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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 5 General examination physical signs
92
Proptosis of eye(s) or exophthalmos
A prominent eye is suggested by sclera showing between the cornea and
upper lid margin; this may also result from lid retraction due to sympa-
thetic overactivity or lung disease. If in doubt, look down on eyes from
above. (In myopia there is a large eyeball but the sclera is not visible.)
Some differential diagnoses and typical outline evidence
Ophthalmic
Graves’ disease
(± thyrotoxicosis)
Suggested by: bilateral (usually) exophthalmos, goiter,
pretibial myxedem,a and lid retraction
Confirmed by: titer of thyroid antibodies ii (with
dTSH or normal, and T3 or T4 i or normal).
CT scan appearance
Orbital
cellulitis
(medical
emergency)
Suggested by: pain, fever, unilateral lid swelling,
decreased vision and double vision. Neurological
signs in advanced disease
Confirmed by: CT or MRI scan appearance and
response to antibiotics
Corticocavernous
fistula
Suggested by: unilateral engorgement of eye surface
vessels, lid and conjunctiva, pulsatile with bruit over
eye.
Confirmed by: CT or MRI scan appearance
Orbital
tumors—
rarely primary,
often secondary,
especially
isthiocytosis
Suggested by: unilateral proptosis and displacement of
the eyeball. Lymph node, liver, or spleen enlargement
Confirmed by: CT or MRI scan appearance
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CHAPTER 5 General examination physical signs
94
Red eye
Gritty pain suggests an external cause. Aching pain suggests an internal
cause. Light sensitivity always accompanies inflammation in the eye.
Fluoresceine (Fl) yellow dye glows green with a blue examination light
and stains all epithelial breaks.
Some differential diagnoses and typical outline evidence
Spontaneous
subconjunctival
hemorrhage
Suggested by: painless, bright red area on conjunctiva
(oxygenated blood) and no light sensitivity
Confirmed by: clinical appearance and resolution over
days. No Fl staining of cornea (not done often)
Conjunctivitis
due to bacterial
infection
Suggested by: red eyes, dilated blood vessels on the
eyeball and tarsal (lid) conjunctiva with a purulent
discharge ± bilateral ± gritty pain
Confirmed by: above clinical appearance. Not light
sensitive and no Fl stain of cornea
Conjunctivitis
due to viral
infection
Suggested by: red eyes with dilated vessels on the
eyeball only, sometimes in one quadrant around the
cornea with a watery “tap-running” discharge. Gritty
pain ± impaired vision
Confirmed by: Fl stain showing dendritic (branching)
pattern and resolution with topical antiviral
Conjunctivitis
due to allergy
Suggested by: red eyes with pink, swollen conjunctiva
and white, stringy mucoid discharge
Confirmed by: no Fl stain and no visual loss and
resolution with chromoglycate (over 6 weeks) or
steroid eye drops
Corneal ulcer
(ulcerative
keratitis)
due to abrasion
or herpes
simplex,
Pseudomonas,
Candida,
Aspergillus,
protozoa
Suggested by: painful, light-sensitive, deeply red eye
with yellowish abscess in the cornea. Purulent
discharge
Confirmed by: slit-lamp examination after fluoresceine
instillation showing hypopyon (pus in the eye)
RED EYE1
95
Episcleritis Suggested by: localized red eye with superficial vessel
dilatation. Mild pain. No visual loss or light sensitivity
Confirmed by: Instillation of one drop of phenylephrine
2.5% causing a blanching of the lesion
Scleritis Suggested by: localized area of dark red, dilated,
superficial and deep vessel on the sclera with aching
pain and tenderness
Confirmed by: failure to blanch with one drop of 2.5%
phenylephrine
Acute
closed-angle
glaucoma
(emergency)
Suggested by: severely painful red eyeball with marked
visual loss, accompanied by nausea and vomiting ±
history of haloes around lights and severe headache
with blurred vision
Confirmed by: dull gray cornea, nonreacting and irregular
pupil with raised ocular pressures
Iritis or uveitis
(see p. 96)
Suggested by: redness around cornea and haze in front
of iris and severe light sensitivity (photophobia)
Confirmed by: small, nonreacting and irregular pupil.
Slit-lamp examination showing flare, cells,
and hypopyon (pus in eye)
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CHAPTER 5 General examination physical signs
96
Iritis (anterior uveitis)
Redness in the cornea next to the iris (circumcorneal injection) occurs,
with a muddy appearance of fluid in front of the iris.
Some differential diagnoses and typical outline evidence
Trauma (usually
surgical)
Suggested by: impact accident, recent surgery
Confirmed by: slit-lamp examination showing blood in
the front of the eye and D-shaped distortion of the
pupil if torn from its base or perforation if the pupil is
pointing
Infection:
herpes simplex,
zoster, TB,
syphilis, leprosy,
protozoa, fungi
Suggested by: general malaise, fever, leukocytosis
Confirmed by: bacteriological culture of eye swab or
viral immunology
Autoimmune
diseases:
ankylosing
spondylitis,
Reiter’s disease,
juvenile chronic
arthritis, immune
ocular disease
Suggested by: arthritis, anemia, no obvious fever, raised
ESR
Confirmed by: immunology (seronegative for rheuma
t
oid
factor). Protein electrophoresis
Sarcoidosis Suggested by: history of dry cough, breathlessness,
malaise, fatigue, weight loss, enlarged lacrimal glands,
erythema nodosum. Raised serum angiotensin
converting enzyme (ACE)
Confirmed by: CXR appearances (e.g., bilateral
lymphadenopathy), tissue biopsy showing non-
caseating granuloma. Slit lamp shows large keratic
precipitates
Ulcerative
colitis
Suggested by: history of diarrhea with mucus and blood
Confirmed by: colonoscopy and histology of biopsy
Crohn’s disease Suggested by: history of abdominal pain, diarrhea,
weight loss
Confirmed by: colonoscopy, barium enema and meal
and follow-through
CLINICAL ANEMIA1
97
Clinical anemia
This is often noticed as subconjunctival pallor (± face, nail, and palmar
pallor).
Some differential diagnoses and typical outline evidence
Microcytic
due to iron
deficiency,
thalassemia,
etc. (see p. 433)
Suggested by: history of blood loss or FH of
hemoglobinopathy (especially in patients of Mediterra-
nean origin) and sideroblastic anemia
Confirmed by: CBC: dHb and dMCV, in thalassemia
ddMCV
Macrocytic
(see p. 434)
Suggested by: FH of pernicious anemia, antifolate, and
cytotoxic drugs or alcohol
Confirmed by: CBC: dHb and iMCV.
Film: hypersegmented polymorphs in B
12
deficiency
Normocytic
(see p. 435)
Suggested by: history of chronic intercurrent illness,
e.g., chronic renal failure, anemia of chronic disease,
etc.
Confirmed by: CBC: dHb and MCV normal
Hypoplastic or
aplastic
Suggested by: gradual onset without blood loss and
potentially causal medication
Confirmed by: CBC: dHb and MCV normal and bone
marrow atrophic
Leukemia Suggested by: gradual onset and large spleen or lymph
node (LN) (can fall ill suddenly with rapid deterioration
in acute leukemia)
Confirmed by: dHb and MCV normal, iiWBC, and
bone marrow replaced by leukemic cells
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CHAPTER 5 General examination physical signs
98
Fever
Temperature is >37*C (99*F). Fever is not a good lead. The causes sug-
gested here are broad.
Some differential diagnoses and typical outline evidence
Infection Suggested by: low-grade or high fever with raised white
cell count and usually symptoms and signs pointing to a
focus
Confirmed by: serology ± cultures of blood and other
body fluids
Thrombus,
tissue necrosis,
neoplasm,
autoimmune
diseases, drugs
Suggested by: low-grade fever, history of severe illness
or trauma
Confirmed by: specific tests, e.g., CXR, Doppler
ultrasound scan of leg veins
Possible hypothermia
Temperature is <35*C (95*F)—but confirm with low-reading thermome-
ter—it could be lower. Also confirm with rectal temperature.
Some differential diagnoses and typical outline evidence
True
hypothermia
due to
prolonged
exposure
to cold or
hypothyroidism
Suggested by: history of immersion or cold-weather
exposure. Temperature <35°C (95°F) with low-reading
rectal thermometer
Confirmed by: temperature chart using low-reading
rectal thermometer
MOUTH LESIONS1
99
Mouth lesions
Examine lips, buccal mucosa, teeth, tongue, tonsils, and pharynx.
Some differential diagnoses and typical outline evidence
Local aphthous
ulcers
Suggested by: red, painful ulcer with associated lymph
node enlargement
Confirmed by: spontaneous resolution within days
Local infection
and gingivitis
Suggested by: vesicles in herpes simplex, creamy white
plaques in oral candidiasis
Confirmed by: spontaneous resolution or after antibi-
otic or antifungal treatment within days
Carious teeth Suggested by: intermittent toothache, broken and/or
severely discolored teeth
Confirmed by: formal dental examination
Traumatic
ulceration
Suggested by: jagged ulcers or lacerations
Confirmed by: history of trauma, injury, ill-fitting
dentures, shallow, painful ulcers
Vitamin
deficiency
e.g., B
12
,
riboflavine,
nicotinic acid
Suggested by: atrophic glossitis, fissured tongue; “raw
beef” tongue in B
12
deficiency, magenta in riboflavin
deficiency
Confirmed by: response to vitamin supplements
Hereditary
hemorrhagic
telangiectasias
Suggested by: telangiectasias on the face, around the
mouth, on the lips and tongue, epistaxis, anemia
Confirmed by: family history and examination of relatives
Peutz–Jegher’s
syndrome
(associated with
intestinal
polyps)
Suggested by: peri-oral pigmentation (not the tongue)
Confirmed by: finding polyps on colonoscopy
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CHAPTER 5 General examination physical signs
100
Red pharynx and tonsils
Some differential diagnoses and typical outline evidence
Viral pharyngitis Suggested by: sore throat, pain on swallowing, fever,
cervical lymphadenopathy and injected fauces.
i lymphocytes, leukocytes normal in WBC
Confirmed by: negative throat swab for bacterial
culture, self-limiting: resolution within days
Acute follicular
tonsillitis
(streptococcal)
Suggested by: severe sore throat, pain on swallowing,
fever, enlarged tonsils with white patches (like straw-
berries and cream). Cervical lymphadenopathy
especially in angle of jaw. Fever, i leukocytes in WBC
Confirmed by: throat swab for culture and
sensitivities of organisms
Infectious
mononucleosis
due to Epstein–
Barr virus
Suggested by: very severe throat pain with enlarged
tonsils covered with creamy membrane. Petechiae on
palate. Profound malaise. Generalized lymphadenopa
t
hy,
splenomegaly
Confirmed by: i atypical lymphocytes in WBC.
Heterophile antibody test positive. Viral titers
Candidiasis of
buccal or
esophageal
mucosa
Suggested by: painful dysphagia, white plaque, his
t
ory o
f
immunosuppression, diabetes, or recent antibiotics
Confirmed by: esophagoscopy showing erythema and
plaques, brush cytology ± biopsy shows spores and
hyphae
Agranulocytosis Suggested by: sore throat, background history of taking
a drug or contact with noxious substance
Confirmed by: low or absent neutrophil count
Meningococcal
meningitis
Suggested by: headache, photophobia, vomiting, sore
throat, red pharynx without purulent patches, neck
stiffness. High blood neutrophil count
Confirmed by: lumbar puncture showing pus or neutro-
phil count and organisms on microscopy or culture
PAROTID SWELLING1
101
Parotid swelling
Swelling from anterior border of masseter muscle (teeth clenched) to
lower half of ear, and from the zygomatic arch to angle of the jaw.
Some differential diagnoses and typical outline evidence
Parotid duct
obstruction
(usually due to
stone)
Suggested by: intermittent infection or no discharge
from duct
Confirmed by: plain X-ray showing radio-opaque stone
or sialography to show filling defect
Parotid tumor Suggested by: no obvious features of alterative
nonmalignant or infective condition
Confirmed by: urgent surgical referral for biopsy or
exploration
Mumps parotitis Suggested by: acute painful swelling of whole gland(s),
contact with others cases
Confirmed by: bilateral swelling or associated
pancreatitis or orchitis (rising mumps viral titer if
doubt)
Suppurative
parotid
infection
Suggested by: hot, tender, fluctuant swelling with high
fever. No discharge from duct orifice
Confirmed by: iWBC, response to drainage ±
antibiotics
Nonsuppurative
parotitis from
ascending
infection along
parotid duct
Suggested by: unilateral swelling, oral sepsis, or poor
general condition
Confirmed by: fever, iWBC discharge from duct orifice.
Resolution with antibiotics
Parotid
Sjögren’s
syndrome
Suggested by: dry mouth and eyes with no tears
Confirmed by: rheumatoid factor positive ± anti- Ro(SSA)
and anti-La(SSB) positive
Parotid
sarcoidosis
Suggested by: history of dry cough, enlarged lacrimal
glands, erythema nodosum, raised serum ACE.
Confirmed by: CXR appearances (e.g., bilateral lympha-
denopathy) and tissue biopsy showing noncaseating
granuloma
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