Differential diagnosis and mini-cases : Sore throat, SoB, Chest Pain, Palpitations, Weight gain, Weigh loss, Dysphagia, Neck mass Flashcards
1
Q
Sore throat - key history ?
A
- Description of CC;
- Onset;
- Fever, infection symptoms;
- Other ENT symptoms - ear pain, sinus congestion, runny nose;
- Pain, its intensity & radiation;
- Odynophagia - pain on swallowing;
- Dysphagia - difficulty swallowing;
- Swollen glands ? Cough ? Rash ? Fatigue ?
- ROS => CRUGS;
- Sick contacts, travel;
2
Q
Sore throat - key physical exam ?
A
- Vital signs;
- ENT exam - oral thrush ? tonsillar exudate ? lymphadenopathy ?
- Lung exam;
- Abdominal exam - splenomegaly !
- Skin exam;
3
Q
What is your differential diagnosis and workup ?
“26 yo F presents with sore throat, fever, severe fa- tigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms”
A
- Differential diagnosis :
- Infectious mononucleosis
- Hepatitis
- Viral/bacterial pharyngitis
- Acute HIV infection
- Secondary syphilis
- Toxoplasmosis
- Cytomegalovirus infection
- Workup :
- CBC with differential
- Monospot test
- Throat culture
- AST, ALT, bilirubin, alkaline phosphatase
- HIV antibody and viral load
- CRP, ESR
- Abdominal US
- Acute hepatits serology
- VDRL/RPR
- Anti-EBV antibodies
4
Q
What is your differential diagnosis and workup ?
“26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles”
A
- Differential diagnosis :
- Acute retroviral disease (HIV)
- Infectious mononucleosis
- Viral/bacterial pharyngitis
- Hepatitis
- Secondary syphilis
- Workup :
- CBC with peripheral smear
- HIV antibody and viral load
- CD4 count
- Monospot test
- Throat culture
- VDRL/RPR
- AST/ALT/bilirubin/alkaline phosphatase
5
Q
What is your differential diagnosis and workup ?
“46 yo F presents with fever and sore throat”
A
- Differential diagnosis ?
- Pharyngitis (bacterial or viral)
- Mycoplasma pneumonia
- Acute HIV infection
- Infectious mononucleosis
- Workup :
- Throat swab for culture and rapid streptococcal antigen
- Monospot test CBC
- Serologic test (cold agglutinin titer) for Mycoplasma
- HIV antibody and viral load
6
Q
Cough / SoB - key history ?
A
- Acute/subacute vs. chronic ?
- Increased frequency of cough if chronic !
- Timing ?
- Presence/description of sputum ?
- Presence of hemoptysis ?
- Associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn);
- Exacerbating and alleviating factors, exposures;
- Smoking history ?
- History of lung disease, posttussive emesis, or heart failure ?
- Allergies ?
- Medications (especially ACE inhibitors) ?
7
Q
Cough / SoB - physical examination ?
A
- Vital signs ± pulse oximetry;
- HEENT/Neck :
- oropharynx : erythema, exudate, postnasal drip;
- nasal mucosa : edema, polyps;
- sinus tenderness;
- cervical lymphadenopathy;
- Cardiac : auscultate for murmurs, gallops, rubs;
- Lungs :
- Inspection : chest wall abnormalities, accessory muscle use;
- Auscultation : decreased or abnormal breath sounds, wheezing;
- Signs of consolidation : dullness, egophony, increased fremitus;
- Abdomen : upper abdominal tenderness - GERD;
- Extremities : peripheral edema, cyanosis, clubbing;
8
Q
What questions should you ask to a patient presenting with chronic cough ?
A
- Could you please describe your cough for me ?
- When did your cough start ? (onset)
- Is it a dry cough or does it bring up sputum ?
- What color is this sputum ? How much sputum do you typicaly cough up (teaspoon, tablespoon)
- Have you ever noticed blood in the sputum ?
- Have you ever noticed that something triggers your cough ? Have you ever noticed factors that make the cough become lesser/go away ?
- Is there anything that makes it better/worse ?
- Have you noticed that something flows in the back of your throat ? / Does mucus drip in the bach of your throat ?
- Do you ever get short of breath ?
- Have you noticed wheezing ?
- Have you noticed fever ? chills ? night sweats ? weight loss ?
- Have you noticed any swollen glands ? on your neck ? around your ears ? elsewhere ?
- Do you sometimes have heartburn ? acid reflux ?
- Do you have a history of heart problems ?
- Have you nocites any swelling in your feet
- Have you ever had chest pain ?
- On how many pillows do you sleep at night ?
- Have you ever woken up being short of breath ? coughing or choking ?
- Do you get short of breath when you lie down ?
- Have you ever had lung or heart problems in the past ?
- Do you have problems with allergies ? egzema ? rhinitis ? red eyes ? Did you have these problems in the past ?
- Do you have HTN ? What medications do you take for that ? (look for ACEI !)
- Is there anyone in your family with asthma ?
- What kind of work do you do ?
- Do you have smoking hx ?
- Have you traveled outside US recently ?
9
Q
What workup do you have to consider in a patient presenting with chronic cough ?
A
- Lung tests :
- Structural : CXR, CT scan
- Functional : pulmonary function tests, arterial blood gas analysis
- Arterial blood gas analysis
- ECG, echocardiogram
- Esophagram
10
Q
What questions will you ask a patient with dyspnea ?
A
- Tell me about your problem with breathing.
- How long has this shortness of breath been going on?
- Do you have a history of cardiac problems?
- Do you smoke?
- What is your occupation?
- Have you had a recent period of prolonged immobilization?
- Do you have a history of cancer or lower extremity weakness?
- Are you taking birth control pills or estrogen?
- Do you have diabetes, high blood pressure, high cholesterol, or heart disease?
- Has anyone in your immediate family had a serious heart condition? At what age?
- Have you had unintentional weight loss, night sweats, or fatigue?
- Do you have any other medical problems?
- Have you traveled in the past year? Have you travelled to foreign countries ?
- Do you have any known allergies to foods, insects, or latex ?
- Have you been taking your prescribed medications, and in the proper doses?
- Have you recently started taking any new medications (eg, β-lactam antibiotics, angiotensin-converting enzyme inhibitors)?
- Is your chest tight, or does it take an increased amount of effort to breathe?
- Do you feel that your breathing is rapid and/or shallow?
- Does your breathing only get heavy with activity?
- Do you feel as if your throat is closing or that air can’t get all of the way in to your lungs?
- Do you have shortness of breath when lying flat?
- Does lying on one side or the other cause increasing shortness of breath?
- Can you exercise for some time before getting short of breath?
- Do you have chest pain?
- Do you have any itching or hives? Are your lips or tongue swelling?
- Have you had a fever?
- Have you been coughing?
- Do you have swelling in your legs or abdomen?
- Have you lost weight?
- Have you had fainting spells?
- Do you have rashes or joint pains?
- Do you have weakness in your arms or legs or difficulty speaking or swallowing?
- Do you have any numbness or tingling in your fingertips?
- Did you feel a sense of impending doom or extreme fear?
11
Q
What is your differential diagnosis and workup ?
“30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months”
A
- Differential diagnosis
- Asthma
- GERD
- Bronchitis
- Pneumonitis
- Foreign body
- Workup
- CBC
- CXR
- Peak flow measurement
- PFTs
- Methacholine challenge test
12
Q
What is your differential diagnosis and workup ?
“56 yo F presents with shortness of breath and a pro- ductive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker”
A
- Differential diagnosis :
- COPD / Chronic bronchitis
- Bronchiectasis
- Lung cancer
- Tuberculosis
- Workup
- Chest XR or Chest CT
- Pulmonary function tests - PFTs
- Arterial blood gasometry
- CBC with differential
- Sputum examination - cytology and gram stain, culture
- PPD
13
Q
What is your differential diagnosis and workup plan ?
“58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD”
A
- Differential diagnosis :
- Pneumonia
- COPD exaccerbation
- Lung abcess
- Tuberculosis
- Lung cancer
- Pericarditis, Pleuritis
- Workup
- chest XR, chest CT
- PFTs
- Sputum gram stain and culture
- CBC with differential
- PPD
- Arterial blood gasometry
- ECG
14
Q
What is your differential diagnosis and workup ?
“25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose”
A
- Differential diagnosis :
- Atypical pneumonia
- Reactive airway disease
- Upper Airway Cough Syndrome (UACS)
- Post-infectious cough
- Upper airway inflammation/infection
- Asthma
- GERD
- Workup :
- CBC
- Induced sputum Gram stain and culture CXR
- IgM detection for Mycoplasma pneumoniae
- Urine Legionella antigen
15
Q
What is your differential diagnosis and workup ?
“65 yo M presents with worsening cough for the past 6 months accompanied by hemoptysis, dyspnea, weakness, weight loss. He is a heavy smoker”
A
- Differential diagnosis :
- Lung cancer
- Tuberculosis
- Lug abcess
- Bronchiectasis
- Chronic bronchitis / COPD
- Vasculitis
- Pneumonia
- Interstitial lung disease
- CHF
- Workup
- CBC
- Sputum Gram stain, culture, and cytology
- CXR
- CT—chest
- PPD
- ANCA
- Bronchoscopy
- Echocardiography
16
Q
What is your differential diagnosis and workup ?
“55 yo M presents with increased dyspnea and spu- tum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago”
A
- Differential diagnosis :
- COPD exaccerbation
- Lung cancer
- Pneumonia
- Upper respiratory infection
- Lung abcess
- Congestive lung failure
- TB
- Bronchiectasis
- Workup :
- CBC
- CXR
- ABG
- PFTs
- Sputum Gram stain and culture
- CT—chest
- Echocardiography
17
Q
What is your differential diagnosis and workup ?
“34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work”
A
- Differential diagnosis :
- Tuberculosis
- Pneumonia
- Lung abcess
- Vasculitis
- Lymphoma
- Metastatic cancer
- Lung cancer
- HIV/AIDS
- Sarcoidosis
- Workup :
- CBC
- PPD/QuantiFERON Gold
- Sputum Gram stain, acid-fast stain, and culture
- CXR
- CT—chest
- Bronchoscopy
- HIV antibody
- Lymph node biopsy
18
Q
What is your differential diagnosis and workup ?
“35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis”
A
- Differential diagnosis :
- Tuberculosis
- Pneumonia
- Bronchitis
- Acute retroviral disease
- Asthma
- Pulmonary embolism
- Acute coronary syndrome
- Cardiomyopathy/CHF
- Workup :
- CBC
- PPD/QuantiFERON Gold
- Sputum Gram stain, acid-fast stain, silver stain, and culture
- CXR
- HIV antibody
- Echocardiography
19
Q
What is your differential diagnosis and workup plan ?
“50 yo M presents with a cough that is exacerbated by lying down (orthopnea) at night and improved by propping up on 3 pillows. He also reports exertional dyspnea”
A
- Differential diagnosis :
- CHF
- Cardiac valvular disease
- GERD
- Pulmonary fibrosis
- COPD
- Upper Airway Cough Syndrome
- Workup plan :
- CBC
- CXR
- ECG
- Echocardiography
- PFTs
- BNP
- CT—chest
20
Q
What is your differential diagnosis and workup plan ?
“60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum”
A
- Differential diagnosis :
- Pulmonary edema - left heart failure
- Acute coronary syndrome with left CHF
- Mitral valve stenosis
- Arrythmia
- Alveolitis
- Acute respiratory distress syndrome
- Pulmonary embolism
- Pneumonia
- Workup : ECG, CXR, CBC, ABG, PFTs, BNP
21
Q
Key history - hemoptysis ?
A
- Onset, timing, precipitating factor, past occurence;
- Description of a typical episode;
- Intensity : amount, frequency;
- Quality : sputum ? amount, color, structure;
- Aggreviating and alleviating factors ?
- Associated symptoms : SoB, chest pain, fever, chills, night sweats, weight loss, appetite, chronic cough, fatigue, palpitations, dysphagia, nausea, vomiting;
- ROS : CRUGS : CV, Respiratory, Urinary, GI, Sleep;
- PMH : Heart, Lung, Hematologic, Oncologic;
- SAD : Smoking, Alcohol, Drugs;
- HITS : Hospitlizations, Immobility, Trauma, Surgieries;
- Medications known to accecerbate bleeding !
- Sexual - unprotected, multiple contacts ?
- Sick contacts ? Recent travel ?
- Occupation ? Housing ?
22
Q
What questions will you ask to the patient with hemoptysis ?
A
- When did you first start coughing up blood ?
- How often are you coughing up blood ?
- What does it look like ? Bright or dark ? Small streaks or large amounts ? Rust colored ?
- How much sputum are you coughing up ? How much sputum are you coughing up ?
- Do you have breathing problems ?
- Have you had chest pain ?
- Have you had fever or chills ?
- Have you had sweats at that that soak you clothes ?
- Do you have cough, fever, dyspnea, arthralgias, or skin rash?
- Do you have hematuria, sinusitis, otitis, or skin lesions?
- Have you lost weight ?
- Have you been exposed to sick people ? Have you been exposed to TB ?
- Have you travelled recently ?
- Have you been diagnosed with other medical conditions ?
- Have you had severe or recurrent pneumonia (including tuberculosis)?
- Do you chronically produce large amounts of purulent sputum?
- Do you take any medications ?
- Does anyone in your family have significant lung disease ?
- What kind of work do you do ?
- Do you smoke ? At what age did you start and how many ciggaretes a day have you been smoking ?
- Do you drink alcohol ? What type ? How much ? How often ?
- Have you ever used recreational drugs ?
23
Q
List main causes of hemoptysis !
A
- Pulmonary :
- Bronchitis
- Lung cancer
- Bronchiectasis
- Cardiac
- Pulmonary embolism
- Mitral stenosis
- Left ventricular failure with acute pulmonary edema
- Infectious
- Tuberculosis
- Lung abcess
- Bacterial pneumonia
- Aspergillosis
- Hematologic
- Coagulopathy
- Vascular
- Vasculitis
- Pulmonary embolism
- Arteriovenous malformation
- Miscallenous
- Granulomatosis with polyangitis
- Goodpasture syndrome
- Trauma
- Cocaine abuse
24
Q
What physical examination will you perform to a patient with hemoptysis ?
A
- HEENT :
- mouth expection, teeth, oropharynx
- nasal passages
- Neck
- lymphadenopathy
- JVD
- Lungs
- inspection - chest size and shape, skin, accessory muscle use, respiratory distress
- palpation - pain, symmetrical fremitus
- percussion - resonance, dulness ?
- auscultation of breath sounds
- Heart
- auscultation : m/g/r - murmurs, gallops , rubs
- Extremities
- clubbing, cyanosis, edema, rash
25
Q
What is your workup plan for a patient with hemoptysis ?
A
- Chest XR, chest CT
- CBC with differential - look for anemia, infection signs, platelet count
- Trothrombin time, partial thromboplastin time - clotting abnormalities
- High sensitivity d-dimers - pulmonary embolism
- Sputum gram stain, culture, acid-fast smear
- Arterial blood gas analysis
26
Q
Chest pain - key history ?
A
- Location, quality, severity, radiation, duration ?
- Context (exertional, postprandial, positional, cocaine use, trauma) ?
- Associated symptoms (sweating, nausea, dyspnea, palpitations, sense of doom, fever) ?
- Exacerbating and alleviating factors (especially medications) ?
- History of similar symptoms ?
- PMH : known heart or lung disease or history of diagnostic testing ? Chronic liver disease? Peptic ulcer disease? Renal disease?
- Cardiac risk factors (hypertension, hyperlipidemia, smoking, family history of early MI) ?
- Pulmonary embolism risk factors (history of DVT, coagulopathy, malignancy, recent immobilization) ?
- Vascular surgeries or tracheotomy ?
27
Q
Chest pain - most important differential diagnosis ?
A
- Is the chest pain pleuritic or nonpleuritic ? => Truly pleuritic chest pain is worsened by respiration;
- Nonpleuritic chest pain :
- Cardiac: myocardial ischemia/infarction, myocarditis.
- Esophageal: spasm, esophagitis, ulceration, neoplasm, achalasia, diverticula, foreign body.
- Referred pain from subdiaphragmatic GI structures :
- Gastric and duodenal: hiatal hernia, neoplasm, PUD.
- Gallbladder and biliary: cholecystitis, cholelithiasis, impacted stone, neoplasm.
- Pancreatic: pancreatitis, neoplasm.
- Dissecting aortic aneurysm.
- Pain originating from skin, breasts, and musculoskeletal structures: herpes zoster, mastitis, cervical spondylosis.
- Mediastinal tumors: lymphoma, thymoma.
- Pulmonary: neoplasm, pneumonia, pulmonary embolism/infarction.
- Psychoneurosis.
- Chest pain associated with mitral valve prolapse.
- Pleuritic chest pain :
- Cardiac: pericarditis, postpericardiotomy/ Dressler’s syndrome.
- Pulmonary: pneumothorax, hemothorax, embolism/infarction, pneumonia, empyema, neoplasm, bronchiectasis, pneumomediastinum, TB, carcinomatous effusion.
- GI: liver abscess, pancreatitis, esophageal rupture, Whipple’s disease with associated pericarditis or pleuritis.
- Subdiaphragmatic abscess.
- Pain originating from skin and musculoskeletal tissues: costochondritis, chest wall trauma, fractured rib, interstitial fibrositis, myositis, strain of pectoralis muscle, herpes zoster, soft tissue and bone tumors;
- Collagen vascular diseases with pleuritis.
- Psychoneurosis.
- Familial Mediterranean fever.
28
Q
What are the most important diagnosis and their differential features ??
A
- Coronary artery disease :
- substernal
- radiation to arm, jaw, neck and shoulder
- precipitated by exertion
- relieved by rest or nitroglycerin
- Pulmonary/pleuritic - pleurisy, pneumonia, pericarditis, PE :
- sharp/stabbing pain
- worse with inspiration
- pericarditis : worse when lying flat
- PE, pneumothorax : respiratory distress, hypoxia
- Aortic - dissection, intramural hematoma
- sudden, severe tearing pain
- radiates to the back
- elderly men
- hypertension, risk factors for atherosclerosis
- GI/esophageal
- nonexcertional
- relieved by antacids
- upper abdominal and substernal
- associated with regurgitation, nausea, dysphagia
- nocturnal pain
- Chest wall/musculoskeletal
- persistent, prolonged pain
- worse with movement or position change
- often follows repetitive activity
29
Q
Chest pain - what questions will you ask ?
A
- Can you please describe your pain for me ?
- Have you ever had pain like this before ?
- If so, what was the outcome ?
- Do you still have the pain or has it resolved ? How is it now compared to before ?
- What were you doing when this pain began ?
- Can you think of anything that may have caused this pain ?
- If past episodes : how often ? how long do they last ? what brings the pain on ? how far can you walk before you develop pain/SoB ? Can you describe your last episode ?
- Point to where the pain is present ? Show me where do you feel the pain ?
- Do you feel it anywhere else ? Does it move anywhere ? Can you please show it to me ?
- On a scale from 1 to 10, how strong is this pain ?
- Describe the quality of pain for me : sharp, stabbing, burning, crushing, squizzing, heavy ?
- Is there anything that makes the pain worse / better ?
- Have you noticed any other symptoms taking place together with the pain ? - SoB, palpitations, nausea, sweating, lightheadedness ?
- Have you had a fever ?
- Have you had a cough ?
- Do you have swelling in the legs ?
- Do you have leg pain while walking ?
- Ask about risk factors of PE : unilateral leg pain/swelling, immobilization, recent surgery, clotting disorders ?
- Have you been diagnosed with othe rmedical conditions ? => hypertension, diabetes, heart problems, hypercholesterolemia ?
- Is there anyone in your immediate family with heart disease ?
- Do you smoke ? At what age did you start and how much do you smoke ?
- Do you drink alcohol ? How much ? How often ?
- Do you use recreational drugs ?
- ROS :
- Pulmonary : cough, wheezing, hemoptysis ?
- Cardiovascular : palpitations, tachycardia, edema, orthopnea ?
- GI : heartburn, esophageal reflux, hematemesis, nausea/vomiting ?
30
Q
Chest pain - what physical examination will you perform ?
A
- Vital signs ± BP in both arms;
- Patient position and ody habitus;
- Complete cardiovascular exam : carotid pulse, carotid bruits, jugular venous pressure, PMI - location and character, heary sounds : S1 and S@, m/g/r, chest wall tenderness, heart sounds, abdominal aorta - bruits or enlargement;
- Lung : work on breathing, accessory muscle use, lung sounds, signs of consolidation : egophony, dullness;
- Abdominal exams : epigastric tenderness, liver/gall bladder enderness : Murphy’s sign;
- Extremity exam : peripheral pulses, lower extremity edema, shoulder examination, signs of DVT;
31
Q
What diagnostic tests are worth performing in patients with chest pain ?
A
- ECG
- Chest XR
- Pulse oximetry
- ABGs
- High sensitivity D-dimer
- CT pulmonary angiogram or ventilation/perfusion scan
- Echocardiogram
- CT scan of the chest
- Barium esophagram
- Upper GI endoscopy
- Liver / gallbladder US
