By Gerald Sandler MD, FRCP, John Fry OBE, MD, FRSC, FRCGP (auth.)
`...a useful and weird revision reduction for any scholar and is this type of ebook which may be consulted quick through a tender docter frightened that she or he may have ignored anything obvious.'
British clinical Journal
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Additional resources for Early Clinical Diagnosis
2 Extra-abdominal findings of diagnostic help in diarrhoea Investigation Faeces for pathogens - only of value if specific organisms are suspected • salmonella (enteric fever) • shigella or entamoeba (dysentery) • Giardia lamblia In 95% of patients with acute gastro-enteritis no organism is isolated. 33 Early Clinical Diagnosis occult blood - helpful in • carcinoma colon • inflammatory disease fat content • increased in malabsorption Urine limited value • sugar ~ diabetes • salmonella ~ enteric fever • increased excretion of 5HIAA ~ carcinoid (a very rare cause of diarrhoea) Blood tests acute diarrhoea • salmonella cultured • haemagglutination tests for amoebiasis chronic diarrhoea • microcytic anaemia ~ chronic blood loss • macrocytic anaemia ~ malabsorption • hypocalcaemia } • hypoalbuminaemia malabsorption ~ • abnormal liver function ~ ulcerative colitis Crohn's disease • raised blood sugar ~ diabetes • reduced serum cortisol ~ Addison's disease • abnormal thyroid tests ~ thyrotoxicosis Endoscopy - very helpful in chronic diarrhoea for procto-sigmoidoscopy • visualization of diseased mucosa • biopsy • carcinoma - blood or mucus with normal mucosa • ulcerative colitis mild - uniform hyperaemia with contact bleeding severe - mucosal ulceration with blood or mucopus • Crohn's disease - patchy mucosal oedema with linear ulceration ('cobblestones') • diverticulitis - diverticulae with mucosal inflammation and muco-pus 34 Diarrhoea • laxative abuse (especiaJly senna) - dark brown stains on rectal mucosa (melanosis coli) colonoscopy - not for routine use in chronic diarrhoea but is helpful in certain circumstances: • differentating ulcerative colitis and Crohn's disease • assessment of extent of bowel disease prior to surgery • to detect carcinoma in long-standing ulcerative colitis • to biopsy proximal lesion suspicious of carcinoma Radiology plain X-ray abdomen - of limited value - may show an outline of ragged ulcerated mucosa in a dilated air-filled segment of bowel in ulcerative colitis.
Abdominal pain the site of abdominal pain indicates whether the small or large bowel are likely to be involved. small - - - t - - - bowel large bowel Symptoms in other systems ulcerative colitis • painful small joints Crohn's disease • pain/stiffness in back • painful eyes • skin-tender lumps ulcers Endocrine/metabolic disease diabetes • thirst • polyuria • loss of weight thyrotoxicosis • heat intolerance • sweating • nervousness and tremors • loss of weight 30 Diarrhoea Addison's disease • excessive fatigue • postural dizziness • darkening of the skin uraemIa • previous kidney disease • polydipsia • hiccups • easy bruising • muscle twitching • paraesthesiae amyloidosis • oedema due to nephrotic syndrome • breathlessness due to heart failure • paraesthesiae due to polyneuropathy scleroderma • difficulty in swallowing • attacks of cold white fingers • painful joints • thickening of the skin carcinoid syndrome • flushing • wheezing Clinical examination The extent of examination depends on the presenting clinical picture: • acute diarrhoea of a few hours/days onset in an adult does not require detailed examination.
1 Radiation ofpain in disc lesions at L4, L5, 51 Precipitation - the diagnostic value of aggravating factors is: worse with movement ~ • mechanical pain • degenerative pain worse after resting ~ inflammatory pain worse on prolonged sitting ~ prolapsed disc 54 Backache worse with prolonged standing ~ 'prolapsed disc worse with coughing ~ prolapsed disc worse in morning ~ ankylosing spondylitis worse at night • neoplastic disease ~ • systemic disease Relief- in general, mechanical causes of pain are better with rest while systemic and neoplastic causes are worse with rest Associated symptoms - the importance of constitutional and other symptoms is shown in Fig.
Early Clinical Diagnosis by Gerald Sandler MD, FRCP, John Fry OBE, MD, FRSC, FRCGP (auth.)