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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 17 Psychiatric symptoms and signs
412
Anxiety in response to specific issues
Some differential diagnoses and typical outline evidence
Anorexia
nervosa
Suggested by: intense fear of gaining weight, though
underweight. Amenorrhea in women for ≥3 months
and diminished sexual interest. Bingeing and vomiting,
purging or excessive exercise. Depression and social
withdrawal, sensitivity to cold, delayed gastric
emptying, constipation, low blood pressure, bradycardia,
hypothermia
Confirmed by: BMI <17.5 kg/m
2
and many of above
clinical features
Bulimia
nervosa
Suggested by: fear of gaining weight, recurrent episodes
of binge eating, far beyond normally accepted amounts
of food. Vomiting, use of laxatives, diuretics ± appetite
suppressants
Confirmed by: normal menses and normal weight
Somatization
or hysteria
alone or with
depression,
anxiety,
schizophrenia,
and substance
abuse
Suggested by: physical symptoms with preoccupation
with bodily sensa
t
ions combined with a fear of physical
illness
Somatization
disorder
(Briquet’s
syndrome)
Suggested by: long history of numerous unsubstantiated
physical complaints with no adequate physical
explanation and refusal to be reassured
Simple phobia Suggested by: symptoms and signs of generalized
anxiety disorder
Confirmed by: inappropriate anxiety in the presence
of particular circumstances, e.g., enclosed spaces
(claustrophobia), spiders (arachnophobia)
Social phobia Suggested by: intense and persistent fear of being
scrutinized or negatively evaluated by others, resulting
in fear and avoidance of social situations (e.g., meeting
people in authority, using a telephone, speaking in
front of a group). May fear most or specific social
situations
ANXIETY IN RESPONSE TO SPECIFIC ISSUES1
413
Agoraphobia Suggested by: panic attacks in crowds or situations
where escape is difficult. Staying at home, will not visit
doctors. Also depression, depersonalization, and
obsessional thoughts
Post-traumatic
stress disorder
caused by
experiencing or
witnessing a
traumatic event,
e.g., major
accident, fire,
assault, military
combat
Suggested by: memories, nightmares (up to years after
event), flashbacks, numbing of emotions, anxiety
and irritability, insomnia, poor concentration,
hypervigilance. Accompanying depression, anxiety,
and drug or alcohol abuse or dependence
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CHAPTER 17 Psychiatric symptoms and signs
414
Depression
Some differential diagnoses and typical outline evidence
Major
depression
Suggested by: depressed mood ± loss of interest in
pleasure
Confirmed by: for example, the additional presence of
≥5 of the following 7 symptoms: (1) change in appetite
or weight, (2) psychomotor agitation or retardation,
(3) insomnia or hypersomnia, (4) sense of worthless-
ness or guilt, (5) fatigue or loss of energy, (6) recurrent
thoughts of death, (7) poor concentration
Mild to
moderate
depression
Suggested by: depressed mood ± loss of interest in
pleasure
Confirmed by: for example, the additional presence of
<5 of the following 7 symptoms: (1) change in appe
t
ite
or weight, (2) psychomotor agitation or retardation,
(3) insomnia or hypersomnia, (4) sense of worthless-
ness or guilt, (5) fatigue or loss of energy, (6) recurrent
thoughts of death, (7) poor concentration
Depression
secondary or
partly due to
other
conditions
Suggested by: history of any other illness that
undermines self-confidence but especially anxiety
disorders, alcohol abuse, substance abuse
Confirmed by: improvement when underlying
condition alleviated
Depression
secondary or
partly due to
medication
Suggested by: history of taking beta blockers, alpha
blockers, anticonvulsants, calcium channel blockers,
corticosteroids, oral contraceptives, antipsychotic
drugs, drugs used for Parkinson’s disease (e.g., levodopa)
Confirmed by: improvement when drug stopped or
changed
Seasonal
affective
disorder
Suggested by: “winter blues”: depression of mood +
i sleep, i food intake (with carbohydrate craving), and
weight gain, sometimes with opposite mood swings in
summer
HALLUCINATIONS, DELUSIONS, OR THOUGHT DISORDER1
415
Hallucinations, delusions, or thought
disorder
Hallucinations are visions, voices, and sounds not apparent to others
present. Delusion is the holding of a belief despite evidence to the con-
trary. In thought disorder, thoughts jump from one idea to another in a
bizarre way.
Some differential diagnoses and typical outline evidence
Mania and
hypomania
Suggested by: persistent high or euphoric mood out of
keeping with circumstances
Confirmed by: pressure of speech, no insight,
over-assertiveness, increased energy and activity,
grandiose delusions, spending sprees, increased appe-
tite, hallucinations, disinhibition, increased sexual desire,
labile mood, elation, self-important ideas, diminished
pain threshold, irritability, poor concentration, hostility
when thwarted, diminished desire or need for sleep
Bipolar disorder
or manic
depression
Suggested by: consists of episodes when
t
he patient has
mania (bipolar I) or hypomania (bipolar II) against a
background of depression
Acute
schizophrenia
Suggested by: sufferer’s apparent inability to distinguish
between imaginary and external world
Confirmed by: at least one of the following Schneider
first-rank symptoms: somatic hallucinations, thought
insertion ± withdrawal, thought broadcasting, primary
delusions (in addition to thought delusions, passivity
feelings, thought echo, or hearing voices referring to
the patient in the third person)
Chronic
schizophrenia
Suggested by: sufferer appearing unable to relate to
external world, with blunting of affect
Confirmed by: thought disorder and poverty of thought,
apathy, inactivity, lack of volition, social
withdrawal, and loss of affect
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CHAPTER 17 Psychiatric symptoms and signs
416
Confusion (global cognitive deficit)
This condition may be acute or chronic.
Some differential diagnoses and typical outline evidence
Acute confusional
state (delirium)
caused by
infection, drugs,
metabolic,
alcohol or drug
withdrawal,
hypoxia, cardio-
vascular disease,
intracranial lesion,
thyrotoxicosis or
hypothyroidism,
carcinomatosis,
epilepsy, nutritional
deficiency
Suggested by: global cognitive deficit with onset over
hours or days, fluctuating conscious level (typically
worse at night), impaired memory (on recovery amn
sia of the events is usual), disorientation in time and
place, odd behavior (may be underactive, drowsy ±
withdrawn or hyperactive and agitated), disordered
thinking, often slow and muddled ± delusions (e.g.,
accuse relatives of taking things), disturbed percep-
tions, hallucinations (particularly visual), mood swing
s
Confirmed by: outcome consistent with underlying
cause and treatment
Chronic confusion
due to Alzheimer’s
disease (60%),
vascular
(multi-infarct)
dementia, dementia
with Lewy bodies
Suggested by: patient admitting to “being a bit
forgetful,” but relatives complain of loss of short-
term memory and inability to perform normally
simple tasks, failure to cope at home, or self-neglect
Confirmed by: no impairment of consciousness, clear
history of progressive impairment of memory and
cognition ± personality change, ± cerebral atrophy
on CT
brain scan
Alzheimer’s
disease
Suggested by: features of dementia
Confirmed by: absence of features of vascular
(multi-infarct) dementia or Parkinsonism
Vascular
(multi-infarct)
dementia
Suggested by: tends to occur with a stepwise
progression of dementia with each subsequent
infarct and pseudobulbar palsy
Confirmed by: by multiple lacunar infarcts or larger
stroke’s cause on CT scan
Lewy body
dementia
Suggested by: fluctuating but persistent dementia
with Parkinsonism and hallucinations
Confirmed by: histology at postmortem
Other neuro-
degenerative
diseases:
Huntington’s
chorea, bovine
spongiform
encephalopathy
Suggested by: other neuromuscular signs, e.g.,
seizures, abnormal posture, etc.
Confirmed by: clinical and postmortem brain
specimens
Chapter 18
417
Laboratory tests
Asymptomatic microscopic hematuria 418
Asymptomatic proteinuria 419
Glycosuria 420
Raised urine or serum bilirubin 421
Hepatocellular jaundice 422
Obstructive jaundice 423
Hypernatremia 424
Hyponatremia 425
Hyperkalemia 426
Hypokalemia 427
Hypercalcemia 428
Hypocalcemia 429
Raised alkaline phosphatase 430
Raised blood urea nitrogen (BUN) and creatinine
(azotemia) 431
Low hemoglobin 432
Microcytic anemia 433
Macrocytic anemia 434
Normocytic anemia 435
Very high ESR or CRP 436
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CHAPTER 18 Laboratory tests
418
Asymptomatic microscopic hematuria
This is detected on routine urine dipstick testing.
Some differential diagnoses and typical outline evidence
Menstruation Suggested by: history of current, recent, or immi-
nent periods and no urinary symptoms
Confirmed by: negative on repeating in mid-cycle
Urinary tract
infection (UTI)
Suggested by: fever, frequency or dysuria, Nitrites i,
leukocytes i on dipstick
Confirmed by: urine microscopy and culture,
response to antibiotics. Ultrasound scan for
possible anatomical abnormality
Recent urethral
trauma
Suggested by: recent urethral catheterization
Confirmed by: history, no infection in urine
Bleeding diathesis Suggested by: bruising, anticoagulant therapy
Confirmed by: abnormal platelet and clotting screen
Calculus or tumor
anywhere in renal
tract
Suggested by: persistent x3 microscopic hematuria
Confirmed by: urinalysis, renal ultrasound, CT scan,
then cystoscopy by urologist
Glomerulonephritis
primary or
secondary to
systemic lupus
erythematosus
(SLE), subacute
bacterial
endocarditis
(SBE), etc.
Suggested by: persistent x3 microscopic
hematuria, associated proteinuria, hypertension
Confirmed by: urine microscopy, renal ultrasound,
immunoglobulins (Igs), complement, anti-nuclear
antibody (ANA), anti-neutrophil cytoplasmic
antibody (ANCA)-positive blood cultures
or response to antibiotics
Nephritis
secondary to
NSAIDs, etc.
Suggested by: persistent x3 microscopic hematuria,
taking NSAID or other suspicious drug
Confirmed by: urine microscopy, renal ultrasound,
improvement on stopping suspected drug
ASYMPTOMATIC PROTEINURIA1
419
Asymptomatic proteinuria
Total protein excretion is usually <50 mg/24 hours, of which albumin alone
is normally <30 mg/24 hours. Abnormal proteinuria is regarded as >150
mg/24 hours.
Some differential diagnoses and typical outline evidence
Postural or
orthostatic
proteinuria
Suggested by: specimen from an ambulatory person
<40 years of age
Confirmed by: protein testing negative on early
morning urine specimen
Nonspecific febrile
illness
Suggested by: known febrile illness
Confirmed by: normal when illness resolved
Urinary tract
infection (UTI)
Suggested by: fever. Presence of nitrites, leukocytes,
and blood on urine dipstick test
Confirmed by: Urine microscopy and culture.
Ultrasound scan of abdomen for possible
anatomical abnormality
Glomerulonephritis
primary or
secondary to SLE,
etc.
Suggested by: proteinuria >1 g/24 hours, persistent
x3 microscopic hematuria, hypertension
Confirmed by: urine microscopy, renal ultrasound,
and serum immunoglobulins, complement, ANA,
ANCA, etc.
Nephritis secondary
to NSAIDs, etc.
Suggested by: proteinuria >1 g/24 hours, taking
NSAID or other suspicious drug
Confirmed by: urine microscopy, renal ultrasound,
improvement on stopping suspected drug
Nephrotic
syndrome due to
minimal-change
disease, diabetes
mellitus, etc.
Suggested by: proteinuria >3 g/24 hours
Confirmed by: serum albumin low (<3 g/dL), edema
and i cholesterol and i triglycerides
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CHAPTER 18 Laboratory tests
420
Glycosuria
This almost always indicates diabetes, and the blood glucose should be
tested, but consider other possibilities.
Some differential diagnoses and typical outline evidence
Diabetes
mellitus
Suggested by: fatigue or other unexplained symptoms,
thirst, polydipsia, polyuria
Confirmed by: fasting blood glucose ≥126 mg/dL on
two occasions OR fasting; random or glucose toler-
ance test (GTT) glucose ≥200 mg/dL once only with
symptoms
Renal glycosuria Suggested by: patient well or renal disease
Confirmed by: glycosuria with normal blood sugar
on GTT
RAISED URINE OR SERUM BILIRUBIN1
421
Raised urine or serum bilirubin
Some differential diagnoses and typical outline evidence
Hepatocellular
jaundice (due to
hepatitis or very
severe liver
failure)
(see p. 422)
Suggested by: jaundice with dark stools and dark urine.
Also raised urine urobilinogen (you can check this
immediately)
Confirmed by: raised serum bilirubin and raised urine
urobilinogen. Highly abnormal liver function tests.
Normal bile ducts but abnormal liver parenchyma on
ultrasound scan
Obstructive
jaundice due to
intrahepatic
causes (drugs,
hepatitis, etc.)
or extrahepatic
(stones, tumors,
etc.)
(see p. 423)
Suggested by: jaundice with pale stools and dark urine.
Also NO raised urinary urobilinogen
Confirmed by: raised plasma bilirubin, markedly raised
alkaline phosphatase; otherwise, slightly abnormal liver
function tests. Dilated bile ducts on ultrasound scan
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