DDx Lists Flashcards
Peripheral Neuropathy
Metabolic
-Diabetes, Hypothyroid, uraemia
Drugs/toxins
-Chemo, nitrofurantoin, TB drugs, amiodarone, antiepileptics, ETOH
Nutritional
-B12, thiamine, vitamin E, manganese
FHx
-Charcot marie tooth, Fredrich’s ataxia
Immunological
-RA, SLE, vasculitis, Sjogrens, amyloid, sarcoid
Paraneoplasic
Infective
-Syphilis, HIV
Proximal myopathy
Broad range of underlying causes most commonly of which is:
- Drugs - Steroids, statins, colchicine, zidovudine - Alcohol
Others to consider: - Endocrine: Thyroid, osteomalacia, diabetic amyotrophy, Addisons - Connective tissue disease: SLE, RA, systemic sclerosis - Idiopathic inflammatory myopathies - Hereditary myopathies - Malignancy - Infections - HIV, Hepatitis Sarcoidosis
PR Bleeding
- Malignancy/pre-cancerous polyps
- Other anatomical: Haemorrhoids, Fissure, fistulae, varices, AVM
- Inflammatory bowel disease: UC, sometimes Crohns
- Infective - c diff, CMV, diverticulitis or parasitic (**immunodeficient population)
Bleeding tendency: Coagulopathy, thrombocytopaenia, medications
Male infertility
• Previous undescended testes (uncorrected)
• Erectile/Ejaculatory dysfunction
• Azo/oligoospermia: CF, pituitary
Ix: Semen anaylsis, post ejaculatory urinalysis
Female infertility
• Infrequent/No ovulation
○ Ovarian pathology: PCOS, chemotherapy/radiotherapy
○ HPA axis pathology: pituitary dysfunction, Cushings, CAH, prolactinoma/hyperprolactinaemia, premature ovarian failure
○ Other endocrine: hypothryoid/hyperthyroid
• Anatomical: PID with adhesions, Karyotype abnormalities, Ashermans
• Recurrent miscarriages (genetics, anatomical eg fibroid, thrombophilias, cigarettes/EtOH/cocaine, obesity, infection)
• Lifestyle/psychological factors: eating disorders, stress, over-exercise
Medications
Female infertility Ix
• bHCG, TSH, Prolactin
• Pelvic US (+/- Karyotype)
• FSH, E2
○ If High FSH/Low E2 –> primary ovarian insufficiency (*think ovarian injury)
○ If Low FHS/Low E2 –> central causes e.g. GnRH deficiency, hypopituitary
○ If Normal FSH/Normal-low E2 –> PCOS, CAH, Cushings
§ Androgen profile, DHEAS, 17-OHP, cortisol, adrenal imaging
Hysterosalpingography or laparoscopy for tubal patency
Secondary HTN
Consider it when a person is <40 years old or on 4 agents or have HTN with hypokalemia.
Always consider end organ damage (eyes, kidney, heart).
Work up:
- Endocrine
○ Thyroid dysfunction- TFTs
○ Primary hyperaldosteronism -Aldo/Renin ratio
○ Cushings - overnight dexamethasone suppression test
○ Pheao: plasma catecholamines
- Other
○ Renal artery stenosis: Renal doppler
Cardiac causes: TTE
Diarrhea
- Infective - c diff, CMV, diverticulitis or parasitic (**immunodeficient population)
- Inflammatory bowel disease, microscopic colitis
- Malabsorptive: Coeliac, Pancreatic insufficiency/obstruction
- Hypermotility: Hyperthyroid, carcinoid, VIPoma, neuro drugs
- IBS
- Drugs (metformin, colchicine, Mg, MMF, CNIs esp tac)
Special circumstances probably evident on history: a. Antibiotic related or Post-antibiotic b. Short gut SND c. Dumping SND d. NSAID enteropathy e. Radiation f. Overflow g. SIBO h. Chemotherapy i. Radiotherapy j. Laxative overuse Rectal cancer with tenesmus
Chronic Nausea DDx
Approach is to consider the many potential causes, categorise as drug-induced, alcohol, gastrointestinal, occult malignancy and neurological and Endo
- Drug-induced: chemotherapy, antibiotics, NSAIDs, metformin, MMF, opiates
- Alcohol and other illicit drugs (THC)
- GORD, functional dyspepsia, gastroparesis, GI obstruction, coeliac, gastric or small bowel Chrones
- Occult malignancy: associated features or B symptoms
- Increased ICP, migraine, vestibular such as vertigo
- Uraemia, hypothyroid, hyperthyroid, Addison’s
Vomiting
- GI
a. Gastritis/PUD
b. Gastric outlet obstruction
c. Gastroparesis
d. Cholecystitis
e. Pancreatitis
f. Gastroenteritis
g. Constipation- Neurological
a. Meningitis
b. Raised ICP: Mass, mets - Drugs
a. Chemo
b. Marijuana
- Neurological
GAstric outlet obstruction
i. Neoplastic: Gastric cancer, lymphoma, pancreatic cancer with extension
ii. Inflammatory - duodenal stricture from pancreatitis, PUD
iii. Infiltrative: Crohn’s, gastric TB, eosinophilic gastritis
Iatrogenic: Complications of surgery
Dysphagia
• Intrinsic: reflux oesophagitis, stricture, oesophageal cancer, pharyngeal pouch, Schatzki ring, foreign body
• Xerostomia: drugs, Sjogrens, elderly, thrush
• Extrinsic: goitre with retrosternal extension, mediastinal tumor, bronchocarcinoma
• Motility: achalasia, diffuse oesophageal spasm, Scleroderma
• Neuro: bulbar and pseudobulbar palsy, myasthenia gravis, polymyositis, myotonic dystrophy
Psychiatric (globus pharyngus)
Constipation
- Dietary and lifestyle
○ Change in diet
○ Poor fluid/fibre intake
○ Immobility
- Local
○ Anal pathology: Anal fissure, hemorrhoids
○ Slow transit
○ Malignancy
- Endocrine
○ Hypothyroid
○ Hypercalcemia
- Drug induced
Constipating drugs: Ondansetron, opioidsMonoarthritis
DDx
- Septic arthritis - Crystal arthropathy - OA - Inflammatory causes: SLE, RA, PsA, Reactive arthritis - Haemarthrosis - Non joint related pathology: Bursitis, tendonitis, enthesitis, referred pain
Work Up: - Bloods ○ WCC, CRP, ESR ○ FBE ○ INR ○ Serum uric acid level ○ If they have an autoimmune disorder: markers of disease activity - Imaging/Interventional ○ XR ○ USS ○ Aspiration: Fluid appearance, MCS, crystals, cell counts
Mx
- Dependent on cause
- Simple analgesia with NSAIDs
Steroids PO/intraarticular if indicated
Polyarthritis
Septic arthritis, important to consider if bacteremia or immunosuppressed
Other infections: viral (EBV, rubella, mumps), rheumatic fever, Q fever
Inflammatory or autoimmune: • Reactive RA • OA • Lupus • UC/CD • Seroneg SpA • Polyarticular gout (uncommon) • Polyarticular pseudogout (uncommon)
Autoinflammatory
• Stills disease
• FMF
Drug reaction
Investigation:
• inflammatory markers
• Antibodies (RF, anti-CCP, dsDNA)
• Urate level
• Viral serologies + (Q fever serology, ASOT titre)
• Esophinilipa (may suggest drug reaction)
• Joint IMAGING +/- aspiration (if concerned for gout or septic arthritis)
Mgmt: • Aetiology based • Control pain • Maintain or maximise joint function MTX is generally useful for autoimmune conditions involving joints
Syncope
DDx - Cardiac/Cardiopulmonary ○ Arrhythmia ○ Valvular heart disease: AS ○ HOCM ○ PE - Autonomic ○ Vasovagal ○ Autonomic neuropathy: Diabetes, MS, MSA, Parkinson's - Drugs ○ Antihypertensives ○ Antipsychotics - Hypovolemia ○ Hemorrhage ○ Dehydration ○ Sepsis - Neurological ○ Vascular event ○ Seizure - Lifestyle ○ ETOH
Ix
- Bystander collateral Hx - Postural BP - ECG - Consider 24 hour holter - TTE - V/Q or CTPA - MRI B, CTA - EEG
Mx
- Dependent on cause
Consider risk with driving
Secondary Amenorrhea
Secondary Amenorrhea defined as no menstruation for 3 months
DDx - Endocrine ○ Pregnancy ○ Normal menopause ○ Premature ovarian failure ○ PCOS ○ Hyperprolactinemia ○ Thyrotoxicosis - External Factors ○ Anorexia ○ Low weight ○ Extreme exercise ○ Poor nutrition
Ix
- Beta HCG
- Sexual Hormone profile: FSH, LH, Testosterone, sex binding hormone level, prolactin level
- TFTs
- Pelvic USS: for PCOS
Consider MRI B for pituitary adenoma in hyperprolactinemia
Menorrhagia
DDx - Structural ○ Fibroids ○ Endometrial cancer ○ Pelvic endometriosis ○ Chronic PID - Bleeding predisposition ○ Haemophilia ○ Thrombocytopenia - Endocrine ○ Hypothyroid - Drugs ○ Copper IUD ○ Anticoagulation
Ix - Bloods: ○ FBE, Coags ○ TFTs - Imaging ○ Pelvic USS/MRI - Surgical ○ Hysteroscopy +/- Biopsy
Mx
- Treat underlying cause
- Tranexamic acid
- Consider GnRH antagonist for fibroids
OCP for endometriosis
Surgical intervention: myomectomy, removal endometrial deposits, hysterectomy
WEight Loss
DDX - Malignancy - GI disease ○ Dysphagia ○ IBD ○ Malabsorption ○ Food intolerance ○ Diarrhea - Endocrine ○ Hyperthyroid ○ Uncontrolled T1DM ○ Addisons - Infection ○ TB ○ HIV ○ Subacute IE - Mechanical (Physical barrier to getting food in) ○ Stroke ○ Dementia ○ Scleroderma - ETOH excess - Psychiatric illness ○ Depression ○ Anorexia
Weight Gain
DDx - Lifestyle ○ Excessive caloric intake ○ Reduced activity - Drugs ○ Steroids ○ Insulin ○ Some OHGs ○ Estrogens - Endocrine ○ Hypothyroid ○ Cushings ○ PCOS - Fluid retention ○ CCF ○ Nephrotic Syndrome ○ Cirrhosis ○ CKD Pregnancy
Headaches
DDx - Acute ○ Meningitis ○ SAH/ICH ○ Venous sinus thrombosis ○ Post LP headache ○ Acute closed angle glaucoma ○ Sinusitis ○ Tension ○ Migraine - Subacute ○ Raised ICP: Tumor, hydrocephalous, IIH ○ Encephalitis ○ GCA - Chronic/Recurrent ○ Migraine ○ Tension ○ Cluster ○ Trigeminal neuralgia ○ Cervical root headache ○ Eye strain Drug side effect or withdrawal
Fatigue
DDx - Sleep ○ Poor sleep/sleep hygiene ○ Narcolepsy ○ OSA ○ Restless legs Syndrome - Psychiatric ○ Depression - Haeme ○ Anaemia ○ Iron deficiency - Infection ○ Chronic infection: HIV ○ TB ○ Post viral fatigue - Chronic Disease ○ CKD ○ CCF ○ Hypothyroid ○ Diabetes ○ Autoimmune disorders: SLE, RA, Scleroderma ○ HIV - Drugs ○ Opioids ○ Antiepileptics ○ Sedating meds Diuretics: Overdiuresis
Tremor
DDX - Essential - Thyrotoxicosis - Anxiety - Neurological ○ Cerebellar disease: MS, stroke ○ Parkinsonism - Flapping tremor ○ Hepatic failure ○ Renal failure: Uremia ○ Hypercapnia - Drugs ○ Thyroxine ○ Salbutamol ○ ETOH withdrawal ○ Tacrolimus, ciclosporin ○ Antiepileptics ○ Antipsychotics Lithium toxicity
Vertigo
DDx Peripheral CAuse -BPPV -Vestibular neuritis -Herpes zoster oticus -Meniere disease -Acoustic neuroma -Otitis media
Central
- Vestibular migraine
- Brainstem ischemia
- Cerebellar infarction and hemorrhage
- MS
- Chiari malformation
- IF CVS risk factors, definitely think central cause
- Hearing loss associated with vertigo suggests peripheral cause
- Vertical nystagmus suggests central cause
- Nystagmus disappearing with a fixed gaze in peripheral
Mx - Symptomatic management ○ Short course of betahistine § SE: drowsy, dry mouth - Lifestyle: ○ Avoid ETOH and coffee PT referral for vestibular rehab and balance stabilization exercises
B12/folate deficiency
Causes of B12/Folate deficiency
- Poor oral intake (ETOH, strict vegan or low protein diet) - Malabsorption (Coeliac, tropical sprue, crohns) - Previous gastric surgery - SIBO - Pernicious anaemia
Drug causes of a megaloblastic anaemia
- MTX
- Trimethoprim
- Metformin
Colchicine
