Churchills pocketbook of differential diagnosis, 4enewmedicalbooks

diverticular disease is a common condition and is a common cause of pain in the left iliac fossa and is therefore coded green.. Central abdominal colicky pain, vomiting and constipation

Content Strategist: Laurence Hunter

Content Development Specialist: Sheila Black

Project Managers: Lucia Perez, Caroline Jones

Designer: Miles Hitchen

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Examiners, Intercollegiate Speciality Board in General Surgery; Formerly Member of Council, Royal College of Surgeons of England; Formerly Honorary Clinical Senior Lecturer in Surgery, University of Sheffield, UK

Eric Lim MB ChB MD MSc FRCS(C-Th)

Consultant Thoracic Surgeon, Royal Brompton Hospital, London;Senior Lecturer, National Heart and Lung Institute, Imperial College, London, UK

Andrew J K Östör MB BS FRACP

Consultant Rheumatologist and Associate Lecturer, Addenbrooke’s Hospital, Cambridge; Director, Rheumatology Clinical Research Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK

FOURTH EDITION

EDINBURGH LONDON NEW YORK OXFORD

PHILADELPHIA ST LOUIS SYDNEY TORONTO 2014

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© 2014 Elsevier Ltd All rights reserved.

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein)

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A catalogue record for this book is available from the British Library

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A catalog record for this book is available from the Library of Congress

Notices

Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should

be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,

to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise,

or from any use or operation of any methods, products, instructions, or ideas contained in the material herein

Printed in China

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SECTION A

PREFACE

We are grateful to the publishers, Elsevier, for the invitation to

produce a fourth edition of the Pocketbook of Differential Diagnosis

The text has been updated and some further conditions added

We have been pleased by the comments from our readership, who have suggested additions and corrections, and these have been taken into account when writing this new edition The introduction of the colour coding system in the third edition was favourably received and has been retained in this edition, with a few modifications in the grading of the relative frequency of some conditions A number

of our readers felt that the addition of illustrations would be helpful and to that end, we have added these to some of the chapters where

we thought it appropriate Readers and reviewers also suggested that the addition of management of diseases would be helpful but this book is a manual of differential diagnosis; treatment of the various conditions is outside the scope of this book

We are pleased with the way that previous editions have sold and that, in these days of self-directed problem-based learning, medical students still see the need for a book offering a didactic approach Indeed, we believe that the book will be particularly helpful to those

on problem-based learning courses We hope this book will continue

to help you on the wards and in the clinics – and in examinations!

A.T.R Sheffield E.L London A.J.K.O Cambridge

2014

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vi ACKNOWLEDGEMENTS

We are extremely grateful to Elsevier and, in particular, to Laurence Hunter, Senior Content Strategist, and Sheila Black, Content Development Specialist, for their support and help with this project

We wish to thank all those who have contributed to the successive editions of this book We would particularly like to express our thanks to our junior staff and medical students who have suggested corrections, amendments and improvements to the book Any errors that may have occurred remain our responsibility We are also indebted to our consultant radiologist colleagues at the Sheffield Teaching Hospitals NHS Foundation Trust who provided images: Matthew Bull, Michael Collins, Peter Brown, Tim Hodgson and Adrian Highland and to Angela Lord for permission to use figure

58 We would also like to thank our wives for their patience and encouragement shown throughout the production of this fourth edition Mr Raftery would like to thank his secretary, Mrs Denise Smith, for the hard work and long hours she has put into typing and re-typing the manuscript into its final form for publication (Mr Raftery cannot use a word processor!)

FIGURE ACKNOWLEDGEMENTS

The following images are reproduced, with kind permission, from other Elsevier titles:

Burkitt, Quick, Reed and Deakin: Essential Surgery – Problems,

Diagnosis and Management, Fourth Edition

Figures 18, 21, 22, 28, 32, 42, 45, 49A&B, 63, 67A&B, 68

Adam and Dixon: Grainger and Allison’s Diagnostic Radiology, Fifth

SECTION A

HOW TO USE THIS BOOK

This book has been written in three sections: Clinical Presentations, Biochemical Presentations and Haematological Presentations

In the Clinical Presentations section (Section A), we have

attempted to indicate the relative frequency of the conditions

causing the various symptoms and signs by colour coding them in green, orange and red, according to whether they are considered common, occasional or rare, respectively

l A common cause of the symptom or sign

l Might occasionally give rise to the symptom or sign

l Will only rarely cause the symptom or sign

This has been no easy task (and indeed in the Biochemical

Presentations and Haematological Presentations sections, we found

it so difficult that we abandoned it) but we hope that it will indicate

to readers whether they are dealing with a common, occasional or rare disorder It is appreciated that some conditions may be common

in the UK and rare in other parts of the world (and vice versa)

Where this is the case, the appropriate colour coding is indicated

in brackets, e.g Campylobacter is a common cause of diarrhoea in

the UK and therefore coded green but rare in tropical Africa and therefore coded red and in brackets We have tried to indicate

the importance of the condition, not only in causing a particular symptom or sign, but also in its overall incidence, e.g diverticular disease is a common condition and is a common cause of pain in the left iliac fossa and is therefore coded green It is only an occasional cause of large bowel obstruction and in this context, is coded

viii ABBREVIATIONS ABBREVIATIONS

ABC airway, breathing and circulation

ABGs arterial blood gases

ACE angiotensin-converting enzyme

ACTH adrenocorticotrophic hormone

AF atrial fibrillation

AIDS acquired immunodeficiency syndrome

ANCA antineutrophil cytoplasmic antibody

anti-CCP anti-cyclic citrullinated peptide

APTT activated partial thromboplastin time

ARDS acute respiratory distress syndrome

ARF acute renal failure

BCG bacille Calmette–Guérin

BPPV benign paroxysmal positional vertigo

antibody

CAPD continuous ambulatory peritoneal dialysis

CCF congestive cardiac failure

CNS central nervous system

COPD chronic obstructive pulmonary disease

CRF chronic renal failure

CVA cerebrovascular accident

CVP central venous pressure

DDH developmental dysplasia of the hip

DHEA dehydroepiandrosterone

DIC disseminated intravascular coagulation

DIP distal interphalangeal

DMSA dimercaptosuccinic acid

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EMSU early morning specimen of urine

ERCP endoscopic retrograde cholangiopancreatography

ESR erythrocyte sedimentation rate

FEV1 forced expiratory volume (1 second)

FNAC fine-needle aspiration cytology

FSH follicle-stimulating hormone

FVC forced vital capacity

βHCG β-human chorionic gonadotrophin

HIV human immunodeficiency virus

ITP idiopathic thrombocytopenic purpura

JVP jugular venous pressure

KUB kidney ureter bladder (plain X-ray)

LFTs liver function tests

LIF left iliac fossa

LVF left ventricular failure

MAG3 mercapto acetyl triglycine

MCHC mean corpuscular haemoglobin concentration

ME myalgic encephalomyelitis

MEN multiple endocrine neoplasia

MRA magnetic resonance angiography

MRCP magnetic resonance cholangiopancreatography

MRI magnetic resonance imaging

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x ABBREVIATIONS

MSU midstream specimen of urine

PAS periodic acid–Schiff

PCR polymerase chain reaction

PIP proximal interphalangeal

RAST radio allergen sorbent test

RDW red cell distribution width

RTA road traffic accident

SLE systemic lupus erythematosus

STD sexually transmitted disease

TFT thyroid function test

TIA transient ischaemic attack

TIBC total iron-binding capacity

TPN total parenteral nutrition

TSH thyroid-stimulating hormone

UTI urinary tract infection

VBGs venous blood gases

VDRL Venereal Disease Research Laboratory

V/Q ventilation/perfusion ratio

a few days or presenting intermittently) It is important to be able

to distinguish causes of abdominal pain which need urgent surgery, e.g ruptured aortic aneurysm, perforated diverticular disease, from those that do not, e.g biliary colic, ureteric colic, acute pancreatitis The causes of abdominal pain are legion and the list below contains some of the more common causes but is not intended to be

Figure 1 Diverticular disease A barium enema showing numerous

diverticulae in the sigmoid colon

● Ruptured ectopic pregnancy

● Torsion of ovarian cyst

● Ruptured ovarian cyst

● Salpingitis

● Severe dysmenorrhoea

● Mesenteric angina (claudication)

● Mesenteric venous thrombosis

 Time and mode of onset, e.g sudden, gradual.

 Character, e.g dull, vague, cramping, sharp, burning.

 Severity.

 Constancy, e.g continuous (peritonitis); intermittent (pain of intestinal colic).

 Location: where did it start? Has it moved?

 Radiation, e.g loin to groin in ureteric colic.

 Effect of respiration, movement, food, defecation, micturition and menstruation.

 Recent trauma, e.g delayed rupture of spleen.

 Menstrual history, e.g ectopic pregnancy.

EXAMINATION

General

Is the patient lying comfortably? Is the patient lying still but in pain, e.g peritonitis? Is the patient writhing in agony, e.g ureteric or biliary colic? Is the patient flushed, suggesting pyrexia?

AbdominAl PAin

Pulse, temperature, respiration

Pulse and temperature are raised in inflammatory conditions

They may also be raised with impending infarction of bowel

An increased respiratory rate might suggest chest infection referring pain to the abdomen

 Inspection Does the abdomen move on respiration? Look

for scars, distension, visible peristalsis (usually due to chronic obstruction in patient with very thin abdominal wall) Check the hernial orifices Are there any obvious masses, e.g visible, pulsatile mass to suggest aortic aneurysm?

 Palpation The patient should be relaxed, lying flat, with arms

by side Be gentle and start as far from the painful site as

possible Check for guarding and rigidity Check for masses, e.g appendix mass, pulsatile expansile mass to suggest aortic aneurysm Carefully examine the hernial orifices Examine the testes to exclude torsion.

 Percussion, e.g tympanitic note with distension with intestinal obstruction; dullness over bladder due to acute retention.

 Auscultation Take your time (30–60 s); e.g silent abdomen of peritonitis; high-pitched tinkling bowel sounds of intestinal obstruction.

Rectal examination

Always carry out a rectal examination

Vaginal examination

There may be discharge or tenderness associated with pelvic

inflammatory disease Examine the uterus and adnexa, e.g

pregnancy, fibroids, ectopic pregnancy

GENERAL INVESTIGATIONS

 FBC, ESR

Hb ↓ peptic ulcer disease, malignancy WCC ↑ infective/

inflammatory disease, e.g appendicitis, diverticulitis ESR ↑ Crohn’s disease, TB

 U&Es

Urea and creatinine↑uraemia Electrolyte disturbances in

vomiting and diarrhoea

Gas under diaphragm (perforated viscus) Lower lobar

pneumonia (referred pain)

 AXR

Obstruction – dilated loops of bowel Site of obstruction Local ileus (sentinel loop) – pancreatitis, acute appendicitis Toxic dilatation – dilated, featureless, oedematous colon in ulcerative colitis or Crohn’s disease Renal calculi Calcified aortic aneurysm Air in biliary tree (gallstone ileus) Gallstones (10% radio-opaque)

 US

Localised abscesses, e.g appendix abscess, paracolic abscess

in diverticular disease Free fluid – peritonitis, ascites Aortic aneurysm Ectopic pregnancy Ovarian cyst Gallstones

Empyema, mucocele of gall bladder Kidney – cysts, tumour.SPECIFIC INVESTIGATIONS

Carcinoma Volvulus Intussusception.

 Small bowel enema

Small bowel Crohn’s disease Lymphoma of small bowel

Carcinoma of small bowel

Biliary tract disease

● Always examine the hernial orifices.

● Always check for localised tenderness if colicky

abdominal pain becomes constant Tachycardia,

fever and a raised white cell count suggests

infarction.

!

ABDOMINAL SWELLINGS

Abdominal swellings may be divided into generalised and localised swellings Abdominal swellings are a common surgical problem They are also frequently the subject of examination questions! Generalised swellings are classically described as the ‘five Fs’, namely fat, faeces, flatus, fluid or fetus For the purpose of description

of localised swellings, the abdomen has been divided into seven areas, i.e right upper quadrant, left upper quadrant, epigastrium, umbilical, right lower abdomen, left lower abdomen and suprapubic area Hepatomegaly, splenomegaly and renal masses, although referred to in this section, are dealt with under the relevant heading

in the appropriate section of the book

Figure 2 Autosomal dominant polycystic kidney disease Both

kidneys are greatly enlarged by numerous cysts of various sizes

RIGHT UPPER QUADRANT

Right colon

Lassitude, weakness, lethargy suggesting anaemia from chronic blood loss Central abdominal colicky pain, vomiting and constipation and change in bowel habit will suggest colonic carcinoma There may

be a history of gross constipation to suggest faecal loading Known history of diverticular disease History of attacks of crying, abdominal pain and blood and mucus in the stool (‘redcurrant jelly’ stool) will suggest intussusception in infants

12 AbdominAl SwellingS

Gall bladder

A mucocele is either non-tender or only mildly tender It is large and smooth and moves with respiration, projecting from under the ninth costal cartilage at the lateral border of rectus abdominis Empyema presents with an acutely tender gall bladder, which is difficult to define due to pain and tenderness The patient may be jaundiced due to Mirizzi syndrome (external pressure from a stone impacted in Hartmann’s pouch

on the adjacent bile duct) Carcinoma of the gall bladder may present

as a hard, irregular mass in the right hypochondrium, but normally presents as obstructive jaundice due to secondary deposits in the nodes

at the porta hepatis causing external compression of the hepatic ducts

A smooth enlarged gall bladder in the presence of jaundice may be due to carcinoma of the head of the pancreas (Courvoisier’s law: ‘in the presence of obstructive jaundice, if the gall bladder is palpable, the cause is unlikely to be due to gallstones’)

Right colon

Faeces are usually soft and putty-like and can be indented but may also feel like a mass of rocks Carcinoma is usually a firm to hard irregular mass, which may be mobile or fixed A diverticular mass is usually tender and ill-defined, unless there is a large paracolic abscess With caecal volvulus, there is a tympanitic mass which may be tender with impending infarction With intussusception, there will be a smooth, mobile tender sausage-shaped mass in the right hypochondrium The mass may move as the intussusception progresses

Liver lesions Gall bladder lesions Renal lesions.

LEFT UPPER QUADRANT

Vomiting will suggest pyloric stenosis, acute dilatation of the

stomach and carcinoma Vomiting food ingested several days

previously suggests pyloric stenosis Lethargy, loss of appetite and weight loss are seen in carcinoma of the stomach

14 AbdominAl SwellingS

Pancreas

There may be a history of acute pancreatitis, which would suggest the development of a pseudocyst Weight loss, backache and jaundice will suggest carcinoma of the pancreas Recent onset of diabetes may occur with carcinoma of the pancreas

EXAMINATION

Stomach

Gastric distension may present with a vague fullness and a succussion splash Carcinoma will present with a hard, craggy, immobile mass Pancreatic tumours may be impalpable or present as a fixed mass, which does not move with respiration Pancreatic pseudocysts are often large, smooth and may be tender

Carcinoma of the pancreas Pancreatic pseudocyst

Liver secondaries Splenomegaly Paracolic abscess

EPIGASTRIUM

Many of the swellings that occur here will have been described under swellings in other regions of the abdomen Although a full list of epigastric swellings is given below, only those not referred to in other sections will be discussed in the history and examination sections.CAUSES

The patient may indicate a soft, subcutaneous swelling, which may

be a lipoma or an epigastric hernia containing extraperitoneal fat The latter always occurs in the midline through a defect in the linea alba They may become strangulated, in which case they are tender, and occasionally the skin is red Occasionally a patient may indicate

a firm bony lump in the upper epigastrium, which is in fact a normal xiphisternum This may have become apparent due to either a deliberate attempt to lose weight or sudden weight loss as a result

of underlying disease Metastatic deposits may present as single or multiple fixed lumps in the skin or subcutaneous tissue, e.g from breast or bronchus

Stomach

A baby may present with projectile vomiting The infant thrives for the first 3–4 weeks of life and then develops projectile vomiting after feeds The first-born male child in a family is most commonly affected There may be a history of a familial tendency, especially on the maternal side

Retroperitoneum

An aneurysm presents as a pulsatile expansile mass Check the distal circulation (emboli, associated peripheral ischaemia) Retroperitoneal lymph node metastases from testicular cancer may present as a

AbdominAl SwellingS

Small bowel

The patient may present with central abdominal colicky pain,

vomiting and diarrhoea, suggestive of Crohn’s disease or more rarely

a carcinoma of the small bowel

EXAMINATION

Superficial

Sister Joseph’s nodule presents as a hard lump or lumps at the

umbilicus Check for carcinoma of the stomach, colon, ovary or breast

Hernia

In infants, there may be an obvious large umbilical defect The

swelling is usually wide-necked and reducible In adults, there

may be a reducible paraumbilical hernia Occasionally it is soft, containing extraperitoneal fat Frequently, there is a sac containing omentum Incarceration may occur A tender red swelling suggests strangulation A Richter’s-type hernia may occur at this site

Vomiting Dehydration, e.g carcinoma of the stomach,

carcinoma of the bowel, Crohn’s disease

20 AbdominAl SwellingS

 Small bowel enema

Crohn’s disease Lymphoma Carcinoma

 Laparoscopy

Carcinoma of the ovaries Omental secondaries Carcinomatosis peritonei

 Biopsy

Benign versus malignant

RIGHT AND LEFT LOWER QUADRANTS

l Carcinoma of the caecum

l Carcinoma of the ascending colon

l Faeces

l Crohn’s disease

l Caecal volvulus

l Intussusception

LEFT LOWER QUADRANT

l Carcinoma of the sigmoid colon

See kidney swellings, p 299.

SPLEEN (MASSIVE SPLENOMEGALY)

Anterior abdominal wall

The patient may have the development of a soft mass that is slow growing, suggestive of a lipoma A spigelian hernia occurs just lateral

to the rectus muscle, halfway between the umbilicus and symphysis pubis It is usually reducible

Large bowel

A short history of central abdominal, colicky pain followed by a

sharply localised pain in the right iliac fossa will suggest the diagnosis

of acute appendicitis After 48 hours, if there is not generalised

peritonitis, an appendix mass will have formed and an abscess may subsequently form in the right iliac fossa With carcinoma of the caecum, the patient will either have noticed a mass or will present with alteration in bowel habit and the symptoms of anaemia,

e.g tiredness, lethargy The same applies to carcinoma of the

ascending colon Faeces will be indentable and hard, rock-like masses will be felt around the colon Caecal volvulus will present with central abdominal colicky pain and abdominal distension Intussusception is more common in infants and usually presents with colicky abdominal pain and the classic ‘redcurrant jelly’ stool Crohn’s disease will present with malaise and diarrhoea with central abdominal colicky pain

Carcinoma of the sigmoid colon will present with lower abdominal colicky pain, a change in bowel habit and bleeding PR Diverticular disease may present with similar symptoms Sigmoid volvulus will present with lower abdominal colicky pain and a tense, palpable mass in the left abdomen, which is tympanitic on percussion Large bowel Crohn’s disease will present with a sausage-like, palpable mass, which may be tender and is associated with diarrhoea

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22 AbdominAl SwellingS

Small bowel

If there is a mass palpable in the right iliac fossa, the site of pathology is likely to be in the terminal ileum This usually involves central abdominal colicky pain and a change in bowel habit Ileo-caecal TB causes abdominal pain, diarrhoea which is associated with malaise and weight loss

A palpable bony lesion suggests an osteogenic sarcoma or Ewing’s tumour of bone

EXAMINATION

The features of most of the lesions described above have been described in the other sections on abdominal swellings Only those findings relevant to the ovary, uterus and fallopian tube will

be described here Examination may reveal a greatly distended abdomen, which may be due to a huge ovarian cyst or ascites associated with an ovarian neoplasm Huge ovarian cysts are often smooth and loculated It is impossible to get below them as they arise out of the pelvis Signs of ascites include shifting dullness and

a fluid thrill With ectopic pregnancy, there may be a palpable mass

in either iliac fossa This may be associated with shock if rupture of the ectopic pregnancy has occurred Shoulder-tip pain may occur from irritation of the undersurface of the diaphragm with blood With tubo-ovarian abscess, there may be a palpable mass arising out of the pelvis, or merely lower abdominal tenderness

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GENERAL INVESTIGATIONS

 FBC, ESR

Hb ↓ Crohn’s disease, carcinoma ESR ↑ carcinoma, Crohn’s

disease, ileo-caecal TB WCC ↑ appendicitis, diverticulitis

Ovarian lesions Uterine lesions Tubo-ovarian abscesses

Pregnancy Ectopic pregnancy Iliac artery aneurysms

Lymphadenopathy Appendix mass Crohn’s mass

Carcinoma Diverticular disease

 Small bowel enema

Crohn’s disease Carcinoma Lymphoma

Missed periods and early morning vomiting will suggest pregnancy Menorrhagia and dyspareunia will suggest fibroids Intermenstrual bleeding suggests carcinoma

AbdominAl SwellingS

prostate associated with carcinoma With carcinoma of the bladder,

a hard, irregular craggy mass may be felt arising out of the pelvis

Uterus

A smooth, regular swelling arising out of the pelvis suggests a

pregnant uterus Later, as the uterus enlarges, fetal heart sounds may

be heard Fibroids are usually smooth and firm and may become very large Uterine carcinoma is hard and craggy Bimanual examination may confirm the diagnosis

GENERAL INVESTIGATIONS

 FBC, ESR

Hb ↓ tumour WCC ↑ infection

 MSU

Red cells White cells Organisms (infection precipitating)

retention Malignant cells with carcinoma

Ovarian lesions Uterine lesions Bladder lesions Urachal cyst

l Abdominal mass in conjunction with weight loss

is suggestive of malignancy and requires urgent

investigation.

l An abdominal mass in association with pyrexia,

tachycardia and localised tenderness suggests an

acute inflammatory cause.

l Always check the βHCG in women of childbearing age.

l A hard, craggy, mobile mass, especially in the

presence of ascites, suggests omental secondaries,

e.g ovary, stomach Check for Virchow’s node, i.e in the left supraclavicular fossa.

!

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ANORECTAL PAIN

Anorectal pain is a common problem The majority of patients have

an obvious cause, e.g fissure-in-ano, perianal abscess or thrombosed haemorrhoids

Figure 3 Thrombosed haemorrhoids Note the oedematous,

congested purplish mass seen at the anal margin

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l Solitary rectal ulcer

l Cauda equina lesions

HISTORY

Constipation with pain on defecation and blood (usually on

the paper) will suggest fissure-in-ano A sudden onset of pain with a tender lump in the perianal region will suggest perianal haematoma A past history of prolapsing piles, with failure to reduce them, associated with pain and tenderness suggests

thrombosed haemorrhoids Gradual onset of pain and tenderness with swelling is suggestive of abscess formation A careful history must be taken of trauma A history of anal sexual exposure will suggest gonorrhoea or herpes With gonorrhoea, there may be irritation, itching, discharge and pain With herpes, there will be pain and irritation Proctalgia fugax is diagnosed on the history of perineal pain, which is spasmodic, the spasms lasting up to 30 min The pain often feels deep inside the rectum The cause is unknown but may be related to paroxysmal contraction of levator ani

Anorectal malignancies will be suggested in alteration of bowel habit and bleeding on defecation Pain will only be apparent if the tumour involves the anal canal below the dentate line, where sensation is of the somatic type Solitary rectal ulcer may present with pain but more usually presents with bleeding PR, passage of mucus and difficulty with defecation Chronic perianal sepsis may

be the presenting symptom of Crohn’s disease or TB These diseases may already be manifest at other sites of the body Rarely lesions of the cauda equina may cause anal pain

proctoscopy may reveal pus and blood in the rectal ampulla with oedematous and friable mucosa The presence of vesicles in the anal area will suggest herpes Solitary rectal ulcer is usually diagnosed

on sigmoidoscopy when redness and oedema of the mucosa is seen, usually, but not always, in association with frank ulceration If a cauda equina lesion is suspected, a full neurological examination should be carried out No abnormality is usually found with

proctalgia fugax

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For fast diagnosis of herpes.

l Recurrent perianal abscesses may be the first presentation of diabetes Ask about thirst and urinary frequency.

l Recurrent perianal problems, especially fissures in unusual places, may be a presentation of Crohn’s disease.

l Do not treat perianal abscesses with antibiotics Perianal abscesses should be incised and drained Failure to do so may result in development of a fistula-in-ano.

!

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Figure 4 A trans-axial image showing a right-sided acute disc bulge

at C6–C7 level, which is compressing the C7 nerve root in the exit foramen (arrow) The patient will experience pain in the right arm

radiating into the middle finger (dermatomal distribution of C7) and weakness of extension of the elbow (weak triceps-myotomal distribution of C7) There will be a reduced or absent triceps reflex

30 Arm PAin

BRACHIAL PLEXUS

● Cervical rib

● Malignant infiltration, e.g Pancoast’s tumour

● Thoracic inlet syndrome

VASCULAR LESIONS

● Myocardial ischaemia (left arm)

● Axillary venous thrombosis

● Subclavian artery stenosis

● Arterial thrombosis

OTHERS

● Repetitive strain injury

● Carpal tunnel syndrome

● Peripheral neuropathy

● Bone tumours

● Compartment syndrome

● Acute, e.g crush injuries

● Chronic, e.g exertional

HISTORY

Symptoms of cervical lesions include: pain and stiffness in the neck; pain radiating down the arm Cervical cord compression may occur.Cervical spondylosis represents ‘wear and tear’ of the cervical spine It is common over the age of 60 years Acute disc lesions usually occur in the younger patient A careful history is needed to exclude trauma

Brachial plexus lesions refer pain down the arm and may result from localised lesions, e.g a cervical rib causing extrinsic compression will affect T1 and cause wasting of the small muscles of the hands and paraesthesia in the dermatomal distribution, i.e the inner aspect

of the upper arm

Subclavian artery stenosis will result in ‘claudication’ in the arm, i.e pain brought on by exercise, relieved by rest, due to inadequate blood flow A history of cardiac problems, e.g AF or widespread arterial disease, will suggest embolism or thrombosis A sudden onset of a painful, swollen, cyanotic limb will suggest axillary vein thrombosis Pain radiating into the left arm brought on by exercise and related to central chest pain and pain radiating into the neck suggests myocardial ischaemia Pain associated with occupation, e.g writing, word-processing (keyboard occupations), suggests repetitive strain injury A history of diabetes mellitus, renal failure, liver failure,

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Arm PAin

alcohol abuse, vitamin B12 deficiency, drugs, e.g phenytoin or

vincristine, suggests peripheral neuropathy

Pain, paraesthesia in the thumb, index and middle finger, which

is worse in bed at night and relieved by hanging the arm out of bed, would suggest carpal tunnel syndrome The latter may be

associated with pregnancy, rheumatoid arthritis, myxoedema,

anterior dislocation of the lunate, gout, acromegaly, amyloidosis and arteriovenous fistula at the wrist created for haemodialysis

Localised bone pain may be due to primary or secondary tumours The latter are most common and may result from a primary in the breast, bronchus, thyroid, prostate or kidney Pathological fractures may occur With compartment syndrome, there may be a history of crush injury, vascular injury or vascular surgery Chronic compartment syndrome may result from unusual exertion, e.g weight-lifting.EXAMINATION

A full neurological examination should be carried out, looking for cervical lesions, brachial plexus lesions or carpal tunnel syndrome There may be limitation in movements of the cervical spine The limbs should be examined for swelling, e.g axillary vein thrombosis, when there will be cyanosis and dilated veins Examine for signs

of ischaemia and feel for pulses The classical signs of an ischaemic limb, i.e pain, pallor, pulselessness, paraesthesia, ‘perishing cold’ and paralysis, may be present Occupation will suggest repetitive strain injury and there will usually be little to find on examination Horner’s syndrome (ptosis, miosis, enophthalmos and anhidrosis) suggests Pancoast’s tumour With bone tumours, there will be localised swelling and tenderness With compartment syndrome, there will be a swollen tender compartment in the forearm, paraesthesia and paralysis Pulses may be normal initially; later they are reduced or absent

GENERAL INVESTIGATIONS

 FBC, ESR

WCC ↑ infection, e.g osteomyelitis or cervical spine TB

ESR ↑ infection and malignancy

 CRP

Infection/inflammatory cause

 Cervical spine X-ray

Cervical spondylosis, bony metastases, cervical spine fractures