Core presentation differentials Flashcards
Acute Confusional State (ACS) Differentials
D rugs E yes/Ears and Endocrine L ow O2 I ctal R estraints/Retention I nfections U ndernutrition M etabolic S troke/Subdural/Sleep deprivation
Acute Confusional State (ACS) Drug Causes
D opamine agonists R ecreational O piates A nticonvulsants A ntidepressants A nticholinergics N euroleptics S edatives
Acute Confusional State (ACS) Hypoxic Causes
AMI, ARDS, PE, CHF, COPD
Acute Confusional State (ACS) Endocrine Causes
Hyperthyroid, hypothyroid, Addison’s disease, diabetic pre-coma, hypoglycaemia
Acute Confusional State (ACS) Infective Causes
Systemic-Pneumonia, UTI, wounds, IV lines
Intracranial- Meningitis, encephalitis, cerebral abscess
Acute Confusional State (ACS) Metabolic Causes
Electrolyte disturbances (eg. severe hyponatraemia, acute hypercalcaemia); hepatic, renal, cardiac or respiratory failure; hypoxia, hypercapnia, anaemia
Acute Confusional State (ACS) Nutritional Causes
Thiamine, nicotinic acid, B12 deficiency
Acute Confusional State (ACS) Intracerebral Vascular Causes
Stroke, MI; brain haemorrhage (subdural, extradural, intracerebral, subarachnoid), venous sinus thrombosis
Acute Confusional State (ACS) Eight Assessable Signs
All acute onset D isordered thinking E uphoria, fearful, angry or depressed L anguage impaired I llusions/delusions/hallucinations R eversal of sleep-wake cycle I nattention U naware/disoriented M emory deficit
Acute Confusional State (ACS) Examination
General Observation + Vitals (signs of sepsis, cardiac/resp failure)
MMSE - abbreviated: [10 points,
Acute Confusional State (ACS) Investigations
Driven by history and examination.
Standard: Blood Glucose, Electrolytes, FBE, ABG, Urine M/C/S, CXR, ECG
Specific: Brain imaging, EEG, Septic source, Endocrine function, Plasma drug concentrations
Altered Bowel Habit Differentials
CD CD MIG
Change in diet Drug induced Cerebral/spinal cord lesion Depression Metabolic Immobility / Infection Gastrointestinal
Altered Bowel Habit Gastrointestinal Causes
Ask: context blood, pain on defecation/relief on defecation/effect of food/weight loss/pallor
Carcinoma of colon and rectum, Irritable Bowel Syndrome (IBS), Diverticular disease, Inflammatory Bowel Disease (UC, Chron’s), rectal dyschezia, irritable colon
Altered Bowel Habit Drug Causes
Ask recent drug history
Constipating drugs (opiods, hypotensive agents, aluminium alkalis), purgative dependence, antibiotics (change in colonic bacterial flora)
Altered Bowel Habit Metabolic Causes
Ask Heat/cold intolerance, change in appetite, lump in neck; moans, stones, groans, polyuria, polydipsia; palpitations
Hypothyroidism, hyperthyroidism, hypercalcaemia, hypokalaemia
Altered Bowel Habit Examinations
Abdominal Exam, DRE
Altered bowel habit Neurological Causes
Ask Neurological symptoms (parasthesia/dysasthesia) +/-abnormal sphincter tone and anal sensation
MS, Spinal Cord Lesion, Cerebral lesion
Altered bowel habit Investigations
Standard: Stool inspection, proctoscopy, sigmoidoscopy; FBE, UEC, LFTs; Abdo Xray and CT
Specific: Colonoscopy with biopsy, barium enema, CT/MRI CNS, thyroid function tests, serum Ca, K, etc.
Acute Abdomen Differentials
SAUCED HIPPO S trangulation of Bowel A ppendicitis U lcer perforation C holangitis E ctopic pregnancy D iverticulitis
H aemorrhage I schaemia (mesenteric, splenic) P ancreatitis P elvic inflammatory disease O bstruction
Abdominal Pain: RLQ
APPENDICITIS
A ppendicitis / Abscess P ID/Period P ancreatitis E ctopic/Endometriosis N eoplasia D iverticulitis I ntussusception C hron's Disease/Cyst I BD T orsion (ovarian) I rritable Bowel Syndrome S tones
Abdominal Pain: RUQ
HD CRAAP
H epatitis
D uodenal ulcer
C ongestive hepatomegaly R ight pneumonia A cute cholecystitis A ppendicitis P yelonephritis
Abdominal Pain: LUQ
GRAPPL
G astric ulcer/Gastritis R uptured spleen A ortic aneurysm P erforated colon P yelonephritis L eft pneumonia
Abdominal Pain: Periumbilical
MA, IDEA!
M esenteric thrombosis
A ortic aneurysm
I ntestinal obstruction
D iverticulitis
E arly appendicitis
A cute pancreatitis
Abdominal Pain: Lower Midline
EPICC FOAM
E ndometriosis P ID I BS C ancer (uterine) C ystitis
F ibroids
O varian cancer
A ortic aneurysm
M enstrual pain
Abdominal Pain: LLQ
CT PRESSUReS
Crohn’s
Tubo-ovarian abscess
Perforated colon Renal/ureteric stone Endometriosis Sigmoid diverticulitis Salpingitis Ulcerative Colitis Ruptured Ectopic Strangulated hernia
Abdominal Pain: History Questions
Nature of Pain (site (+ radiation), severity, quality, time course (onset, constancy), context, aggravating/relieving factors)
–Effect of respiration, food, movement, micturition, menstruation, defecation
Vomiting: onset, frequency, content
Change in Defecation: constipation/diarrhoea- onset, frequency, content
Infection: Fever, rigors, Immunisations, Contacts, Travel, Occupation, Animals, Drugs, Sexual contacts
Constipation: Distension
Cancer/Chronic infections: Systemic symptoms (weight loss, tiredness, anorexia, night sweats)
PMHx: previous surgery, recent trauma, menstrual history
Abdominal Pain: Examination
Vitals (raised pulse and temperature in inflammatory conditions)
Chest Examination
Abdominal, Rectal and Vaginal Examinations
Abdominal Pain: Investigations
Standard: FBE, UEC, LFTs, serum amylase/lipase, MSU, CXR, AXR, US
Specific: ECG, BSL, serum calcium, betaHCG, IVU, gastrograffin enema, angiography, CT
Microcytic Anaemia: DDx
Find Those Small, Plump Cells
Fe deficiency Thalassaemia Sideroblastic anaemia Pb poisoning Chronic disease
Microcytic Anaemia: History Questions
Blood loss: Menstrual history, PR bleed
Iron deficiency: PUD - malaena, reflux, poor diet
Thalassaemia: FHx, Mediterranean origin
PMHx: Chronic disease
Microcytic Anaemia: Investigations
Standard: FBE (thalassaemia has much lower MCV), film, iron studies (serum Fe, Ferritin, Total Iron Binding Capacity)
Specific: Hb electrophoresis
Macrocytic Anaemia: DDx
FAT Dumb RBC
Foetal
Alcohol
Thyroid (Hypothyroid)
Drug (AZT, cytotoxic, phenytoin, barbituates)/Dysplasia
Reticulocytosis
B12/folate deficiency
Cirrhosis and Chronic liver disease
Macrocytic Anaemia: History
Med Hx: Autoimmune disease eg. primary hypothyroidism, vitiligo, etc; Malabsorption, surgery
Dietary history (including alcohol)
Pregnancy, lactation
Drugs: Phenytoin, barbiturates, methotrexate
Symptoms of liver disease, hypothyroidsm and haemolysis (jaundice?)
Macrocytic Anaemia: Investigations
Standard: FBE, film, serum B12 and folate
Specific: Intrinsic factor antibody, TFTs, Urine-urobilinogen, Bone marrow biopsy
Normocytic Anaemia: DDx
Anaemia of chronic disease (eg. rhematoid arthritis, hypogonadism, etc) Chronic renal failure Anaemia of pregnancy Hypothyroidism Haemolysis Bone marrow failure
Normocytic Anaemia: History
Med Hx of chronic disease, renal failure
Uraemic symptoms (fatigue, weight loss, tremors, muscle wasting)
Pregnancy
Symptoms of hypothyroidism (reduced appetite, weight gain, puffy eyes, constipation, etc), haemolysis, pancytopaenia (bruises, infections, etc)
Normocytic anaemia: Investigations
FBE, UEC, iron, B12, folate, TFTs, bone marrow biopsy
Anorectal Pain: DDx
Acute: thrombosed hemorrhoids, perianal hematoma, anal fissure, perianal abscess, trauma, anorectal gonorrhea, herpes
Chronic: proctalgia fugax, hemorrhoids, anorectal malignancy, rectal ulcer, anal fistula, chronic perianal sepsis
Anorectal Pain: History
Pain (time course (onset, duration), context, aggravating/relieving factors, associated features (defecation, tenesmus, blood, itching, discharge, spasms, abdominal pain, diarrhea)) Any changes in bowel habit, fever, weight loss PMHx: hemorrhoids, trauma Sexual Hx (anal sexual exposure)
Anorectal Pain: Examination
Rectal Examination (external examination including buttocks; digital rectal examination)
Anorectal Pain: Investigations
Standard: FBE, proctoscopy (swab), sigmoidoscopy
Specific: endo-anal US, MRI
Arthritis: DDx
Monoarthritis: septic arthritis, trauma, crystal arthropathies (gout/pseudogout), osteoarthritis, monoarticular presentation of a polyarticular disease (e.g. RA), psoriatic and reactive arthritides
Polyarthritis: viruses, RA, OA, spondyloarthritides (seronegative), connective tissue diseases (e.g. SLE), crystal arthropathies, post-streptococcal reactive arthritis
Arthritis: Hx
Site, severity, quality, time course (onset, duration), context, aggravating/relieving factors
Associated features (swelling, weakness, instability, neurological symptoms (numbness/tingling), deformity, stiffness)
Systemic symptoms (fever, eye or skin involvement, lungs, kidneys (dysuria), heart, GI (mouth ulcers, bloody diarrhea, CNS))
PMHx: recent trauma, infection, OA, past trauma, RA, gout
Drugs: pain medications (past/present), side effects or concerns
Arthritis: Investigations
Standard: FBE, RF, XR
Specific: blood culture, joint aspiration, arthroscopy, CT/MRI, serum uric acid, CXR
Back Pain: DDx
DISK MASS
D egeneration (DJD, osteoporosis, spondylosis) and Drugs
I nfection/Injury
S pondylitis
K idney
M ultiple Myeloma and other neoplasms/Metabolic
A bdominal pain/Aneurysm
S kin (HSV)/Strain/Scoliosis and lordosis
S lipped disk/Spondylolisthesis
Back Pain: Neoplastic causes
Mets from breast, prostate, bronchus, kidney, thryoid, colon
Direct invasion from oesophagus, myeloma, leukaemia, lymphoma, meningioma, glioma, lipoma, neurofibroma, osteoblastoma, hamangioma and osteoid osteoma
Back pain: Drug Causes
Steroids, methysergide
Back pain: Metabolic Causes
osteoporosis, osteomalacia, Paget’s, hypre and hypoparathyroidism
Back pain: Hx Questions
Pain (site (+ radiation + localisation, underlying bone pathology or malignancy), severity, quality, time course (onset, constancy), context, aggravating/relieving factors, pattern of pain)
Fever, rigors, night sweats
Age of patient!!!
Systemic symptoms (weight loss, tiredness, anorexia, night sweats)
Urinary symptoms and changes in defecation
PMHx: previous surgery, recent trauma, malignancy
Meds: corticosteroids
Back pain: Examination
Vitals (raised pulse and temperature in inflammatory conditions)
Spine:
Fixed deformities eg kyphosis
Spinal tilt/scoliosis
Haematoma
Neuro: • Peripheral neuropathy • Cauda equina • Loss of knee jerk (L3,4) • Loss of big toe extension (L5) • Upgoing plantars • Test sensation in saddle area S3-5 Signs of steroid use ie. Cushingnoid facies
Cardio - Look for aortic aneurysm/dissection
GI: • Signs of pancreatitis • Tenderness under right costal margin • Polycystic kidneys • DRE
Back pain: investigations
Standard: FBE, UEC, LFTs (ALP), serum amylase/lipase, ESR, CRP, spinal XR, calcium, PTH
Specific: PSA, CT abdomen, pelvis, CXR, breast US, BMD-DEXA, Bence Jones protein, bHCG, MRI if spinal compression suspected, Vit D, HLA-B27 testing, blood cultures, blood film, KUB, gastroscopy for IBD, lumbar puncture.
