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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 9 – Symptoms, signs, and laboratory results Chapter 9 Symptoms, signs, and laboratory results In general practice, patients do not come neatly packaged with a diagnosis. Moreover, they do not know what characteristics they must show to be a typical patient with a particular condition—and frequently present atypically. When confronted with a symptom, sign, or abnormal laboratory result, we need to know what the possible diagnoses are and then, placing that knowledge in clinical context, decide what the best course of action is. This section is an A-Z catalogue of symptoms and signs seen in general practice and suggestions about their likely causes, it is followed by a catalogue of commonly requested laboratory tests and the likely meaning of abnormal results. P.246
A Abdominal masses Abdominal masses are distinguished from pelvic masses by the ability to get beneath them. Causes of solid abdominal mass

  • Stool
  • Malignancy (any intra-abdominal organ or kidney)
  • AAA
  • Crohn’s mass
  • TB mass
  • Appendix mass or abscess
  • LNs
  • Splenomegaly
  • Hepatomegaly

Pelvic mass p.278 Abdominal distention Consider the 6F’s—

  • Fluid—ascites or full bladder
  • Fat
  • Faeces
  • Flatus—intestinal obstruction; air swallowing
  • Foetus
  • Food (e.g. in malabsorption)

Abdominal pain Acute abdomen p.1066 Acute abdominal pain in pregnancy p.796 Colic p.253

Table 9.1 Differential diagnosis of abdominal pain
Renal and gynaecological causes Gl causes Other causes
Renal colic IBS Post-herpetic neuralgia
UTI Constipation Spinal arthritis
Pyelonephritis Diverticular disease Muscular pain
Hydronephrosis Gallbladder disease AAA
Ectopic pregnancy Liver disease Mesenteric artery ischaemia
Pelvic inflammatory disease Crohn’s Mesenteric adenitis
Ovarian cyst UC MI
Gynaecological malignancy Gastritis Pneumonia
Peptic ulcer Subphrenic abscess
Appendicitis DM
Meckel’s diverticulum Porphyria
Pancreatitis Addison’s
Bowel obstruction Lead poisoning
Gl malignancy

P.247
History Consider:

  • Site of pain—see Figure 9.1
  • Onset: How long? How did it start? What started it? Change over time?
  • Character of pain: Type of pain—burning, shooting, stabbing, dull, etc.
  • Radiation
  • Associated symptoms e.g. nausea, vomiting, diarrhoea
  • Timing/pattern e.g. constant, colicky, relationship to food
  • Exacerbating and relieving factors
  • Severity
  • Previous treatments tried and result

Examination Temperature, pulse, BP, jaundice, anaemia, site of pain (Figure 9.1), guarding/rebound tenderness, rectal/vaginal examination as necessary. Management Try to ascertain cause from history and examination (Table 9.1) and treat accordingly.

Figure 9.1 Site of abdominal pain gives important clues about the organ involved

P.248
Absent periods Amenorhoea/absent periods—p.728 Absent testis May be absent because it is undescended, retractile, or has been removed. Retractile testis Usually young boys with active cremasteric reflex. No treatment needed. Examination: scrotum is usually well developed. Try to find the testis and milk it down into scrotum. May be found anywhere from the scrotum to the internal inguinal ring. If not found or unable to bring down into scrotum, assume undescended. Undescended testis p.840 Acanthosis nigricans p.633 Acute abdomen p.1066 Acute confusion p.976 Acute retention of urine p.690 Alopecia Hair loss or alopecia—p.658 Altered colour or smell of menstrual blood No known associations. Anaemia p.522 Anal pain Treat the cause. Consider:

  • Anal fissure
  • Haemorrhoids
  • Perianal abscess
  • Anal fistula
  • Skin infection (e.g. hidradenitis suppurativa)
  • Perianal heamatoma (thrombosed pile)
  • Pilonidal sinus
  • Functional pain (proctalgia fugax)
  • Anal carcinoma

Anorexia Absence of appetite. Non-specific symptom. Possible causes:

  • Malignancy—Gl tract e.g. stomach, colon, or disseminated malignancy from any cause
  • Infection e.g. appendicitis, pneumonia
  • Inflammatory diseases e.g. Crohn’s disease
  • Right ventricular failure
  • Metabolic disease e.g. uraemia, hypercalcaemia
  • Drugs e.g. cytotoxics
  • Psychiatric conditions e.g. anorexia nervosa, depression, anxiety

Anosmia Bilateral anosmia More common than unilateral.

  • Local causes: URTI, rhinitis, enlarged turbinates, nasal polyps.
  • Central causes: CNS tumours (meningioma of the olfactory groove, ethmoid tumours, frontal lobe tumours), after head injury, meningitis, hydrocephalus, Kallman’s syndrome.

Unilateral anosmia One-sided loss of the sense of smell. Causes: head injury, frontal lobe lesion (e.g. meningioma of the olfactory groove, frontal lobe tumour). Anuria Failure of the kidneys to excrete urine. Classified as:

  • Obstructive: Urinary tract obstruction—p.690
  • Non-obstructive: Renal failure—p.680

P.249
Anxiety p.960, 961, 962, 963, 964 Apex beat

  • The normal position of the apex beat of the heart is the 5th intercostal space, in (or just medial to) the midclavicular line.
  • Infants and children have apex beats which are superior and more lateral to those of adults.
  • Apex beat may not be palpable if the patient is obese, has hyper-expanded lungs (e.g. COPD), or a pericardial effusion.
  • The apex beat is moved sideways or inferiorly if the heart is enlarged (e.g. CCF) or displaced (e.g. pneumothorax).

Aphasia Dysphasia—p.257 Arthralgia Joint pain—p.271 Ascites Free fluid in the peritoneal cavity. Signs: abdominal distention, shifting dullness to percussion, fluid thrill. Causes:

  • Malignancy—any intra-abdominal organ, ovary, or kidney
  • Hypoproteinaemia e.g. nephrotic syndrome
  • Right heart failure
  • Portal hypertension

Asterixis Movement patterns (abnormal)—p.275 Athetosis Movement patterns (abnormal)—p.275 B Back pain p.550 Beliefs (abnormal) Decide whether a belief is normal in the context of the patient. If not, decide if the belief is a:

  • Delusion i.e. a belief that does not seem to have a rational basis and which is not amenable to argument (p.255) or
  • Overvalued idea i.e. belief that is odd but understandable given the patient’s background

Blackouts Establish what the patient means by blackout:

  • Fall: p.996
  • Loss of consciousness: p.274
  • Dizziness or vertigo: p.256
  • Visual loss: p.942

Blistering of the skin p.652 Bone pain Consider:

  • Fracture—due to injury, stress fracture, or pathological fracture
  • Arthritis—referred pain from affected joints
  • Malignancy—primary bone malignancy, haematological malignancy e.g. multiple myeloma, or secondaries (usually from breast, prostate, lung, thyroid, kidney—more rarely, bowel melanoma)
  • Benign bone tumour
  • Osteomyelitis
  • Metabolic causes—e.g. hypercalcaemia

P.250
Bowel motions (abnormal) Bloody stool Find out what the patient means:

  • Is the blood changed or unchanged? The further proximal the bleed, the more likely the blood will be changed (though a brisk gastric or duodenal bleed can result in red rectal bleeding).
  • Is the bleeding related to passage of stool? Blood on the toilet paper or in the pan not mixed with stool is often from anal bleeding due to haemorrhoids or an anal fissure.
  • Is blood mixed with stool? Mixed blood + stool implies bleeding proximal to the sigmoid colon; blood around the stool implies a distal bleed.

Change in bowel habit p.251 Constipation p.472 Diarrhoea p.255 Fresh rectal bleeding Lower Gl bleed—p.1040 Melaena Upper Gl bleed—p.1040 Slimy stool Caused by overproduction of mucus in the large bowel. Almost always associated with colonic disease or irritable bowel syndrome. Investigate further. Steatorrhoea p.291 Aluminium paint stools China clay stools—pale cream coloured stools usually caused by pancreatic cancer. Bradycardia Heart rate <60bpm—p.312 and 346 Breast

  • Enlargement—men: Gynaecomastia—p.515
  • Lump: p.512
  • Pain: p.513

Breathlessness Dyspnoea—p.258 Breath sounds: Assess character of breath sounds and added sounds:

  • Bronchial breathing: Breath sounds are harsher than normal—often caused by lung consolidation e.g. due to pneumonia
  • ↓ breath sounds: Consider: pleural effusion, pneumothorax, emphysema, lung collapse
  • Added sounds: Pleural rub (p.279); wheeze (p.298); crepitations/crackles (p.254)

C Cachexia Severe generalized muscle wasting. Causes: Neoplasia, malnutrition, chronic infection (e.g. TB); prolonged inactivity; dementia. Carotid bruits May signify stenosis (>30%), often near the origin of internal carotid. Heard best behind the angle of the jaw. Usual cause: atheroma. P.251
Carotid artery stenosis p.609 Carotid pulse Pulses— p.283 Change in bowel habit Once obvious causes (e.g. gastroenteritis, constipation due to opiates) have been excluded, investigate persistent diarrhoea or constipation in all patients, especially those >45y. Common causes:

  • Carcinoma of the colon
  • UC
  • Crohn’s disease
  • Diverticular disease
  • Pancreatic disease
  • Bowel obstruction

Chest deformity Barrel chest AP diameter ↑, expansion ↓ Seen with chronic hyperinflation (e.g. asthma/COPD). Pigeon chest (pectus carinatum) Prominent sternum with a flat chest. Seen in patients with chronic childhood asthma or rickets. Funnel chest (pectus excavatum) The lower end of sternum is depressed. Kyphosis ↑ forward spinal convexity. Usually affects the thoracic spine.

  • Postural kyphosis (‘drooping shoulders’ or ‘roundback’) is common and voluntarily correctable.
  • Structural kyphosis cannot be corrected voluntarily. Common causes: osteoporosis, Paget’s disease, ankylosing spondylitis, and adolescent kyphosis (Scheuermann’s disease). May cause a restrictive ventilatory defect.

Scoliosis ↑ lateral curvature of the spine. Above and below the scoliosis, secondary curves develop to maintain normal position of head and pelvis. In all cases, refer to orthopaedics for assessment.

  • Non-structural scoliosis (‘mobile scoliosis’) is usually secondary to an abnormality outside the spine e.g. unequal leg length. It disappears when that is corrected.
  • Structural scoliosis (‘true scoliosis’) is non-correctible. Causes: Idiopathic, neuromuscular (e.g. cerebral palsy, muscular dystrophy, neurofibromatosis), trauma, osteoporosis, TB of the spine (rare), spinal tumours (rare), congenital abnormalities of the spine (rare).

Harrison’s sulcus Groove deformity of the lower ribs at the diaphragm attachment site. Suggests chronic childhood asthma or rickets. (E. Harrison(1766–1838)—British physician) Chest pain Common symptom. Always think—could this be an Ml, PE, dissecting aneurysm, or pericarditis? If a patient is acutely unwell with chest pain and the cause is not clear, err on the side of caution and admit for further assessment. See ‘Acute chest pain’—p.1046 History Ask about site and nature of pain, duration, associated symptoms (e.g. breathlessness, nausea), provoking and relieving factors, PMH, drug history, smoking history, FH (e.g. heart disease).

Table 9.2 Causes of chest pain
Potentially fatal Poorly localized Well localized
MI Angina Fractured rib
Aortic dissection MI Muscle sprain
PE Myocarditis Tietze’s syndrome
Oesophageal rupture Mitral valve prolapse Pericarditis
HOCM Pleurisy
Pneumonia PE
Tracheitis Shingles
Reflux oesophagitis Mastitis
Oesophageal spasm Biliary colic
Peptic ulcer Da Costa’s syndrome
Cervical spondylosis Bornholm disease

P.252
Examination Check BP in both arms, general appearance (distress, sweating, pallor), JVP, apex beat, heart sounds, lung fields, local tenderness, pain on movement of chest, skin rashes, swelling or tenderness of legs (?DVT). Investigations ECG and CXR may be helpful. Central chest pain

  • Angina: Constricting pain. May radiate to one/both arms, neck, or jaw. Can be provoked by exercise (relieved by stopping), cold, or ingestion of food. Often associated with breathlessness and/or palpitations. Rapidly relieved by GTN spray—p.328.
  • Ml: Constricting or crushing pain or intense dull ache lasting >½ h. despite GTN spray. Radiates to either or both shoulders/arms and/or neck/jaw. Associated with dyspnoea, sweating, palpitations, nausea ± vomiting, and often a sense of doom. Admit.
  • Dissecting thoracic aneurysm: May present with sudden tearing interscapular back pain or pain similar to Ml ± radiation through to the back. Often the patient is very unwell and shocked (though not always)—BP is different in the 2 arms. Admit.
  • Pericarditis and pleurisy: Sharp pain, worse on inspiration ± fever, breathlessness. Treat the cause.
  • Oesophageal pain: May be very similar to cardiac pain. Suspect if related to food or alcohol ingestion or occurs in bed on lying flat. Relieved by antacids e.g. Gaviscon. Relieved by GTN spray, but less rapidly than angina.

Non-central chest pain Remember—may still be cardiac.

  • Pleuritic pain/pleurisy: Sharp pain, usually well localized, prevents deep inspiration (‘catches as I breath’). Implies inflammation of the pleura. Treat the cause. Causes: chest infection, PE, malignancy e.g. mesothelioma.
  • Fractured rib: Usually history of injury (though may not be—especially if pathological fracture). Pain well localized and point tenderness overrib. P.253
    Pain made worse by light pressure over sternum. Treat with simple analgesia. Heels spontaneously. No need for X-ray except if diagnosis is unsure or unless other pathology is suspected.
  • Musculoskeletal pain: Common. Sharp or dull pain. Due to radiation of pain from thoracic spine or local muscular injury. Usually made worse by movement and relieved by rest and NSAIDs.
  • Shingles: Pain (often burning in nature)in a dermatomal distribution. Vesicles appear days later. Treatment—p.494.
  • Gallbladder and pancreatic disease: May mimic cardiac pain or be felt as atypical chest pain. Management—p.446 and 448 respectively.
  • Functional: Continuously varying locations, brief stabbing pains (<30sec.). Beware of addicts feigning chest pain to receive opiate analgesia.

Cheyne-Stokes respiration Breathing becomes progressively deeper and then shallower (± episodic apnoea) in cycles. Causes: brain-stem lesions/compression (stroke, ↑ ICP); chronic pulmonary oedema; poor cardiac output. It is enhanced by narcotics. Chorea Movement patterns (abnormal)—p.275 Chronic retention of urine p.691 Clubbing of nails p.661 Claudication p.36 Clonus Reflexes—p.285 Coffee grounds vomit p.1041 Colic

  • Infantile: p.831
  • Colicky abdominal pain: Pain which comes and goes. Can be the result of obstruction in a viscus (e.g. Gl obstruction, renal colic, biliary colic) or IBS.

Compulsion Forced behaviour repeated in spite of inappropriateness, or unreasonableness and associated discomfort in response to an obsession. Can be disabling e.g. repeated handwashing hundreds of times a day. Obsessive-compulsive disorder—p.965. Confusion

  • Acute: p.976
  • Longstanding: p.978

Constipation

  • Adults: p.472
  • Children: p.856

Coryza Discharge from the mucous membrane of the nose. Usually due to acute viral URTI. Other causes: rhinitis (allergic or vasomotor), prodrome to measles or pertussis. P.254
Cough Reaction to irritation anywhere from pharynx to lungs Acute cough (<3wk.) Causes:

  • URTI
  • Croup
  • Tracheitis
  • LRTI
  • Pneumonia—productive, loose cough
  • Acute exacerbation of asthma normally well controlled
  • Inhaled foreign body—especially in well children

Reserve CXR for patients with marked focal chest signs or where inhalation of foreign body is suspected. Management: Treat the cause where possible; advise OTC cough mixture as needed e.g. simple linctus; steam inhalation often eases symptoms temporarily; review if not clearing. Chronic cough (>2wk.) Causes:

  • Postnasal drip
  • Postviral
  • Pertussis
  • Bronchiectasis
  • Pulmonary oedema
  • Lung cancer
  • COPD
  • Asthma
  • Foreign body
  • Vocal cord palsy
  • GORD
  • LVF
  • Drug-induced (e.g. ACE inhibitors)
  • Smoker’s cough
  • Psychogenic

Red flags: Weight ↓, night sweats. Management: Treat the cause. If no cause is found, refer for medical opinion. Crackles in the chest Produced by air flow moving secretions from airways or lung tissue.

  • Fine crackles: Consider pulmonary oedema (early inspiratory); early pneumonia; fibrosing alveolitis (late inspiratory).
  • Coarse crackles: Consider TB; resolving pneumonia; bronchiectasis; lung abscess.

Cramp Painful muscle spasm. Common—especially at night and after exercise. Rarely associated with disease—salt depletion, muscle ischaemia, myopathy. Forearm cramps suggest motor neurone disease. Night cramps in the elderly may respond to quinine bisulfate 300mg nocte twice weekly. Writer’s cramp p.259 Crying babies p.890 Cyanosis Dusky blue skin. Central cyanosis Cyanosis of mucus membranes e.g. mouth. Causes: lung disease resulting in inadequate oxygen transfer (e.g. COPD, PE, pleural effusion, severe chest infection); shunting from pulmonary to systemic circulation (e.g. Fallot’s tetralogy, PDA, transposition of the great arteries): inadequate oxygen uptake (e.g. met- or sulf-haemoglobinaemia). Peripheral cyanosis e.g. cyanosis of fingers. Causes: as for central cyanosis plus: physiological (cold, hypovolaemia); local arterial disease. Feet can be a dusky blue colour due to venous disease too. When occurs without central cyanosis, does not imply abnormal oxygen saturation. P.255
D Deafness p.924 Delayed puberty 282 Delirium

  • Acute confusion—p.976
  • Delirium tremens—p.1068

Delusions Beliefs held unshakably, despite available counter-evidence, and which are unexpected in view of circumstances and background. The belief is usually (but not always) false.

  • Primary delusions: Belief arrives in the head fully formed. e.g. thought insertion; strongly suggestive of schizophrenia.
  • Secondary delusions: Belief arises on the basis of experience e.g. someone who has lost their job several times through no fault of their own may believe they are unemployable.

Paranoid delusions Delusions which concern the relationship between the patient and other people. Associated with schizophrenia, depressive states, and acute and chronic cognitive impairment. Can be:

  • Delusions of reference: Ideas of reference—p.292
  • Delusions of persecution: p.293
  • Delusions of grandeur: p.293

Depersonalization Perceptions (abnormal)—p.278 Derealization Perceptions (abnormal)—p.278 Diarrhoea Acute diarrhoea Usually self-limiting, lasting 2–5d. Causes:

  • Dietary indiscretion
  • Infection e.g. food poisoning, traveller’s diarrhoea
  • Constipation with overflow
  • Pseudomembranous colitis—recent history of oral antibiotics
  • Onset of inflammatory bowel disease or other chronic diarrhoea

Management

  • Send a stool sample for M, C&S if fever, bloody diarrhoea, food worker, recent return from tropical climate, immunocompromised patient, or lasts >7d.
  • Treat with rehydration: Encourage clear fluid intake ± rehydration salts. Reserve antidiarrhoeals (e.g. loperamide) for patients in whom diarrhoea would be difficult (e.g. immobility, travel, work). Never give children antidiarrhoeal agents.
  • Food: Stick to a bland diet, avoiding dairy products, until diarrhoea has settled. Babies who are breast fed or have not been weaned should continue their normal milk. Some advocate using half-strength milk for non-breast fed babies, though the benefits of this have not been demonstrated.
  • If dehydrated and unable to replace fluids e.g. concomitant vomiting, child refusing to drink: Admit.
  • If no cause found and lasts >3wk. or any atypical features: Refer for urgent investigation or admit.

P.256
Chronic diarrhoea p.450 Difficulty walking

  • Walking difficulty: p.297
  • Gait (abnormal): p.263

Disturbed behaviour Acute management p.1082 Causes

  • Physical illness: Infection (e.g. UTI, chest infection); hypoglycaemia; hypoxia; head injury; epilepsy.
  • Drugs: Alcohol (or alcohol withdrawal); prescribed drugs (e.g. steroid psychosis); illicit drugs (e.g. amphetamines).
  • Psychiatric illness: Schizophrenia; mania; anxiety/depression; dementia.
  • Personality disorder: e.g. attention-seeking.

Dizziness and giddiness Distinguish between true vertigo (the illusion of rotatory movement—the room spinning) and a feeling of unsteadiness or lightheadedness:

  • Vertigo: p.928.
  • Imbalance: Implies difficulty in walking straight (e.g. from disease of peripheral nerves, posterior columns, or cerebellum).
  • Faintness: The feeling of being about to pass out. Some seizure disorders and a variety of non-neurological conditions (e.g. postural hypotension; vasovagal fainting; hyperventilation; hypoglycaemia; arrythmias; cough syncope). Sometimes 2 or 3 elements co-exist.

Dry eyes p.938 Dry mouth Causes: anxiety, drugs, or Sjögrens syndrome. Look for cause and rectify if possible. Prescribe artificial saliva e.g. glandosane. Dysarthria Difficulty with articulation due to incoordination or weakness of the musculature of speech. Language is normal. Ask to repeat ‘baby hippopotamus’ or ‘British constitution’. Treat the cause if possible; otherwise support with speech therapy and aids to communication. Causes:

  • Cerebellar disease: Slurring as if drunk. Speech is irregular in volume and scanning in quality.
  • Extrapyramidal disease: e.g. PD—soft, indistinct, and monotonous.
  • Pseudo-bulbar palsy: Patients may present with alteration of speech (typically nasal speech sounding like Donald Duck), difficulty swallowing or chewing. The tongue is spastic and jaw jerk ↑. Causes: stroke (bilateral); MS; MND.
  • Bulbar palsy: Loss of function of the tongue, muscles of chewing/swallowing ± facial muscles. Examination: flaccid, fasciculating tongue, jaw jerk normal or absent, speech—quiet, hoarse, or nasal. Causes: MND, Guillain Barré syndrome, alcoholic brainstem myelinolysis (central pontine myelinolysis), brainstem tumours (1° or 2°), syringobulbia, polio, hyponatraemia.
  • Other lesions: Neuromuscular junction—myaesthenia gravis; palate paralysis (nasal speech).

P.257
Dyslexia p.898 Dyspareunia

  • Female: p.726.
  • Male: Usually associated with infection e.g. urethritis, prostatitis.

Dyspepsia or indigestion p.432 Dysphagia Difficulty swallowing food or liquids. Refer all patients with dysphagia for urgent endoscopy or to a rapidaccess dysphagia clinic if available. Causes

  • Acute
    • Sore throat
    • Epiglottitis
    • Quinsy
    • Glandular fever
    • Foreign body in throat
    • Acute caustic stricture
  • Progressive
    • Within the oesophagus: p.434 and 440. Carcinoma of the oesophagus, foreign body, chronic benign stricture, achalasia, pharyn-geal pouch, Plummer-Vinson syndrome, oesophageal perforation.
    • Compression from outside: Enlarged mediastinal LNs, lung cancer, enlarged left atrium, large retrosternal goitre, thoracic aneurysm.
    • Other: Bulbar palsy, myaesthenia gravis, hysteria, anxiety state.

Dysphasia Impairment of language due to brain damage to the dominant hemisphere. The left hemisphere is dominant for 99% of R-handed people and 60% L-handers. In most cases, due to stroke or brain tumour. Rarely due to head injury or dementia. Assessment:

  • Is speech fluent, grammatical, meaningful, and apt? If yes, dysphasia unlikely.
  • Comprehension—can the patient follow 1, 2, or multiple step commands?
  • Repetition—can the patient repeat a phrase after you?
  • Naming—can the patient name common and uncommon items?
  • Reading and writing? Usually affected too. If not, question the diagnosis of dysphasia.

Classification Table 9.3. Mixed pictures are common. Treatment Speech therapy (may or may not be helpful), support (e.g. dysphasia groups: contact via Stroke Association—p.607), aids to communication (e.g. computers, picture boards).

Table 9.3 Classification of dysphasia
Characteristics of dysphasia Broca’s (expressive) Wernicke’s (receptive) Conduction Transcortical
Fluent? × [check mark] [check mark] [check mark] or ×
Repetition normal? × × × [check mark]
Understanding impaired? × [check mark] × [check mark] or ×
Table 9.4 Causes of dyspnoea
  Acute Subacute Chronic
Cardiac disease Acute LVF
Arrythmia
Shock
Arrythmia CCF
Mitral stenosis
Aortic stenosis
Lung disease Pneumothorax
Acute asthma attack
PE
Acute pneumonitis e.g. due to inhaling toxic gas
Asthma
Infective
Exacerbation of COPD
Pleural effusion
Pneumonia
COPD
Fibrosing alveoloitis
Occupational lung diseases
Mesothelioma
Lung cancer
Other Hyperventilation
Foreign body inhalation
Guillain-Barré syndrome
Altitude sickness
Ketoacidosis
Polio
Aspirin poisoning
Myaesthenia gravis
Thyrotoxicosis
Kyphoscoliosis
Anaemia
MND
MS

P.258
Dyspnoea Sensation of shortness of breath. Try to quantify exercise tolerance (e.g. dressing, distance walked, climbing stairs). Speed of onset helps diagnosis Table 9.4 Combined chest pain and dyspnoea Consider:

  • Ml Pericarditis
  • Dissecting aneurysm
  • PE
  • Oesophageal pain
  • Musculoskeletal pain
  • Chest infection
  • Pulmonary malignancy e.g. mesothelioma, Ca lung

Orthopnoea p.277 Paroxysmal nocturnal dyspnoea p.278 Exertional dyspnoea Breathlessness with exercise. Generally, causes are the same as dyspnoea. The New York Heart Association classifies 4 grades of severity:

  • Normal
  • Moderate: Walking on the level causes breathlessness.
  • Severe: Has to stop due to breathlessness when walking on the flat. All but the lightest housework is impossible.
  • Gross: Slightest effort → severe breathlessness. The patient is almost bed/chair bound.

Dyspraxia Impairment of performance of complex movements despite preservation of ability to perform their individual components. Test by asking the patient to perform everyday tasks (e.g. dress/undress), copy complex hand movements, and do familiar sequences of movements (e.g. ‘head, shoulders, knees, and toes’). P.259
Childhood p.898 Adults Most common causes are stroke or SOL. Involve rehabilitation services and OT.

  • Dressing dyspraxia: Patient is unsure of the orientation of clothes on his/her body.
  • Constructional dyspraxia: Difficulty in assembling objects or drawing (ask to draw 5-pointed star).
  • Gait dyspraxia: Gait disorder, although the lower limbs function normally—more common amongst the elderly.

Dystonia Prolonged muscle contraction producing abnormal postures or repetitive movements.

  • Spasmodic torticollis: Head is pulled to one side and held there by a contracting sternomastoid muscle. Treat with physiotherapy.
  • Blepharospasm: Involuntary contraction of the orbicularis oculi.
  • Writer’s cramp: Spasm of the hand and forearm muscles on writing.

Dysuria and urgency Painful micturition due to urethral or bladder inflammation. Causes: UTI, urethral syndrome, inflammation (e.g. interstitial cystitis, radiation induced cystitis), intravesical lesion (tumour, stone), atrophy (menopause). E Ear

  • Discharge: p.922
  • Pain: p.922

Eccymosis Purpura—p.284 Encoparesis p.895 Enuresis p.894 Epigastric pain Treat the cause. Acute causes

  • Peptic ulcer/gastritis
  • Gallbladder disease
  • Irritable bowel syndrome
  • Peritonitis
  • Pancreatitis
  • GI obstruction
  • Ruptured aortic aneurysm
  • MI
  • Pneumonia or other disease affecting the pleura
  • Spinal disease e.g. spondylosis

Chronic causes Peptic ulcer; gastric cancer; chronic pancreatitis; aortic aneurysm; root pain referred from the spine. Epistaxis p.1042 Erectile dysfunction p.702 Erythema Redness of the skin—usually due to vasodilation. It may be localized (e.g. pregnancy—on the palms) or generalized (e.g. drug eruption, viral exanthem). Excess hair Hairiness—p.658 P.260
Excess sweating Hyperhydrosis—p.659 Exertional dyspnoea p.258 Exophthalmos The eyes protrude from the orbit and thus have a staring appearance. Stand at the same level as the patient and look at the patient’s eyes. There should be no white of the sclera visible below the iris. If the eye is pushed forward, as in exophthalmos, white sclera is seen below the iris and the patient can look upwards without moving his/her eyebrows (distinguishes from lid retraction). Bilateral Caused by Grave’s disease. Unilateral Caused by Grave’s disease, orbital disease (e.g. tumours, cellulitis); vascular disease (e.g. cavernous sinus thrombosis, carotidcavernous fistula); sinus disease (e.g. tumour). Eyelid problems p.936 and 938 Eye pain Consider:

  • Painful conditions: Corneal abrasion, foreign body, keratitis, iritis, scleritis, acute glaucoma, ophthalmic shingles, arc eye.
  • Eye discomfort: Conjunctivitis, entropion, trichasis, dry eye, episcleritis, optic neuritis.
  • Referred pain: Tension type headache, migraine, refractive error, trigeminal neuralgia, ophthalmic shingles, giant cell arteritis, ocular muscle imbalance, ↑ ICP.

Eye (red) p.936 F Facial flushing Flushing—p.261 Facial pain Treat the cause. Common causes:

  • Trigeminal neuralgia
  • TMJ disorders
  • Dental disorders
  • Sinusitis
  • Migrainous neuralgia
  • Shingles and post-herpetic neuralgia

No cause is found in many patients—it is then termed atypical facial pain. Atypical facial pain may respond to simple analgesia with paracetamol or a NSAID. If this fails, try nerve painkillers e.g. amitriptyline nocte. Refer those with troublesome symptoms to ENT, maxillofacial surgery, or neurology. Facial palsy Paralysis of the facial nerve → facial weakness ± loss of taste in the anterior 2/3 of the tongue. Assessment: Check facial movements e.g. ask the patient to screw up his eyes, smile, and blow out his cheeks. Always ask the patient to raise his eyebrows—the brow is spared if unilateral upper motor neurone lesion (e.g. CVA). Causes:

  • Unilateral upper motor neurone lesion: Tumour, CVA.
  • Unilateral lower motor neurone lesion: Tumour (e.g. acoustic neuroma), CVA, MS, Bells palsy, Ramsay–Hunt syndrome, otitis media, fracture in the temporal bone, parotid tumour, facial laceration (including post-op), sarcoid, HIV.
  • P.261

  • Bilateral: Rare. Consider Bells palsy, sarcoid, Guillain-Barré syndrome, polio, and other causes of facial weakness e.g. myasthenia gravis, myopathies.

Fainting Vasovagal attack/simple faint. Common. Peripheral vasodilation, bradycardia, and venous pooling → postural hypotension. Often cause is unclear though ♀>♂. Known precipitants: fright (e.g. during venesection) or emotion. Features:

  • Prodrome: Dizziness, visual disturbance, nausea, sweating, ringing in the ears, a sinking feeling, and yawning;
  • Faint: Extreme pallor, momentary unconsciousness (with fall to the floor if standing ± tonic-clonic jerks if held upright);
  • Rapid recovery.

Management Exclude other reasons for loss of consciousness (p.274). No treatment needed—reassure. Falls p.996 Fatigue p.582 and p.626 Fever Pyrexia—p.284 Flatulence 400–1300mL of gas are expelled per rectum daily. If this seems excessive to the patient, he may complain of flatulence. Most patients complaining of flatulence have no GI disease. The most likely cause is air-swallowing (aerophagy). Reassure. Flight of ideas Thought disorders—p.292 Flushing Erythema due to vasodilation. Common and usually benign. Tends to affect face, neck, and upper trunk. Causes:

  • Physiological: exertion, heat
  • Emotion e.g. anger, anxiety, embarrassment
  • Foods e.g. spices, chillies, alcohol
  • Endocrine e.g. menopause, Cushing’s
  • Drugs e.g. morphine, tamoxifen, danazol, GnRH analogues, clomifene, nitrates, calcium channel blockers
  • Dermatological: rosacea (unknown mechanism); contact dermatitis
  • Inflammatory: SLE, dermatomyositis
  • Infection e.g. slapped cheek syndrome (5th disease), celluliltis, or erysipelas
  • Tumour: pancreatic tumours, medullary thyroid cancer, carcinoid, phaeochromocytoma.

Management Treat cause if possible (e.g. avoid alcohol; HRT). Embarrassing flushing may be helped with a small dose of propranolol (e.g. 40mg od/bd) or clonidine (e.g. 50 mcgm bd). Foot drop The patient trips frequently or walks with a high stepping gait. On examination, the patient is unable to walk on his heels and cannot dorsiflex his foot. Check ankle jerk. Causes:

  • Common peroneal palsy: e.g. due to trauma—normal ankle jerk
  • Sciatica: ankle jerk absent
  • L4, L5 root lesion: ankle jerk may be absent
  • Peripheral motor neuropathy: e.g. alcoholic—ankle jerk weak or absent
  • P.262

  • Distal myopathy: ankle jerk weak or absent
  • Motor neurone disease: ↑ ankle jerk

Foot pain Forefoot pain Causes: forefoot pathology (e.g. pes cavus, pes planus), stress fractures, RA, DM, gout, OA, paralytic deformity, post-traumatic syndromes, nerve root pathology, tarsal nerve compression. Heel pain Causes:

  • Within the heel: osteomyelitis, tumours, Paget’s disease, arthritis of the subtalar joint
  • Behind the heel: ruptured Achilles tendon, Achilles tendinitis
  • Under the heel: tender heel pad, plantar faciitis, plantar calcaneal bursitis

Foot pulses p.283 and p.361 Frequency Passage of urine more often than usual. Causes:

  • UTI
  • Urethral syndrome
  • Detrusor instability
  • Inflammation (e.g. interstitial cystitis)
  • Fibrosis (e.g. post-radiotherapy)
  • Atrophy (menopause)
  • Neurogenic bladder (e.g. MS)
  • External pressure (e.g. pregnancy, fibroids)
  • Bladder tumour or stone
  • Enlarged prostate
  • Drugs (e.g. diuretics)
  • DM
  • Excessive fluid intake
  • Habit

Funny turns in small children Consider: Epilepsy p.866 Non-epileptic attacks Usually self-limiting and harmless but can be very frightening for parents/carers. Parental education about the likely duration and cause of attacks and reassurance that the child will come to no harm are important.

  • Simple blue breath-holding attacks: Onset usually >6mo. of age. Common. Provoked by frustration or upset. Signs: +ve valsalva manoeuvre, cynanosis, stiffening, and coma. No treatment needed— spontaneous recovery. Most children ‘grow out’ of the attacks by 3y.
  • White reflex asystolic (anoxic) attacks: May start before 6mo. but most common from 6mo.-2y. Usually triggered by minor injury or anxiety. Signs: vagal asystole, pallor, rapid coma, stiffening, upward eye movement ± urinary incontinence. No treatment needed— spontaneous recovery.
  • Reflex syncope: ‘Faints’. Common—p.261
  • Others causes are rare but include:
    • Benign paroxysmal vertigo
    • Benign myoclonus of infancy
    • Cardiac arrhythmias
    • Sleep phenomena
    • Pseudoseizures
    • Munchhausen syndrome by proxy
    • Hypoglycaemia
    • Hyperventilation

P.263
G Gait (abnormal) Gait means manner of walking. Abnormal movements Normal gait is interrupted by abnormal movements e.g. choreiform movements, athetoid movements, or hemiballismus (p.275). Antalgic gait Gait adjusts to try to minimize pain in a joint—usually OA hip. The patient leans towards the affected side and takes a rapid step on that side followed by a slower step on the contralateral side. Drunken gait As its name suggests, a drunken gait is the type of gait adopted by someone who is drunk. The other major cause is a cerebellar lesion. Features:

  • Wide-based gait or reeling gait on a narrow base
  • Feet are often raised too high and placed over carefully with the patient looking ahead
  • If a cerebellar lesion, the patient falls to the side of the lesion

Foot drop Patients have a high-stepping gait to prevent scraping the toe on the ground. Frontal lesions Marked unsteadiness—the feet appear stuck to the floor causing a wide-based, shuffling gait. Hemiplegic gait Style of walking seen in patients with UMN lesions. Features:

  • Arm adducted and internally rotated, elbow flexed and pronated ± finger flexion
  • Foot is plantar flexed and the leg swings in a lateral arc

Parkinsonian gait Seen in patients with PD and other causes of Parkinsonism. Features:

  • Akinesia: Hesitation in starting walking (may be relieved by placing a line on the floor for the patient to step over).
  • Marche au petit pas: Small, shuffling steps.
  • Festinant gait: Flexed posture as if hurrying to keep up with feet.
  • Lack of normal arm swing
  • Kinesia paradoxica: Patients can perform fast or energetic movements more easily than slow ones e.g. running may be easier than walking.

Scissor gait As the name implies, the patient walks as if his legs were like a pair of scissors. Associated with spastic paraplegia:

  • Both legs are held rigid with plantar flexion of the ankle, extension of the knee, and adduction/internal rotation of the hips.
  • The patient walks on tiptoe and the knees rub together/cross during the walking cycle.
  • Often accompanied by complex movements of the upper limbs to assist the walking movements.

P.264
Sensory ataxic gait Loss of proprioception due to peripheral neuropathy or spinal cord disease (e.g. cervical spondylosis, MS, syphilis, combined degeneration of the cord) results in an ataxic gait similar to that seen with cerebellar disease. Features:

  • Broad-based gait with a tendency to stamp feet down clumsily
  • Patient tends to look at feet throughout the walking cycle
  • Romberg’s sign +ve

Waddling gait Typically seen in patients with proximal myopathy e.g. due to muscular dystrophy. Other causes: pregnancy, CDH. Features:

  • Broad-based gait in which the pelvis drops to the side of the leg being raised
  • The patient moves his body and hips to accommodate this, resulting in a duck-like waddle in the swing phase
  • Commonly accompanied by ↑ forward curvature of the lower spine

Galactorrhoea Hyperprolactinaemia—p.428 Genital ulcers Causes:

  • Genital herpes
  • Primary syphilis
  • Behcet’s syndrome.

If history of foreign travel, partner from abroad, or doubt about diagnosis, refer to GUM clinic. Gingivitis p.910 Globus pharyngis (or hystericus) A sensation of a lump/discomfort in the throat. Discomfort is often relieved by eating and there is no obstruction to swallowing of fluids or solids. Probably due to cricopharyngeal spasm. Associated with reflux oesophagitis/peptic ulcer in some patients. Investigate to exclude other pathology e.g. with barium swallow/upper Gl endoscopy.

Table 9.5 Differential diagnosis of groin lumps
Position relative to the skin Groin lump Position relative to the inguinal ligament
Above Below
In the skin Lipoma, fibroma, haemangioma, and other skin lumps [check mark] [check mark]
Deep to the skin Femoral or inguinal lymph nodes [check mark] [check mark]
Saphena varix of the femoral vein × [check mark]
Femoral artery aneurysm × [check mark]
Femoral hernia × [check mark]
Inguinal hernia [check mark] ×

P.265
Groin lumps The inguinal ligament runs from the pubic tubercle medially to the anterior superior iliac spine laterally. Differential diagnosis of groin lumps—Table 9.5. Guarding Reflex contraction of abdominal muscles signifying local or general peritoneal inflammation. Gums

  • Bleeding gums: Consider periodontal disease (by far the most common cause); pregnancy; leukaemia, bleeding disorders; scurvy.
  • Hypertrophied gums: Associated with phenytoin use.
  • Blue line: Along the margin of the teeth—suggests lead poisoning.
  • Gum inflammation: Gingivitis—p.910

Gynaecomastia p.515

Table 9.6 Causes of haematuria
Gynaecological
  • Menstruation
  • PMB
  • Bleeding in pregnancy
  • Cervical bleeding
  • Atrophic vaginitis
Kidney
  • Stones
  • Tumour
  • Infection
  • Glomerulonephritis
Ureter
  • Stones
  • Tumour (rare)
Bladder
  • UTI
  • Stones
  • Tumour
  • Chronic inflammation
Prostate
  • Prostatitis
  • Tumour
Urethral inflammation

H Heamaturia Causes—Table 9.6

  • May be frank (visible) or microscopic (up to 20% population).
  • Investigate ail cases of haematuria further.
  • Check MSU for M,C&S, check blood for U&E, creatinine. Free Hb and myoglobin make urine test sticks +ve in absence of red cells.
  • Urine discolouration can result from beetroot ingestion, porphyria, or rifampicin.
  • If cause is identified (e.g. sample taken when menstruating, UTI)—repeat the check for blood in urine once treated/resolved.
  • Refer if no cause is found. Rapid access one-stop clinics now operate in most areas.

Haematospermia Blood in semen. In most cases benign and selflimiting. Persistent symptoms are more likely to be pathological. In ♂<40y. examine testes and epididymes and check MSU to exclude UTI. In ♀>40y. examine testes, epididymes and prostate, check MSU and PSA. May be associated with prostatitis, UTI, minor trauma or rarely prostate cancer. If no cause found and continues, refer to urology. P.266
Haemoptysis Expectoration of blood or blood-stained sputum. Melaena occurs if enough blood is swallowed. Haemoptysis rarely needs treating in its own right but always requires investigation to find the cause. If massive, admit as an acute emergency. If terminal event (e.g. inoperable lung cancer), consider prompt IV morphine ± sedative. Causes:

  • Respiratory: Lung cancer; TB; bronchitis; bronchiectasis; lung abscess; pneumonia; violent coughing; inhaled foreign body; aspergilloma; trauma.
  • Cardiovascular: PE (blood is not mixed with sputum); mitral stenosis; acute LVF.
  • Other: Collagen vascular disease (e.g. polyarteritis nodosa); bleeding diathesis; mycoses (e.g. aspergilloma); foreign body.

Hairiness p.658 and p.659 Hair loss or alopecia p.658 Halitosis Common after sleep. Short-term halitosis is associated with acute illness e.g. tonsillitis, appendicitis (foetor oris), gastroenteritis, diabetic ketoacidosis. Chronic halitosis is usually caused by bacterial putrefaction of food debris and dental plaque and is related to poor oral hygiene. Associated with gingivitis ± peridontitis. Smoking, alcohol, isosorbide dinitrate, and disulfiram exacerbate the problem. Management

  • Examine the mouth and recommend a dental check
  • Advise on oral hygiene e.g. regular brushing of teeth and tongue, dental flossing
  • Give advice on smoking cessation
  • Dietary advice—avoid garlic, onions, curries
  • Treat any local infection e.g. gingivitis
  • Mouthwashes e.g. 0.2% aqueous chlorhexidine gluconate help ↓ dental plaque

Hallucinations Sensory experiences in the absence of stimuli. May be visual, auditory, gustatory, olfactory, or tactile.

  • Visual, tactile, and auditory hallucinations suggest mental illness:
    • Visual and tactile hallucinations suggest organic disorder e.g. dementia, acute confusional state, metabolic encephalopathy, drug abuse.
    • Auditory hallucinations suggest psychosis.
  • Hallucinations experienced when the patient is falling asleep (hypnagogic hallucination) or waking up (hypnapompic hallucination) are features of narcolepsy.
  • Olfactory and gustatory hallucinations often occur together. May be suggestive of psychosis but also occur with temporal lobe epilepsy and olfactory bulb tumours

Headache p.596 Hearing loss p.924 P.267
Heartburn Retrosternal gripping or burning pain occurring in waves and rising towards the neck. Sometimes radiates → back and may be accompanied by reflux of acid into the mouth. Worsened by stooping, lying down, large and/or fatty meals, alcohol, smoking, and/or pregnancy. Generally, heartburn is the result of gastric acid reflux onto the oesophageal mucosa. It may be a feature of dyspepsia, but dyspepsia can occur without heartburn. Causes:

  • No cause found (30%)
  • Oesophagitis (24%)
  • DU (17%)
  • Hiatus hernia (15%)
  • Gastritis (9%)
  • Duodenitis (6%)
  • Gastric ulcer (5%)
  • Reflux of bile (0.7%)
  • Gastric cancer (0.2%)

23% patients have ≥2 identifiable causes of heartburn Management See dyspepsia p.432

Table 9.7 Differential diagnosis of heart murmurs
Type of murmur Description Causes
Ejection systolic murmur ↑ to reach a peak midway between the heart sounds.
  • Flow murmurs e.g. children, pregnancy, with fever, during/after exercise
  • Aortic stenosis or sclerosis (p.354)
  • Pulmonary stenosis (p.355)
  • HOCM (p.352)
Pan-systolic murmur Uniform intensity between the 2 heart sounds. Merges with 2nd heart sound.
  • Mitral valve regurgitation or prolapse (p.354)
  • Tricuspid regurgitation (p.355)
  • VSD (p.356)
  • ASD (p.356)
Early diastolic murmur Occurs just after the 2nd heart sound. High pitched and easily missed.
  • Aortic regurgitation (p.355)
  • Pulmonary regurgitation (p.355)
  • Tricuspid stenosis (mitral stenosis coexists)
Mid-diastolic murmur Midway between 2nd heart sound of 1 beat and 1st of the next. Rumbling and low pitched.
  • Mitral stenosis (p.354)
  • Aortic regurgitation. (Austin–Flint murmur—p.355).

Heart murmurs Red flag symptoms

  • Cyanosis
  • Breathlessness
  • Lethargy and tiredness
  • Collapse
  • Weight loss (or failure to thrive in children)

Due to abnormalities of flow within the heart and great vessels. Very common. Often incidental findings. Described by:

  • Location—where heard loudest
  • Intensity—graded out of 6, 1 being virtually undetectable and 6 being heard by an observer without a stethoscope
  • P.268

  • Timing—systolic or diastolic, and
  • Radiation—does the murmur spread elsewhere e.g. to the axilla (mitral regurgitation murmur)?

Always refer for echocardiographic confirmation. Differential diagnosis—Table 9.7 (p.267). Heart sounds Low- and medium-frequency sounds (e.g. 3rd and 4th heart sounds) are more easily heard with the bell applied lightly to the skin. High-frequency sounds (e.g. 1st and 2nd heart sounds and opening snaps) are more easily heard with a diaphragm. Interpretation of heart sounds—Table 9.8. Heat rash Fine, red, maculopapular rash, most common in small children. Usually on trunk/neck and self-limiting. Heavy periods Menorrhagia/heavy periods—p.724 Heel pain p.262 Hemiballismus Movement patterns (abnormal)—p.275 Hepatomegaly Causes:

  • Apparent: Reidel’s lobe, low-lying diaphragm
  • Tumours: Secondary (most common), primary
  • Venous congestion: Heart failure, hepatic vein occlusion
  • Haematological: Leukaemia, lymphoma, myeloproliferative disorders, sickle cell disease
  • Biliary obstruction: Particularly extrahepatic
  • Inflammation: Hepatitis, abscess, schistosomiasis
  • Metabolic: Fatty liver, early cirrhosis, amyloid, glycogen storage disease
  • Cysts: Polycystic liver, hydatid

Hirsutism p.658 Hoarseness p.916 Hyperhidrosis p.659 Hyperpigmentation Normally due to hypermelanosis—occasionally, other pigments e.g. iron, carotene. Causes:

  • Genetic: Racial; freckles/lentigo; neurofibromatosis; Peutz-Jeghers syndrome.
  • Drugs:
    • Amiodarone—blue-grey pigmentation of sun-exposed areas
    • Minocycline—blue-black pigmentation in scars and buccal mucosa
    • Chloroquine—blue-grey pigmentation of face and arms
    • Chlorpromazine—grey pigment in sun-exposed sites
    • Cytotoxics
  • Endocrine: Addison’s disease; chloasma; Cushing’s syndrome.
  • Nutritional: Excess ingestion of carrots (carotinaemia); malabsorption; malnutrition; pellagra.
  • Post-inflammatory: Eczema; lichen planus; systemic sclerosis.
  • Other: Benign naevi; malignant melanoma; chronic renal failure; acan-thosis nigricans.

Hypertrichosis p.659

Table 9.8 Heart sounds, abnormalities, and their causes
Heart sound Causes
1st heart sound Soft Mitral regurgitation, low BP, rheumatic carditis, severe heart failure, LBBB
Heard loudest at the apex Loud AF, tachycardia, atrial premature beat, mitral stenosis
Caused by closing of the mitral and tricuspid valves Variable intensity Varying duration of diastole, complete AV block
Split RBBB, paced beat from the left ventricle, left ventricular ectopics, ASD, Ebstein’s anomaly, tricuspid stenosis
2nd heart sound Soft A2—calcification of the aortic valve, dilatation of the aortic root
P2—pulmonary stenosis
Caused by closure of the aortic (A2) and pulmonary (P2) valves Loud A2—↑ BP, thin patients
P2—pulmonary hypertension, ASD
A2 and P2 split on inspiration so that P2 is heard after A2 Wide splitting May be the result of early A2 or delayed P2
Early A2—mitral regurgitation, VSD
Delayed A2—RBBB, pulmonary stenosis, ASD, right ventricular failure
Reversed splitting A2 is delayed. P2 occurs before A2 so the split between the sounds ↓ on inspiration
Delayed A2—LBBB, systolic hypertension, HOCM, severe aortic stenosis, PDA, left heart failure
Single Calcification of the aortic valve, pulmonary stenosis, Fallot’s tetralogy, Ebstein’s anomaly, pericardial effusion, large VSD, obesity, emphysema
Clicks and snaps Early systolic Caused by opening of the aortic or pulmonary valves
Aortic—aortic stenosis, bicuspid valve
Pulmonary—pulmonary stenosis, pulmonary hypertension
Mid/late systolic Mitral valve prolapse
Diastolic Caused by opening of the mitral or tricuspid valves. Silent in the healthy heart
Mitral—mitral stenosis, rapid mitral flow e.g. PDA, VSD, severe mitral regurgitation
Tricuspid (rare)—rheumatic stenosis, ASD
3rd heart sound
Heard in diastole after the 2nd heart sound
Right ventricle Loudest at lower left sternal edge. Never normal.
Causes—right heart failure, tricuspid regurgitation, ASD, constrictive pericarditis
Left ventricle Loudest at the apex when inclined to the left. Can be normal in children and pregnancy. Other causes: LVF, mitral regurgitation, anterior MI
4th heart sound Maximal at the apex or lower left sternal edge.
Heard in late diastole Never normal. Causes—ventricular hypertrophy or fibrosis and HOCM

P.269
P.270
Hyperventilation May be fast (>20 breaths/min) or deep (tidal volume ↑). If inappropriate, results in palpitations, dizziness, faintness, tinnitus, chest pains, perioral and peripheral tingling (due to plasma Ca2+ ↓)— most common cause is anxiety; others include PE, early pulmonary oedema, hyperthyroidism, fever, lymphangitis, and weakness of respiratory muscles. Kussmaul respiration Deep, sighing breathing that is principally seen in metabolic acidosis e.g. diabetic ketoacidosis and uraemia. Neurogenic hyperventilation Hyperventilation produced by stroke, tumour, or CNS infection. Hypoventilation Abnormally decreased pulmonary ventilation. Respiration may be too slow or tidal volume ↓. Causes include:

  • Respiratory depression e.g. opiate analgesia, anoxia, trauma
  • Neurological disease e.g. Guillain-Barré disease, polio, motor neurone disease, syringobulbia
  • Lung disease e.g. pneumonia, collapse, pneumothorax, pleural effusion
  • Respiratory muscle disease e.g. myasthenia gravis, dermatomyositis
  • Limited chest movement e.g. kyphoscoliosis

I Ideas of reference Thought disorders—p.292 Illusions Perceptions (abnormal)—p.278 Impotence Erectile dysfunction—p.702 Incontinence

  • Faeces: p.451
  • Urine: p.694

Insomnia p.242 Itch Pruritus—p.281 J Jaundice: Yellow pigmentation due to excessive bile pigment. Clinical jaundice appears when serum bilirubin >35µmol/l. Always refer for further investigation (pre-hepatic and hepatic jaundice → physician; posthepatic jaundice → surgeon)—Table 9.9. Causes:

  • ↑ production (pre-hepatic jaundice): Haemolytic anaemia, druginduced haemolysis, malaria, Gilbert’s and Crigler-Najjar syndrome
  • Defective processing (hepatic jaundice): Hepatitis, cirrhosis
  • Blocked excretion (obstructive jaundice): Gallstones, carcinoma of the pancreas, primary biliary cirrhosis, primary sclerosing cholangitis, cholangiocarcinoma, sepsis, enlarged porta hepatis (e.g. due to lymphoma)
Table 9.9 Distinguishing different types of jaundice
  Type of jaundice
Pre-hepatic Hepatic Obstructive
Tests
Bilirubin ↑↑ ↑↑ ↑↑
ALT Normal ↑↑ ↑
Alkaline phosphatase Normal ↑ ↑↑↑
Hb ↓ Normal Normal
Jaundice Mild, lemon yellow Marked jaundice Deep jaundice
Other symptoms Tender, enlarged liver. Stools normal colour. Itching skin, pale stools.

P.271
A mixed picture is common and can be confusing. Joint pain Pain in 1 joint Common. Ask:

  • Is the problem articular or periarticular?
    • Articular disease (e.g. osteoarthritis)—joint line tenderness and pain at the end of the range of movement in any direction.
    • Periarticular problems (e.g. ligamentous injury)—point tenderness over the involved structure, and pain exacerbated by movements.
  • If periarticular, which structure is causing pain? Options: Bursa; tendon; tendon sheath; ligament; soft tissue.
  • If articular, is the problem inflammatory or mechanical? Look for:
    • Signs of inflammation—warmth, redness, effusions. May indicate joint infection or inflammatory arthritis.
    • Features of a mechanical problem—locking or catching e.g. cartilage tear.

Red flags: Features which should prompt early/urgent referral—

  • Inflamed joint with associated fever or constitutional disturbance—beware of infection.
  • Any joint which is ‘locked’ or so painful that movement is impossible.
  • Severe pain at rest or at night.
  • Pain that gets relentlessly worse over a period of days or weeks.

Pain in multiple joints

  • Differentiate between articular or periarticular disease and whether the condition is inflammatory or not, as for pain in 1 joint (above). Screening with blood tests (ESR or CRP, FBC ± autoimmune profile) may help.
  • Look for the pattern of disease—joint sites involved and other symptoms/signs.

P.272
Common arthropathies

  • Osteoarthritis
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • SLE
  • Reactive arthritis
  • Psoriatic arthritis
  • Enteropathic arthropathy
  • Gout or pseudogout
  • Sicca syndrome
  • Malignancy

Red flags: Features which should prompt early/urgent referral—

  • Severe systemic symptoms—high fevers, significant weight loss, or a very ill patient (suggests rheumatoid arthritis, sepsis, or malignancy).
  • Focal systemic signs e.g. rashes, nodules, or GI disturbances.
  • Severe pain and/or inability to function.

Jugular venous pressure Observe internal jugular vein at 45° with head turned slightly to the left. Vertical height is measured in relation to the sternal angle. Raised if >4cm. Causes of ↑ JVP

  • Fluid overload
  • Right heart failure and CCF
  • SVC obstruction (non-pulsatile)
  • Tricuspid or pulmonary valve disease
  • Pulmonary hypertension
  • Arrythmia—AF or atrial flutter, complete heart block
  • ↑ intrathoracic pressure e.g. pneumothorax, PE, emphysema

Kussmaul’s sign The JVP usually drops on inspiration, along with intrathoracic pressure. The reverse pattern is called Kussmaul’s sign. Caused by ↑ intrathoracic pressure or constrictive pericarditis. (A. Kussmaul (1822–1902)—German physician) Wave patterns

  • A wave: Due to right atrial systole; coincides with the 1st heart sound; precedes the carotid pulse.
  • C wave: Due to transmission of right ventricular pressure before the tricuspid valve closes. Rarely visible.
  • X descent: Due to relaxation of the right atrium.
  • V wave: Due to venous blood filling the right atrium whilst the tricuspid valve is closed as the ventricles contract. Occurs at the same time as the carotid pulse.
  • Y descent: Due to opening of the tricuspid valve when the ventricles relax.

Abnormal wave patterns: Table 9.10 K Koilonychia p.661

Table 9.10 Abnormal JVP wave patterns and their causes
Condition Abnormal wave pattern
Tricuspid regurgitation Large systolic wave which replaces the C and V wave with steep Y descent
Tricuspid stenosis Large A wave, small V wave, slow Y descent
Complete heart block, VT, or other causes of atrioventricular dissociation Cannon waves: very large A waves which occur when the right atrium contracts against a closed tricuspid valve
AF Absent A wave, C wave normal
Constrictive pericarditis Kussmaul’s sign, steep Y descent

P.273
L Left iliac fossa pain Treat the cause. Common causes: Acute

  • Gastroenteritis
  • Ureteric colic
  • UTI
  • Diverticulitis
  • Torted ovarian cyst
  • Salpingitis
  • Ectopic
  • Volvulus
  • Pelvic abscess

Chronic/subacute

  • Constipation
  • Irritable bowel syndrome
  • Colon cancer
  • Inflammatory bowel disease
  • Hip pathology

Left upper quadrant pain Treat the cause. Causes:

  • Large kidney or spleen
  • Gastric or colonic cancer
  • Pneumonia
  • Subphrenic or perinephric abscess
  • Renal colic
  • Pyelonephritis

Leg ulceration p.640 Lethargy Tired all the time—p.582 Leoconychia p.660 Lid lag Lagging behind of the lid as the eye looks down.

  • Lid retraction: Static state of the upper eyelid traversing the eye above the iris, rather than transecting it.
  • Causes of lid lag and lid retraction: Thyrotoxicosis and anxiety.

Limping child p.872 Loin pain Pain in the side at the back below the ribs. Causes:

  • Pyelonephritis
  • Pain referred from the back
  • Hydronephrosis
  • Renal stone
  • Renal tumour
  • Perinephric abscess

P.274
Loss of consciousness (history of) Check the patient lost consciousness, not felt faint or dizzy. Causes:

  • Vasovagal—fainting p.261
  • Micturition or cough syncope—p.292
  • Effort syncope—loss of consciousness on exercise, usually of cardiac origin
  • Carotid sinus syncope—loss of consciousness on turning head too far
  • Epilepsy—p.618
  • Stokes-Adams attacks—p.346
  • TIA—p.606
  • Hypoglycaemia—p.413 and 1070
  • Postural/orthostatic hypotension—p.280

Lumps in the neck Most neck lumps are reactive LNs—suggested by a short history, soft tender mobile lump, and concurrent infection. Give these a few weeks to settle. If not settling, check FBC and ESR and refer for further investigation. Other lumps—consider history and site. If superficial to the underlying muscle and fascia Consider:

  • Sebaceous cyst
  • Lipoma
  • Lymphoma
  • TB
  • Neurofibroma

Midline swelling Consider:

  • Dermoid cyst
  • Thyroglossal cyst (moves on sticking out tongue)
  • Pharyngeal pouch
  • Laryngocoele
  • Subhyoid bursa
  • Plunging ranula
  • Carcinoma of the larynx, trachea, or oesophagus

Lateral structures Reactive LNs are most common. Other causes:

  • Thyroid swelling
  • Branchial cyst
  • Cystic hygroma
  • Carotid artery aneurysm
  • A-V fistula
  • Spinal abscess
  • Cervical rib
  • Carotid body, sternomastoid, or salivary gland tumour

Lymphadenopathy Palpable enlargement of the LNs Benign causes

  • Infective
    • Bacterial—pyogenic, TB, brucella
    • Fungal
    • Viral—EBV, CMV, HIV
    • Toxoplasmosis
    • Syphilis
  • Non-infective: Sarcoid, connective tissue disease (rheumatoid); skin disease (eczema, psoriasis); drugs (phenytoin); berylliosis.

Malignant Lymphoma, CLL, ALL, metastases. Management

  • Adults: If LNs persist >2wk. check FBC, ESR ± EBV screen. Refer lymphadenopathy >1cm diameter persisting for >6wk. for urgent further investigation.
  • Children: Refer to paediatrics urgently if:
    • Non-tender, firm/hard LN >3cm diameter
    • Progressively enlarging LNs
    • P.275

    • LNs associated with other signs of ill-health (e.g. fever, weight loss)
    • Enlarged axillary nodes or supraclavicular nodes in the absence of local infection

Lymphoedema p.1013 M Meningism Headache, stiff neck, and photophobia. Associated with meningitis. May also be seen with encephalitis and SAH. Menstrual problems Period problems—p.279 Mouth ulcers Treat the cause. Consider:

  • Apthous ulcers
  • Trauma e.g. sharp tooth, false teeth
  • Crohn’s
  • UC
  • Coeliac
  • Drugs e.g. steroids, gold
  • Reiter’s disease
  • Bechet’s disease
  • Herpes simplex
  • Herpes zoster
  • Vincent’s angina
  • Erythema multiforme
  • Self-inflicted e.g. burns

If a mouth ulcer remains for >3wk, refer to oral surgeons for biopsy. Sore mouth p.290 Movement patterns (abnormal) Asterixis Intermittent lapses of an assumed posture. May involve arms, neck, tongue, jaw, and eyelids. Usually bilateral, absent at rest, and asynchronous on each side. Causes: Liver failure (flapping tremor), heart failure, respiratory failure, renal failure, hypoglycaemia, barbiturate intoxication. Athetosis Slow, confluent, often rhythmic, purposeless movements of hands, tongue, fingers, or face. Causes: Cerebral palsy, kernicterus. Chorea Non-rhythmic, jerky, purposeless movements (especially hands) with voluntary movements possible in between. Most common causes: Cerebral palsy, Huntington’s chorea, Sydenham’s chorea. Gait (abnormal) p.263 Hemiballismus Large-amplitude, involuntary flinging movements of limbs. May occur after stroke, in Huntington’s disease, or with high doses of L-dopa for PD. Myoclonus Sudden involuntary focal or general jerks. May be normal, especially if occurs when falling asleep. Other causes:

  • Neurodegenerative disease (e.g. CjD)
  • Myoclonic epilepsy
  • Benign essential myoclonus (generalized myoclonus beginning in childhood as muscle twitches; may be inherited as autosomal dominant)
  • Asterixis (metabolic flap e.g. liver failure, uraemia)

Treatment: If needed, treat with sodium valproate or clonazepam. P.276
Tardive dyskinesia Involuntary chewing and grimacing movements due to long-term neuroleptics (metoclopramide and prochlorperazine are also possible causes). Withdraw neuroleptic—if no improvement after 3–6mo. consider tetrabenazine 25–50mg tds po. Tics Brief, repeated, and stereotyped movements which are able to be suppressed voluntarily for a while. Common in children and usually resolve spontaneously. Consider clonazepam or clonidine if tics are severe. Gilles de la Tburette syndrome p.891 Myalgia Isolated myalgia can be a result of overuse or soft tissue injury. Generalized myalgia is associated with many diseases including:

  • Infection
  • Fibromyalgia
  • PAN
  • Wegener’s granulomatosis

Myoclonus Movement patterns (abnormal)—p.275 N Nail changes p.660 Nasal obstruction p.918. Common symptom experienced by most people from time to time. Causes:

  • Mucosal swelling: Coryza, allergic, or vasomotor rhinitis, iatrogenic, polyps
  • Septal deviation: Trauma, congenital e.g. 2° to cleft lip
  • Other: Tumour, enlarged adenoids (associated with glue ear and deafness), foreign body

Red flag: Assume consistent unilateral blockage is neoplastic until proved otherwise. Refer urgently to ENT. Neck

  • Pain: p.548
  • Lumps: p.274
  • Stiffness: Exclude life-threatening causes e.g. meningitis, SAH. Other causes are neck arthritis, painful cervical lymphaedenopathy, upper lobe pneumonia.

Night sweats Consider: TB; lymphoma; leukaemia; solid tumour (e.g. renal carcinoma); menopause; anxiety states. Nipple discharge p.513 Nipple eczema p.513 Nodules Skin lesions—p.289 Nose bleeds p.1042 Nystagmus Involuntary, oscillatory eye movements. Can be congenital or due to labyrinthine or visual system problems. Refer all cases, unless associated with self-limiting labyrinthitis, for assessment. P.277
O Obesity p.230 Obsessions Thought disorders—p.293 Odd ideas

  • Acute confusion: p.976
  • Compulsions: p.253
  • Delusions: p.255
  • Dementia: p.978
  • Flight of ideas: Thought disorders—p.293
  • Hallucinations: p.266
  • Ideas of reference: Thought disorders—p.292
  • Obsessions: Thought disorders—p.293
  • Overvalued ideas: Beliefs (abnormal)—p.249
  • Perceptions (abnormal): p.278
  • Thought disorders: p.292

Oedema Abnormal accumulation of fluid in the intercellular spaces. Results from:

  • ↓ drainage of the intercellular fluid by the lymphatics e.g. lymphoedema (p.1013)
  • ↑ capillary permeability → ↑ intercellular fluid e.g. infection, inflammation
  • ↓ capillary hydrostatic pressure due to:
    • ↑pressure at the arterial end of the capillary
    • ↑ venous back-pressure e.g. DVT, paralysis of a limb, right heart failure
    • ↓ intracapillary protein e.g. hypoalbuminaemia due to cirrhosis, nephritic syndrome, or malignancy

Swelling of the ankles/legs p.291 Off legs Walking difficulty—p.297 Oliguria Urine output <400ml/24h. Causes: dehydration, cardiac failure, ureteric obstruction, acute or chronic renal failure. Orthopnoea Dyspnoea on lying flat and relieved by sitting up. Associated with left heart dysfunction e.g. LVF. P Painful periods Dysmennorhoea/painful periods—p.726 Pallor Non-specific sign which may be racial, familial, or cosmetic. Pathology suggested includes anaemia, shock, Stokes-Adams attack, vasovagal faint, myxoedema, hypopituitarism, and albinism. Palmar erythema Associated with pregnancy, liver disease, and polycythaemia. P.278
Palpitations The uncomfortable awareness of heart beat. Can be physiological (e.g. after exercise, at times of stress) or signify arrhythmia. Ask the patient to tap out the rhythm.

  • Bradycardia: p.346
  • Occasional missed beat: suggests ventricular ectopics—p.342
  • Tachycardia: p.342

Papilloedema Causes:

  • Intracranial SOL
  • Encephalitis
  • SAH
  • Benign intracranial hypertension
  • Malignant hypertension
  • Optic neurtitis
  • Disc infiltration e.g. leukaemia
  • Ischaemic optic neuropathy
  • Retinal venous obstruction
  • Metabolic causes e.g. hypoclacaemia

Always refer any patient with papilloedema for immediate specialist medical opinion. Parasternal heave Detect by placing the heel of the hand over the left parasternal region. When a heave is present, the heel of the hand is lifted off the chest wall with each heart beat. Causes: Usually due to right ventricular enlargement; rarely due to left atrial enlargement. Parkinsonism p.610 Paroxysmal nocturnal dyspnoea Acute form of dyspnoea that causes the patient to awake from sleep. The patient is forced to sit up-right or stand out of bed for relief. Associated with pulmonary oedema. Pelvic mass Characterized by not being able to get beneath it. Causes of pelvic mass

  • Foetus
  • Full bladder
  • Fibroids
  • Gynaecological malignancy
  • Bladder cancer

Pelvic pain p.720 Penile discharge Associated with urethritis e.g. due to Chlamydia or gonorrhoea. Refer to GUM clinic. Perceptions (abnormal) Consider:

  • Illusion: Misinterpretation of visual or other information e.g. a person seeing a shadow of a tree moving in the breeze might interpret it as a person moving. Can happen if ↓ level of consciousness or occasionally if visual impairment.
  • Hallucination: False perception i.e. without an external stimulus—p.266.
  • Pseudohallucination: Vivid perception which is recognized as not being real e.g. delirium tremens.
  • Depersonalization: Feeling of being unreal—like an actor playing yourself. Associated with a wide range of mental illness e.g. depression, schizophrenia.
  • Derealization: Feeling of everything around you being unreal—like in a dream. Often linked to depersonalization.

P.279
Perianal pain Treat the cause. Consider:

  • Haemorrhoids
  • Anal fissure
  • Perianal haematoma
  • Perianal abscess
  • Rectal/anal tumour
  • Perianal fistula
  • Proctalgia fugax—intense stabbing pain for no apparent cause; aetiology unknown

Period problems

  • Absent/infrequent periods: p.728
  • Menorrhagia/heavy periods: p.724
  • Dysmenorrhoea/painful periods: p.726
  • Infrequent periods: p.728
  • Intermenstrual bleeding: p.714
  • Postcoital bleeding: p.714
  • Postmenopausal bleeding: p.713
  • Prolonged menstruation: p.280
  • Wish to postpone a period: p.748

Perseveration Thought disorders—p.293 Petechiae Purpura—p.284 Photophobia Painful vision in normal light. One of the 3 principle features of meningism. Associated with meningitis. Discomfort in the light can also be a feature of eye disease e.g. conjunctivitis and migraine. Photosensitivity p.662 Pigmentation of skin

  • Hypopigmentation—p.656
  • Hyperpigmentation—p.656

Pleuritic chest pain/pleurisy Chest pain—p.251 Pleural effusion p.392 Pleural rub Creaking sound produced by movement of visceral over parietal pleura when both are inflamed (e.g. pneumonia, infarction). Polydipsia Over-frequent drinking of fluid; often associated, for logical reasons, with polyuria. Ask if it is associated with thirst. Take a history of fluid intake. If no history of excess fluid intake and BM/fasting blood glucose is normal, investigate further with U&E, Cr, and Ca2+. Common causes

  • Change in lifestyle—may be associated with polyuria but no other symptoms. No history of thirst.
  • DM—usually accompanied by a history of thirst.

Other causes Diabetes insipidus, hypercalcaemia, compulsive water drinking (may be a feature of psychotic illness), and phosphorus poisoning. Polyuria Passage of excessive urine. Check the patient does not mean frequency of urination. It can be difficult to distinguish the two. Causes are similar to those of polydipsia and the 2 symptoms are related. Take a history of fluid intake. If no history of excess fluid intake and BM/fasting blood glucose is normal, investigate further with MSU (for M, C & S), U&E, Cr, and Ca2+. P.280
Consider

  • DM—always check a BM and/or fasting blood glucose if a patient complains of polyuria
  • Diabetes insipidus
  • Hypercalcaemia
  • Excessive intake—due to change in lifestyle or psychiatric conditions e.g. schizophrenia
  • Chronic renal failure
  • Drugs—diuretics, caffeine, alcohol

Postcoital bleeding p.714 Postural hypotension At-risk groups:

  • Young women, particularly if pregnant
  • The elderly
  • Patients taking medication with hypotensive side-effects e.g. β-blockers
  • Patients with autonomic neuropathy e.g. 2° to PD or DM

Presentation Patients complain of falls, faints, or feeling light-headed when they stand up, particularly when getting out of bed or a hot bath. Examination Confirm diagnosis by checking BP—lying and then standing. Standing usually causes a slight ↓ in the systolic BP (<20mmHg) and a slight ↑ in the diastolic BP (<10mmHg). In postural hypotension, there is usually a marked ↓ in both systolic and diastolic BP. Management

  • Review medication—Stop any non-essential medication contributing to symptoms e.g. night sedation, unnecessary diuretics
  • Optimize treatment of intercurrent heart disease, PD, or DM
  • Advice—advise patients to take care when standing, especially when getting up from their beds, on getting out of a hot bath or shower, and after meals

Precocious puberty p.282 Priapism Persistent painful erection not related to sexual desire. Cause Intracavernosal injection for impotence, idiopathic, leukaemia, sickle cell disease, or pelvic tumour. Treatment Ask the patient to climb stairs (arterial ‘steal’ phenomenon), apply ice packs. If unsuccessful, refer to A&E for aspiration of corpora. Rarely, surgery is needed. Prolonged menstruation Bleeding for >5–6d./cycle. Most loss occurs in the first 3d. Long periods do not equate to ↑ menstrual loss, so prolonged menstruation per se does not need investigation. Frequently goes with menorrhagia—p.724. Prostatism Symptoms of prostate enlargement. In all cases consider alternative causes of symptoms. 2 elements: P.281
Irritative symptoms Urgency, dysuria, frequency, nocturia. Differential diagnosis: Enlarged prostate, UTI, polydipsia, detrusor instability, hypercalcaemia, uraemia. Obstructive symptoms ↓ size and force of urinary stream, hesitancy and interruption of stream whilst voiding. Differential diagnosis: Prostatic enlargement, strictures, tumours, urethral valves, bladder neck contracture. International prostate symptom score p.704 Management of BPH and prostate cancer p.686, 687, 688, 689 Pruritus Itch. Are there skin lesions present? Skin lesions present

  • Examine the skin lesion: Search for unexcoriated lesions.
  • Investigation: Normally not warranted. Exceptions are patch testing for contact dermatitis and skin biopsy for dermatitis herpetiformis.

Causes

  • Urticaria
  • Contact dermatitis and allergies to food and drugs
  • Prickly heat
  • Skin infestations e.g. scabies, pediculosis, insect bites
  • Infections—viral e.g. chickenpox; fungal
  • Dermatitis herpetiformis
  • Lichen planus
  • Senile atrophy

Don’t forget psychological causes in which excessive excoriation causes lichenification of the skin. Skin lesions absent Large differential diagnosis:

  • Examination: Look for pallor, jaundice, weight ↓, LN enlargement, and abdominal organomegaly.
  • Investigation: As necessary—consider urinalysis (dipstick and MSU), FBC, ESR, Serum ferritin, LFTs (including alkaline phosphatase), U&E, glucose, serum Ca2+ (correct for low albumin), TFTs, and CXR.
  • If still undiagnosed, refer.

Causes

  • Hepatic—obstructive jaundice, pregnancy
  • Endocrine—DM, thyrotoxicosis, hypothyroidism, hyperparathyroidism
  • Renal—chronic renal failure
  • Haematological—polycythaemia rubra vera, iron deficiency, leukaemia, Hodgkin’s disease
  • Malignancy—any carcinoma
  • Drug allergies
  • Psychological—obsessive states, schizophrenia
  • Rare causes—diabetes insipidus, roundworm infection

P.282
Pruritus ani

  • Itch occurs if the anus is moist or soiled e.g. poor personal hygiene; anal leakage or faecal incontinence; fissures; nylon/tight underwear.
  • Other causes: Dermatological conditions (e.g. contact dermatitis, lichen sclerosus); threadworm infection; anxiety; other causes of generalized pruritus (above).

Management Treat cause if possible; avoid spicy food; moist wipe post-defaecation. Pseudohallucination p.278 Ptosis Drooping of the upper eyelid. Causes:

  • 3rd nerve lesion: Usually causes unilateral complete ptosis. Look for other evidence of 3rd nerve lesion (opthalmoplegia with outward deviation of the eye, pupil dilated and unreactive to light, and accommodation).
  • Sympathetic paralysis: Usually causes unilateral partial ptosis. Look for other evidence of sympathetic lesion (constricted pupil, lack of sweating on same side of face—Horner’s syndrome).
  • Myopathy (dystrophia myotonica, myasthenia gravis): Usually causes bilateral partial ptosis.
  • Congenital (present since birth): May be unilateral or bilateral; is usually partial; and is not associated with other neurological signs.
  • Syphilis

Puberty Delayed puberty No pubertal changes in a girl aged 13y. or boy aged 13 ½y. or failure of progression of puberty over 2y. Affects ~2% population. In all cases refer to paediatrics for further investigation. Constitutional delay accounts for 90%. Other causes: Chromosomal abnormalities (e.g. Turner’s or Klinefelter’s syndromes); GnRH deficiency (e.g. pituitary lesions, gonadal failure, hypothyroidism); hypothalamic suppression (e.g. anorexia nervosa, sportsmen, systemic illness). Precocious puberty Puberty before the normal age for the population. In the UK this is <8y. for girls and <9y. for boys. In all cases, refer for specialist investigation and advice on management. Precocious puberty may be:

  • True: Course and pattern are normal, but early. Causes: Idiopathic (90% ♀ 50–60% ♂), hypothalamic tumour, other CNS pathology.
  • Pseudo: Pattern is abnormal e.g. 1 element of puberty occurs (e.g. breast development), but other elements do not. Causes: Idiopathic, testicular or ovarian tumour, congenital adrenal hyperplasia, hepatoblastoma, adrenal virilizing tumours, Cushing’s syndrome.

Pulmonary oedema Accumulation of fluid in the pulmonary tissues and air spaces. Causes include: Cardiac/vascular

  • Left heart failure
  • Mitral stenosis
  • Ml
  • Hypertension
  • Pulmonary venous obstruction
  • IV fluid overload

Other

  • High altitude
  • Kidney failure
  • Nephrotic syndrome
  • Cirrhosis
  • Lymphatic obstruction e.g. due to tumour

P.283
Lung

  • Pneumonia
  • Pneumonitis due to inhalation of toxic substances e.g. gases or radiation
  • PE

Pulses When assessing the pulse, consider: Rate

  • Tachycardia: >100bpm—p.342
  • Bradycardia: <60bpm—p.346

Rhythm

  • Irregularly irregular: AF, multiple ectopics
  • Regularly irregular: 2nd degree heart block

Character and volume Assess with a central pulse e.g. carotid or femoral.

  • Small volume: Shock, pericardial tamponade, aortic stenosis (slow-rising).
  • Large volume: Hyperdynamic circulation (e.g. pregnancy), aortic incompetence (water-hammer, collapsing pulse), PDA.
  • Pulsus paradoxus: Pulse weakens in inspiration by >10mmHg—asthma, cardiac tamponade, pericarditis.

Foot pulses p.361. Pupil abnormalities Pupils are normally central, of equal size, and react equally to light and accommodation. Pupil abnormalities: Fixed dilated pupil Causes: trauma (e.g. blow to the iris), mydriatics, acute glaucoma, 3rd nerve palsy, coning. Afferent pupillary defect Pupils are the same size but there is an absent constriction response to light in the affected eye. Constriction does occur if light is shone into the other eye (consensual response). Causes: optic neuritis, retinal disease. Argyll-Robertson pupil Occurs in patients with DM and neurosyphilis. Bilateral small irregular pupils with no light response. (D. Argyll Robertson (1837–1909)—Scottish ophthalmologist) Holmes-Adie pupil Accommodation is partially paralysed causing blurring of near vision, slight pupil dilation, and a very slow pupil response to light and accommodation (minutes). Occurs unilaterally in young adults. It is not associated with serious neurological disease. (G.M. Holmes (1876–1965)—Irish neurologist; W.J. Adie (1886–1935)—British neurologist) Horner’s syndrome Sympathetic nerve disruption to the iris causes a small (miotic) pupil, partial lid ptosis, and lack of pupil dilation in the dark. Causes: Pancoast tumour, aortic aneurysm, MS, posterior inferior artery or basilar artery occlusion, cervical cord or mediastinal tumour, hypothalamic lesions, syringomyelia. (J. F. Horner (1831–1886)—Swiss ophthalmologist) P.284
Purpura Blue-brown discolouration of the skin due to bleeding within it. Petechiae are small dot-like purpura, whilst ecchymoses are more extensive. Treat the cause. Causes:

  • Idiopathic: e.g. idiopathic pigmented purpura (brownish punctate lesions on the legs).
  • Vessel wall defects: Vasculitis; paraproteinaemia; infection (e.g. meningococcal meningitis, septicaemia, EBV); ↑ intravascular pressure (e.g. venous disease).
  • Clotting defects: Abnormal platelet function; thrombocytopoenia; anticoagulant therapy; coagulation factor deficiency.
  • Defective dermal support: Dermal atrophy (e.g. ageing, steroids, disease); scurvy (vitamin C deficiency).

Admit any patient with new purpura who is unwell as a 999 emergency. Henoch-Schönlein purpura (HSP) Presents with a purpuric rash over buttocks and extensor surfaces. Often follows a respiratory infection. Commoner in children than adults; ♂ > ♀. Other features:

  • Urticaria
  • Abdominal pain (± intussusception)—may mimic an acute abdomen
  • Nephritis
  • Platelet count is normal
  • Joint pains

Prognosis Most recover fully over a few months. (E. Henoch (1820–1910) and J. Schönlein (1793–1864)—German physicians) Pyrexia Oral temperature raised above 37.5°C. Normal range varies according to where the temperature is measured—Table 9.11. Common causes: Infection By far the most common cause in general practice.

  • Viral infection (e.g. EBV, URTI, influenza)
  • UTI
  • Chest infection
  • Tonsillitis
  • OM
  • Sinusitis
  • Cholecystitis
  • Cellulitis

Don’t forget tropical diseases e.g. malaria in patients returning from abroad. Think of TB and SBE—especially in high-risk patients. Cancer Lymphoma; leukaemia; solid tumours (e.g. hypernephroma). Immunogenic causes Connective tissue disease and autoimmune disease (e.g. RA, SLE, PAN, polymyalgia rheumatica); sarcoidosis. Thrombosis DVT; PE Drugs: e.g. antibiotics

Table 9.11 Normal temperature as measured in different locations
Place of measurement Normal range
Oral 35.5–37.5°C (95.9–99.5°F)
Rectal 36.6–38.0°C (97.9–100.4°F)
Axillary 34.7–37.3°C (94.5–99.1°F)
Ear 35.8–38.0°C (96.4–100.4°F)

P.285
Pyrexia of unknown origin Defined as a fever (either intermittent or continuous) which has lasted for >3wk. and for which no cause has been found. Re-check history. Re-examine carefully. Check FBC; monospot (depending on age of the patient); ESR; LFTs; urine (M,C&S); viral titres and blood cultures; and CXR. If cause does not become obvious, refer urgently for further investigation. R Rash Skin eruption—p.288 Rebound abdominal pain Present if, on the sudden removal of pressure from the examiner’s hand, the patient feels a momentary increase in pain. It signifies local peritoneal inflammation. Rectal bleeding in adults p.1040 Rectal bleeding in children p.856 Red eye p.936 Reflexes A reflex is an automatic response to a stimulus. The pathway a reflex follows (reflex arc) goes from the stimulus, via a sensory nerve, to the spinal cord, and then back along a motor nerve to cause muscle contraction, without involvement of the brain. Absent or ↓ reflex Implies a breach in the reflex arc e.g.

  • Sensory nerve or root e.g. neuropathy, spondylosis
  • Anterior horn cell e.g. MND, polio
  • Motor nerve or root e.g. neuropathy, spondylosis
  • Nerve endings e.g. myasthenia gravis
  • Muscle e.g. myopathy

↑ reflex Implies lack of higher control—an upper motor neurone lesion e.g. post-stroke Infantile reflexes p.816 Reinforcement Method of accentuating reflexes. Use if a reflex seems absent. Ask the patient to clench his teeth (to reinforce upper limb reflexes) or clench his hands and pull in opposite directions (to accentuate lower limb reflexes). This effect only lasts ~1s., so ask the patient to perform the manoeuvre simultaneously with the tap from the tendon hammer. Key tendon reflexes Table 9.12 (p.286). Record whether absent, present with reinforcement, normal, or brisk ± clonus.

Table 9.12 Tendon reflexes and nerve roots involved
Reflex Test Expected result Nerve roots
Jaw Ask the patient to let his mouth open slightly. Place a finger on the chin and tap the finger with a tendon hammer. Contraction of the masseters and closure of the mouth 5th cranial nerve
Biceps Tap a finger placed on the biceps tendon by letting the tendon hammer fall on it. Contraction of the biceps + elbow flexion C5, C6
Supinator Tap the lower end of the radius just above the wrist with the tendon hammer. Contraction of brachioradialis + elbow flexion C5, C6
Triceps Support elbow in flexion with 1 hand. Tap the triceps tendon with a tendon hammer held in the other hand. Contraction of the triceps + elbow extension C6, C7
Knee Support the knees so relaxed and slightly bent. Let the tendon hammer fall onto the infrapatellar tendon. Contraction of quadriceps + extension of the knee L3, L4
Ankle Externally rotate the thigh and flex the knee. Let the tendon hammer fall onto the Achilles tendon. Contraction of the gastrocnemius + plantar flexion of the ankle S1

P.286
Other reflexes

  • Gag reflex (IXth/Xth cranial nerves): Touch the back of the patient’s pharynx on each side with a spatula → contraction of the soft palate. If absent, ask the patient whether he can feel the spatula. If he can, then Xth nerve palsy.
  • Abdominal reflexes (T7–12): Lightly stroke the abdominal wall diagonally towards the umbilicus in each of the 4 abdominal quadrants. Absent abdominal wall contractions can be normal or indicate UMN or LMN lesion.
  • Cremaster reflex (L1): Male patients only. Pre-warn the patient. Stroke the superior and medial aspect of the thigh in a downwards direction → contraction of the cremasteric muscle → raising of scrotum and testis on the side stroked. Absent in UMN and LMN lesions.
  • Plantar reflex (S1): Pre-warn the patient. Run a blunt object up the lateral side of the sole of the foot, curving medially before the MTP joints → flexion of the big toe (if >1y. old). Extension implies UMN lesion.
  • Anal reflex (S4/S5): Scratch the perianal skin → reflex contraction of the external sphincter. Absent in UMN and LMN lesions.

Clonus Rhythmic involuntary muscle contraction due to abrupt stretching of a tendon e.g. by dorsi flexing the ankle. Associated with UMN lesions. P.287
Regurgitation Gastric and oesophageal contents are brought back effortlessly into the mouth. Regurgitation is rarely preceded by nausea, and when due to gastro-oesophageal reflux, often associated with heartburn. Causes: Gastro-oesophageal reflux, oesophageal pouch. Very high GI obstructions (e.g. gastric volvulus) cause non-productive retching rather than true regurgitation. Renal colic p.684 Restless legs p.624 Respiratory rate Normal rate for an adult is 14 breaths/min. at rest. Higher in children:

  • Neonate: 30–60 breaths/min.
  • Infant: 20–40 breaths/min.
  • 1–3y.: 20–30 breaths/min.
  • 4–10y.: 15–25 breaths/min.
  • >10y.: 15–20 breaths/min.

↑ respiratory rate Consider:

  • Lung disease e.g. pneumonia, asthma
  • Heart disease e.g. LVF
  • Metabolic disease e.g. ketoacidosis
  • Drugs e.g. salicylate overdose
  • Psychiatric causes e.g. hyperventilation

↓ respiratory rate Consider:

  • CNS disease e.g. CVA
  • Drugs e.g. opiates
  • Cheyne-Stokes respiration

Retention of urine p.690 Rhinorrhoea Runny nose. If clear discharge, then may be physiological (e.g. due to cold) or due to allergy (e.g. hayfever or viral URTI). If green, indicates active bacterial infection. A yellow discharge may indicate viral or bacterial infection or allergy. Right iliac fossa pain Treat the cause. Common causes: Acute

  • Gastroenteritis
  • Ureteric colic
  • UTI
  • Appendicitis
  • Torted ovarian cyst
  • Salpingitis
  • Ectopic
  • Volvulus
  • Pelvic abscess

Chronic/subacute

  • Constipation
  • Irritable bowel syndrome
  • Colon cancer
  • Inflammatory bowel disease
  • Hip pathology

P.288
Right upper quadrant (hypochondrial) pain Treat the cause. Consider:

  • Gallstones
  • Hepatitis
  • Appendicitis e.g. if pregnant
  • Colonic cancer at the hepatic flexure
  • Perinephric abscess
  • Right kidney pathology e.g. renal colic; pyelonephritis
  • Intrathoracic conditions e.g. pneumonia
  • Subphrenic abscess

Rigors Shaking episodes (sometimes violent) associated with sudden rise in fever. Romberg’s sign Ask the patient to stand with feet together. Observe how steady he is. Then ask the patient to shut his eyes. Again, observe how steady he is. +ve if the patient requires vision to stand steadily. Interpretation

  • Sensory ataxia: Lack of proprioception → unsteadiness without visual feedback.
  • Cerebellar ataxia: The patient is equally unsteady whether his eyes are open or closed.

Runny nose Rhinorrhoea—p.287 S Scrotal lumps Causes: Hydrocoele, epididymal cyst, testicular tumour, varicocoele. If you cannot get above the lump, consider inguinal hernia. Sexual problems

  • Postcoital bleeding: p.714
  • Dyspareunia: p.726
  • Psychosexual problems: p.746
  • Impotence/erectile dysfunction: p.702

Short stature p.885 Sinusitis p.919 Skin discolouration

  • Hyperpigmentation: p.656
  • Hypopigmentation: p.656

Skin eruption Clues come from:

  • Age and gender of patient
  • History: Time course, distribution, exposure to possible provoking factors, similar symptoms in others
  • PMH: Atopy, similar symptoms, genetic conditions, drugs, alcohol
  • FH: Atopy, similar symptoms, genetic conditions
  • Examination: Distribution and characteristics of lesions (see skin lesions—see opposite), general examination
  • Investigation: Often unnecessary—direct at confirming cause

P.289
Treat according to cause (p.631, 632, 633, 634, 635, 636, 637, 638, 639, 640, 641, 642, 643, 644, 645, 646, 647, 648, 649, 650, 651, 652, 653, 654, 655, 656, 657, 658, 659, 660, 661, 662, 663, 664, 665, 666, 667, 668, 669, 670, 671, 672, 673, 674, 675). Differential diagnosis:

  • Psoriasis
  • Eczema
  • Urticaria
  • Lichenoid eruptions
  • Photodermatoses
  • Heat rash
  • Papulosquamous eruptions
  • Erythroderma
  • Vasculitis
  • Blistering disorders
  • Bacterial infection
  • Viral infection
  • Fungal infection
  • Scabies
  • Insect bites

Skin lesions Blisters p.652 Brown spots Consider:

  • Freckles
  • Moles
  • Lentigos—like freckles but darker and not affected by sunlight
  • Melanoma
  • BCC
  • Café au lait spots—>5 associated with neurofibromatosis
  • Seborrhoeic warts
  • Senile keratoses
  • Dermatofibroma
  • Systemic disease— Addison’s Acanthosis nigrans, Haemachromatosis

Linear lesions Consider:

  • Koebner phenomenon—psoriasis, eczema, lichen planus
  • Linear urticaria
  • Self-inflicted trauma—dermatitis artefacta
  • Reaction to garden plants—psoralen-induced phytophotodermatitis
  • Impetigo—may spread along scratch marks
  • Herpes zoster—at the edge of a dermatome

Ring-shaped lesions Consider:

  • Psoriasis
  • Fungal infection e.g. ringworm
  • Granuloma annulare
  • Discoid eczema
  • Erythema multiforme
  • BCC
  • Urticaria
  • Pityriasis rosea
  • Lichen planus
  • Burns (especially on a child—may be NAI)

Scaling

  • Silvery scaling on the surface of red patches—psoriasis
  • Fine scaling accompanied with rash—pityriasis
  • Coarse, scaly skin with no rash—ichthyosis

Subcutaneous nodules Consider:

  • RA
  • Xanthelasma
  • Neurofibroma
  • Granuloma annulare
  • Sarcoid
  • Polyarteritis

White patches Consider all causes of patchy hypopigmentation:

  • Vitiligo
  • After inflammation—cryotherapy, eczema, psoriasis, morphoea
  • Pityriasis alba—white post-inflammatory patch on a child’s face; no treatment needed
  • Following exposure to some chemicals—substituted phenols, hydroquinone
  • Certain infections—pityriasis versicolor, leprosy, yaws
  • Tuberous sclerosis
  • Halo naevus (pale area around a mole)
  • Piebaldism (from birth—associated with a white forelock)
  • Extensive hyperpigmentation e.g. chloasma—the patches of normal skin may appear hypopigmented

P.290
White spots Consider:

  • Pustules/whiteheads e.g. due to acne, folliculitis, or rosacea
  • Molluscum contagiosum—white, firm, raised spots with a pearl-like appearance
  • Milia—small, white spots usually on upper arms/face of children; resolve spontaneously

Yellow crusting Usually due to staphylococcal infection (impetigo). Sleep apnoea p.400 Sneezing Often associated with rhinitis. Snoring p.400 Sore mouth Treat the cause. Consider:

  • Oral thrush
  • Apthous ulcers
  • HSV
  • Dry mouth
  • Trauma (e.g. burn)
  • Side-effects of chemo- or radiotherapy
  • Anaemia
  • Hand, foot, and mouth disease (child)
  • Gingivitis

Sore throat p.914 Sore tongue Tongue problems—p.294 Speech problems

  • Dysarthria: p.256
  • Dysphasia: p.257
  • Stammer:p. 291

Spider naevi Small red lesions in the distribution of the superior vena cava i.e. on the arms, neck, and chest wall. Consist of a large arteriole with numerous small vessels radiating from it giving the appearance of a spider—hence the name. Vary in size from barely visible to 0.5cm diameter. Pressure applied to the central arteriole (e.g. with a pointed object) causes blanching of the whole lesion. Presence of >2 spider naevi is abnormal. Causes:

  • Cirrhosis—most frequently, alcoholic
  • Oestrogen excess—usually in association with chronic liver disease; part of normal hepatic function is the inactivation of oestrogens
  • Rheumatoid arthritis—rarely
  • Viral hepatitis (transient)
  • Pregnancy—usually appear during the 2nd-5th mo. and disappear in the final trimester

Splenomegaly Causes:

  • Haematological: Lymphoma; leukaemia; myeloproliferative disorders; sickle cell disease (children usually); thalassaemia
  • Inflammatory: RA (Felty’s syndrome); Sjogren’s; sarcoid; amyloid
  • Infection: Glandular fever; malaria; SBE; TB; leischmaniasis

Splinter haemorrhages p.660 P.291
Sputum

  • Smoking is the leading cause of excess sputum production (look for black specks of inhaled carbon).
  • Yellow-green sputum is due to cell debris (bronchial epithelium, neutrophils, eosinophils) and is not always infected.
  • Bronchiectasis causes copious greenish sputum.
  • Blood-stained sputum (haemoptysis) always needs full investigation—p.266.
  • Pink froth suggests pulmonary oedema.
  • Absolutely clear sputum is probably saliva.

Steatorrhoea Excess fat in faeces. The stool is pale-coloured, foul smelling, and floats (‘difficult to flush’). Usually due to malabsorption—p.451. Stammer Disorder of rhythm and fluency of speech in which syllables, words, or phrases are repeated. ♂:♀≈4:1. Cause unknown. Can result in stress and embarrassment.

  • Younger children: Often short-lived and, in most cases, resolves spontaneously
  • Older childrenadults: Refer to speech therapy

Strangury Distressing desire to pass something per urethra that will not pass e.g. stone. Stridor p.916 and 1011 Sweating Excess sweating—Hyperhydrosis p.659 Swelling of the ankles/legs Occurs when the rate of capillary filtration > rate drainage. Capillary filtration ↑ occurs due to ↑ venous pressure, hypoalbuminaemia, or local inflammation. ↓ drainage occurs due to lymphatic obstruction. Consider whether the swelling is acute or chronic, symmetrical or asymetrical, localized or generalized. Ask about associated symptoms e.g. breathlessness. Treat according to cause. Causes: Acute

  • DVT
  • Superficial thrombophlebitis
  • Cellulitis
  • Joint effusion/haemarthrosis
  • Haematoma
  • Baker’s cyst
  • Arthritis
  • Fracture
  • Acute arterial ischaemia
  • Dermatitis

Chronic

  • Gravitational oedema e.g. due to immobility—common in the elderly. Advise elevation of feet above waist level, support stockings (ideally apply stockings before getting out of bed), avoid standing still. Diuretics are not a long-term solution.
  • Heart failure
  • Hypoproteinaemia e.g. nephrotic syndrome
  • Idiopathic oedema
  • Reflex sympathetic dystrophy
  • Lymphoedema—infection, tumour, trauma
  • Post-thrombotic syndrome
  • Chronic venous insufficiency/venous obstruction
  • Lipodermatosclerosis
  • Congenital vascular abnormalities.

P.292
Syncope Loss of consciousness—p.274 Micturition syncope Occurs as an isolated symptom in middle-aged and elderly men—usually when they get up at night to urinate. Does not require further investigation. Advise patients to sit to urinate. Cough syncope May occur at any age after a prolonged bout of cough which impairs venous return. T Tall stature p.885 Tachycardia Heart rate >100bpm–p.342 Tardive dyskinesia Movement patterns (abnormal)—p.276 Telangectasia Visible dilation of distal venules or an arteriole (spider naevus). Causes:

  • Congenital e.g. hereditary haemorrhagic telangectasia
  • Venous disease in the leg e.g. venous stars
  • Rosacea—facial
  • Excess oestrogen e.g. liver disease; the COC pill; pregnancy
  • Skin atrophy e.g. ageing skin; radiation dermatitis; topical steroids

Spider naevi p.290 Tenesmus This is a sensation, felt in the rectum, of incomplete emptying following defecation—as if there was something left behind which cannot be passed. It is very common in irritable bowel syndrome, but can be caused by a tumour. Testicular pain Treat the cause. Causes:

  • Epididymo-orchitis
  • Torsion of the testis
  • Trauma and haematoma formation
  • Varicocoele
  • Testicular tumour

Testis

  • Absent testis: p.248
  • Testicular lump: p.698

Thought disorders Consider disorders of: Content

  • Ideas of reference: The patient feels he is noticed by everyone around him/stands out from the crowd; media content e.g. television or radio, refers to himself; or that others are talking or thinking about him. Becomes a delusion of reference when insight is lost. Associated with schizophrenia, depressive states, and acute and chronic cognitive impairment.
  • Delusions: p.255
  • P.293

  • Delusions of persecution: Most common type of paranoid delusion. Belief that a person or organization is intentionally harassing or inflicting harm upon the patient. Associated with schizophrenia, depressive states, and acute and chronic cognitive impairment.
  • Delusions of grandeur: Beliefs of possessing exaggerated power, importance, knowledge, or ability. Associated with manic depression.

Flow

  • Fight of ideas: Leaps from idea to idea. There is always some association between ideas but may seem odd e.g. rhymes. Associated with manic illness.
  • Perseveration: Persistence of a verbal or other behaviour beyond what is apparently intended, expected, or needed. Associated with dementia and brain damage e.g. cerebral palsy, CVA.
  • Loosening of association: Series of thoughts appear only distantly (or loosely) related to one another or completely unrelated. Associated with schizophrenia.
  • Thought block: Abrupt and complete interruption in the stream of thought, leaving a blank mind. Associated with schizophrenia.

Form

  • Preoccupation: The patient thinks about a topic frequently but can terminate the thoughts voluntarily. Common symptom e.g. in anxiety states. Ask about preoccupation with suicide in depressed patients.
  • Obsession: Thought or image repeated in spite of its inappropriateness or intrusiveness and associated discomfort. The thought and efforts to stop it can be disabling.

Possession

  • Thought insertion: Thoughts do not belong to the patient but have been planted there by someone else. One of the 1st rank symptoms of schizophrenia.
  • Thought withdrawal: Opposite of thought insertion. The patient perceives a thought is missing and has been removed by someone else. A 1st rank symptom of schizophrenia.
  • Thought broadcasting: The patient believes his thoughts can be heard by other people—either directly or via the newspapers, radio, etc. Associated with schizophrenia.

Thrills Palpable murmurs—always indicate pathology. Note whether systolic or diastolic and where felt strongest. Systolic thrills

  • Felt most strongly at the apex: VSD or mitral regurgitation
  • 3rd/4th interspace: VSD
  • Base of heart on the right: Aortic stenosis, aortic aneurysm
  • Base of the heart on the left: CHD e.g. pulmonary stenosis

Diastolic thrills

  • Apex: Mitral stenosis

Tics Movement patterns (abnormal)–p.276 Tinnitus p.928 P.294
Tired all the time p.582 Tongue problems

  • Blue tongue: Central cyanosis—p.254
  • Dry and furred: Dehydration
  • Geographic tongue: Irregular, smoother, redder patches on the dorsum of the tongue that change position over time. Due to papillae loss. May be asymptomatic or cause soreness. Rarely, due to vitamin B2 deficiency.
  • Large tongue: Consider acromegaly, amyloidosis, myxoedema.
  • Smooth tongue: Iron, riboflavin, nicotinic acid, B12, or folate deficiency; idiopathic—usually elderly; antibiotic use.
  • Sore tongue: Glossitis of anaemia; Crohn’s disease, coeliac disease, carcinoma of the tongue; psychogenic causes.
  • Strawberry tongue: Yellowish-white tongue coating with the dark red papillae of the tongue projecting through. Associated with scarlet fever, though also present in Kawasaki’s disease.
  • Ulcer: Presume any non-healing ulcer is due to carcinoma of the tongue until proven otherwise. Refer to oral surgeon for biopsy. Treatment is with surgery or laser ablation ± radiotherapy.

Toothache p.912 Tremor

  • Resting tremor: Present at rest but abolished on voluntary movement. Most common cause—PD when tremor is rhythmic.
  • Intention tremor: Irregular large-amplitude tremor worse on movement e.g. reaching for something. Typical of cerebellar disease.
  • Tremors on movement: Thyrotoxicosis, anxiety, benign essential tremor (inherited), and drugs (e.g. β-agonists) cause a fine tremor abolished at rest. Alcohol and β-blockers may help.

U Ulcer (leg) p.640 Unconscious patient p.1032 Urgency Dysuria and urgency—p.259 Urticaria p.642 V Vaginal bleeding

  • Menorrhagia/heavy periods: p.724
  • Intemenstrual bleeding: p.714
  • Bleeding in early pregnancy: p.736
  • Bleeding in later pregnancy: p.792
  • Postcoital bleeding: p.714
  • Post-menopausal bleeding: p.713
  • Prolonged periods: p.280

P.295
Vaginal discharge p.740 Varicose veins p.362 Vertigo p.928 Visual disturbance Consider:

  • Eye disease: p.931, 932, 933, 934, 935, 936, 937, 938, 939, 940, 941, 942, 943, 944, 945, 946, 947, 948, 949, 950, 951, 952, 953, 954, 955.
  • Drugs
  • CNS lesions
    • History of visual field loss e.g. stroke
    • Double vision—MS, trauma, tumour, basilar artery insufficiency, chronic basilar meningitis
    • Flashing lights—migraine, seizure disorder
    • Visual hallucinations—seizure disorder, drugs
    • Transient blindness—vascular lesions, migraine

Visual field defects Figure 9.2

  • Cortical blindness: Normal eyes. Normal papillary responses but no conscious vision. Due to bilateral damage to the visual cortex.
  • Tunnel vision: Loss of peripheral vision in all directions. Consider: migraine; glaucoma; optic atrophy; tertiary syphilis; papilloedema; retinal abnormalities e.g. retinitis pigmentosa; hysteria. Refer to ophthalmology.
  • Enlarged blind spot: The blind spot is a small area lateral to the centre of the visual field where there is no vision perception. Due to interruption of the retina by the optic disc. Blind spot is enlarged if the optic disc is enlarged e.g. papilloedema.
  • Central scotoma: Loss of central vision with normal vision around it. May be unilateral or bilateral. Consider:
    • Bilateral: methylated spirit ingestion, B12 deficiency, tobacco
    • Unilateral/bilateral: MS
    • Unilateral: glioma of the optic nerve, vascular lesion
Figure 9.2 Visual pathways and visual field defects caused by interruption anterior to the optic chiasm, at the optic chiasm, and behind the optic chiasm

P.296
Loss of vision from one eye Due to a lesion anterior to the optic chiasm (Figure 9.2) e.g. retinal artery occlusion, tumour.

  • Bitemporal hemianopia: Due to interruption of the visual pathways at the optic chasm where fibres from the nasal half of the retina cross. Results in bilateral temporal field loss. If partial, may cause partial loss (i.e. quadrantinopia). Consider: pituitary tumours, craniopharyngioma, meningioma.
  • Homonymous hemianopia: Due to interruption of the visual pathway after the optic chiasm. Results in loss of vision on the same side in both eyes i.e. left-hand sided lesions → nasal side visual loss in the left eye and temporal side visual loss in the right eye. Partial interruption results in quadrantinopia or macular sparing. Causes include: CVA, head injury, or brain tumour.

Visual loss

  • Sudden: p.942
  • Gradual: p.944

Voice disturbance

  • Dysarthria: p.256
  • Dysphasia: p.257
  • Stammer: p.291

Vomiting In children p.857 In adults Common symptom. History: duration, colour, and frequency, ability to retain food and fluids, nature of vomitus, presence of blood or ‘coffee grounds’, relationship to eating. Examination: abdomen (masses, tenderness, hepatomegaly), dehydration. Advise patients to drink small amounts of clear fluids regularly to maintain hydration. Treat according to cause. Causes:

  • Gl: food poisoning; gastroenteritis; Gl obstruction; pyloric stenosis; ‘acute abdomen’.
  • CNS: ↑lCP; head injury; motion sickness; migraine; Ménière’s disease; labyrinthitis; cerebellar disease.
  • Psychiatric: anorexia; bulimia.
  • Metabolic: pregnancy; uraemia; drugs (e.g. opiates); toxins.
  • Infection: tonsillitis, OM—especially in children.
  • Carcinomatosis

Vulval itching (Pruritus vulvae) Treat the cause. Causes:

  • Infection (e.g. candida, herpes genitalis, genital warts, threadworms, pubic lice, scabies)
  • Atrophic vulvitis
  • Vulval dystrophy
  • Vulval carcinoma
  • Generalized causes of pruritus—p.281

Vulval lumps Common and usually benign. General causes

  • Sebaceous cyst
  • Varicose veins
  • Haematoma
  • Benign skin tumours (lipoma, papilloma, etc.)
  • Malignant skin tumours (1° or 2°)

P.297
Specific causes

  • Bartholin’s gland cyst/abscess
  • Urethral caruncle
  • Endometriosis
  • Carcinoma of the vulva
  • Inguinal hernia
  • Hydrocoele of the canal of Nuck.

W Walking difficulty (‘off legs’) Common amongst the elderly. Causes:

  • Musculoskeletal: Osteoarthritis or RA, osteoporotic fractures, fractured neck of femur, osteomalacia, Paget’s disease, polymyalgia rheumatica;
  • Psychological: Depression, bereavement, fear of falling;
  • Neurological: Stroke, Parkinson’s disease, peripheral neuropathy;
  • Spinal cord compression
  • Systemic: Pneumonia, UTI, anaemia, hypothyroidism, renal failure, infection, hypothermia.

Management Treat according to cause. Refer if inadequate support at home, cause warrants admission, or no cause is found. Gait (abnormal) p.263 Watery eyes p.939 Weight loss Non-specific symptom. Treat the cause. Causes:

  • Gl: Malabsorption, malnutrition, dieting;
  • Chronic disease: Hyperthyroidism, DM, heart failure, renal disease, degenerative neurological/muscle disease, chronic infection (e.g. TB, HIV) or infestation;
  • Malignancy
  • Psychiatric: Depression, dementia, anorexia.
Table 9.13 Fluorescence under Wood’s light and its associations
Colour of fluorescence Association
Golden yellow Tinea versicolor
Pale green Trichophyton schoenleini
Bright yellow-green Microsporum canis
Greeny blue Pseudomonas aeruginosa
Pinky orange Porphyria cutanea tarda
Purple brown Hyperpigmentation
Pale white Hypopigmentation
Ash leaf-shaped spot Tuberous sclerosis
Bright white or blue white Depigmentation, vitiligo
Bright white Albinism
Bluey white Leprosy

P.298
Wood’s light Filtered UV rays (Wood’s light) can be used as a diagnostic aid. Normal skin does not fluoresce or shine under ultraviolet light, Abnormal findings may indicate infection or depigmentation—Table 9.13, p.297. Wheeze Musical sound heard during expiration.

  • Polyphonic wheeze: indicates narrowing of many small airways—typical of asthma or COPD.
  • Monophonic wheeze: indicates single large airway obstruction e.g. due to foreign body or tumour.

X Xanthomata Localized collections of lipid-laden cells. Appear as yellowish coloured lumps. Often caused by ↑ lipids.

  • Plane xanthoma: Yellow/orange macules/plaques in the skin—particularly skin creases. Palmar xanthoma are indicative of familial hypercholesterolaemia.
  • Tendon xanthoma: Mobile nodules in tendons especially on the backs of the hands, fingers, elbows, knees, and heels. Associated with familial hypercholesterolaemia.
  • Eruptive xanthoma: Crops of small yellowish brown papules surrounded by erythema on buttocks, posterior thighs, knees, and elbows. Associated with some types of lipoproteinaemia and uncontrolled DM.
  • Tuberous xanthoma: Yellow/orange nodules in the skin over the elbow/knee. Associated with hyperlipoproteinaemia, myxoedema, and rarely, biliary cirrhosis.
  • Xanthelasma: Collection of lipid-laden cells on the eyelid. Associated with ↑ lipids in ~ 50%. Also associated with cholestasis, myxoedema, and renal disease.

P.299
Laboratory tests BIOCHEMISTRY Alanine-amino transferase (ALT; SGPT) ↑ in liver disease—suggests hepatocyte damage. Albumin High albumin Causes: dehydration; artefact (e.g. haemostasis). Low albumin Results in oedema. Causes:

  • Malignancy
  • Liver disease
  • Nephrotic syndrome
  • Burns
  • Protein-losing enteropathy
  • Malabsorption
  • Malnutrition
  • Late pregnancy
  • Artefact (e.g. blood taken from arm with IVI)
  • Posture (5g/L higher if upright)
  • Genetic variations

Alkaline phosphatase ↑ in liver disease—suggests cholestatsis; bone disease, especially Paget’s; growing children; healing fractures; osteomalacia; metastases; hyperparathyroidism; and renal failure. The placenta makes its own isoenzyme in pregnancy. Placental alkaline phosphatase (PLAP) ↑ in pregnancy, carcinoma of ovary, seminoma, and smokers. Alpha-amylase ↑ in acute pancreatitis; severe uraemia; diabetic ketoacidosis. Not ↑ in chronic pancreatitis. ALT Alanine amino transferase—see above. Amylase Alpha-amylase—see above. Aspartate-amino transferase (AST; SGOT) ↑ in liver disease (suggesting hepatocyte damage); following Ml; skeletal muscle damage; and haemolysis. Calcium

  • Hypercalcaemia: p.424
  • Hypocalcaemia: p.424

Creatinine Commonly ordered test to detect renal dysfunction (Table 9.14). Severity of renal impairment is measured in terms of glomerular filtration rate. Serum creatinine is a rough guide to glomerular filtration rate (GFR) when corrected for age, gender, and weight—↓ in GFR is associated with ↑ in serum creatinine, Renal function ↓ with age. Many elderly patients have a GFR <50ml/min. which, because of ↓ muscle mass, may not be indicated by a ↑ serum creatinine.

Table 9.14 Causes of an abnormal serum creatinine
↑ creatinine (>150µmol/l) ↓ creatinine (<70µmol/l)
Renal disease/renal failure Muscular dystrophy (late stage)
Drugs e.g. trimethoprim, probenecid, cimetidine, potassium sparing diuretics (e.g. amiloride) Myasthenia gravis
Large muscle bulk
Muscle breakdown e.g. muscular dystrophy

P.300
Creatine kinase (CK) p.311 Gamma-glutamyl transpeptidase (GGT, γGT) ↑ in liver disease—particularly alcohol-induced damage. GGT Gamma-glutamyl transpeptidase—see above. Glucose

  • Blood glucose: p.404
  • Glycosuria: p.306

Lactate dehydrogenase (LDH) Causes of ↑ LDH:

  • Ml
  • Liver disease—suggests hepatocyte damage
  • Haemolysis
  • PE
  • Tumour necrosis

Potassium Hyperkalaemia plasma potassium >6.5mmol/l needs urgent treatment.

  • Check it is not an artefact e.g. due to haemolysis inside the bottle
  • Admit for investigation of cause and treatment

ECG changes associated with hyperkalaemia Tall tented T-waves; small P-wave; wide QRS complex becoming sinusoidal, VF. Causes Table 9.15. Treat the cause. Hypokalaemia plasma potassium >2.5mmol/l needs urgent treatment.—admit Presentation Muscle weakness, hypotonia, cardiac arrhythmias, cramps, and tetany. ECG changes associated with hypokalaemia Small or inverted T-waves; prominent u-wave (after T-wave); prolonged P-R interval; depressed ST segment. Causes Table 9.15 Treatment

  • If mild (>2.5mmol/l, no symptoms): Give oral potassium supplement (at least 80mmol/24h. e.g. Sando-K 2 tabs bd). If the patient is taking a thiazide diuretic, hypokalaemia >3.0mmol/L rarely needs treating.
  • If severe (<2.5mmol/L, dangerous symptoms): Admit to a general medical team
Table 9.15 Causes of altered serum potassium
↑ potassium (>5mmol/l) ↓ potassium (<3.5mmol/l)
Renal failure Diuretics
Drugs, e.g. ACE inhibitors: excess K+ therapy; K+ sparing diuretics Cushing’s syndrome/steroids
Vomiting and/or diarrhoea
Addison’s disease Conn’s syndrome
Metabolic acidosis (DM) Villous adenoma of the rectum
Artefact (haemolysed sample) Purgative or liquorice abuse
Intestinal fistulae
Renal tubular failure
Hypokalaemic periodic paralysis—interrmittent weakness lasting <72h

P.301
Renal function

  • Acute and chronic renal failure: p.680
  • Creatinine: p.299
  • Urea: p.302
Table 9.16 Causes of altered serum sodium
↑ sodium (>145mmol/l) ↓ sodium (<135mmol/l)
Usually due to water loss > Na+ loss Renal loss Na+
  • Fluid loss without water replacement (e.g. diarrhoea, vomit, burns)
  • Diabetes insipidus—suspect if large urine volume
  • Osmotic diuresis
  • Primary aldosteronism: suspect if ↑ BP, ↓ K+, alkalosis (HCO3↑)
  • Diuretic excess—especially thiazides
  • Addison’s disease
  • Renal failure
  • Loss of Na+ elsewhere
  • Diarrhoea
  • Vomiting
  • Fistula
  • Villous adenoma of the rectum
  • Small bowel obstruction
  • CF
  • Heat exposure

Dilution with water

  • SIADH (p.429)
  • Water overload (e.g. polydipsia in schizophrenia)
  • Severe hypothyroidism
  • Glucocorticoid deficiency
  • Nephrotic syndrome
  • Cardiac failure
  • Cirrhosis
  • Renal failure

P.302
Sodium Hyponatraemia Low serum sodium (<135mmol/l). Rarely symptomatic in general practice. May present with signs of water excess—confusion, fits, ↑BP, cardiac failure, oedema, anorexia, nausea, muscle weakness. Causes: Table 9.16. Management: Treat the cause. If unwell admit for investigation. Hypernatraemia Excess serum sodium (>145mmol/l). Rare in general practice. Presentation: Thirst, confusion, coma, fits, signs of dehydration; dry skin, ↓ skin turgor, postural hypotension, and oliguria if water deficient. Causes: Table 9.16. Management: Admit for further investigation. Urea Commonly ordered test to detect renal dysfunction. While ↓ in glomerular filtration rate (GFR) is associated with ↑ in serum urea, urea may alter independently of the GFR. Causes of abnormal serum urea—Table 9.17.

Table 9.17 Causes of an abnormal serum urea
↑ urea (>6.7mmol/l) ↓ urea (<2.5mmol/l)
Renal failure Liver disease (↓ urea production)
Gl bleeding Anabolic state
High-protein diet High ADH levels (high GFR)
Drugs—high-dose steroids, tetracycline Starvation or low-protein diet
Dehydration Pregnancy

Uric acid/urate Hyperuricaemia Causes: ↑ turnover or ↓ excretion of urate.

  • Drugs: Cytotoxics; thiazides; ethambutol
  • ↑ cell turnover: Lymphoma; leukaemia; psoriasis; haemolysis; muscle necrosis
  • ↓ excretion: Primary gout; chronic renal failure; lead nephropathy; hyperparathyroidism

In addition Associated with ↑ BP and hyperlipidaemia. Urate may be ↑ in disorders of purine synthesis (e.g. Lesch-Nyhan syndrome). HAEMATOLOGY Anaemia p.522 B12 p.523 Basophils ↑ in—viral infections; urticaria; myxoedema; postsplenectomy; CML; UC; malignancy; systemic mastocytosis (urticaria pigmentosa); haemolysis; polycythaemia rubra vera. Coagulation tests (sodium citrate tube; false results if under-filled).

  • Prothrombin time (PT): Prolonged by coumarins (e.g. warfarin); vitamin K deficiency; liver disease
  • Thrombin time: ↑ in heparin treatment, DIC, or afibrinogenaemia
  • INR: Time the sample takes to clot as a ratio to a control sample—p.366, 367

P.303
Eosinophils ↑ in:

  • Parasitic infestations: e.g. ascaris, strongyloides
  • Allergic disorders: e.g. hayfever, drug reactions
  • Skin disorders: e.g. urticaria, pemphigus, eczema
  • Pulmonary disorders: e.g. asthma, aspergillosis, PAN
  • Malignant disorders: e.g. lymphoma, carcinoma, leukaemia
  • Miscellaneous disorders: e.g. hypereosinophilic syndrome, sarcoidosis, hypoadrenalism, eosinophilic gastroenteritis.

Erythrocyte sedimentation rate (ESR) Rate of fall of red cells in a column of blood. A measure of the acute phase response—the pathological process may be infective, immunological, malignant, ischaemic, or traumatic. ESR ↑ with age; ♀>♂; ↑ in patients with severe anaemia. Folate p.523 INR p.366, 367 Lymphocytes 1.3–3.5 × 109/l (20–45%). ↑ in

  • Viral infections—EBV, CMV, rubella
  • Toxoplasmosis
  • Whooping cough
  • Brucellosis
  • Chronic lymphatic leukaemia.

Large numbers of abnormal (‘atypical’) lymphocytes are characteristically seen with EBV infection. ↑ in

  • Steroid therapy
  • SLE
  • Uraemia
  • Legionnaire’s disease
  • AIDS
  • Marrow infiltration
  • Post chemotherapy or radiotherapy

Mean cell volume (MCV) Low MC (microcytic <75fl): Most common cause: Iron-deficiency anaemia. Confirm by showing that serum ferritin is ↓. Rarer causes: Thalassaemia (suspect if MCV is ‘too low’ for the level of anaemia); congenital sideroblastic anaemia (very rare). High MC (macrocytic >110fl): Vitamin B12 or folate deficiency; alcohol; liver disease; drugs (e.g. iron, azathioprine, zidovudine); haemolysis; pregnancy; hypothyroidism; marrow infiltration; myelodysplasia. Monocytes ↑ in—acute and chronic infections (e.g. TB; brucellosis; protozoa); malignant disease (including acute myeloid leukaemia and Hodgkin’s disease); myelodyspalsia. P.304
Neutrophils ↑ ↑ in Leukaemia; disseminated malignancy; severe childhood infection ↑ in

  • Bacterial infection
  • Trauma
  • Surgery
  • Burns
  • Haemorrhage
  • Inflammation
  • Infarction
  • Polymyalgia
  • PAN
  • Myeloproliferative disorders
  • Drugs (e.g. steroids)

↑ in

  • in
  • Viral infections
  • Typhoid
  • TB
  • Septicaemia
  • Drugs (e.g. carbimazole, sulfonamides)
  • Hypersplenism
  • Anti-neutrophil antibodies (e.g. in RA or SLE)
  • B12 or folate deficiency—↓ manufacture
  • Bone marrow failure

Pancytopoenia Causes:

  • Aplastic anaemia
  • Megaloblastic anaemia
  • Bone marrow infiltration or replacement (e.g. by lymphoma, leukaemia, myeloma, 2° carcinoma, myelofibrosis)
  • Hypersplenism
  • SLE
  • Disseminated TB
  • Paroxysmal nocturnal haemoglobinuria.

Platelets ↓—platelets (thrombocytopoenia—<150×109/l) Causes:

  • ↓ production: Marrow failure; megaloblastosis.
  • ↓ survival: ITP; viruses; DIC; drugs; SLE; lymphoma; thrombotic thrombocytopenic purpura; hypersplenism; genetic disease.
  • Platelet aggregation: Heparin (5% patients).

↑ platelets (thrombocythaemia—>400×109/l) Causes: ~50% with unexplained thrombocytosis have a malignancy. Other causes: Kawasaki disease; myeloproliferative or inflammatory disease (e.g. RA); bleeding; splenectomy. Polycythaemia Increase in the number of circulating red cells. May be 1° (polycythaemia rubra vera) or 2°. 2° polycythaemia may be:

  • Appropriate—high altitude, chronic lung disease (e.g. COPD), cardiovascular disease with a R → L shunt, heavy smoking, ↑ affinity for haemoglobin (familial polycythaemia) or
  • Inappropriate—due to excess erythropoietin e.g. from renal tumour, hepatocellular tumour, or massive uterine fibroid.

Hb may also appear ↑ if the patient is dehydrated—concentration effect. Red cells

  • Polycythaemia: See above
  • Anaemia: p.522
  • ↑ MCV: p.303

P.305
Thrombocytosis ↑ platelet count >1000×109/l. Causes:

  • Essential thrombocytosis: Rare
  • Reactive (2°) throbocytosis: Due to infection, malignant disease, acute or chronic inflammatory disease, pregnancy, after splenectomy, iron deficiency, or following haemorrhage.

Thrombocytopoenia Opposite and p.528 White cells

  • Neutrophils: (p.304)
  • Lymphocytes: p.303
  • Eosinophils: p.303
  • Basophils: p.302
  • Monocytes: p.303

OTHER BLOOD TESTS C-reactive protein (CRP) Acute phase protein which ↑ ≤6h. after an acute event. Follows clinical state more rapidly than ESR. Not ↑ by SLE, leukaemia, UC, pregnancy, OA, anaemia, polycythaemia, or heart failure. Highest levels are seen in bacterial infections (>10mg/L). Plasma viscosity Measure of the acute phase response—pathological process may be infective, immunological, malignant, ischaemic, or traumatic. ♂ = ♀: ↑ slightly with age; unaffected by the level of Hb. Prostate specific antigen (PSA) Causes of ↑ pSA Prostate cancer, BPH, prostatitis, old age, acute urinary retention, prostate instrumentation (includes prostate biopsy, urinary catheterization, and rectal examination). Screening for prostate cancer There is no prostate screening programme in the UK but men can request a PSA test. Warn patients about the poor specificity of the test before performing the test, and provide information about the pros and cons of testing—p.160. Performing a PSA test Do the PSA test before doing a digital rectal examination. If that’s not possible, delay the test for 1wk. after the examination. Do NOT do a PSA test if the man has:

  • A UTI
  • Ejaculated within 48h.
  • Exercised vigorously in the previous 48h.
  • Had a prostate biopsy <6wk. ago

ReferralG Table 9.18

Table 9.18 PSA cut-offs which should prompt referral
Age (y.) Refer to urology if PSA (ng/ml) is
50–59 ≥3.0
60–69 ≥4.0
≥70 >5.0

P.306
Monitoring prostate cancer

  • PSA >40: High chance of nodal or metastatic spread
  • PSA >100: Metastatic spread is very likely

URINE Creatinine clearance A more accurate method of assessing GFR is to use 24h. collection of urine together with serum creatinine to measure creatinine clearance: Glycosuria Causes:

  • DM
  • Pregnancy
  • Sepsis
  • Renal tubular damage
  • Low renal threshold

In all cases, check fasting blood glucose (+ glucose tolerance test if pregnant). Check immediate BM if other symptoms suggestive of DM. Haematuria p.265 Proteinuria Normally discovered with urine dipstick If +ve, then repeat with another sample to exclude spurious results. Treat the cause where necessary. If accurate estimation is needed, use 24h. urine collection. Normally, adults excrete <150mg protein/d. Protein:creatinine ratio in morning urine can be used for monitoring chronic proteinuria. Causes

  • UTI
  • Vaginal mucus
  • DM
  • ↑ BP
  • Glomerulonephritis
  • Pyrexia
  • CCF
  • Pregnancy (and PET)
  • Postural proteinuria—2–5% adolescents; rare >30y.
  • Haemolytic-uraemic syndrome
  • SLE
  • Myeloma
  • Drugs (e.g. gold, penicillamine)
  • Amyloid

Microalbuminuria Albuminuria in the range 30–200 mg/l. Not detectable with standard urine dipsticks. Special sticks are available for routine screening of high-risk groups e.g. diabetics. Causes:

  • DM: Microalbuminuria precedes frank proteinuria. Treatment with antihypertensives slows progression in both type 1 and type 2 DM. In type 1 DM, patients should be started on an ACE inhibitor if they screen +ve for microalbuminuria, even if normotensive—p.416.
  • P.307

  • Arteriopathy: Microalbiminuria may be present in patients with CCF or ↑ BP. There is evidence from the HOPE study (Gerstein et al. (2001) JAMA 286: 421–6) that presence of microalbuminuria predicts ↑ risk of Ml, CVA, CCF, and cardiovascular and all-cause mortality.
  • Other chronic illness: Malignancy, COPD
  • Acute illness: Inflammatory bowel disease, Ml, acute pancreatitis, trauma, burns, meningitis

Standard urine dipsticks do not detect Bence-Jones proteinuria.

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