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OSCE > Cardioresp differentials > Flashcards

Cardioresp differentials Flashcards

1
Q

What is a key question to ask in a palpitations history and what are the red flags?

A 
Presenting complaint: palpitations
(1) essential to establish a timeline!
- has the patient kept a record?
NB: also if the patient is having palpitations in the consultation: ask them to tap it out on the table
Red Flags:
(2) chest pain?
(3) collapse?
(4) FHx of sudden cardiac death
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2
Q

What conditions should be considered as Ddx for palpitations?

A

1) ventricular tachycardia
2) Atrial fibrillation
3) Supraventricular tachycardia
4) ventricular ectopics
5) Anxiety
6) Thyrotoxicosis
7) Phaeochromacytoma

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3
Q

What are the S&Sx and HPC associated with ventricular tachycardia?

A 
"Ventricular Tachy:
• Dizziness/ sweating/ pain
• Paroxysmal noct dyspnoea
• Symptoms of acute HF/ shock/ chest pain/ syncope may be a medical emergency → A to E assessment and CPR (however, less likely as OSCE)
• Broad QRS complex ECG"
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4
Q

What are the risk factors and Ddx associated with ventricular tachycardia?

A 
• Recent MI
• Any ischaemic changes to the heart
• Normal cardiac RFs
Ddx: 
• Any other palpitation
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5
Q

What investigations should be done if palpitations are suspected?

A 
"• Bedside: 
full exam and hx, basic obs, ECG, BM
• Labs: 
FBC, U+E, Lipid screen, Mg2+, Ca2+, TSH
• Imaging: 
consider 24hr ECG, consider ECHO for structural changes "
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6
Q

What would the signs and symptoms/HPC of AF be?

A 
"AF
• Irregularly irregular
• Consider type (first episode, paroxysmal, persistent, permanent)
• Dizziness/ faintness
• Consider in a HF pt"
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7
Q

What are the risk factors and DDx for AF?

A 
"• Normal cardiac RF
• Cardiac: HF, mitral stenosis, HTN
• Infectious: pneumonia
• Metabolic: hyperthyroidism
• Stimulants: alcohol, caffeine"
DDx= any other palpitation
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8
Q

What investigations should be done in palpitations?

A

“• Bedside: full exam and hx, basic obs, ECG, BM
• Labs: FBC, U+E, Lipid screen, Mg2+, Ca2+, TSH
• Imaging: consider 24hr ECG, consider ECHO for structural changes “

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9
Q

What are the S/Sx and HPC associated with supraventricular tachycardia?

A

“SVT
• Paroxysmal palpitations
• Possible syncope
• Dizziness/ sweating”

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10
Q

What are the risk factors for SVT?

what is the DDx?

A

“• Recent MI
• Any ischaemic changes to the heart
• Normal cardiac RF”
ddx: any other palpitation

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11
Q

What are the S/Sx associated with ventricular ectopics?

A

“Ventricular ectopics
• Pts feel a skipped beat then an uncomfortable lurch in their chest
• Associated sympathetic actvity (sweating, dizziness)
• Positional association: laying down
• On ECG the QRS complexes are wide”

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12
Q

What are the RF for ventricular ectopics?

What DDx are there for ventricular ectopics?

A

“• Recent MI
• Any ischaemic changes to the heart
• Normal cardiac RF”
Ddx: any other palpitation

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13
Q

What are the S/Sx and HPC of Anxiety?

A

“Anxiety
• Associated with a trigger
• Paroxysmal
• Tingling around lips, tingling in fingertips
• Make a big point of talking about social Hx for this one
• Associated nausea/ sweating/ dry mouth

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14
Q

What are the risk factors associated with anxiety?

What Ddx are there for anxiety?

A

RF:
• Make a point about SHx

DDx:
• Any of palpitations
• Anxiety precipitated by hyperthyroidism
[do HAD10 score]

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15
Q

What are S/Sx and HPC for thyrotoxicosis?

A

Thyrotoxicosis
• Classic thyroid symptoms
• ?Thyroid storm (delerium/ diarhhoea/ nausea/ vomiting with possible precipitating factors ie. recent illness/ stress/ trauma)

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16
Q

What are the RF and ddx for thyrotoxicosis?

A

RF: FHx
DDx: Anxiety [do anxiety screen e.g. HAD10 score] & AF

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17
Q

What are the S/Sx and HPC for phaeochromacytoma?

A

5 P’s
Pain, pallor, pressure (raised BP), pain (headache), perspiration

These Sx will occur in episodes and at the same time

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18
Q

What are the RF and DDx for phaeochromacytoma?

A

RF: Fhx
DDx: any of palpitations

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19
Q

What are the DDx for dyspnoea as a PC?

A 
Dyspnoea
Acute: 
• Asthma
• Pneumonia
• Acute pulmonary oedema
• ACS
• PE
• Tension pneumothorax
Chronic
• Lung malignancy
• COPD (excluding IECOPD)
• Pulmonary fibrosis
• HF"
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20
Q

What are the red flags for a dyspnoea PC?

A 
• Chest pain (MI)
• Haemoptysis 
(PE/ lung ca)
• Weightloss 
(lung ca/ COPD/ pulmonary fibrosis)
• Heavy smoking history 
(lung ca/ COPD)
• Asbestos 
(lung cancer> mesothelioma)
• Unilateral leg swelling 
(PE)
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21
Q

What are the S/Sx & HPC for asthma?

A 
"Asthma
• Wheezing and breathlessness
• Trigger (cold air/ exercise/ aspirin)
• Night time worst
• Consider background eczema/ allergy"
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22
Q

What are the RF and DDx for asthma?

A 
RF:
"• Atopic triad
• Triggers
• Care for aspirin induced"
DDx:
"• Acute pulmonary oedema
• Foreign body obstruction"
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23
Q

What investigations should be done for a PC ?asthma in a Hx of dyspnoea?

A
  • Bedside: full exam and Hx, peak flow, basic obs
  • Labs: FBC, U+E, CRP, ESR, ABG
  • Imaging: consider CXR (especially to rule out a foreign body obstruction)
  • Special: spirometry, methacholine reversal test”
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24
Q

What are the S/Sx & HPC for pneumonia?

A

“Pneumonia
• Cough with green sputum (maybe haemoptysis)
• Fevers
• Pleuritc chest pain
• Possible background of COPD (H.Influenzae)
• It is essential to determine whether community/ hospital acquired”
e.g. have they been in hospital recently

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25
Q

What are the RF and Ddx for pneumonia

A 
RF:
"• Immunocompromised patients
• HAP: care home/ hospital stay
• ""Is anyone else around you experiencing similar symptoms)"
DDx:
"• Flu
• Infective exac COPD (in smokers)
• Asthma"
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26
Q

What investigations should be done for dyspnoea?

A

“• Bedside: full exam and Hx, peak flow, basic obs
• Labs: FBC, U+E, CRP, ESR, ABG, sputum culture, from results you would like to assess CURB65
• Imaging: CXR
• Special: spirometry, methacholine reversal test

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27
Q

What are the S/Sx of acute pulmonary oedema?

A 
"Acute pulmonary oedema
• Severe breathlesness
• On background of ACS/ arrhythmia/ HF/ CRF
• Orthopnoea and PND
• ""Pink frothy sputum""
• ?silent MI in elderly pt"
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28
Q

What are the RF & Ddx for acute pulmonary oedema?

A

RF:
• Recent: HF/ MI/ ChronicRenalFailure/ liver failure

Ddx:
• Asthma
• COPD
• Pneumonia

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29
Q

What investigations should be done for ?acute pulmonary oedema in dyspnoea hx?

A
  • A to E assessment but keeping the patient as up right as possible
  • Investigate possible causes
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30
Q

What are the S/Sx & HPC for MI?

A

MI
• Central crushing chest pain >20mins
• Radiates
• N+V, sweating associated

Unstable angina
• Pain <5 minutes
• Relieved by GTN

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31
Q

What are the RF and Ddx for MI?

A

• Classic cardiac risk factors
ddx:
• The other ACSs that you don’t think it is

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32
Q

What investigations should be done for ?MI in dyspnoea hx?

A
  • A to E assessment
  • Bedside: ECG, BM, start ACS protocol
  • Labs: FBC, U+E, troponin I (for SGUL), CK-MB, lipid profile
  • Imaging: ECG
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33
Q

What are the S/Sx & HPC of a PE?

A 
"PE
• RF inc. Virchow's triad
• Recent leg swelling
• Cough and haemoptysis
• Pleuritic chest pain
• Associated weightloss ?undiagnosed malignancy"
34
Q

What are the RF and DDx for PE?

A 
RF: 
• Classic PE risk factors (think Virchow's triad)
• Care for associated weightloss!
• Remember to ask about pregnancy/ OCP
• Remember to ask about kidney problems (important for management)
DDx:
• Acute pulmonary oedema
• Tension pneumothorax
35
Q

What investigations should be done for a ?PE in a dypnoea hx?

A

“• A to E assessment
• Risk stratify, Well’s score
• Depending on Well’s score/ pregnancy do D-dimer/ CTPA
• Bedside: ECG, ABG
• Labs: FBC, U+E, possible clotting screen, possible serum Ca2+/ LFTs for ?malignancy
• Imaging: CXR”

36
Q

What are the S/Sx & HPC of tension pneumothorax?

A

Tension pneumothorax
• Pleuritic chest pain
• ?Marfan’s/ Ehlers Danlos

37
Q

What are the RF and DDx for tension pneumothorax?

A

• Trauma!
• Other pneumothoraces: primary spontaneous (think marfan’s)/secondary spontaneous (tb, asthma, COPD)/ traumatic”
Ddx: PE, Asthma

38
Q

What should the investigation for ?tension pneumothorax in a dypnoea hx be?

A

“• (If tension large bore needle into second intercostal space midclavicular line)
• A to E assessment
• Bedside: ECG, ABG
• Imaging: CXR (if suspected pneumothorax insert needle before CXR!)

39
Q

What are the S/Sx & HPC of lung malignancy?

A

Lung malignancy
• Cough/ haemoptysis
• Chest pain
• Progressive decline
• Constitutional symptoms
• If you have time you can ask about mets (ie. bones ““any bone pain?””/ liver ““has your skin become more yellow””/ brain- ask about focal neurological defecits)
• If you have more time.. paraneoplastic syndromes (lambert eaton/ SIADH/ ectopic ACTH/ PTHrp)

40
Q

What are the RF and DDx associated with lung malignancy?

A 
RF: 
• Long smoking history
• Asbestos exposure
DDx:
• COPD
• Pulmonary fibrosis
41
Q

What investigations should be done in a ?lung malignancy for dyspnoea hx?

A
  • Bedside: Full exam and hx
  • Labs: FBC, U+E, serum Ca2+, anaemia screen
  • Imaging: CXR

• Depending on results of XR: if central lesion bronchoscopy for biopsy for histology and brushings for cytology, if peripheral lesion do biopsy for histology and FNA for cytology under CT guidance

42
Q

What are the S/Sx & HPC of COPD?

A 
"COPD
• Cough/ wheeze/ sputum
• Overlying pneumonia/ IECOPD?
• Long smoking Hx
• Weightloss"
43
Q

What are the RF and ddx for COPD?

A 
RF: 
• Long smoking history
Ddx: 
• Asthma
• Lung cancer
44
Q

What Ix should be done for ?COPD in a dyspnoea Hx?

A
  • Bedside: full exam and Hx, PEF, BMI
  • Labs: FBC, U+E, serum Ca2+, anaemia screen
  • Imaging: CXR
  • Special: spirometry
45
Q

What are the S/Sx and HPC for pulmonary fibrosis?

A 
"Pulmonary fibrosis
• SOBOE
• Weightloss
• Persistent dry cough
• Might be idiopathic or associated with asbestos/ living or working on a farm/ other occupational hazards"
46
Q

What are the RF and ddx for pulmonary fibrosis?

A 
RF:
• Occupational
• Be prepared for pt to get worried at the mention of asbestos
Ddx:
"• Lung cancer
• COPD"
47
Q

What Ix should be done for ?pulm fibrosis in a dyspnoea hx?

A
  • Bedside: full exam and Hx, ABG
  • Labs: FBC, U+E,
  • Imaging: CXR/ high resolution CT
48
Q

What are the S/Sx & HPC for heart failure?

A 
HF
• SOBOE
• PND/ orthopnoea
• Cough with pink frothy sputum (sig: pulm oed)
• Leg swelling
• Consider determining whether RHF/ CHF
49
Q

What are the RF and Ddx for HF?

A 
RF: 
• Recent: MI
• Underlying HTN
• Valvular problems
Ddx:
• Acute pulmonary oedema
50
Q

What investigations should be done in a ?heart failure in a SOB hx?

A
  • Bedside: full exam and hx, ABG
  • Labs: FBC, U+E, BNP
  • Imaging: CXR/ TOE
51
Q

What are the S/Sx & HPC of pleural effusion?

A

“Pleural effusion
• Pleuritic chest pain
• Exudative (inflam leaky capils): infection (pneumonia/tb)/ neoplasm/ inflammation (RA/ SLE)/ infarction
• Transudative (high pressure): CCF/ renal failure/ decreased albumin”

52
Q

What are the RF and Ddx for pleural effusion?

A

RF:• Any underlying cause
ddx:• Pulmonary oedema

53
Q

What Ix should be done for a ?pleural effusion in SOB Hx?

A

“• Full exam and Hx
• Labs: FBC, U+E, LFT, TFT, Ca ESR
• Imaging: CXR, US (for tapping)
• Diagnostic tap, send to: chemistry, bacteriology, cytology, immunology”

54
Q

What are the red flags for chest pain?

A
  • Sudden onset
  • Duration >10/20 mins
  • not relieved by GTN
  • Associated dyspnoea
  • PE RF
  • Weight loss
  • New onset dyspepsia and ALARMS (anaemia, loss of weight, malena, swallowing diff)
55
Q

What are the differentials for chest pain?

A
  • Stable angina
  • unstable angina
  • MI (and silent)
  • Pneumonia
  • PE
  • Tension pneumothorax
  • GORD
  • MSK
  • Aortic dissection
  • Pericarditis
56
Q

What are the S/Sx & HPC for stable angina?

A 
"Stable angina
• Lasts for 5 mins
• Central chest pain that radiates
• SOBOE
• Relieved by: GTN, sometime antacids/ rest"
57
Q

What are the RF and Ddx for stable angina?

A 
RF:
• Cardiac risk factors
• Ask about cholesterol
• Ask about diabetes
• Ask about HTN"
Ddx:
• Other ACSs
58
Q

What investigations should be done for ?stable angina in a chest pain hx?

A

“• Bedside: full exam and Hx, ECG, BM, basic obs (including BP)
• Labs: FBC, U+Es, lipid profile, trops to rule out
• Imaging: coronary angiography with Doppler
• Special: 24 hour ECG/ stress echo”

59
Q

What are the S/Sx & HPC of unstable angina?

A 
"Unstable angina
• Lasts for 5 mins
• Central chest pain that radiates
• SOBOE
• Background of stable angina
• Not relieved by: GTN, sometime antacids/ rest"
60
Q

what are the rf and ddx for unstable angina?

A 
• Cardiac risk factors
• Ask about cholesterol
• Ask about diabetes
• Ask about HTN
ddx: 
• Other ACSs
61
Q

What investigations should be done for ?unstable angina in a chest pain hx?

A
  • Bedside: full exam and Hx, ECG, BM, basic obs (including BP)
  • Labs: FBC, U+Es, lipid profile, trops to rule out
  • Imaging: coronary angiography with Doppler
  • Special: 24 hour ECG/ stress echo
62
Q

What are the S/Sx & HPC of MI?

A

MI
• Central crushing chest pain >20mins
• Radiates
• N+V, sweating associated

Silent MI
• N+V, sweating associated
• Diabetics and elderly

63
Q

What are the RF and Ddx in a ?MI chest pain hx?

A 
RF:
• Cardiac risk factors
• Ask about cholesterol
• Ask about diabetes
• Ask about HTN"
Ddx:
• Other ACSs
64
Q

What are the investigations in a ?MI chest pain hx?

A
  • A to E assessment
  • Bedside: ECG, BM, start ACS protocol
  • Labs: FBC, U+E, troponin I (for SGUL), CK-MB, lipid profile
  • Imaging: ECG
65
Q

What are the S/Sx of pneumonia?

A

“Pneumonia
• Cough with green sputum (maybe haemoptysis)
• Fevers
• Pleuritc chest pain
• Possible background of COPD (H.Influenzae)
• It is essential to determine whether community/ hospital acquired”

66
Q

What are the RF and ddx for pneumonia (chest pain hx?)

A 
RF:
• Immunocompromised patients
• HAP: care home/ hospital stay
• ""Is anyone else around you experiencing similar symptoms)
Ddx:
"• Flu
• IECOPD (in smokers)
• Asthma"
67
Q

What are the investigations to be done in a ?pneumonia chest pain hx?

A

“• Bedside: full exam and Hx, peak flow, basic obs
• Labs: FBC, U+E, CRP, ESR, ABG, sputum culture, from results you would like to assess CURB65
• Imaging: CXR
• Special: spirometry, methacholine reversal test”

68
Q

What are the S/Sx & HPC of PE?

A 
"PE
• RF inc. Virchow's triad
• Recent leg swelling
• Cough and haemoptysis
• Pleuritic chest pain
• Associated weightloss ?undiagnosed malignancy"
69
Q

What are the RF and ddx associated with PE?

A 
RF:
• Classic PE risk factors (think Virchow's triad)
• Care for associated weightloss!
• Remember to ask about pregnancy/ OCP
• Remember to ask about kidney problems (important for management)"	"• 
Ddx:
Acute pulmonary oedema
• Tension pneumothorax"
70
Q

What are the Ix for a ?PE in a chest pain history?

A
  • A to E assessment
  • Risk stratify, Well’s score
  • Depending on Well’s score/ pregnancy do D-dimer/ CTPA
  • Bedside: ECG, ABG
  • Labs: FBC, U+E, possible clotting screen, possible serum Ca2+/ LFTs for ?malignancy
  • Imaging: CXR”
71
Q

What are the S/Sx of tension pneumothorax?
the RF?
the ddx?
treatment?

A 
"Tension pneumothorax
• Pleuritic chest pain
• ?Marfan's/ Ehlers Danlos"
RF:
• Trauma!
• Other pneumothoraces: primary spontaneous (think marfan's)/secondary spontaneous (tb, asthma, COPD)/ traumatic"
DDx:
• PE
• Asthma
Ix:
"• (If tension large bore needle into second intercostal space midclavicular line)
• A to E assessment
• Bedside: ECG, ABG
• Imaging: CXR (if suspected pneumothorax insert needle before CXR!)
72
Q

What are the S/Sx of GORD?

A

“GORD
• Retrosternal/ pain on laying flat/ bending forward/ straining
• Relieved by swallowing/ antacids
• ALARM: Anorexia/ Loss of weight/ Anaemia/ Recent onset or progression/ Melaena (>55 with dyspepsia, ALARM and dyspepsia with dysphagia get 2wr)”

73
Q

What are the RF and ddx for gord?

A 
RF:
• Increased abdominal pressure (weight/ prengancy)	
ddx:
"• Gastritis
• Oesophageal carcinoma"
74
Q

What investigations should be done for GORD?

A
  • Bedside: full exam and hx
  • Labs: FBC, anaemia screen
  • Imaging: OGD
75
Q

What are the S/Sx of MSK on a chest pain hx?
RF?
DDx?

A 
MSK
• Pain on pressure
• Trauma
• Younger	
RF:
• Trauma	
ddx:
• Pleuracy
• GORD
76
Q

What are the S/Sx of aortic dissection?

A 
"Aortic dissection
• Tearing between shoulder blades
• Recent trauma/ surgery
• Background HTN/ bicuspid aortic valve/ Ehler's Danlos
• Ischaemic limbs/ "
77
Q

What are the RF and ddx for an aortic dissection?

A 
RF
• Recent trauma/ surgery
• Background HTN/ bicuspid aortic "
ddx:
- ACS
78
Q

What are the investigations that should be done in a ?aortic dissection chest pain hx?

A

“• A to E assessment
• Bedside: obs/ BM, full exam and hx, ECG
• Labs: FBC, U+E, cardiac enzymes
• Imaging: CT angiogram”

79
Q

What are the S/Sx of pericarditis?

A

“Pericarditis
• Pleuritc chest pain felt retrosternally
• Aggravated by coughing
• Better leaning forward
• Dresslers: high grade fever/ malaise/ weakness
• Post fibrinous: low grade fever”

80
Q

What are the Rf & ddx for pericarditis?

A

RF:
• Previous MI

Ddx:
• GORD
• ACS

81
Q

What are the investigations for a ?pericarditis in a chest pain history?

A

“• Bedside: full exam and Hx, basic obs, ECG

• Labs: FBC, U+E, CRP, ESR

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