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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
112
Galactorrhea
This characterized by spontaneous or expressible milky fluid.
Some differential diagnoses and typical outline evidence
Primary hyper-
prolactinemia
Suggested by: infertility, oligomenorrhea, or
amenorrhea
Confirmed by: iprolactin and normal TSH and T4
.
Pituitary CT or MRI scan: normal or microadenoma
Prolactinoma Suggested by: infertility, oligomenorrhea, or amenor-
rhea. In large tumors, field defects and loss of secon-
dary sexual characteristics
Confirmed by: i prolactin and normal TSH and T4.
Micro- or macroadenoma on CT or MRI scan pituitary
Pregnancy Suggested by: amenorrhea, frequency of urine, etc., in
woman of childbearing age
Confirmed by: pregnancy test positive
Primary
hypothyroidism
Suggested by: cold intolerance, tiredness, constipation,
bradycardia
Confirmed by: iTSH, dFT4
Drugs Suggested by: taking metoclopramide,
chlorpromazine, and other major tranquilizers
Confirmed by: iprolactin and iTSH and dT4,
resolution and lowering of prolactin after stopping
suspected drug
Idiopathic
galactorrhea
Suggested by: galactorrhea alone, no other findings
Confirmed by: normal prolactin and TSH and T4
NIPPLE ABNORMALITY1
113
Nipple abnormality
Some differential diagnoses and typical outline evidence
Paget’s disease
of nipple with
underlying
carcinoma
Suggested by: breast nipple eczema
Confirmed by: in situ malignant change on histological
examination of skin scrapings
Duct ectasia
and chronic
infection
Suggested by: green or brown nipple discharge
Confirmed by: chronic inflammation on histology of
excised ducts
Duct papilloma Suggested by: bleeding from nipple
Confirmed by: excision of affected ducts. Benign
histology of excised ducts
Mamillary
fistula
Suggested by: discharge from para-areolar region,
patient age 30–40 years
Confirmed by: excision of affected ducts. Benign
histology of excised ducts
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CHAPTER 5 General examination physical signs
114
Breast lump(s)
Some differential diagnoses and typical outline evidence
Benign fibrous
mammary
dysplasia
Suggested by: generally painful breast lumpiness, greatest
near axilla. Cyclically related to periods
Confirmed by: relief on aspiration of cysts, diuretics or
estrogen suppression
Fibroadenoma Suggested by: smooth and mobile lump (“breast
mouse”) usually in patients 15–30 years of age
Confirmed by: appearance on mammogram Confirmed
by benign histology after excision
Cyst(s) Suggested by: spherical, fluctuant lump, single or
multiple, painful before periods
Confirmed by: cysts on mammography, benign tissue
after excision
Acute or
chronic abscess
Suggested by: fluctuant lump, hot and tender, acute presen-
tation often in puerperium. Chronic after antibiotics
Confirmed by: response to drainage, chronic abscess
excision and histology to exclude carcinoma
Fat necrosis or
sclerosing
adenosis
Suggested by: firm, solitary, localized lump
Confirmed by: appearance on mammogram Confirmed
by benign histology after excision
Carcinoma
(infiltrating
ductal cancer
or invasive lobar
cancers)
Suggested by: some of the following: fixed, irregular,
hard, painless lump, nipple retraction, fixed to skin
(peau d’orange) or muscle and local, hard or firm, fixed
nodes in axilla. Metastases to lymph nodes, or via
blood to bones, brain, liver, lung, and abdominal cavity
Confirmed by: ill-defined speculate borders, faint linear
or irregular calcification, and abnormal adjacent
structures on mammography. Malignant histology after
aspiration or excision
GYNECOMASTIA1
115
Gynecomastia
These findings should have been discovered during the general examination.
Breast swelling occurs in males, with a disc of firm tissue. If there is no disc,
it is fatty tissue only.
Some differential diagnoses and typical outline evidence
Immature testis Suggested by: adolescence and no testicular lump
Confirmed by: normal testosterone, estrogen, and LH
levels; normal ultrasound scan of testis
Digoxin,
spironolactone
Suggested by: taking of drug and no testicular lump
Confirmed by: improvement when drug stopped
High alcohol
intake
Suggested by: high alcohol intake and no testicular lump
Confirmed by: improvement when alcohol stopped
Hepatic
cirrhosis
Suggested by: long history of high alcohol intake
(usually), spider nevi, abnormal liver size (large or
small) and consistency (fatty or hard)
Confirmed by: very abnormal biochemical liver
function tests, dLH, iestrogens, dtestosterone
Testicular
tumors
Suggested by: scrotal mass ± pain, tenderness if hemor-
rhage occurs (sometimes arising in undescended testis)
Confirmed by: testicular ultrasound, inguinal
exploration, iA-fetoprotein, iB-hCG
Hypogonadism
(primary to
testicular
disease,
or secondary
to low LH from
pituitary defect
or tumor)
Suggested by: sparse pubic hair, no drug or alcohol
history, poor libido
Confirmed by: testosteroned, LHi (in primary
testicular disease), LHd or normal (when secondary
to pituitary diseases)
Lung carcinoma Suggested by: smoking history, hemoptysis, weight loss,
clubbing
Confirmed by: CXR, bronchoscopy with biopsy
Klinefelter’s
syndrome
Suggested by: poor sexual development, infertility,
eunuchoid
Confirmed by: 47, XXY karyotype
Obesity Suggested by: no breast tissue, only mammary fat
Confirmed by: improvement with weight loss
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CHAPTER 5 General examination physical signs
116
Axillary lymphadenopathy
Axillary lymphadenopathy ± tenderness.
Some differential diagnoses and typical outline evidence
Reaction to
infection, e.g.,
viral prodrome,
HIV infection,
etc.
Suggested by: tender, solid nodular swelling(s),
especially at <20 years of age
Confirmed by: clinical features
Infiltration by
secondary
tumor,
e.g., breast
Suggested by: non-tender, solid nodular swelling(s)
Confirmed by: excision biopsy
Histiocytosis or
primary tumor
Suggested by: non-tender, solid nodular swelling(s)
Confirmed by: excision biopsy
Drug effect Suggested by: drug history, e.g., phenytoin,
retroviral drug
Confirmed by: improvement when drug withdrawn
HIRSUITISM IN FEMALES1
117
Hirsuitism in females
Upward extension of pubic hair in females. Hirsute upper lip and chin
and sideburns can also occur.
Some differential diagnoses and typical outline evidence
Racial skin
sensitivity
Suggested by: family history, normal menstrual periods
(and fertility if applicable)
Confirmed by: LH normal, testosterone normal
Polycystic ovary
syndrome
Suggested by: gradual increase in hirsutism since
puberty, thin head hair, irregular periods, infertility
Confirmed by: testosterone i, SHBGd, LHi (tests done
in follicular phase of menstrual cycle). Ultrasound scan
showing cystic ovaries
Ovarian or
adrenal
carcinoma
Suggested by: change in hair pattern over months,
deeper voice, breast atrophy, no periods,
clitoromegaly
Confirmed by: dLH and iitestosterone. Ultrasound
scan and laparoscopy findings
Cushing’s
syndrome
pituitary-driven
Cushing’s
disease, or
autonomous
adrenal
Cushing’s, or
glucocorticoid
therapy
Suggested by: round, florid face (and trunk with purple
striae) with thin arms and legs, hirsuitism. Inability to
rise from squatting position (due to proximal myopathy)
Confirmed by: i24-hour urinary free cortisol, midnight
cortisol i, and/or failure to suppress cortisol after
48 hours on dexamethasone 0.5 mg 6 hourly or drug
history of glucocorticoids
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CHAPTER 5 General examination physical signs
118
Abdominal striae
White striae are healed pink or purple striae.
- Pink striae
Some differential diagnoses and typical outline evidence
Pregnancy Suggested by: no periods and obvious pregnant uterus
Confirmed by: pregnancy test positive and ultrasound
scan of abdomen or pelvis
Simple obesity Suggested by: large abdomen and usually rapid weight
increase
Confirmed by: above clinical findings
- Purple striae
Some differential diagnoses and typical outline evidence
Glucocorticoid
steroid therapy
Suggested by: truncal obesity, purple striae, bruising,
moon face and buffalo hump
Confirmed by: drug history: taking high dose of
glucocorticoid
Cushing’s
disease
(ACTH driven)
Suggested by: truncal obesity, purple striae, bruising,
moon face and buffalo hump. Pigmented creases
indicate high ACTH, especially in ectopic ACTH (from
a carcinoma or carcinoid tumor)
Confirmed by: i24-hour urinary free cortisol, midnight
cortisolsIi, and/or failure to suppress cortisol after
dexamethasone, iACTH and bilaterally large adrenals
on CT or MRI scan
Cushing’s
syndrome due
to adrenal
adenoma
Suggested by: truncal obesity, purple striae, and bruising.
No pigmentation in skin creases
Confirmed by: i24-hour urinary free cortisol, midnight
cortisol i, and/or failure to suppress cortisol after
dexamethasone, dACTH and unilateral large adrenal
on CT or MRI scan
OBESITY1
119
Obesity
The definition of obesity is body mass index (BMI) >30.
Some differential diagnoses and typical outline evidence
Simple obesity Suggested by: limb and truncal obesity
Confirmed by: TSH
and FT4 normal. 24-hour urinary
cortisol normal
Hypothyroidism Suggested by: cold intolerance, tiredness, constipation,
bradycardia
Confirmed by: iTSH, dFT4
Cushing’s
syndrome
Suggested by: moon face, truncal obesity, hirsutism,
buffalo hump, abdominal striae, proximal weakness
Confirmed by: i24-hour urinary free cortisol, midnight
cortisol i, and/or failure to suppress cortisol after
dexamethasone
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CHAPTER 5 General examination physical signs
120
Pigmented creases and flexures
(and buccal mucosa)
This condition suggests excess adrenocorticotropic hormone (ACTH)
secretion.
Some differential diagnoses and typical outline evidence
Addison’s
disease =
primary adrenal
failure due to
autoimmune
destruction or
tuberculosis
Suggested by: fatigue, low BP, and postural drop
Confirmed by: low 9
AM cortisol with poor response to
ACTH stimulation test and ACTHi
(Pituitary)
Cushing’s
disease
Suggested by: facial and truncal obesity with striae,
limb wasting, and proximal myopathy
Confirmed by: i24-hour urinary free cortisol and/or
failure to suppress cortisol after dexamethasone.
Midnight cortisol i and ACTH i
Ectopic ACTH
secretion
Suggested by: general weakness, proximal myopathy,
usually evidence of lung cancer or other malignancy
Confirmed by: d serum potassium and ii midnight
cortisol and iACTH
SPIDER NEVI (NEVUS ARANEUS)1
121
Spider nevi (nevus araneus)
These are red, pin-head-sized spots with radiating blood vessels that
empty when the center is pressed by a pin-head-sized object.
Some differential diagnoses and typical outline evidence
Normal Suggested by: small numbers on chest (≤3), usually in a
young woman on the chest and upper back
Confirmed by: no increase with time
Taking
estrogens
Suggested by: small numbers on chest in a young
woman on estrogen-containing contraceptive pill
Confirmed by: decrease when pill stopped in due
course (no urgency)
Pregnancy Suggested by: moderate numbers in a pregnant woman
Confirmed by: decrease when pregnancy over
Liver failure Suggested by: large numbers on chest, also on neck and
face, jaundice, features of liver failure
Confirmed by: dalbumin, iprothrombin time (PT)
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