pneumonia); often correctable by increasing inspired O2. 2 Shunting from pulmonary to systemic circulation (e.g., R \200\223L shunting VSD, patent d uctus arteriosus, transposition of the great arteries); cyanosis is not reversed by increas ing inspired O2. 3 Inadequate oxygen uptake (e.g., met-, or sulf-hemoglobinemia). Cyanosis \200\223Dyspepsia and indigestion s n g i s Figure 4.1 How to test for finger clubbing The dorsal aspect of 2 fingers, side by side with the nails touching. Normally, you should see a kite-shaped gap. If not, there is clubbing. d n a s m o t p m y S Fig. 1a No dip \200\224therefore clubbing Fig. 1b Fig. 1c Acute cyanosis is a sign of impending emergency. Is there asthma, an inhaled foreign body, a pneumothorax (X-RAY PLATE 6), or left ventricular failure (LVF) (p. 128)? Peripheral cyan osis will occur in causes of central cyanosis, but may also be induced by changes in the pe ripheral and cutaneous vascular systems in patients with normal oxygen saturations. It occu rs in the cold, in hypov- olemia, and in arterial disease and is therefore not a specific s ign. Deafness (p. 357) Dehydration (p. 458) Diarrhea (p. 210) Dizziness is a trinity: (1) V ertigo (p. 355) is the illusion of rotation, as if one just stepped off a merry-go-round. ( 2) Imbalance (i.e., difficulty in walk- ing straight) e.g., from peripheral nerve, posterio r column, cerebellum, or other central pathway failure. (3) Faintness (sense of collapse) e .g., seen in anemia, BP, hypoglycemia, carotid sinus hypersensitivity, and epilepsy. 1 \200\2233 may coexist. Dysarthria (p. 66) Dyspepsia and indigestion These are broad terms, used by patients to signify epigastric or retrosternal pain (or discomfort) that is usually related to meals. Find out exactly what your patient means. Thirty percent have no real ab normality on endoscopy. Of positive findings: Esophagitis alone Duodenal ulcer (DU) Hiatal hernia 73 24% Gastritis 17% Duodenitis 15% Gastric ulcer 23% 9% \211 2 lesions 6% Bile reflux 0.7% 5% Gastric cancer 0.2% Endoscopic or nonendoscopic testing can be used to diagnose Helicobacter pylori infection. Noninvasive tests include the 13 C-urea breath test, serologi- cal tests, and stool antigen tests. Antibody testing identifies an immuno- logic reaction to the disease, whereas the b reath test and stool antigen test detect the presence of active infection. Prior to perform ing a urea breath test, patients must be off antibiotics for 4 wks and off proton pump inhi bi- tors for 2 wks to avoid false negatives. Do endoscopy if there are \200\234alarm \200 \235 Dyspepsia and indigestion \200\223Facial pain symptoms (>45 yrs, weight, vomiting, hemat emesis, anemia, dysphagia, family history of upper GI malignancy). Dysphasia (p. 84) Dyspho nia (p. 66) Dyspnea (p. 90) is the subjective sensation of shortness of breath, often exace rbated by exertion. Try to quantify exercise tolerance (e.g., dressing, distance walked, cl imbing stairs, New York Heart Association [NYHA] clas- sification [p. 129]). Causes: \212C ardiac : E.g., mitral stenosis or left ventricular failure of any cause; LVF is associated with orthopnea (dyspnea worse on lying; \200\234how many pillows? \200\235) and paroxysmal nocturnal dyspnea (PND; dyspnea waking with the sensa- tion of air hunger). There may also be ankle edema. Any patient who is in shock may also be dyspneic: This may be shock \200 \231s presenting feature. \212Lung : Both airway and interstitial disease. May be hard to separate from cardiac caus es; asthma may wake the patient as well as cause early morn- ing dyspnea and wheeze. Focus on the circumstances in which dyspnea occurs (e.g., on exposure to an occupational allergen ). \212Anatomical : I.e., diseases of the chest wall, muscles, or pleura. \212Others : Thyro toxicosis, ketoacidosis, aspirin poisoning, anemia, psycho- genic. Look for other clues: Dy spnea at rest, not associated with exertion may be psychogenic; look for respiratory alkale mia (peripheral perioral paresthesia carpopedal spasm). Speed of onset helps diagnosi s: Acute Foreign body Pneumothorax (PLATE 6) Acute asthma Pulmonary embolus Acute pulmonary ed ema Subacute Asthma Parenchymal disease (e.g., alveolitis) Chronic COPD and chronic parenchymal diseases 74 Nonrespiratory causes (e.g., cardiac failure) Effusions Pneumonia Anemia Dyspraxia (p. 358) Dysuria is painful micturition (from urethral or bladder inflammation, t ypi- cally from infection; also urethral syndrome [p.257]). Edema Causes: ^ Venous pressure (e.g., DVT or right-heart failure) or low- ered intravascular oncotic pressure ( plasma proteins; e.g., cirrhosis, nephro- sis, malnutrition, or protein-losing enteropathy; here, water moves down the osmotic gradient into the interstitium to dilute the solutes there). On standing, venous pressure at the ankle rises due to the height of blood from the heart ( 100 mm Hg). This is short-lived if leg movement pumps blood through valved veins; but if v enous pressure rises or valves fail, capillary pressure rises, fluid is forced out (edema), PCV rises locally, and micro- vascular stasis occurs. Pitting edema , nonpitting (i.e., no nindentible)edema; caused by poor lymph drainage (lymphedema), either primary (Milroy \200 \231s syndrome) or secondary (radiotherapy, malignant infiltration, infection, filariasis). The mechanism is complex. Epigastric pain Acute causes: Peritonitis, pancreatitis, GI obst ruction, gall bladder disease, peptic ulcer, ruptured aortic aneurysm, irritable bowel synd rome. Referred pain: Myocardial infarct, pleural pathology; psychologi- cal causes are also important. Chronic causes: Peptic ulcer, gastric cancer, chronic pancreatitis, aortic aneu rysm, nerve root pain. Facial pain This can be neurological (e.g., trigeminal neuralgia) or from any other pain-sensitive structure in the head or neck (see Table 4.1). Postherpetic neuralgia: This nasty burning-and-stabbing pain (e.g., ophthalmic division of V) all too of ten becomes chronic and intractable. Skin previously affected Facial pain \200\223Fatigue s n g i s Table 4.1 Non-neurological causes of facial pain Cervical disc pathology Sinusitis, neoplasia Glaucoma, iritis, eye strain Arthritis Caries, abscess, malocclusion Otitis media, otitis externa Giant cell arteritis Neck Sinuses Eye Temporomandibular joint Teeth Ear Vascular When all causes are excluded, a group that is mostly young and female remains ( \200\234atypical facial pain \200\235) who complain of unilateral pain deep in the face or at the angle of cheek and nose, which is c onstant, severe, and unresponsive to analgesia. Do not dismiss this as psychological. Do no t expose these patients to the risks of destructive surgery; few meet the criteria of depre ssion. Although many are prescribed antidepressants, some neurologists advocate no treatmen t. d n a s m o t p m y S by zoster is exquisitely sensitive. Treatment is difficult. Give strong psy- chological sup port, whatever else is tried. Transcutaneous nerve stimula- tion, capsaicin ointment, and i nfiltration of local anesthetic may be tried. Amitriptyline (e.g., 10 \200\22325 mg at bedt ime) may help, as may carbamazepine (number needed to treat [NNT] \211\210 4). NB : Meta-a nalyzes indicate that famciclovir and valacyclovir given in the acute stage may decrease du ration of neuralgia. Fecal incontinence Common in the elderly; be sure to find out who bath es the patient as they may be under particular stress and benefit from assistance at home. The cause may disappear if constipation (p. 213) is treated ( \200\234overflow incontinence \200\235/diarrhea). A rectal exam will help identify overflow incontinence from retained h ard stool. Other GI causes : Rectal prolapse, sphincter laxity, severe hemorrhoids. Others: See Table 4.2. Fatigue This feeling is so common that it is a variant of normality. Only 1 in 400 episodes leads to a consultation with a doctor. Do not miss depres- sion, which oft en presents in this way. Even if the patient is depressed, a screening history and examinat ion is important to rule out chronic disease. Tests should ##include CBC, erythrocyte sedim entation rate (ESR), chem- istry panel, thyroid function tests (TFTs) chest x-ray (CXR). Arrange follow-up to see what develops and to address any emotional problems that develop. 75 Table 4.2 Nongastrointestinal causes of fecal incontinence Spinal cord compression, Parkinson \200\231s disease, Neurological stroke, epilepsy Endocrinological Diabetes mellitus (autonomic neuropathy), myxedema Obstetric Damage to puborectalis (or nerve roots) at childbirth Treatment is directed to the cause if possible. Avoid dehydration. If all sensible measures fail, try the brake-and-accelerator approach: Enemas to empty the rectum (e.g., twice week ly) and codeine phosphate (e.g., 15 mg/12 h PO) on nonenema days to constipate. This is not a cure, but makes the incontinence predictable. Fever and night sweats \200\223Hemoptysis Fever and night sweats Although moderate night sw eating is common in anxiety states, drenching sweats requiring several changes of night-clo thing is a more ominous symptom associated with infection (e.g., TB), lymphop- roliferative disease, or mesothelioma. Patterns of fever may be relevant (p. 542). Rigors are uncontrol led, sometimes violent episodes of shivering that occur with some causes of fever (often ac ute pyogenic infections bacteremia). Flank pain Causes: Pyelonephritis, hydronephrosis, renal calculus, renal tumor, perinephric abscess, pain referred from vertebral column. Flat ulence 400 \200\2231,300 mL of gas are expelled PR per day, and if this, cou- pled with bel ching (eructation) and abdominal distension, seems excessive to the patient, the patient ma y complain of flatulence. Eructation may occur in those with hiatal hernia. Most patients c omplaining of flatulence have no GI disease. The most likely cause is air-swallowing (aerop hagia). Frequency (urinary) means increased frequency of micturition. It is important to di fferentiate increased urine production (e.g., diabetes insipi- dus [p. 325], diabetes melli tus, polydipsia, diuretics, renal tubular disease, adrenal insufficiency, and alcohol) from frequent passage of small amounts of urine (e.g., cystitis, urethritis, neurogenic bladder , extrinsic bladder com- pression [e.g., pregnancy], bladder tumor, enlarged prostate). Gua rding Reflex contraction of abdominal muscles occurring as you press (gently!) on the abdom en; signifies local or general peritoneal inflammation. It is an imperfect sign of peritoni tis, but is one of the best we have; e.g., if you decide not to operate on someone with rig ht lower quadrant guarding, the risk of missing appendicitis is about 25%. If you do operat e, the chance of finding appendicitis is 50%. Gynecomastia (p. 319) Hematemesis (p. 204) He maturia (p. 251) Halitosis (bad breath; see Table 4.3) results from gingivitis (Vincent \200\231s angina), metabolic activity of bacteria in plaque, or sulfide-yielding food putre faction. Contributory factors: Smoking, alcohol, drugs (disulfiram, iso- sorbide), lung dis ease. Delusional halitosis is quite common. Treatment: Try to eliminate anaerobes: \212 \212 \212 Headache (see p. 345) Heartburn An intermittent, gripping, retrosternal pain usu ally worsened by stooping/lying, large meals, and pregnancy. See Esophagitis (p. 209). Hemi ballismus This refers to the uncontrolled unilateral movements of proximal limb joints caus ed by subthalamic lesions. Hemoptysis See Table 4.4. The blood is coughed up (e.g., frothy, alkaline, and bright red, often in a context of known chest disease). Always think of TB malignancy. Don \200\231t confuse with hematemesis: The vomiting of blood \200\224 acidic and dark \200\234coffee grounds. \200\235 NB : Melena occurs if enough blood is swallowed . Blood not mixed with sputum suggests infarction or trauma. Consider upper airway source: Epistaxis, gum bleeding. Hemoptysis rarely needs treating in its own right, but if massive (e.g., trauma, TB, echinococ- cus, cancer, arteriovenous [AV] malformation), call a chest p hysician/sur- geon (the danger is drowning; lobe resection, endobronchial tamponade, or art ery embolization may be needed); set up IVF, do CXR, blood gasses, CBC, International Norma lization Ratio/activated partial thromboplastin time (INR/aPTT), cross-match. If distressin g, consider prompt IV morphine (e.g., if inoperable malignancy). 76 Use the toothbrush more frequently Use dental floss 0.2% aqueous chlorhexidine gluconate Hepatomegaly \200\223Hyperventilation s n g i s Table 4.3 The science of halitosis Locally retained bacteria metabolize sulfur-containing amino acids to yield volatile hydrog en sulfide and methylmercaptan. Not only do these stink, but they also damage surrounding t issue, thereby perpetuating bac- terial retention and periodontal disease. At night and bet ween meals, conditions are optimal for odor produc- tion. To supplement conventional oral h ygienic measures some people advise brushing of the tongue. Oral care products containing m etal ions, especially zinc (Zn), inhibit odor formation, possibly by affinity between the m etal ion and sulfur. d n a s m o t p m y S Table 4.4 Causes of hemoptysis 1 Respiratory causes of hemoptysis Traumatic Infective Wounds, postintubation, foreign body Acute bronchitis, pneumonia, lung abscess, bron- chiectasis, TB, fungi, paragonimiasis Neoplastic Vascular Primary or secondary Lung infarction, vasculitis (Wegener \200\231s, rheumatoid arthritis [ RA], SLE, Osler \200\223Weber \200\223Rendu), AV fistula, malformations 77 Parenchymal Diffuse interstitial fibrosis, sarcoidosis, hemosidero- sis, Goodpasture \200\231s syndrome, cystic fibrosis 2 Cardiovascular (pulmo-nary hypertension) Pulmonary edema, mitral stenosis, aortic aneurysm, Eisenmenger \200\231s syndrome 3 Bleeding diatheses Hepatomegaly failure \200\224 may be pulsatile in tricuspid incompetence, hepatic vein thro mbosis. Infection: Mononucleosis, hepatitis viruses, malaria, amoebic abscess, hydatid cyst . Malignancy: Metastatic or primary (usually hard nodular hepatomegaly),myeloma, leukemi a, lymphoma. Others: Sickle-cell disease, other hemolytic anemias, porphyria, myeloprolifer ative disorders (e.g., myelofibrosis), storage disorders (e.g., amyloidosis, Gaucher \200 \231s disease), early cirrhosis, or fatty infiltration. Hoarseness (p. 54) Hyperpigmentatio n See Skin discoloration (p. 82). Hyperventilation is overbreathing that may be either fast (tachypnea; i.e., >20 breaths/min) or deep (hyperpnea; i.e., ^ tidal volume). Hyperpnea ma y not be perceived by the patient (unlike dyspnea) and is usually \200\234exces- sive \200 \235 in that it produces a respiratory alkalosis. This may be appropriate (Kussmaul respira tion) or inappropriate; the latter results in palpitations, dizziness, faintness, tinnitus, chest pains, perioral, and peripheral tingling ( plasma Ca 2+ ). The most common cause for hyperventilation is anxiety; others include fever and brainstem lesions. \212Kussmaul respiration is deep, sighing breathing that is principally seen in Causes: Hepatic congestion: Right heart metabolic acidoses, such as diabetic ketoacidosis and uremia. \212Neurogenic hyperventilation is produced by pontine lesions. Insomnia \200\223Jugular venous pulse and pressure Insomnia When we are sleeping well this is a trivial and irritating com- plaint, but if we suffer a few sleepless nights, sleep bec omes the most desir- able thing imaginable and the ability to bestow sleep the best thing w e can do for a patient, second only to relieving pain. Do not resort to drugs without askin g: \200\234What is the cause? Can it be treated? \200\235 Self-limiting causes Travel Stress Arousal Psychological Some typical organic causes Depression Drugs Jet lag Shift work Anxiety In hospital Mania, grief Tinnitus Nocturia Alcoholism Pain/itch Asthma Dystonias Sleep apnea (p. 189) Management: \200\234Sleep hygiene \200\235 \212 Avoid daytime naps. Establish regular bedtime and waking time with an alarm clock set for m orning even if the patient reports spontaneously awaking at the correct time. Bedroom shoul d be completely dark and quiet for sleeping, without back- ground music or noise. Do not re ad, eat, or watch TV in the bedroom. Upon waking in the middle of the night, do not eat or get out of bed. Avoid caffeine, nicotine, and alcohol. Avoid exercise within 2 hours of bed time (sexual activity may be the exception). Encourage daytime aerobic exercise to fatigue muscles. Do not prescribe benzodiazepines or alcohol at bedtime due to their addictive natu re and interference with quality of sleep. Consider sedating antihistamine as a sleep aid. Consider sleep study to evaluate for restless legs or sleep apnea. Trazodone at bedtime is helpful for nightmares from posttraumatic stress disorder \212 \212 \212 \212 \212 78 \212 \212 \212 Internuclear ophthalmoplegia A failure of eye adduction (on the affected side) with nystagm us in the other, abducting, eye. It is due to a lesion in the medial longitudinal fasciculu s (e.g., caused by multiple sclerosis [MS] or stroke). Itching (pruritus) is common and can be as debilitating as pain. Local causes Systemic (perform CBC, ESR, ferritin, liver function tests [LFT], urinalysis, TFTs) Liver d isease (bile salts) Eczema, atopy, urticaria Old age, pregnancy Scabies Lichen planus Dermatitis herpetiformis Chronic renal failure Lymphomas Polycythemia Drug reactions Iron deficiency Thyroid disease Questions: Are there wheals (urticaria)? Is itching worse at night, and are others affected (scabies)? What provokes it? After a bath, look for poly- cythemia or aquagenic urticaria. Exposure (e.g., to animals [?atopy] or fiber- glass [irritant eczema])? Look for local cau ses: Scabies burrows in the finger webs, lice on hair shafts, knee and elbow blisters (derm atitis herpetiformis). Systemic: Splenomegaly, nodes, jaundice, or flushed face or thyroid signs? Treat primary diseases; try moisturizing creams, emollient bath oils and H1-antih istamines at night (e.g., hydroxyzine or diphenhydramine). Jaundice (p. 215) Jugular venous pulse and pressure (p. 47) Left iliac fossa pain Acute \200\223Palpitations Left iliac fossa pain Acute: Gastroenterit is, ureteric colic, urinary tract infection (UTI), diverticulitis, ovarian torsion, salping itis, ectopic, volvulus, pelvic abscess, cancer in undescended testis. Chronic/subacute: Co nstipation, irritable bowel syndrome, colon cancer, inflammatory bowel disease, hip patholo gy. Left upper quadrant pain Causes: Large kidney or spleen, gastric or colonic (splenic fl exure) cancer, pneumonia, subphrenic or perinephric abscess, renal colic, pyelonephritis, s plenic rupture. Lid lag is lagging behind of the lid as the eye looks down. Lid retraction is the static state of the upper eyelid traversing the eye above the iris, rather than over it. Causes (both): Thyrotoxicosis and anxiety. Lymphadenopathy Causes may be divided into: Reactive: Infective: Bacterial (pyogenic, TB, brucella, syphilis), fungal (coccidi- omycos is), viral (Epstein-Barr virus [EBV], cytomegalovirus [CMV], HIV), toxoplasmosis, trypanoso miasis. Noninfective: Sarcoid, connective tissue disease (rheumatoid), dermatopathic (eczem a, psoriasis), drugs (pheny- toin), berylliosis. Infiltrative: Benign: Histiocytosis, metas tases. Musculoskeletal symptoms Chiefly pain, deformity, reduced function . Pain: Degenerat ive arthritis generally produces an aching pain worse with exercise and relieved by rest. D iscomfort may be increased in certain positions or with certain motions. Cervical or lumbar spine degeneration may also pro- duce subjective changes in sensation not following dermat ome distribution. Both inflammatory and degenerative joint disease produce morning stiffnes s in the affected joints but, in the former, this generally improves during the day, wherea s in the latter, the pain is worse at the end of the day. The pain of bone erosion due to t umor or aneurysm tends to be deep, boring, and constant. The pain of fracture or infection of the bone is severe and throb- bing and is increased by any motion of the part. Acute ner ve compression causes a sharp, severe pain radiating along the distribution of the nerve. J oint pain may be referred (e.g., that from a hip disorder to anterior and lateral aspect of the thigh or to knee; shoulder to the lateral aspect of the humerus; cervical spine to the interscapular area, medial border of scapulae or tips of shoulders + lateral side of arms) . (See back pain [p. 402].) Reduced function: Causes: Pain, bone or joint instability, or r estriction of joint movement (e.g., due to muscle weakness, contractures, bony fusion or me chanical block by intracapsular bony fragments or cartilage). Nodules ( subcutaneous ) Rheu matoid nodules, polyarteritis nodosa (PAN), xanthomata, tuberous sclerosis, neurofibromata, sarcoid, granuloma annu- lare, rheumatic fever. Oliguria is defined as a urine output of < 400 mL/24 h. This occurs in extreme dehydration, severe cardiac failure, urethral or bilate ral ureteral obstruction, acute and chronic renal failure. Orthopnea (p. 40). Pallor is a n onspecific sign and may be racial or familial. Pathology sug- gested by pallor includes ane mia, shock, Stokes \200\223Adams attack, vasovagal syncope, myxedema, hypopituitarism, and albinism. Palmar erythema Causes: Pregnancy, polycythemia, cirrhosis (e.g., via reduced ina ctivation of vasoactive endotoxins by the liver). Palpitations represent to the patient the sensation of feeling his own heart beat; the symptom is notoriously elusive. Have the pati ent tap out the rate and regularity of the palpitations. s n g i s d n a s m o t p m y S lipoidoses. Malignant: Lymphoma, 79 Palpitations \200\223Ptosis \212 Irregular fast palpitations are likely to be paroxysmal atrial fibrillation (AF), or flutte r with variable block. Dropped or missed beats related to rest, recumbency, or eating are l ikely to be atrial or ventricular ectopic beats. Regular pounding is likely to be due to an xiety. -blockers, or to Slow palpitations are likely to be due to drugs, such as bigemin y. Ask about associated pain, dyspnea, and syncope (fainting), sug- gesting hemodynamic com promise. Ask when symptoms occur: People often feel their (normal) heart beat in the anxiou s nocturnal silence of the bedroom. \212 \212 \212 Consider checking electrocardiogram (ECG), thyroid stimulating hormone (TSH), and hematocri t (Hct). Event monitors allow event capturing and are more likely to capture an event than 48 hour Holter monitoring. If a diagnosis of \200\234normal \200\235 ectopy is made, reass urance is essential. Paraphimosis occurs when a tight foreskin is retracted and then become s nonreplaceable as the glans swells. It can occur when a doctor/nurse fails to replace the patient \200\231s foreskin after catheterization. The general principle is to start with t he least invasive techniques (manual manipulation) and progress to more invasive techniques (needle puncture or incision) if initial efforts are unsuccessful. If significant glans pe nis ischemia with necrosis is present, emergent involvement by urologist is warranted \200 \224these patients warrant sedation and immediate reduction by invasive techniques. Pelvic pain Causes: UTI, urine retention, bladder stones, menses, labor, pregnancy, endometriosis, salpingitis, endometritis, ovarian cyst. Cancer of rectum, colon, ovary, cervix, bladder. Percussive pain Pain on percussion of the abdomen is a sign of peritonitis and is often les s painful for the patient than testing rebound abdominal pain (p. 467). Phimosis The foresk in occludes the meatus, obstructing urine. Time ( trials of gentle retraction) usually ob viates the need for circumcision. Polyuria (e.g., urine >3.5 L/24 h). Causes: Diabetes mell itus (DM), over- enthusiastic IVF treatment, diabetes insipidus (p. 325), ^ Ca 2+ , polydip sia, chronic renal failure. Postural hypotension is defined as a drop in systolic or diasto lic of >15 mm Hg on standing for 3 min, compared with lying down. Causes: Hypovolemia, Addi son \200\231s disease (p. 312), hypopituitarism, autonomic neuropathy (e.g., diabetes, mult isystem atrophy), idiopathic orthostatic hypotension, drugs (e.g., vasodilators, diuretics) . Prostatism (p. 681) Symptoms of prostate enlargement are often termed \200\234prostatism , \200\235 but it is better to use the terms cystitis symptoms or obstruc- tive bladder sym ptoms. Don \200\231t assume the cause is prostatic. (1) Irritative bladder symptoms : Urgen cy, dysuria, frequency, nocturia (the last two are also caused by UTI, polydipsia, detrusor instability, hypercalcemia, or uremia); (2) obstructive symptoms (e.g., reduced size and f orce of urinary stream, hesitancy, and interruption of stream during voiding) may also be p roduced by strictures, tumors, urethral valves, or bladder neck contrac- ture. Maximum flow rate of urine is normally 18 \200\22330 mL/sec. Pruritus See Itching (p. 78) Ptosis is dr ooping of the upper eyelid. It is best observed with the patient sitting up with head held by the examiner. The third cranial nerve (CN III) innervates the levator palpebrae superior is, but nerves from the cervical sympathetic chain innervate the adjoining smooth muscle of the superior tarsal. A lesion of these nerves will cause a mild ptosis that can be over- c ome on looking up. 80 Ptosis \200\223 Pupillary abnormalities Causes: (1) Third-nerve lesions usually causing uni lateral complete ptosis. Look for other evidence of third-nerve lesion (ophthalmoplegia wit h out- ward deviation of the eye, pupil dilated and unreactive to light, and accom- modatio n). (2) Sympathetic paralysis usually causes unilateral partial ptosis. Look for other evid ence of sympathetic lesion (constricted pupil, lack of sweating on same side of the face [H orner \200\231s syndrome]). (3) Myopathy (dystrophia myotonica, myasthenia gravis); these u sually cause bilateral par- tial ptosis. (4) Congenital (present since birth); may be unila teral or bilat- eral, is usually partial and is not associated with other neurological sign s. (5) Syphilis. Pulses (p. 48) Pupillary abnormalities The key questions are: \212 \212 \212 Irregular pupils are caused by iritis, syphilis, or globe rupture. Dilated pupils Cau ses: Third cranial nerve lesions and mydriatic drugs. But always ask: \200\234Is this pupi l dilated, or is it the other which is constricted? \200\235 Constricted pupils are associa ted with old age, sympathetic nerve damage (Horner \200\231s syn- drome; and see Ptosis [p. 80]), opiates, miotics (e.g., pilocarpine eye-drops for glaucoma), and pontine damage. Une qual pupils (anisocoria) may be due to a unilateral lesion, eyedrops, eye surgery, syphilis , or be a Holmes \200\223Adie pupil (below). Some inequality is normal. Reaction to light: Test by covering one eye and shining light into the other obliquely. Both pupils should con strict (one by the direct, the other by the consensual or indirect light reflex). Lesion si te may be deduced by know- ing the pathway: From the retina, the message passes up the opti c nerve to the superior colliculus (midbrain) and thence to the third-nerve nuclei bilatera lly. The third nerve causes pupillary constriction. If a light in one eye causes only contr alateral constriction, the defect is \200\234efferent, \200\235 as the afferent pathways f rom the retina being stimulated must be intact. Test for a relative afferent pupillary defe ct by moving the light quickly from pupil to pupil. If an eye has severely reduced acuity ( e.g., due to optic atrophy), the affected pupil will paradoxically dilate when the light is moved from the normal eye to the abnormal eye. This is because, in the face of reduced aff erent input from the affected eye, the consensual pupillary relaxation response from the no rmal eye predominates. This phenomenon is also known as the Marcus Gunn sign . Reaction to accommodation/convergence: If the patient first looks at a distant object and then at the e xaminer \200\231s finger held a few inches away, the eyes will converge and the pupils cons trict. The neural pathway involves a pro- jection from the cortex to the nucleus of the thi rd nerve. Holmes \200\223Adie (myotonic) pupil: This is a benign condition, which occurs us u- ally in women and is unilateral in about 80% of cases. The affected pupil is normally mo derately dilated and is poorly reactive to light, if at all. It is slowly reactive to accom modation; wait and watch carefully: It may eventu- ally constrict more than a normal pupil. It is often associated with dimin- ished or absent ankle and knee reflexes, in which case, the Holmes \200\223Adie syndrome is present. Argyll Robertson pupil: This occurs in neuros yphilis, but a similar phenom- enon may occur in diabetes mellitus. The pupil is constricte d. It is unreactive to light, but reacts to accommodation. The iris is usually patchily atr ophied and depigmented. Hutchinson pupil: This is the sequence of events resulting from rap idly rising unilateral intracranial pressure (e.g., in intracerebral hemorrhage). The pupil s n g i s d n a s m o t p m y S Are the pupils equal, central, circular, dilated, or constricted? Do they react to light, d irectly and consensually? Do they constrict normally on convergence/accommodation? 81 Pupillary abnormalities \200\223Tactile vocal fremitus on the side of the lesion first cons tricts then widely dilates. The other pupil then goes through the same sequence. Rebound ab dominal pain is present if, on the sudden removal of pres- sure from the examiner \200\231s hand, the patient feels a momentary increase in pain. It signifies local peritoneal inflam mation, manifest as pain as the peri- toneum rebounds after being gently displaced. Rectal bleeding Ascertain details about \212 \212 \212 Causes and classical features: Diverticu losis (painless, large volumes of blood in bowl), colorectal cancer (blood mixed with stool ), hemorrhoids (bright red blood on paper and in bowl), anal fissure (painful, bright red b lood on paper and surface of stool), inflammatory bowel disease (blood and mucus mixed with loose stool), trauma, polyps, vascular malformation, ischemic colitis, iatrogenic (radiati on proctitis, postpolypectomy bleeding, aortoen- teric fistula after aortic surgery). Regur gitation Gastric and esophageal contents are regurgitated effort- lessly into the mouth, wi thout contraction of abdominal muscles and dia- phragm (so distinguishing it from true vomi ting). Regurgitation is rarely preceded by nausea, and when due to gastroesophageal reflux, it is often associated with heartburn. An esophageal pouch may cause regurgitation. Very h igh GI obstructions (e.g., gastric volvulus) cause nonproductive retch- ing rather than tru e regurgitation. Right iliac fossa pain Causes: All causes of left iliac fossa pain (p. 79) plus appendicitis, but usually excluding diverticulitis. Right upper quadrant pain Causes: Gallstones, hepatitis, appendicitis (e.g., if pregnant), colonic cancer at the hepatic fle xure, right kidney pathol- ogy (e.g., renal colic, pyelonephritis), intrathoracic condition s (e.g., pneu- monia), subphrenic or perinephric abscess. Rigors are uncontrolled, sometime s violent episodes of shivering that occur as a patient \200\231s temperature rises quickly from normal. See FUO (p. 542). Skin discoloration Generalized hyperpigmentation due at lea st in part to melanin may be genetic, or due to radiation, Addison \200\231s (p. 312), chro nic renal failure, pregnancy, oral contraceptive pill, any chronic wasting (e.g., TB, carci noma), malabsorption, biliary cirrhosis, hemochromatosis, or medica- tions such as antipsyc hotics (chlorpromazine), alkylating agents (busulfan), antibiotics (tetracyclines). Hyperpi gmentation due to other causes occurs in jaundice, carotenemia, and gold therapy. Splenomeg aly means an abnormally large spleen. If massive, think of leish- maniasis, malaria, myelof ibrosis, chronic myeloid leukemia. Sputum (p. 155) Stridor is an inspiratory sound caused b y partial obstruction of the upper airways. An obstruction may be due to something within t he lumen (e.g., foreign body, tumor, bilateral vocal cord palsy), within the wall (e.g., ed ema from anaphylaxis, laryngospasm, tumor, croup, acute epiglottitis), or extrin- sic (e.g. , goiter, lymphadenopathy). It is a medical (or surgical) emergency if the airway is compro mised. Subcutaneous emphysema is a crackling sensation felt on palpating the skin over the chest or neck, caused by air tracking from the lungs (e.g., due to a pneumothorax). It may rarely occur due to a pneumomediastinum (e.g., following esophageal rupture). Tactile vocal fremitus (p. 56) Pain on defecation? Is blood mixed with stool, or just on surface? Is blood just on toilet paper, or also in the toilet bowl? 82 Tenesmus \200\223Visual loss Tenesmus is a sensation felt in the rectum of incomplete empty ing fol- lowing defecation, as if there was something else left behind that cannot be passe d. It is very common in irritable bowel syndrome but can be caused by a tumor. Terminal dri bbling Dribbling at the end of urination, often seen in con- junction with incontinence fol lowing incomplete urination; it is commonly associated with outlet obstruction. See prostat ism (p. 79). Tinnitus (p. 357) Tiredness See Fatigue (p. 75) Tremor is rhythmic oscillation of limbs, trunk, head, or tongue. Three types: 1 Resting tremor : Worst at rest; feature o f parkinsonism, but the tremor is more resistant to treatment than bradykinesia or rigidity . This is usually a slow tremor (frequency: 3 \200\2235 Hz) s n g i s d n a s m o t p m y S 2 Postural tremor : Made worse with certain positions (e.g., arms out- stretched). Typicall y, a rapid tremor (frequency: 8 \200\22312 Hz). May be exag- gerated physiological tremor ( e.g., anxiety, thyrotoxicosis, alcohol, drugs), metabolic (e.g., hepatic encephalopathy, CO 2 retention), due to brain damage (e.g., Wilson \200\231s disease, syphilis), or benign ess ential tremor (BET). This last is usually a familial (autosomal dominant) tremor of arms an d head presenting at any age. It is suppressed by alcohol and is rarely pro- gressive. Prop ranolol (40 \200\22380 mg/8 \200\22312 h PO) helps 30%. 3 Intention tremor: Made worse with movement; occurs in cerebellar disease (e.g., in MS). No effective drug has been found. 83 Trousseau \200\231s sign is elicited by inflating a BP cuff on an arm/leg to above systolic pressure. The hands and feet go into spasm (carpopedal spasm) in hypocalcemia. The metacar pophalangeal joints become flexed and the interphalangeal joints are extended. See Chvostek \200\231s sign (p. 72). Urinary changes Cloudy urine suggests pus (infection, UTI) but is often normal phosphate precipitation in an alkaline urine. Pneumaturia (bubbles in urine as it is passed) occurs with UTI due to gas-forming organisms or may signal an enterovesical (bowel-bladder) fistula from diverticulitis or neo- plastic diseases of the gut. Nocturia i s caused by bladder outlet obstruction (prostate enlargement), uncontrolled diabetes mellit us, UTI, and absorption of peripheral edema. Hematuria (red blood cells [RBCs] in urine) is due to neoplasia or glomerulonephritis until proven otherwise. Visual loss Get ophthalmic help. If sudden, ask: \212 \212 Is the eye painful/red (glaucoma; iritis)? Optic neuritis may be painful. What is each eye \200\231s acuity? Is there a contact lens problem (e.g., infection)? History of trauma, mig raine, TIA, MS, or diabetes; what is the blood sugar? Any detachment)? Is the cornea cloudy (corneal ulcer; glaucoma)? Is there a visual field problem/hemianopsia (stroke, space-occu pying lesion, glaucoma)? Formal field testing requires ophthalmic help. Any heart disease/b ruits (emboli)? Hyperlipidemia (xanthoma)? Is the BP raised or lowered? Measure it lying an d standing. Are there focal central nervous system (CNS) signs? Is there an afferent pupill ary defect (p. 81)? Tender temporal arteries steroids (p. 418). Any distant signs, such as HIV (causes retinitis), SLE, sarcoid, Beh et \200\231s disease, etc.? \212 \212 flashes/floaters (TIA, migraine, retinal artery occlusion, \212 \212 \212 \212 \212 \206\221 ESR points to giant cell arteritis: Urgent \212 \212 Voice and disturbance of speech \200\223Walking difficulty Voice and disturbance of speech (p. 66) may be noted by the patient or the doctor. Assess if difficulty is with articulatio n (dysarthria, e.g., from muscle problems), or of word command (dysphasia; always central). Vomiting Causes of nausea/vomiting include: Gastrointestinal Gastroenteritis Peptic ulceration Pyloric stenosis Intestinal obstruction Paralytic ileus Acute cholecystitis Acute pancreatitis CNS Meningitis/encephalitis Uremia Migraine Hypercalcemia \206\221 Intracranial pressure H yponatremia Brainstem lesions Motion sickness M ni re \200\231s disease Labyrinthitis Psychiatric disorder: \212 \212 \212 Metabolic/endocrine Pregnancy Diabetic ketoacidosis Addison \200\231s disease Drugs: \212 \212 \212 \212 \212 Alcohol Antibiotics Cytotoxics Digoxin Opiates Other Myocardial infarction Autonomic neuropathy UTI Self-induced Psychogenic Bulimia nervosa The history is very important: Ask about timing, relationship to meals, amount, and content (liquid, solid, bile, blood, \200\234coffee grounds \200\235). Associated symptoms and pr evious medical history often indicate the cause. Signs: Look for signs of dehydration. Exam ine the abdomen for distension, tender- ness, an abdominal mass, a succussion splash (pylor ic stenosis), or tinkling bowel sounds (intestinal obstruction). See Table 4.5 for non-GI c auses of vomiting. Walking difficulty In the elderly, this is a common and nonspecific pres en- tation: The reason may be local (typically osteo- or rheumatoid arthritis, but remember fractured neck of femur), systemic (e.g., pneumonia, UTI, anemia, drugs, hypothyroidism, r enal failure, hypothermia), or even a manifestation of depression or bereavement. It is onl y rarely a manipulative strategy. More specific causes to consider are Parkinson \200\231s disease (p. 382), polymy- algia rheumatica (very treatable, p. 417), and various neuropathi es/myopa- thies. One of the key questions is \200\234Is there pain? \200\235 Another issue to address is whether there is muscle wasting and, if so, is it symmetrical? If there is a lso ataxia, the cause is not always alcohol: Other chemicals may be involved (cannabis, ars enic, thallium, mercury, or prescribed 84 Table 4.5 Non-GI causes of vomiting Never forget these, as they can be a sign of serious disease. The follow- ing mnemonic cove rs the most important nongastrointestinal causes of vomiting: ABCDEFGHI \212A cute renal f ailure/ A ddison \200\231s disease \212B rain (e.g., ^ ICP [p. 722]) \212C ardiac (myocar dial infarct) \212D iabetic ketoacidosis \212E ars (e.g., labyrinthitis, M ni re \200\231s disease) \212F oreign substances (alcohol, drugs [e.g., opiates]) \212G ravidit y (e.g., hyperemesis gravidarum) \212H ypercalcemia/ H yponatremia \212I nfection (e.g., UTI, meningitis)