Mechanical obstruction of the bowel may be simple (one-point obstruction) or closed loop (obstruction at two points enclosing a segment of bowel). If the bowel is viable, the obstruction is termed non-strangulating. If the arterial blood supply is compromised, strangulating obstruction occurs with subsequent infarction of the bowel. Intestinal obstruction is a common surgical emergency. Causes Small bowel In the lumen ● Gallstone ileus ● Food…

Hypertension is the persistent elevation of blood pressure. An individual is classified as hypertensive when there is a sustained rise in blood pressure to more than 140/90 mmHg. Most patients have essential hypertension with contributory factors such as aging, obesity, alcohol and salt intake. An underlying cause is identified in less than 10% of patients. The causes of secondary hypertension are considered below. Causes Renal ●…

Hirsutism is the presence of male-pattern (androgen dependent) hair growth in women. This is not the same as virilism, which, in addition to hirsutism, is associated with the development of male secondary sexual characteristics in women. Whilst hypertrichosis refers to the excessive growth of hair occuring in either sex (i.e. androgen independent). Causes Physiological ● Senility ● Familial (varies with ethnicity) Pathological Drugs ● Ciclosporin ●…

Hiccups (hiccoughs) are the characteristic sounds produced by the involuntary contractions of the diaphragm terminated by sudden closure of the glottis. In the majority of patients, it is a self-limiting condition. The most common cause of hiccups is thought to be gastric distension after rapid ingestion of food, fluid or air. The causes of intractable persistent hiccups are listed below, with aetiology characterised by the hiccup…

Hepatomegaly is enlargement of the liver. The most common causes in the UK are cirrhosis, cardiac failure and secondary malignancy. Causes Hepatitis/infection Acute ● Alcohol ● Viruses (Hep A/B/C, EBV) ● Bacteria (Leptospirosis, actinomycosis, pyogenic abscess) ● Protozoans (malaria, amoeba) ● Parasites (hydatid cyst, liver fluke) Chronic ● Chronic active hepatitis Congestion ● Congestive cardiac failure ● Constrictive pericarditis ● Budd–Chiari syndrome Infiltration ● Fatty liver…

Hemiparesis is weakness or paralysis of one side of the body; it usually arises from unilateral lesions above the midcervical spinal cord. Causes (all causes of acute hemiparesis require urgent assessment) Vascular ● Cerebrovascular ischaemia ● Cerebral or spinal infarction ● Intracerebral haemorrhage ● Paradoxical embolus ● Cerebral vasculitis Traumatic ● Subdural haematoma ● Extradural haematoma You’re Reading a Preview Become a Clinical Tree membership for…

When assessing a patient with headache, it is important to exclude life-threatening causes first. Causes Acute headache ● Trauma ● Cerebrovascular ● Subarachnoid haemorrhage ( Fig. 33 ) ● Intracranial haemorrhage/infarction ● Systemic infection ● Meningitis ● Acute angle-closure glaucoma Chronic or recurrent headache ● Tension headache ● Migraine (important to also consider in acute headache as may be first presentation) ● Medication overuse headache ●…

Impairment of hand function can lead to severe disability and is a common presentation. Causes Congenital Failure of formation ● Absent digit ● Finger and thumb hypoplasia ● Radial club hand ● Macrodactyly Failure of separation ● Syndactyly (fusion of digits) ● Camptodactyly Duplication ● Polydactlyl Primary muscle contractures ● Arthrogryposis multiplex congenita Acquired ● Dupuytren’s contracture ● Rheumatoid arthritis ( Fig. 32 ) ● Osteoarthritis…

An hallucination is an apparent sensory perception of an external object when no such object is present. They may be auditory, visual, tactile, olfactory or gustatory in nature. It is to be differentiated from an illusion, which is a real perception that is misinterpreted. Causes ● Fever (especially children and the elderly) ● Drugs (and drug withdrawal) ■ Marijuana ■ Cocaine ■ LSD ■ Ecstasy ■…

Haemoptysis is the expectoration of blood or bloodstained sputum. With massive haemoptysis, the main priorities are to secure the airway and initiate emergency resuscitative measures before establishing a diagnosis. Causes Respiratory ● Bronchial carcinoma ● Pneumonia ● TB (worldwide) ( Fig. 30 ) ● Chronic obstructive pulmonary disease (COPD) ● Bronchiectasis ● Pulmonary oedema ● Goodpasture’s syndrome ● Granulomatosis with polyangiitis (GPA – formerly Wegener’s granulomatosis)…

Haematuria is the passage of red blood cells in the urine. Care must be taken to distinguish it from other causes of discoloration of urine. All patients with haematuria must be fully investigated. If haematuria has initially been diagnosed on dipstick testing, it must always be confirmed by microscopy. Causes Kidney ● Glomerular disease ● Carcinoma ● Stone ● Infection – pyelonephritis ● Trauma (including renal…

Haematemesis is the vomiting of blood. This may be frank blood or blood altered by the action of gastric acid and digestive enzymes, i.e. ‘coffee grounds’. Haematemesis is usually caused by lesions proximal to the duodenojejunal junction. Causes (all patients with significant haematemesis should be urgently assessed) Swallowed blood ● Epistaxis ● Haemoptysis Oesophagus ● Reflux oesophagitis ● Oesophageal varices ( Fig. 28 ) ● Oesophageal…

Gynaecomastia is enlargement of the male breast. There is an increase in the ductal and connective tissue elements of the breast. The condition should not be confused with fat in the mammary region, which may occur in obese patients and in old age with weight loss. In most cases, gynaecomastia is a result of an increase in the oestrogen–androgen ratio. In many cases, the actual mechanism…

These are common clinical problems, especially hernias. They are therefore common in clinical examinations. Causes Above the inguinal ligament ● Sebaceous cyst/abscess ● Lipoma ● Direct inguinal hernia ● Indirect inguinal hernia ( Fig. 26 ) ● Imperfectly descended testis ● Hydrocele of the cord/canal of Nuck Below the inguinal ligament ● Sebaceous cyst/abscess ● Lipoma ● Femoral hernia ● Lymph nodes ● Saphena varix ●…

A goitre is an enlargement of the thyroid gland ( Fig. 25 ). It can result from physiological causes such as puberty (due to increased demand for thyroid hormone) which require no treatment, to frank malignant disease requiring urgent diagnosis and treatment. Open full size image Figure 25 Endemic goitre . This condition, caused by iodine deficiency, is extremely common in isolated mountainous regions. The thyroid…

Disorders of gait may be structural or neurological. When assessing gait, it is important to observe the whole patient and not merely the feet. Causes Structural ● Pain – antalgic gait ● Length discrepancies – short leg gait ● Weak hip abductors – Trendelenburg or waddling gait ● Femoral anteversion – intoe gait Neurological ● Stroke – hemiplegic gait ● Parkinson’s disease – festinant gait ●…

Ulcers on the feet are common. The majority of them are of vascular or neuropathic origin. Causes Vascular Large vessel disease ● Arteriosclerosis ● Embolism Small vessel disease ● Diabetes ● Raynaud’s disease ● Embolism ● Vasculitis, e.g. SLE, rheumatoid arthritis, scleroderma ● Buerger’s disease Neuropathic Peripheral nerve lesions ● Diabetes ( Fig. 24 ) ● Peripheral nerve injuries ● Leprosy • (in endemic areas) ●…

Pain in the foot is a common presenting complaint. The majority of causes are related to injury, overuse or conditions causing inflammation. Causes Traumatic ● Fractures ● March fracture Infective ● Cellulitis – esp if suspected necrotising fascitis ● Osteomyelitis ● Pyogenic arthritis Inflammatory ● Rheumatoid arthritis ● Plantar fasciitis ● Reiter’s disease ● Osteochondritis of the navicular bone (Köhler’s disease) ● Osteochondritis of the metatarsal…

The deformity will often be apparent at birth but occasionally does not present until the child starts walking. A deformity of the foot and ankle is normally referred to as ‘talipes’. Other terms may qualify the word talipes, e.g. varus (inverted heel), valgus (everted heel) and equinus (foot plantar-flexed). Deformities of the toes are dealt with under toe lesions (p. 426). Causes Congenital ● Talipes congenital…

A painful finger is a common presenting symptom. This may vary from an obvious local lesion to part of a generalised disease, e.g. rheumatoid arthritis. Impairment of the function of even a single finger may grossly impair the overall function of the hand. Causes Traumatic ● Subungual haematoma ● Fractures Inflammatory/infective ● Paronychia ● Pulp space infection ● Tendon sheath infection – especially if open Neoplastic…