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_3230_Библиотеки_им_академика_М_И_Перельмана
.pdf
CHAPTER 11 GI signs
282
Fresh blood on finger on rectal
examination
This is usually suggestive of lower GI bleeding but occasionally from
massive upper GI bleeding passing through rapidly without alteration.
Some differential diagnoses and typical outline evidence
Hemorrhoids Suggested by: rectal bleeding follows defecation,
perianal protrusion with pain
Confirmed by: anal inspection and proctoscopy
(hemorrhoids drop over edge of proctoscope as it is
withdrawn)
Rectal
carcinoma
Suggested by: rectal bleeding with defecation, blood
often limited to surface of stool
Confirmed by: sigmoidoscopy with rectal biopsy
Colonic
carcinoma
Suggested by: alternate diarrhea and constipation with
red blood
Confirmed by: colonoscopy with biopsy, barium enema
Ulcerative
colitis
Suggested by: loose blood-stained stools, anemia,
arthropathy, uveitis and iritis
Confirmed by: colonoscopy with biopsy, barium studies
Crohn’s disease Suggested by: aphthous ulcers, anemia, tender mass,
scars of previous surgery, anal fissures, fistulae
Confirmed by: colonoscopy with biopsy, barium studies
Angiodysplasia Suggested by: chronic, recurrent GI bleeding
Confirmed by: endoscopy, mesenteric angiography
Diverticulitis Suggested by: history of red “splash” in the toilet bowl,
LIF tenderness ± tender mass
Confirmed by: flexible sigmoidoscopy, barium
enema
Ischemic
colitis
Suggested by: left-sided abdominal pain, loose stools,
dark clots
Confirmed by: barium enema (may show “thumb-
printing” sign), colonoscopy
Meckel’s
diverticulum
Suggested by: usually asymptomatic, anemia, rectal
bleeding
Confirmed by: technetium-labeled red blood cell scan,
laparotomy
FRESH BLOOD ON FINGER ON RECTAL EXAMINATION1
283
Intussusception
(in children or
elderly)
Suggested by: child, usually between 6 and 18 months
of life, acute onset of colicky, intermittent abdominal
pain, “red currant jelly” rectal bleed, and ± a sausage-
shaped mass in upper abdomen
Confirmed by: barium or air enema, may reduce the
intussusceptions with appropriate hydrostatic pressure
Mesenteric
infarction
(acute
occlusion)
Suggested by: acute abdominal pain, generalized
tenderness, shock, and profuse diarrhea (patient
often in atrial fibrillation)
Confirmed by: mesenteric angiography, exploratory
laparotomy
Massive upper
GI bleed
Suggested by: hypotension or associated hematemesis
Confirmed by: esophagogastroscopy
Trauma Suggested by: pain, history or physical signs of trauma
(e.g., sexual assault)
Confirmed by: sigmoidoscopy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
This page intentionally left blank
Chapter 12
285
Neurological symptoms
Headache
—acute, new onset 286
—subacute onset 288
—chronic and recurrent 289
Stroke 290
Dizziness 292
Vertigo 294
Seizure 296
Transient neurological deficit 298
Fatigue, “tired all the time” 300
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
286
Headache—acute, new onset
Onset is over seconds to hours.
Some differential diagnoses and typical outline evidence
Meningitis
viral or
bacterial
Suggested by: photophobia, fever, neck stiffness,
vomiting, Kernig’s sign. Petechial or purpuric rash
(in meningococcal meningitis)
Confirmed by: CT brain if neurological signs present,
Lumbar puncture—viral meningitis: cerebrospinal fluid
(CSF) clear, i lymphocytes, i protein, normal glucose.
Bacterial meningitis: CSF with i neutrophils, i protein,
dglucose, i visible bacteria on Gram stain
Low CSF
pressure
Suggested by: worsening or recurrence of headache
after lumbar puncture (usually for suspected meningi
t
is)
made worse by sitting up
Confirmed by: spontaneous resolution after a few days
Subarachnoid
hemorrhage
Suggested by: sudden occipital headache (often
described as “like a blow to the head” or “worst
headache of my life”), variable degree of consciousness,
± neck stiffness, subhyaloid
hemorrhage, ± focal neurological signs
Confirmed by: CT or MRI brain scan. Lumbar
puncture: blood-stained CSF that does not clear in
successive bottles, presence of xanthochromia in CSF
(up to 2 weeks after the hemorrhage)
Intracranial
hemorrhage
Suggested by: focal neurological signs
Confirmed by: CT/MRI brain scan
Head injury
with cerebral
contusion
Suggested by: history of trauma, cuts or bruises,
reduced conscious level, lucid period, amnesia
Confirmed by: skull X-ray, CT head normal or showing
edema but no subdural hematoma or extradural
hemorrhage
Acute
angle-closure
glaucoma
Suggested by: red eyes, haloes, reduced visual acuity
due to corneal clouding, pupil abnormality
Confirmed by: raised intraocular pressure
Sinusitis Suggested by: fever, facial pain, mucopurulent nasal
discharge, tender over sinuses ± upper respiratory
infection (URI)
Confirmed by: X-ray of sinuses or CT scan: mucosal
thickening, air-fluid level or opacification
HEADACHE—ACUTE, NEW ONSET1
287
Tension
headache
Suggested by: generalized or bilateral, continuous, tight
band-like, worsens as the day progresses, associated
with stress or tension, ± aggravated by eye movement
Confirmed by: spontaneous improvement with
simple analgesia
Bilateral
migraine
Suggested by: bilateral, throbbing, ± vomiting, aura
± visual or other neurological disturbances with
precipitating factor, e.g., premenstrual
Confirmed by: resolu
t
ion over hours in a dark room and
analgesics, helped by sleep
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
288
Headache—subacute onset
Onset is over hours to days.
Some differential diagnoses and typical outline evidence
Raised
intracranial
pressure
due to tumor,
hydrocephalus,
cerebral
abscess, etc.
Suggested by: dull headache, worse on waking,
vomiting, aggravated by, e.g., cough, sneezing, bending,
look for papilledema, iBP, d pulse rate, progressive
focal neurological signs
Confirmed by: CT/MRI brain scan
Encephalitis Suggested by: fever, confusion, reduced conscious level
Confirmed by: CSF microscopy, serology or PCR
Temporal/giant
cell or cranial
arteritis
Suggested by: scalp tenderness, jaw claudica
t
ion, loss of
temporal arterial pulsation, sudden loss of vision.
iiESR
Confirmed by: temporal artery biopsy (may be done
shortly after starting corticosteroids)
HEADACHE—CHRONIC AND RECURRENT1
289
Headache—chronic and recurrent
Onset is over weeks to months.
Some differential diagnoses and typical outline evidence
Tension
headache
Suggested by: generalized or bilateral, continuous, tight
band-like, worsens as the day progresses, associated
with stress or tension, often aggravated by eye
movement
Confirmed by: spontaneous improvement with simple
analgesia
Migraine Suggested by: typically unilateral, throbbing, ±
vomiting, aura ± visual disturbances, precipitating
factors
Confirmed by: resolution over hours in a dark room
and analgesics, helped by sleep
Cluster
headache
Suggested by: episodic, typically nightly pain in one eye
for weeks
Confirmed by: episodes resolving over hours (like
migraine)
Cervical root
headache
Suggested by: occipital and back of the head, temples,
vertex and frontal regions, worse on neck movement
or restricted neck movements
Confirmed by: cervical X-ray showing degenerative
changes (or normal) and response to NSAIDs
Eye strain Suggested by: headaches worse after reading.
Refractory error
Confirmed by: improvement with appropriate
eye glasses
Drug side effect Suggested by: drug history (e.g., nitrates)
Confirmed by: improvement on drug withdrawal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 12 Neurological symptoms
290
Stroke
This is a sudden onset of a neurological deficit.
Some differential diagnoses and typical outline evidence
Cerebral
infarction
Suggested by: onset over minutes to hours of
hemiparesis or major neurological defect that lasts
>24 hours
Confirmed by: CT scan findings appearing after days
Transient
cerebral
ischemic
attack
due to carotid
artery stenosis,
etc. (see below)
Suggested by: onset over seconds to minutes of a
neurological deficit that is improving already
Confirmed by: deficit resolving within 24 hours
Cerebral
embolus
due to atheroma,
atrial fibrillation,
myocardial
infarction
Suggested by: onset over seconds of hemiparesis or
other neurological defect that lasts >24 hours
Confirmed by: CT scan and lumbar puncture
showing little change originally. Evidence of a
potential source for an embolus
Cerebral
hemorrhage
due to
atheromatous
degeneration,
cerebral tumor
Suggested by: onset over seconds of hemiparesis or
major neurological defect that lasts >24 hours
Confirmed by: CT showing high attenuation
± surrounding low attenuation (edema) area ± high
density (blood) in ventricles
Subdural
hemorrhage
(or hematoma)
due to blunt
head injury
Suggested by: onset over hours, days, or weeks of a
fluctuating hemiparesis following history of head injury
or fall, especially in elderly or alcoholic
Confirmed by: CT showing low attenuation parallel to
skull if chronic but high attenuation if acute
Extradural
hemorrhage
due to skull
fracture
lacerating middle
meningeal artery
Suggested by: onset over minutes or hours of
confusion, disturbed consciousness, and hemiparesis
after lucid interval of hours following head injury
Confirmed by: CT head showing high attenuation
adjacent to skull ± hyperdensity ± dark (edema)
± midline shift
STROKE1
291
Subarachnoid
hemorrhage
from berry
aneurysm
Suggested by: sudden onset over seconds of headache
± disturbance of consciousness (usually under 45 years
of age), neck stiffness
Confirmed by: CT head showing high-attenuation area
on surface of brain. Lumbar puncture showing blood
Cerebellar
stroke
Suggested by: sudden onset of ataxia
Confirmed by: MRI scan (CT head poorly visualizes
hind brain)
Pontine stroke Suggested by: sudden loss of consciousness.
Cheyne–Stokes breathing (cycles of tachypnea [rapid
breathing] and bradypnea [slowing breathing),
pin-point pupils, hemiparesis and eyes deviated toward
paresis
Confirmed by: above clinical findings ± MRI scan
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Соседние файлы в папке Библиотека им академика М.И. Перельмана