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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
122
Thin, wasted, cachectic
Some differential diagnoses and typical outline evidence
Low-calorie
intake
(e.g., anorexia
nervosa
alcoholism, drug
abuse, any
prolonged
systemic illness
e.g., severe
COPD)
Suggested by: dietary history
Confirmed by: dietician’s assessment, as inpatient if
necessary
Thyrotoxicosis Suggested by: normal appetite and adequate intake,
frequent loose bowel movement, lid retraction and lag,
sweats, tachycardia
Confirmed by: ddTSH, iFT4
AIDS Suggested by: signs of opportunistic infection, e.g., oral
candidiasis, oral hairy leukoplakia, Kaposi’s sarcoma,
lymphadenopathy
Confirmed by: detection of HIV antibodies in serum,
HIV RNA in plasma
Malignancy Suggested by: progressive weight loss and malaise, poor
appetite
Confirmed by: metastases in liver on ultrasound scan,
bone metastases on plain X-rays, endoscopy for gut
tumors, bronchoscopy, etc.
Tuberculosis Suggested by: cough, night sweats, hemoptysis, CXR:
abnormal shadowing
Confirmed by: AFB
in sputum on microscopy,
mycobacteria on culture, response to antibiotics
PURPURA1
123
Purpura
This covers a spectrum from small, pin-point petechiae to large areas of
“bruising” in skin that do not blanch when compressed.
Some differential diagnoses and typical outline evidence
Thrombocytopenia
due to autoimmune
process or
idiopathic (ITP), SLE
Suggested by: petechiae and history of associated
condition
Confirmed by: dplatelet count but RBC and
W
BC
normal
Pancytopenia
due to aplastic anemia,
hypersplenism,
myelodysplasia,
disseminated vascular
anticoagulation
Suggested by: petechiae and history of associated
condition
Confirmed by: dplatelet count, dWBC,
and iHb
Platelet
dysfunction
due to aspirin,
NSAIDs, renal
failure
Suggested by: bruising and drug history
Confirmed by: less bruising when aspirin stopped
or other cause removed
Congenital
vasculopathy
due to Osler–
Weber–Rendu
syndrome, etc.
Suggested by: bruising from punctiform malformations
on mucous membranes. Nose bleeds, GI bleeding
Confirmed by: clinical findings and normal platelet
count and clotting
Acquired
vasculopathy
due to senile changes,
autoimmune
vasculitis
(Henoch–Schönlein),
steroids, scurvy
Suggested by: bruising into associated thin skin
with atrophied subcutaneous tissue
Confirmed by: normal platelet count and clotting
Acquired
coagulopathy
due to liver disease,
vitamin K deficiency,
DIC
Suggested by: bruising and history of associated
condition
Confirmed by: prolonged prothrombin time
Congenital
coagulopathy
e.g., Von
Willebrand’s
disease
Suggested by: lifelong bruising and bleeding (after
tooth extraction, heavy periods)
Confirmed by: abnormal platelet function (count
normal) and long activated partial thromboplastin
time (PTT)
Drug effect Suggested by: drug history, e.g., warfarin, steroids
Confirmed by: improvement or drug withdrawal
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CHAPTER 5 General examination physical signs
124
Generalized lymphadenopathy
Some differential diagnoses and typical outline evidence
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
lymphadenopathy, splenomegaly
Confirmed by: Heterophile antibody test positive.
Viral titers
Hodgkin’s
lymphoma
Suggested by: anemia, splenomegaly, multiple lymph
node enlargement
Confirmed by: characteristic histology showing
Reed–Sternberg cells
Non-Hodgkin’s
lymphoma
Suggested by: anemia, multiple lymph node
enlargement
Confirmed by: characteristic histology with no Reed–
Sternberg cells, tumor markers, flow cytometry
Chronic
myeloid
leukemia (CML)
Suggested by: splenomegaly, variable hepatomegaly,
bruising, anemia
Confirmed by: presence of Philadelphia chromo-
some, iiWBC, e.g., >100 cells/μL
Chronic
lymphocytic
leukemia
(CLL)
Suggested by: anorexia, weight loss, enlarged, rub-
bery, non-tender lymph nodes. Hepatomegaly, late
splenomegaly. Bruising, anemia
Confirmed by: marked lymphocytosis. Bone marrow
infiltration
Acute myeloid
leukemia (AML)
Suggested by: variable hepatomegaly, bruising, anemia
Confirmed by: Blast cells in bone marrow biopsy
Acute
lymphoblastic
leukemia (ALL)
Suggested by: variable hepatomegaly, bruising, anemia
Confirmed by: presence of immunological marker of
common (CD10), T-cell, B-cell, null-cell
Sarcoidosis Suggested by: dry cough, breathlessness, malaise,
fatigue, weight loss, enlarged lacrimal glands,
erythema nodosum
Confirmed by: CXR appearances (e.g., bilateral
lymphadenopathy) and tissue biopsy showing
noncaseating granuloma
Drug effect Suggested by: drug history, e.g., phenytoin,
retroviral drug
Confirmed by: improvement when drug withdrawn
LOCALIZED GROIN LYMPHADENOPATHY1
125
Localized groin lymphadenopathy
This is a nonspecific finding.
Some differential diagnoses and typical outline evidence
Infection
somewhere in
lower limb or
pelvis
(usually in past
and node
remained large)
Suggested by: enlarged nodes confined to groin
Confirmed by: local infection in foot or leg, or no
symptoms or signs of generalized condition
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CHAPTER 5 General examination physical signs
126
Pressure sores
These are blisters or ulcers on the heel or sacrum.
Some differential diagnoses and typical outline evidence
Prolonged
contact
Suggested by: history of sensory loss, e.g., spinal cord
injury, cerebrovascular accident (CVA)
Confirmed by: response to frequent turning and
dressings and wound care
Poor nutrition Suggested by: dHb. Low total serum protein and low
potassium
Confirmed by: formal dietary assessment, response to
improved nutrition, nurses turning patient frequently,
and dressings and wound care
Chapter 6
127
Cardiovascular
symptoms
Chest pain—alarming and increasing over minutes
to hours 128
Chest pain—sharp and aggravated by breathing
or movement 130
Severe lower chest or upper abdominal pain 132
Orthopnea and paroxysmal nocturnal dyspnea (PND) 133
Palpitations 134
Cough and pink frothy sputum 136
Syncope 138
Leg pain on walking—intermittent claudication 140
Leg pain on standing—relieved by lying down 141
Bilateral ankle swelling 142
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CHAPTER 6 Cardiovascular symptoms
128
Chest pain—alarming and increasing
over minutes to hours
This refers to chest pain that is not sharp and is not an easily recognized
pattern by the patient (e.g., as predictable, familiar angina). Ideally, the
detailed history is taken where resuscitation facilities are available. Early,
nonspecific ECG changes will suggest an acute coronary syndrome, a
blanket term that includes angina or infarction (MI), but serial ECG or
enzyme changes may be needed to distinguish between them.
- Normal troponin 12 hours after pain: probability of MI <0.3%
- iTroponin indicates episode of muscle necrosis up to 2 weeks before
- ST-segment elevation indicates current ischemia (or rarely ventricular
aneurysm).
Some differential diagnoses and typical outline evidence
Angina (new
or unstable)
Suggested by: central pain ± radiating to jaw and ei
t
her
arm (left usually). Intermittent, brought on by
exertion, relieved by rest or nitrates, and lasting
<30 minutes. May be associated with transient ST
depression or T inversions or, rarely, ST elevation.
Confirmed by: no itroponin after 12 hours (excludes
MI). Stress test showing inducible ischemia
ST-elevation
myocardial
infarction
(STEMI)
Suggested by: central chest pain ± radiating to jaw and
either arm (left usually). Continuous, usually over
30 minutes, not relieved by rest or nitrates
Confirmed by: ST elevation 1 mm in limb leads or
2 mm in chest leads on serial ECGs (this is regarded
as sufficient evidence to treat with thrombolysis).
itroponin indicates episode of muscle necrosis up to
2 weeks before. itroponin may not be present in the
first 4 hours after the onset of chest pain.
Non-ST-
elevation
myocardial
infarction
(NSTEMI)
Suggested by: central chest pain ± radiating to jaw
and either arm (left usually). Continuous, usually over
30 minutes, not relieved by rest or nitrates
Confirmed by: elevated troponin after 12 hours. T-wave
and ST-segment changes but no ST elevation on serial
ECGs
Esophagitis and
esophageal
spasm
Suggested by: past episodes of pain when supine, after
food. Relieved by antacids
Confirmed by: no i in troponin after 12 hours and no
ST-segment changes on ECG. Improvement with
antacids. Esophagitis on endoscopy
CHEST PAIN—ALARMING & INCREASING OVER MIN TO HOURS1
129
Pulmonary
embolus
arising from leg
DVT, silent pelvic
vein thrombosis,
right atrial
thrombus
Suggested by: central chest pain, also abrupt shortness
of breath, cyanosis, tachycardia, loud second sound in
pulmonary area, associated deep vein thrombosis
(DVT) or risk factors such as cancer, recent surgery,
immobility
Confirmed by: V/Q scan with mismatched ventilation
and perfusion, spiral (helical) CT (CT-pulmonary
angiogram) showing clot in pulmonary artery
Pneumothorax Suggested by: abrupt pain in center or side of chest
with abrupt breathlessness. Resonance to percussion
over site
Confirmed by: expiration CXR showing dark field with
loss of lung markings outside sharp line containing lung
tissue
Dissecting
thoracic aortic
aneurysm
Suggested by: ‘tearing pain often radiating to back
and not responsive to analgesia, abnormal or absent
peripheral pulses, early diastolic murmur, low BP,
and wide mediastinum on CXR
Confirmed by: loss of single clear lumen on CT
scan
or MRI
Chest wall pain
e.g.,
costochondritis
and Tietze’s
syndrome,
strained muscle
or rib injury
Suggested by: chest pain and localized tenderness
of chest wall or chest pain on twisting of neck
or thoracic cage
Confirmed by: no i in troponin after 12 hours, and no
ST-segment changes or T-wave changes serially on
ECG
. Response to rest and analgesics
Chest pain—alarming & increasing over
min to hours
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CHAPTER 6 Cardiovascular symptoms
130
Chest pain—sharp and aggravated
Chest pain—sharp and aggravated by
breathing or movement
This is a common symptom experienced in mild or transient forms by
many in the population; it usually resolves with no cause being discovered.
It frightens a patient into seeking advice when it is severe or accompanied
by other symptoms, such as breathlessness, when a specific cause is more
likely to be found.
Some differential diagnoses and typical outline evidence
Pleurisy
due to
pneumonia
Suggested by: being worse on inspiration, shallow
breaths, pleural rub, evidence of infection (fever, cough,
consolidation, etc.)
Confirmed by: opacification in lung periphery on CXR
and sputum/blood culture
Pulmonary
infarct
due to embolus
arising from
DVT in leg,
silent pelvic vein
thrombosis, silent
right atrial
thrombosis
Suggested by: sudden shortness of breath, pleural rub,
cyanosis, tachycardia, loud P2, associated DVT, or risk
factors such as recent surgery, cancer, immobility
Confirmed by: V/Q scan mismatch, spiral CT showing
clot in pulmonary artery
Pneumothorax Suggested by: pain in center or side of chest with abrupt
breathlessness. Diminished breath sounds, resonance
to percussion over site
Confirmed by: expiratory CXR showing loss of lung
markings outside sharp pleural line
Pericarditis
caused by MI,
infection, espe-
cially viral, malig-
nancy, uremia,
connective
tissue diseases
Suggested by: sharp pain worse lying flat or with trunk
movement, relieved by leaning forward. Pericardial rub
Confirmed by: ECG: diffuse concave ST elevations and
PR depressions. CXR: globular heart shadow and relief
with pericardial drainage (if hypotensive)
Musculoskeletal
injury or
inflammation
(often Borholm’s
disease,
Cocksackie B
infection)
Suggested by: associated focal tenderness. Often
history of trauma
Confirmed by: excluding other explanations. Normal
troponin
CHEST PAIN—SHARP AND AGGRAVATED1
131
Chest wall pain
e.g., chostochon-
dritis orTietze’s
syndrome,
strained muscle
or rib injury
Suggested by: chest pain and localized tenderness of
chest wall or chest pain on twisting of neck
or thoracic cage
Confirmed by: no itroponin after 12 hours, and no
ST-segment or T-wave changes serially on ECG
.
Response to rest and analgesics
Referred
cervical root
pain
Suggested by: previous minor episodes, exacerbation
by neck movement (producing closure of nerve root
foramina related to area of pain)
Confirmed by: clinical features and MRI scan
Shingles Suggested by: pain (often burning in nature) in a
dermatomal distribution, previous exposure to
chicken pox or shingles attacks. More common in
immunocompromised patients
Confirmed by: vesicles appearing within days
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