common presentations Flashcards
Haematemesis
Oesophagitis/gastritis Hiatus herniia PUD (gastric or duodenal) Varices Mallory weiss Oesophageal cancer Gastric cancer AV malformation Vascular angiodysplasia Hereditary hemorrhagic telangiectasia Scleroderma Aorto enteric fistula
Umbilical pain
Early appendicitis AAA Mild pancreatitis Early mesenteric thrombus Eosophagitis Gastritis PUD Associated distention and peritonism Gastric outlet Large bowel obstruction Ileocaecal valve competent Stricture Volvulus Hernia Small bowel - billous/faecal vomit Gallstone adhesion hernia Intussception
Rectal Bleed
Haemorrhoids Rectal polyp/cancer Anal polyp/cancer Anal fissure Anal fistula Radiation proctitis Diverticular disorder Angiodysplasia Colitis Infections Ischaemic gut Colon polyp/tumour/cancer Vasculitis Anastomotic leak Angiodysplasia AV Crohn's Coeliac Aorto-enteric fistula Small bowel tumour Meckel's diverticulum
Constipation
Always ask if passing wind Peristalsis IBS Drugs - opioids, iron tablets, calcium blockers, antidepressants Hypothyroid, Hyperclacaemia, Hypoklaememia Spinal cord compression MS Renal failure Parkinson's Idiopathic megacolon Slow transit DM - autonomic neuropathic Scleroderma Low fibre Dehydration Bowel obstruction Colon cancer Sigmoid volvulus Pelvic masses - uterine fibroids, ovarian tumour Colon stricture Diverticular Radiation If not pushing - haemorrhoids, anal fissure Physiological - slow transit, outlet obstruction, animus, rectocele, sigmoidocele
Flank Pain
MSK Nephrolithiasis Leaky AAA Spinal fracture, mets, disc prolapse Pyelonephritis Renal cancer Renal abscess Perforated ulcer Basal pneumonia
Ascites
Increased portal venous pressure:
Pre hepatic - portal vein compression, thrombosis, shistosomiasis
Hepatic - cirrobisis, acute hepatic necrosis, viral hepatitis
Post - budd chiari, myeloproliferative, constrictive pericarditis, RHF, hypercoaguable statesHypoproteinuria:Renal disease
Acute chronic liver disorder
Malnutrition/malabsorption
Protein losing enteropathy
Chronic peritoneal inflammation:TB, fungal, carcinoma, post irradiation
Leakage of lymphatics:Congenital, surgical trauma, primary or secondary lymphatic malignancy
Other - pancreatic ascites, billows ascites, urinary ascites
Ascites treatment
Sodium restriction 60-90mg day
Spirinolactone then add thiazide
Paracentesis
Treat SBP (>250)
Venous obstruction - angiogram and platy
Portal HTN - trans jugular intrahepatic portosystemic shunt
Portovenous shunt –> if refractory medical or carcinomatous peritoneal cavity –> subcut to SVC
Incontinence
Abnormal faeces:
Sphincter defect - obstetric, postanorectal surgery, perineal trauma
Neuropathic - LMN - stretch pudendal neuropathy, DM
Demylination UMN - stroke, tumour, demylination
Rectal prolapse
Congenital anorectal malformation
Normal sphincter
Faecal impaction
Diarrhoea
Dementia or mentally retarded
Neck lumps
Lymphadenopathy
Sebaceous cysts
LipomasMidline - thyroid nodule, thyroglossal cyst, dermoid cystThyroid nodule - colloid cysts, follicular adenoma, hyperplastic nodule, carcinoma, papillary, follicular cancer, medullary, anapaestic
Anterior triangle - brachial cyst, carotid body tumour, carotid aneurysm, lateral thyroid, parotid, cystic hygroma, laryngocele
Posterior triangle - developmental remnants, cystic hygroma, bronchial sinus cyst, vpancoast tumour, cervical rib
Submandibular - salivary gland, cervicofacial actinomycosis, siadaldenitis, sialolithiasis, neoplasm
Goitre - hashimoto’s, graves, nutrient, suppurative, transient, sarcoidosis, dyshormogensisLaryngocele, pharyngeal pouch
Skin ulcers
Traumatic
Decubitus
Venous, varicose veins, thrombophlebitis
Arterial insufficiency
Skin infarct thrombus
Vasculitis - SLE, RA, scleroderma, buerger’s, PAN
Infective - topical, TB, Myco ulcers, post cellulitis
Malignant - SCC, BCC, melanoma
Neurotrophic, DM, peripheral neuropathy
Haem - spherocytosis, leprosy
Pyoderma gangrenosumIX: ABI, venous duplex, biopsy
Dysphagia
Bulbar, pseudo bulbar, myasthenic
Pharyngeal pouch, mediastinal mass, AAAVascular abnormality
Nutcracker oesophagus
CREST
Chagas
Dysmotility - barium swallow –> achalasia, oesophageal spasm, non-specific
Oesophagitis - candida, peptic, eosinophilicStricture:Drugs - bisphosphonates, NSAIDs, iron tablet, zidovudineIron deficiency - web
Benign - peptic, fibrous rings, eosionophilicMalignant - thyroid, oesophageal, carcinoma stomach
Tonsilitis - schatzkiring, Patternson-Brown kelly syndrome
Haematuria and Dysuria
White cells - infections, bladder, urethritis, pyelonephritis, prostate
Blood at start - urethra and prostateBlood at end - pyelo and bladder
Red cells - glomerular - IgA, thin membrane, glomerulonephritis (Glomerular disease - minimal change, thin basement membrane, membranous GN, focal segmental, post infectious, membranoproliferazive, HSP, SLE, good pasture)
Stones + Infarct + infection = painful and carcinoma or urethral stricture
PCKD + trauma - painless, vascular malformation, bladder radiation, BPH
Infarct - IE, SLE, PAN
Bladder, prostate, renal cell, renal pelvic carcinoma
Haemoglobin - haemolytic anaemia
Myoglobin - rhabdo, viral myositis (snake bite, influenza, statin)
Dark - bilirubin, rifampicin, porphyria, urethral dysuria
Stone Stricture, phimosis, mental stenosis
Reactive arthritis
UTI, STI
Prostatitis
Urethral caruncle
Vaginitis
Vaginal prolapse
Bladder, prostate, urethral carcinoma
Chronic diarrhoea
IBS, hypothyroid, carcinoid
Inflammation - IBD, diverticular, microscopic colitis
Infection - C difficile, guardia, cryptosporidium, entamoeba
Malabsorption - coeliac, pancreatic (chronic pancreatitis, cancer) tropical sprue, lactose deficiency, Whipples, crohn’s, lymphoma, short loop
Overflow - colon cancer, ovarian cancerMeds - digoxin, metformin, H2, orlistat, antibiotics, thiazide, laxative
Coeliac, small bowel bacterial overgrowth
Anal pain
Without swelling: Anal fissure ANal herpes Ulcerative proctitis Proctalgia fugax Solitary rectal ulcer Tenesmus
Painful swelling: Perianal haematoma Strangulated internal haemorrhoid Abscess - perianal, ischiorectal Pilonidal sinus Fistula-in-ano
Red flags - weight loss, change in bowel habit, fever, recurrent (Crohn’s)
Carpal Tunnel
Idiopathic Acromegaly Amyloid DM Hypothyroid Occupation Myeloma Paget's Pregnancy + Premenstrual oedema RA Tophaceous gout Trauma Fibrosis Granulomatous disorder - TB
Haemoptysis
Acute infection - URTI, acute bronchitis - COMMONEST
Chronic bronchitis
Bronchiectasis
Lobar pneumonia (rusty) + staph
TBNeoplasms - mets, bronchial cancer
PE
Foreign body
Cardiac - CCF, Mitral stenosis, AV malformation
Anticoags, haemophilia, leukaemia
Vasculitis - Wegener’s, Good pasture, PAN, SLE, HHT
Idiopathic pulmonary haemosiderosis
Post-operative fever
Inflammatory reaction to surgery Reaction to blood products Malignant hyperthermia Drug fever Toxic Shock MI Stroke Infarct in operated tissue Transplant rejection Seroma Underlying disease Haematoma Subarachnoid Atelectasis Early wound infection Aspiration penumonitis UTI Surgical site infection Pneumonia Septic thrombophlebitis Septicaemia Calculus Cholcystitis OM Meningitis Transufion related acute infection Fat embolism MI Leakage C difficile Intraabdominal abscess DVT/PE Foeign body Deep wound infection Leaky anastamosis Osteomyletis Sinusitis Catheter related Cavernous sinus infection Infected serumInfected prosthesis Alcohol withdrawal
Bowel obstruction
Mechanical - adhesions, neoplasm, hernia, IBD, intussception, volvulus
Functional - Paralytic ileum, inflammation, metabolic (hypokalaemia, hypercalcemia), drugs (anti-choliniergics), pseudo obstruction (Ogilvie, Chagas, DM, Hirschprung, collagen vascular, Kawasaki)
Ischaemic bowel
Vomiting
Vestibular - vertigo, DPPV, labrinthitis, motion sickness, menderes
GI obstruction - pyloric stenosis, gastroparesis, paralytic ileum, volvulus
Brain - Raised ICP, meningitis, encephalitis, anxiety, migraine
Metabolic - uraemia, DKA, addison’s, toxinsInfection - food poison, enteritis
Acute abdomen - hepatitis, pancreatitis, gallstone, peritoneum, appendix, nephrology, MI, pregnancy, drugs, Child - URTI, pneumonia, OM, UTI, achalasia, oesophageal atresia
Haemoptysis
URTI Acute bronchitis Bronchiectasis TB Pneumonia - necrotising Neoplastic - carcinoma or mets PE Foreign body Cardiac - acute LV failure, mitral stenosis, AV malformation ANticoags, haemophilia, leukaemia,Vasculitis - Wegener's, good pasture, PAN, SLE, HHT Trauma
Acute Diarrhoea
Gastro- Salmonella, campylobacter, shigella, e coli, staph Viral - rotavirus, norovirus, hep A In HIV - cryptosporidium parvum Entomoaba, giardiasis Diethyindescrtion Antibiotic drug reactions contacts, food, travel history
LIF
Acute diverticulits Constipation IBD Ischaemic - af, embolism, athero Pseudomembranous colitis Leaky AAA Locally perforated Cancer UTI Ureter colic Pyelonephritis Shingles Rectus sheath haematoma Sigmoid volvulus Bowel obstruction Hernia Gynae causes
RIF
Appendix Gastroenteritis ureteric colic Pancreatitis Testes torsion Meckel's Small bowel obstruction Caecal volvulus Perforated PUD Pyelonephritiis DKA Acute ileitis Constpiation Caecal diuretic Mesenteric adenitis UTI Cholecystitis Hernia Epiploic Gynae - ectopic, PID, ovary torsion, cyst rupture, haemorrhage, Mittelschmerz
Jaundice
Prehepatic - haemolytic anaemia, Gilberts, sepsis, crippler major, dubin johnson
Hepatocellular - hepatitis, drugs (paracetamol), hepatic (CCF), ischaemia, Budd chair, Cryptospirosis, mets, Wilsons, Alcohol, Reye, Acute cirrhosis, fatty liver
Obstructive - Gallstones, pancreatic cancer, bile duct cancer, hepatic mets, hepatocellular cancerPainless - pancreatic cancer, bile, hepatitis, primary biliary cirrhosis, haemolytic anaemia, CHF, Gilber’’s, cirrhosis, primary sclerosing cholangitis
Haemolytic - megaloblastic, GOPD, spherocytosis
Post op - transfusion, viral, drugs, transfusion, overload, sepsis, chronic liver disorder, cholestasis, thallasseamia major, autoimmune, blood transfusion
Liver cirrhosis
Alcohol
Viral - B and C
NASHimmune - primary sclerosing cholangitis, autoimmune hepatitis (ANA, ASMA, SLA, ALK, MI, ALC)
Biliary - primary biliary cirrhosis, CF, secondary biliary cirrhosis
Genetic - haemochromatosis, OC, Wilson’s
Chronic venous outflow obstruction
Back pain
Mechanical - MSK, discogenic, posterior ligament, facetogenic dysfunction Degenerative Fracture Malignancy - breast, bronchus, prostate, melanoma, thyroid, kidney Multiple myeloma Osteoporosis Spinal stenosis Hypercalcaemia Pagets Spondylothesis Scheuermann's disease Psoriatic Reactive IBD related Epidural abscess Osteomyelitis Diabetes Meningioma Mets Glioma Syrynx Pancreatitis, PUD, Depression, Hypercalcaemia
Cholestasis
Alcoholic hepatitis/cirrhosisDrugs - OCA, amytryptiline, chlorpromazine, gold
Biliary cirrhos
Viiral hepatitis
Cancers and mets
Extrahepatic: Bile duct cancer Pancreatic cancer Other cancer mets Cholangitis PSC Gallstones in common bile duct Pancreatitis Post surgery stricture/oedema
Charcot triad - fever upper abdominal pain + jaundice, acute cholecystitis
Epigastric pain
Acute pancreatitis Gastritis/duodenitis PUDBiliary colic Acute cholecystitis Basal pneumonia Oesophagitis AAA rupture Ascending cholangitis MI Mesenteric ischaemia Acute hepatitis Non ulcer dyspepsia Bowel obstruction Gastric cancer Pancreatic cancer Boerhaave perforation
Hyperlipidaemia
Hyper cholesterol:
Hypothyroid
Cholestasis
Nephrotic Drugs - thiazide, cyclosporin, carbamazepine
Hypertryglycerides: obesity, DM Cushing Alcohol renal failure
Drugs - oanzapine, steroids, oestrogen, SSRIPrimary familial hyperchoelsterolaemia
Anorexia - increased LDL
HCC - increased LDL
Hepatitis - increased VLDL
Odynophagia
GORD Oesophageal spasm Candidia HSV CMV Pill induced Cancer Achalasia
Peritonism
Acute:
Primary - splenectomy, cirrhosis, nephrotic syndrome
Secondary - Perforation - gallbladder, appendix, ulcer, diverticular, Crohn’s
Infection - appendix, abscess, pyosalpinx
Ischaemia - volvulus, mesenteric, ischaemia, strangulated hernia
Chemical - blood, bile
Chronic - infection (TB and candida), carcinomatosis, chemical (talc powder on gloves)
RUQ pain
Biliary colic Cholecystitis Duodenal ulcer Pancreatitis Basal pneumonia Ascending cholangitis Gastric ulcer Small bowel obstruction Appendix Hepatitis Pyelonephritis Ovarian pathology
MMSE
Orientation Registration Attention and calculation Recall Language
Dengue
Fever
haemorrhage
Low platelet
Leaky capillary - ascites, pleural effusion, low haematocrit 70%, low albumin
Tests - FBC, leukopenia, platelets, LFT (increased AST, ALT, low albumin), UEC
Parkinsonism
Parkinsons
CUD
Drugs - antipsychotics, metoclopramide, lithium, sodium valproate, manganese, tetraberazine
Neurodegenerative - levy body dementia, progressive supra nuclear palsy, impaired up and down gaze, cognitive impairment, bulbar symptoms
MSA - parkinsons, cerebellar, autonomicCorticobasilar degeneration - dystonia, myoclonus, alien limb + parkinsons
Anoxic, genetic, Fragile X, Huntington, Wilsons
Chronic Cough
Dry: GORD Postnatal drip Lung cancer COPD Drugs Interstitial lung disease Pulmonary oedema -CCF Pleurisy - RA/SLE Fibrosing alveoli's, penumoconious, sarcoid
Productive: Bronchiectasis TB COPD Lung cancer Congenital - CF, Kartagener Lung abscess Foreign body - late Extrinsic alveolitis
ASTHMA in both
SOB - minutes
Acute asthma Anaphylaxis Laryngeal oedema PE Pneumothorax AMI, mitral regurg Flash P oedema Croup Foreign body Epiglottitis Angina A stenosis Arrhythmia in HF Acidosis Uraemia
SOB - weeks - months
COPD Chronic asthma Heart failure Pulmonary fibrosis Pneumoconisis, sarcoid, allergic alveolitis Anaemia Bronchiectasis Decondition Pleural effusions Pul HTN Mesothelium Pulmonary TB Kyphoscoliosis MND Ankylosing Spondlyitis
Dysphasia
Fluent - input or receptive and comprehension
Wernickes - fluent, poor comprehension, poor repitiion
Conduction - good comp, poor repitition
Transcortical sensory - poor comprehension, good repetition
Non fluent - good comprehension, difficult articulation
Broca - good comp, poor reputation
Transcortical motor - good comprehension, good reputation
GLOBAL
Pleural effusion
Common: Pneumonia TB Pulmonary infarct Pluerisy, empyema Malignancy CCF Subphrenic abscess, pancreatitis
Uncommon: Lowered protein - nephrotic, liver failure --> lymphoma SLE, RA ARF Post MI syndrome Megs Asbestos Myxoedema Uraemia - failure kidney
Painful shoulder
Rotator cuff tendinopathy Frozen shoulder Subacromial bursitis Bicepital tendinitis Glenoid labral tears OA Polymalgia rheymatiuca Posterior dislocation Recurrent subluxation Neoplasia - pancoast and bone Referred - diaphragm, gallbladder Axillary vein thrombosis Gout/psuedo - rare Winged scapula Cervical spine Avascular necrosis and post fracture
Clipping bra/touching shoulder blade - internal rotation
Combing hair - external rotation - frozen shoulder
Pain at night - capsule or cuff
Fatigue
Depression/anxietyViral or post viral OSA Cardiac failure PUD Anaemia HIV/AIDSMalignancy Hypo/hyperthyroid Addison's DM Kidney failure Liver cirrhosis Respiratory - COPD/ashtma Neuro - Parkinsons, MS, Myasthenia Met - hypokalemia, magnesium, haemochormatosis Nutrient - coeliac Cushing SLE/RA Post infectious RRV Barmah
Syncope
Reflex - vasovagal, carotid sinus sensitivity, situational (urination, defaecation, cough)
Cardiac - Arrhythmia, outflow obstruction, aortic stenosis, HOCM, massive PE, AAA
Orthostatic - Dehydration, drugs, baroreceptor, anaemia dysfunction, Addison’s, Parkinson’s, Autonomic neuropathy
Cerebrovascular - vertebrobasilar insufficiency, subclavian steal
Non syncope - Head trauma, hypoglycaemia, Epilepsy, alcohol
Dizziness
Light headed - presyncope, hypoglycaemia, post concussive, anxiety, hyperventilation, addison’s
Loss of balance - ataxia, weakness, loss of joint sense, gait apraxia, visual
Movement and vertigo - see vertigo card + ear wax
AF causes - PIRATESHIV
Pulmonary - PE, COPD, pneumonia Idiopathic/ischaemia RHF Alcohol Thyrotoxicosis Endocarditis/cardiomyopathy Sick sinus HTN Ischaemic Valve disease
osteoporosis - SHATTERED
Steroid Hyperthyroid, hyperplasia, hypercalcaemia Alcohol and tobacco Thin <22 Testosterone low - antiandorgens Early menopause Renal/liver failure Erosion bone disorder - RA, myeloma Dietary ca low, Diabetes
Fx Heparin
FAILURE - heart failure causes
Forgot medications Arrhythmia/anaemia Ischaemia/infection Lifestyle - salt and fluid overload Upregulation of CO - pregnant, hyperthyroid, hypothyroid Renal failure Extras - PE/Endocarditis/Drugs (NSAIDs)
Ear pain
External ear - perichondritis, otitis externa (candida, aspergillus nigra, psuedomonas, staph aureus), furunculosis, trauma, neoplasia, zoster, viral myringitis, wax impacted
Middle ear - Eustacian tube dysfunction, barotrauma, AOM, chronic cholesteatoma, acute mastoiditis
Referred - Dental, TMJ, cervical spine, parotiditis, temporal arteritis, nodes
Other referred - pharyngeal, tonsillitis
Red flag - offensive discharge, downward displaced pinna, swelling behind hear, neuro (headache, drowsiness), older, unexplained, intractable ear pain, fever
Tonic Clonic Seizure
Generalisation of focal - tumour, infection, abscess, trauma, cerebrovascular (infarct, haemorrhage, AV malformations, cavernous hemangioma) Genetic Trauma Hydrocephalus Cerebral anoxia Drugs - penicillin, isoniazid, chloroquine, lidocaine, TCA, lithium Alcohol withdrawal Organophosphate Metabolic - hypoglycaemia/calcemia/natremia/magnesimia Liver and renal failure Meningitis Alzheimer's DM SSLE Eclampsia Epilepsy Hyperthermia
Bulbar and Pseudobulbar
Pseudo: Bilateral lacunar MND MS Vasculitis - cerebral High brainstem
Increased gag reflex or normal, spastic tongue, increased jaw jerk, speech is spastic dysarthria, labile emotions, Donald duck dysarthria involves V and VII
Bulbar: Kennedy Medullary MND, synringobulba Myasthenic GBS Polio Vasculitis Brainstem glioma Malignant Meningitis
Absent gag reflex, wasted and fasciculated tongue, absent or normal jaw jerk, normal emotion, limb fasciculation
Hearing loss
Conduction: Cerumen, osteomata, otitis externa, Eustachian tube dysfunction, congenital mental atresia, chronic otitis media, glue ear, perforated TM, otosclerosis, Pagets, cholesteatoma
Sensorineural: Trauma, viral infection, syphilis, TB, drugs, Menieres, congenital, cochlear otosclerosis
Mixed: Acoustic neuroma, cerebellopontine angle tumours, zoster, central, vestibular neuritis
Perilymph fistula –> after sapedcctomy + sudden onset deafness
Glomus tumour –> tinnitus, hearing loss as it grows
Acute painful joint
Articular: Trauma (fracture, haemarthrosis, meniscus) Gout Pseudogout Septic Seronegative 1st presentation of RA or OA Sarcoid Vasculitis SLE Rheumatic fever
Peri-articular Ligament Tendonitis Bursitis Fascitis Perioxtis
Non-articular: Nerve entrapment Radiculopathy Osteomyelitis Malignancy Leukaemia
Viral arthritis –> RRV, polyarthritis
Brain stem syndromes
Anterior cerebral peduncle: 3rd nerve palsy, contralateral increased UMN, contralateral hemiplegia
Claude: cerebral peduncle + red nucleus: ipsilateral 3rd contralateral cerebellar
Parinaude: Dorsal-midbrain-tectum: Vertical gaze palsy, convergence disorder, convergence retraction nystagmus, pupillary + lid disorder
Milard-Gubler: Pontomedullary junction –> ipsilateral 6th, ipsilateral 7th, contralateral hemiplegia
Wallenber - lateral medulla, ipsilateral 5th, 9th, 10th, 11th, ipsilateral horner’s, ipsilateral cerebellar, contralateral spinothalamic sensory loss, vestibular disturbance
Painful knee
Haemarthrosis - ACL, osteochondral fracture, dislocated subluxation of patella, capsule, peripheral medici
Synovial fluid effusion - ligament, meniscus
Bursitis
Chronic - patellofemoral pain syndrome, osteochondritis dessicans, degenerative meniscal, arthritis
Others: Osgood schlauer, patellar tendinopathy, anserine bursitis, prepatellar bursitis, infra patellar bursitis, quadriceps tendinopathy, ITB, hamstring knee, synovial plica syndrome / infra patellar fat pad
Dysarthria
Cerebellar - slurred, sing song, impaired timing
Bulbar - slurred, nasal, indistinct
Myopathy - indistinct, poor articulation
Myasthenic - indistinct with fatigue, dysphonia, fluctuating severity
Dystonic - strained, high pitch
Parkinson’s - soft, rapid, indistinct
Pseudobulbar - indistinct, mumbling, breathy
Vertigo
Peripheral:
Labryinth - labyrinthitis, menderes, BPPV, Drugs, trauma, ear wax, perilymph fistula, cholesteatoma, otosclerosis
8th nerve - vestibular neuritis, acoustic neuroma, drugs
Central:
Demyelination, migraine, posterior fossa mass (4th ventricle cerebellum), vertebobasilar insufficiency, visual-vestibular mismatch, seizure (complex/partial), temporal lobe ischaemia
Dyspepsia
Upper GI, PUD, Acute gastritis, gallstones, oesophageal malignancy, oesophageal spasm, IBS, non ulcer dyspepsia
Other: pancreatitis, colon cancer, chronic hepatitis, mets, acute loop, pancreatic cancer
Systemic - Renal, hyperglycaemia + oesophagitis + hiatus hernia
Drugs: NSAID, steroids, iron and potassium, digoxin
Other - alcohol, depression
Upper GIT malignancy - stomach, oesophagus, pancreas
Giardia
Chest pain (peripheral)
Peripheral - bronchospasm, PE, pneumonia, tacheitis, pneumothorax, malignancy, TB, CTD
MSK - OA, rib fracture, chostochondritis (TIetze’s syndrome), intercostal muscle, endemic myalgia (Borholm)
Neuro: Intervertebral disc, herpes zoster, thoracic outlet syndrome
GAITS
Extrapyramidal
Pyramidal - UMN (stroke, hemiplegia –> extend toe –> circumduct hip)
Foot drop
Myopathic - proximal weakness
Ataxic - cerebellum, vestibular, proprioception
+ vermis ; broad based
+ vestibular - normal walk + vertigo
+proprio - stamping
Apraxic - bilateral hemisphere (frontal lobe, hydrocephalus) - feet stuck to ground
Marche a petit pas - small vessel (LUD: show small steps + marked instability, lacks increased pace or freezing)
Headache
Primary: Tension, migraine, cluster, drugs –> medical overuse
Secondary - subdural, SAH, intracerebral Increased ICP: Tumour, idiopathic, intracranial HTN Infection - encephalitis, meningitis, brain abscess Inflammation - temporal arteritis, other vasculitis Central vein thrombosis Glaucoma TMJ, neck, sinusitis Eye strain Post trauma Dental Sleep apnoea Hypoglycaemia Cervical spondylosis ICE pick HTN Sex Exertion/cough Transformed migraine Anaemia
Chest pain - Central
Cardiac - MI, angina, unstable angina, myocarditis, pericarditis, mitral valve prolapse, AS
Oesophageal - oesophagi’s, spasm, Mallory Weiss
Massive PE
Mediastinal - rachitis, malignancy
AAA, dissection
PE Risk factors
EMBOLISM
Existing DVT, malignancy, baby, oestrogen, Large, Immune diseases, Surgery, Mobilisation
SOB - hours-days
Pneumonia Bronchitis Heart failure Pleural effusion Exacerbation of COPD Post operative atelectasis ARDS Lung collapse Myasthenia gravis GBS Hyperventilation DKA Pericardial tamponade Extrinsic allergic alveolitis
Cough - acute
Dry: Asthma Rhinitis/sinusitis with post nasal drip URTI ACE Foriegn body Lung cancer obstructs main bronchus Pulmonary oedema - CCF Atypical pneumonia (viral and mycoplasma) Whooping cough GORD Pleurisy Infants - dust, smoke, sarcoid
Productive: LRTI - bronchitis, pneumonia Bronchiectasis COPD + exacerbation TB Asthma Lung abscess
PUO
Infective - Abscess - diverticular, UTI, hepatobiliary, CNS, lungs, pelvic
Viral - IM, HIV, hepatitis, Q fever, CMV
Parasite - amoebasis, malaria, toxoplasmas,
Other - IE, brucella, rate bite fever, listeria, Biliary, lyme disease, typhoid, osteomyeletis
HIV - RJP, MAC, CMV, chronic septicaemia
Nosocomial - Surgery, prosthesis
More - Malaria, B psuedomallei, liver abscess, dengue –> imports
Malignant - Hodgkins, Cancer kidney, pancreas, GIT, lung mets, atrial myxoma
Inflammation - temporal arteritis, stills, SLE, RA, PAN, sarcoid, ARF
Undetermined - MI, drugs, PE, CVA
GIT - IBD, pancreatitis, hepatitis
Endo - Thyrotoxicosis/Thyroiditis, adrenal insufficiency, increased triglycerides
Haem - haemolytic anaemia, TTP, paroxysmal nocturnal haemoglobinurai, GV host
INVESTIGATIONS: FBC ESR Blood film LFT Urinanalysis MCS Blood culture CXR Abdo US Tubercillin test Serology - HIV, heterophilic ab, Q fever, CMV, hepatitis, ACE (sarcoid), EBV, Typhoid Collagen - ANA, RF, ANCA, Complement CT abdo chest Echocardiograpy Lower limb duplex Thyroid uptake BM aspirate, node biopsy, laparoscopy
HTN
Essential - 90-95%
Secondary
Kidney - GN, renal failure, kidney artery stenosis, other neuromuscular, DM, PCKD
Endo - Conn syndrome, phaochromocytoma, thyroid, cushing’s
OCP, NSAIds
Coarctation of aorta
Immune - PAN
Pregnant
Malabsorption
Coeliac
Tropical sprue
Lactose deficiency
Crohn’s
Whipples - 2 weeks ceftriaxone, 12 months cotrimoxazole/tetracycline
Giardia + other parasites
Lymphoma
Seronegative arthropathy
Pancreas - chronic pancreatitis, CF, tumour
Associations - IDA< T1DM, pernicious anaemia, PBC, sub fertility, thyroid, osteoporosis, Downs
Hip pain
Muscular strain
Referred from spina
OA –> antalgic gait, quad wasting + fixed flexion and ER
Mets - sarcoma, lymphoma, myeloma)
Osteoma
Septic arthritis
Osteomyelitis
Pelvic infections
Avascular necrosis - steroid, SLE, sickle cell, alcoholic at risk
Bursitis - greater trochanter, ischial, iliopsoas
Neurogenic claudication
Nerve entrapments - sciatic, obturator, lateral anterior nerve to thigh
Polymyalgia rheumatica
Fracture - stress fracture femoral neck, sacrum, [pubic rami, subcapital
Labrum, CAM + Gauz lesion
Sacroileitis / dysfunction
Osteitis pubis
Kids:
DOG - acetabulum dysplasia, O-bm - Pavlic harness - transient synovitis
Perthre - JIA
Slipped femoral epiphysis - hip lies in external rotation
Depression
Psychiatric - anxiety, schizophrenia (delusions and hallucinations), drug and alcohol abuse, dementia
Organic - malignancy (lung, pancreas), hypothyroid, hypoparathyroid, other endocrine (e.g. Cushing), anaemia (especially pernicious), past infections (EBM), CCF, SLE
Drugs - antihypertensives, benzodiazepines, steroids, NSAIDs, OCP, cytotoxins, antiparkinsons
Dysthymia
MDE
MDD
Knee Symptoms
Chronic - PFP, degenerative knee + meniscus, osteochonritis desicans
Locking - meniscus, loose body (retropatellar fragment) - osteochondritis desicans, ALL, articular cartilage, tibial spine, displaced patellar, synovial oesteochondromatosis
Pseudolocking - patella femoral dislocation, 1st/2nd medial ligament tear, ACL sparain, gross effusion, spasm hamstring, catching –> locking + sublimed patellar + loose body
Click - patellar/maltrack/sublux, loose body, meniscus
Anterior pain:
PFDS, OA, Patellar tendinopathy, osteonecrosis
Medial pain:
OA, medial meniscus, PFPS, MCL
Lateral
OA, lateral meniscus, PFPS, ITB, LCL
Lung nodules
Bronchial carcinoma Solitary met Granuloma Hamartoma Bronchial adenoma AUM Hydatid GUR Haematoma
Pigmented skin lesions
Non melanocytes: Pigmented/BCC Seborrhoiec keratosis Solar keratosis Dermatofibroma Pyogenic granuloma Foreign body granuloma Tinea nigra Becker navus
Melanocytic:
Non melanoma - freckles, lengiines, naevi (congenital, acquired), melanoma
Types of melanoma:
Lentigo, superficial spreading, nodular, acrolentiginous, desmoplastic
ARDS
Sepsis Shock Trauma Burns Multiple transfusion Drug overdose Obstetric Cx - eclampsia, AFE Pulmonmary aspiration Toxic gas Blast injury SARS pancreatitis
Expansion lowered, no heart failure, fine crackles, rib retraction, laboured breathing
Erythema nodosum
Sarcoid - commonest
Infection - strep, viral, TB, leprosy, chlamydia, infection, fungal
IBD
Drugs - sulphonurea, tetracycline, OCP, iodines
Malignancy - lymphoma, leukaemia
Pregnancy
MUST DO FBC, CXR, ESR
Erythema multiforme
Target lesion + mucosal ulcers
HSV
Mycoplasma
Parapoxivirus, VZV, Adenovirus, hepatitis, HIV, CMV, Viral vaccine
Drugs <10%
Hypoglycaemia
DM - drugs, insulin, sulphonurea Drugs - guanine, salicylates, pentamicheric Alcohol Fasting Tumours - insulinomas Addisons Hypopituitar Liver disease Post gastrectomy Gastric dumping disease Autoimmune - insulin, antibodies, receptor antibodies GH deficiency Epinephrine deficiency Post prandial
Critical illness - renal, liver, starvation, sepsis and organ failure
Weight loss
Psychological - stress, anxiety, anorexia, bulimia, dementia
Serious:
CCF
Malignancy
Chronic infection - HIV, TB, hidden abscess, IE, brucellosis
Malabsorption - parasites, coeliac, IBD, others, malabsorption
CKD, liver cirrhosis, gastric ulcer
CTD, chronic vomiting + diarrhoea
Addisons, hypopituitary, hyperthyroid
DM
Rashes
Maculopapular Measles Rubella Scarlet fever Viral exanthem Roxola infantum Priamry HIV Secondary syphilis Urticaria Erythema multiforme Drug RRV/Barmah
Maculopapular vesicular Varicella Herpes zoster and simplex Eczema herpeticum Impetigo hand food and mouth Drug
Purpura
Purpura
Vasculitis - PAN, HSP
Palpitations
Sinus tachycardia - emotion (anxiety), stress, fever, exercise
Atrial x ventricular ectopics - alcohol, caffeine, stress, smoking, thyroid
Drugs - codeine, beta agonist
PS VT - faster in onset and offset, higher rate than sinus achy
AF - PIRATE SHIV see other flash card, atrial flutter
Valve - aortic incompetence, mitral regurgitation, mitral stenosis (hyper dynamic state)
Rare: VT Sick sinus Anaemia Long QT Heart block Thyroid WPW Electrolyte - Hypokalaemia, hypermagnesaemia, hypoglycaemia Pregnancy Menopause Phaeochromocytoma
Lymphadenopathy
Malignant: Lymphoma - NHL, HL Leukemia - ALL (kids), AML Metastases - lungs, liver and GIT (supraclaviucular), breast, head and neck (anterior triangle) CT disease - SLE, RA Sarcoid Amyloid Phenytoin Infections: Viral - EBV, CMV, HIV, Rubella Bacterial - TB, syphilis, atypical TB, brucellosis, cat scratch protozoa - Toxoplasmosis
Epilepsy in kids
Febrile seizures
Infantile spasms - generalised tonic with flexion of arms, forward flexion of trunk and extension of legs - give ACTH
Lennox-Gastaut syndrome - triad - difficult to control seizure, mental retard, EEG
Benign volandic epilepsy - strong FHx, simple partial motor
Somatosensory –> occur during sleep –> gurgling mouth, males, unable to speak, rheumatoid contorsion
Childhood absence
Juvenile myoclonic epilepsy - head of myoclonic jerks tonic clonic absences, sodium valproate for treatment
Medial temporal lobe epilepsy - post ictal confusion and speech dysfunction
Hoarseness
Probability: URTI Post nasal drip Nonspecific irritative pharyngitis Vocal abuse Nodules of vocal cord Presbyphoria Acute tonsillitis GOR GOitre Physical trauma Fungus Allergy - laryngioedema Leukoplakia SLE Wegener's
Not to be missed:
Ca, airway obstruction (epiglottis and croup), TB, diphtheria, foreign body, MND, myasthenia
Kids - laryngomalacia, laryngeal stenosis, laryngeal paralysis, croup, tonsil, epligottis, pappiloedema
Sore throat
Viral pharyngitis - Severe (EBC, herpangina, HSV) milder (adeno, corona, entero, influenza, rhino, pincorna, varicella)
Bacterial - GABHS, haemophilus, moraxella, gonococcal, diphtheria, staph, sphyilis, vincent angina syndrome
Chronic sinusitis + post nasal drip
Candida
Neoplasic
Other infection - mycoplasma + chlamydia
Apthous ulcers
Severe infection - epiglottitis, quinsy, pharyngeal abscess
Blood dyscrasia - leukaemia, agranulocytosis
Reflux - pharyngiolaryngitis, irritants - smoke
Rare - scleroderma, becket’s, sarcoid, TB, malignant, granuloma
Bruising
Vascular
inherited - HHT, Marfan’s, Osler weber
Acquired - infection, purport simplex, HSP, steroid purport, scurvy
Coagulation
Inherited - haemophilia A and B, VWMB
Acquired - DIC, liver disease, vitamin K deficiency, warfarin and anticoags
Thrombocytopenia:
Inherited - Fanconi syndrome, anega karycyte thrombocytopaenia
Immune acquired - ITP, drug induced, TTP/HUS, post transfusion purport + megaloblastic anaemia
Functional platelet
Inherited - Glanzmann, Bernard-soulier, storage pool defieicny
Acquired - Drugs (NSAID, aspirin), uraemia, myeloproliferative, dysproteinaemias
Sterile pyuria
Recent UTI treated Glucocorticoid Acute febrile episode Cyclophosphamide Pregnancy Renal transplant rejection Genitourinary tract trauma Prostatitis and cystourethritis - STD, etc. Renal TB Genitourinary tract malignancy Presence of urinary catheter or recent use Urinary tract stones Pelvic irradiation PCKD Renal vein thrombosis ITN or analgesic nephropathy Papillary necrosis Interstitial cystitis SLE or kawasaki
PALM COIEN
Polyps Adenomyosis Leiomyomata Malignant and hyperplasia Coags Ovulation Iatrogenic Endometriosis Not yet classified
Breast changes
Nipple discharge Change in appearance Cylcic pain./ pain SKin changes Redness Skin tethering and puckering Tenderness Change in density L:ump Lymphon nodes Bone pain
DDX: Fibrocystic Fibroadenoma DCIS/LCIS Ductule/lobule cancers Abscess, mastitis, galactocele Papillary and Medullary
Ask about nulliparity, FmHx, early menarche, oestrogen/progesterone, radiation, personal history of cancer
Menorrhagia
Fibroids Adenomysis DUB Hypotyhyroidism PID Polyps Leukaemias ZBleeding disorders Prostalgandin excess Stress Liver and renal disease
Amenorrhea
Pregnancy Breast feeding Meno[pause Medications Stress, exercise, weight PCOS Thyroid Puituitary tumour uterine scarring Genital malformations Turner's Metabolic disturbance
Post menopausal bleeding
Cervical cancer Endometrial hyperplasia Uterine body cancer Urethral curuncle Atrophic vaginitis Polyps
Vaccination schedule
Birth - Hep B 2 months - Hep B-IPV, DTPA, 13vPCV, rotavirus 4 months same as above 6 months - same as above minus rotavirus 12 months - MMR + Men C - HIB 18 - MMRV + dtpa 4 years - dtpa and IPV year 7 - HPV, dTPA Year 10 - Men nonavalent
Otalgia
Primary: Infection Trauma + foreignbodies Impacted cerumen otological neoplasms
Secondary: Dental TMJ Trigeminal Head and neck cancer Eagle's Temporal arteritis
Red flags: Discharge Downward pinna Swelling Focal neuro Older Persistent fever
Red eye
Blephiritis Conjunctivitisd Keratitis Iritis Epislceritis Acute glaucoma
Back pain
Mehcanical Degenerative Fracture Malignancy Spinal Paget's Spondylothesis Scheumanns Psoriatric, reactive, IBD Epidural abscerss Osteomyelitis Depression Pancreatitis
Bleeding
Platelet disorders Leukaemia Anaemia Trauma Enlarged spleen liver failure Ethanol Toxins Sepsis
PLATETLS
DIC
Sepsis Trauma Obstetric Pancreatitis Malignancy Nephrotic snydromes Transfusion
STOP making new thrombi
CHADVASC
Congerstive HF HTN Age above 75 DM Stroke Age 65-75 Sex female
HASBLED
HTN Abnormal renal and liver Stroke Bleeding Labile INR Elderly over 65 Drugs or alcohol
Renal failure
Bleeding Hiccups Bone pain/back ache Diarrhoea Hypercalcemia Itching SOB Flkuid overload Metallic taste in mouth Nausea and vomiting
Anuria/urinary retention
BPH Cancers Stricture Stones Retroperitoneal fibrosis Bilateral renal infarction Conspitation LMH Cystocele, rectocele STI Cauda equina
Pain in groin
Hernia Bowel obstruction Epieidymitis STI Endometriosis Ectopic Mittelschermz Rupture of ovarian cyst Femoral artery aneurysm torsion Cancer
Tachycardia
Anemia Anxiety Dehydration Electrolyte imbalance (especially hypokalemia and hypomagnesemia) Fever/ sepsis Hyperthyroidism Hypoglycemia Ischemia Metabolic disorders Pain Poisoning and toxic exposure Pulmonary embolism Respiratory disease (e.g. pneumonia, pneumothroax) Shock Trauma Withdrawal syndromes
M spike
MGUS
Multiple myeloma
Waldenstrom Macroglobinemia
Unilateral limb swelling
Long standing venous disease (post thrombotic syndrome)
DVT
Lymphoedema
- Surgical excision of local lymph nodes
- Radiotherapy to local lymph nodes
- Tumour infiltrating the lymphatics
- Trauma
- Filiriasis
- Lymphoedema artifacta: patient tying a tourniquet around the limb
Extrinsic pressure (pregnancy, fibrosis, tumour)
Lipoedema
Klippel–Trénaunay syndrome
Disuse/hysterical edema
Bilateral limb swelling
Heart failure Liver failure/cirrhosis Renal failure Hypoproteinemia Hereditary angioedema