,
urine protein, and urinalysis (3), and testing for toxicology and drugs of abuse.
IV. DIAGNOSIS. Although the causes of anorexia are numerous and span the biopsychosocial
spectrum, a thoughtful evaluation will generally reveal the underlying cause(s) of the loss of
appetite, and specific interventions can then be instituted.
REFERENCES
1. Murphy KG, Bloom SR. Gut hormones in the control of appetite. Exp Physiol 2004;89:507–516.
2. Anorexia nervosa in adults: diagnosis, associated clinical features, and assessment. Up To Date
2012. Accessed at http://www.uptodate.com/contents/anorexia-nervosa-in-adults-diagnosis- associated-
clinical-features-and-assessment?source-search_result&search=anorexia&selectedTitle=2%7E150
#H549367385 on May 14, 2012.
3. Brooke Huffman G. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician
2002;65:640–651.
4. Beck FK, Rosenthal TC. Prealbumin: a marker for nutritional evaluation. Am Fam Physician
2002;65:1575–1578.
2.2
Dizziness
Richard H. Hurd
I. BACKGROUND. Dizziness is a rather imprecise term often used by patients to describe any of
a number of peculiar subjective symptoms. These symptoms may include faintness, giddiness,
lightheadedness, or unsteadiness. True vertigo, a sensation of irregular or whirling motion,
is also included in a patient’s complaint of dizziness. Dizziness represents a disturbance in a
patient’s subjective sensation of relationship space (1).
II. PATHOPHYSIOLOGY
A. Etiology.
The causes of dizziness are numerous. It is helpful for the diagnostician to think
in general categories of causes when searching for an etiology (see Table 2.2.1).
B. Epidemiology. Dizziness is the complaint in an estimated 7 million clinical visits in the
United States each year (2, 3). It is one of the most frequent reasons for referral to neurolo-
gists and otolaryngologists. The reasons for frequent referral of this usually benign condition
are many. Ruling out potentially serious causes, including those of cardiac and neurologic
origin, can be difficult. In addition, the fact that there is no specific treatment for many of
the causes of dizziness leads to frustration for both the patient and physician.
III. EVALUATION
A. History.
It is extremely important, and can be very difficult, to get patients to describe
exactly what they mean when complaining of dizziness. A description of the attack, context,
length, duration, and frequency is important. Any precipitating factor should be explored.
Concurrent symptoms such as nausea, headache, chest fluttering, or tinnitus can help to
direct the clinician to the cause. Any new medication or medication changes should be
inquired about.
B. Physical Examination. The physical examination, although thorough, is often focused
on a specific system based on the history. It is seldom diagnostic in itself but is more often
confirmatory.
1. Vital signs including orthostatic blood pressures begin the examination.
2. A neurologic examination must be completed.
Chapter 2 • Undifferentiated Problems
7