Differentials

Question 1

Presenting complaint: weight loss

Answer 1

How much, over how long, associated symptoms.
-Malignancy: Breast lump, haemoptysis (lung cancer), prostatic symptoms, change in bowel habit (bowel), haematuria (TCC), jaundice (head of pancreas), , post menopausal bleed (uterine).

• GI issues: colon cancer (elderly, blood/melaena PR, change in bowel habit). Inflammatory bowel disease (diarrhoea with blood/mucus, abdominal pain).
• Coeliac disease: diarrhoea, steatorrhoea, anaemia symptoms e.g SOB, tierdness, abdominal discomfort.
• Endocrinological : thyrotoxicosis :diarrhoea, heat intolerance, irritability/restlessness, tremor, oligomenorrhoea/amenhorrea.
• Psychological: anorexia/bulimia nervosa (BMI <17.5 in anorexia, binge eating in bullimia, effort to lose weight (gym, vomiting, laxatives), menstrual cycle disturbance. Depression (core: low mood, anhedonia, biological (poor sleep, lack of energy), future: hopelessness, suicidal thoughts. Stress: organic stress).

Other differentials include: diet changes/malnutrition, substance misuse, end organ failure, diabetes mellitus type 1, chronic inflammatory diseases, chronic infection (e.g TB), HIV/AIDS.

Question 2

Tiredness

Answer 2

Haematological: Anaemia (breathlessness on exertion, weakness, may get palpitations, worsening angina, worsening claudication).

Endocrine: hypothyroidism (constipation, cold intolerance, weight gain). Diabetes: (polydipsia., thirst, polyuria, weight loss, visual disturbance).

Psychological: depression (core: low mood, anhedonia) biological: poor sleep, lack of energy, future: hopelessness, suicidal thoughts|).

Respiratory: sleep apnoea (loud snoring, night time breathing interrupted by apnoeas/gasping/snorting, excessive daytime sleepiness, obesity is a risk factor).

Stress, post-viral fatigue, organ failure, drugs (recreational, B-blockers, diuretics), malignancy, chronic inflammatory diseases (e.g connective tissue diseases), chronic infection (e.g TB), Addison’s disease.

Question 3

Headache differentials

Answer 3

Primary:
Tension headache: bilateral tight band sensation, recurrent, occurs late in day, associated with stress.
Cluster headache: short painful attacks around 1 eye, Last between 30 minutes to 3 hours.
Occur once/twice a day for 1-3 months.
May have lacrimation and flushing.
Migration: Unilateral pulsating headache in trigeminal nerve distribution, lasts between few hours-days. May have aura (usually visual), need to lie down in dark room (photophobia).
-Trigeminal neuralgia: 2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution. Face screws up with pain.

Secondary intracranial: meningitis (photophobia, neck stiffness systemic symptoms, e.g fever, non-blanching rash). Temporal arteritis (unilateral throbbing pain, scalp tenderness and jaw claudication, >55 years, may have visual involvement). Subarachnoid haemorrhage (very sudden onset, severe headache, ‘Like someone hit me with a brick over the head’, Meningism. Raised intracranial pressure: (e.g a tumour, benign intracranial hypertension)–>worse in morning and with coughing and bending. Vomiting and reduced GCS, may have neurological symptoms/seizures, history of malignancy/immunocompromise.

Secondary extracranial: Glaucoma: pain around one eye, swollen red eye, visual blurring and halos. Sinusitis: facial pain exacerbated by leaning head forward, rhinorrhoea. Intracranial venous thrombosis, intracranial haemorrhages (intracerebral, subarachnoid, subdural), infections (abscess, encephalitis, meningitis), malignant hypertension, hypoxia/hypercapnia, viraemia, cervical spondylosis, pre-eclampsia, drugs (nitrates, PPI, caffeine, analgesiaa overuse, hormones).

Question 4

Vertigo

Answer 4

Peripheral (vestibular):

• benign positional vertigo (attacks of sudden rotational vertigo, evoked by head turning, lasts 30 seconds).
• Vestibular neuritis (e.g Herpes virus): Often preceded by URTI, sudden rotational vertigo and vomiting, lasts several days but imbalance may persist, may re-occur several times per year.
• Viral labyrinthitis: often preceded by URTI, severe vertigo and hearing disturbance, may have tinnitus, otalgia, nausea, fever.
• Meniere’s disease: TRIAD: vertigo + tinnitus + hearing loss, attacks last minutes-hours.

Central: vertebrobasilar insufficiency: momentary vertigo attacks precipitated by neck extension, elderly with cervical osteoarthritis.

Other differentials:
Peripheral: acoustic neuroma (vestibular schwannoma), chronic otitis media, eustachian tube dysfunction, Ramsay-Hunt syndrome (vertigo, facial palsy, otalgia, zoster rash), cholesteatoma).
Central: vertebrobasilar stroke, cerebellar stroke, neurological conditions (e.g MS, epilepsy, brain tumour, migraine). Head injury.
Drugs: e.g alcohol, salicylates, quinine, aminoglycosides, metromisazole, co-trimoxazole, diuretics.

Question 5

Fit/fall/syncope

Answer 5

Cardiovascular: postural hypotension–> dizziness plus minus loc on standing from lying.
-Arrhythmia: fall after transient arrhythmia, may have had palpitations or felt strange before collapse, cardiac history or family history of sudden death, may have occurred during exercise or when supine.
-Aortic stenosis: collapse on exertion, SOB worse on exertion.
Neurological: seizure: partial: simple partial: focal motor seizure, no LOC). Complex partial (e.g temporal lobe epilepsy): strange actions with impaired awareness. Or generalised:Tonic-clonic (grand mal): sudden LOC, limbs stiff then jerk, may become incontinent, bite tongue, feel awful with myalgia and confusion afterwards.
Absence (petit mal): unresponsively stare into space for approximately 5 seconds (in child hood), atonic: all muscles relax and drop to floor. Tonic: all muscles become rigid.
Myoclonic: involuntary flexion.
Parkinsons disease: TETRAF: Rigidity, tremor, bradykinesia and postural instability.
TIA/Stroke: neurological symptoms, e.g. limb/face weakness, slurred speech, hemianopia, LOC/syncope, very uncommon.
Vasovagal: occurs in response to stimuli, e.g emotion/pain/ fear/prolonged standing. Preceding nausea, pallor, sweat, closing visual fields. Then LOC for approximately 2 minutes.

Other differentials include: mechanical: mechanical fall/postural instability,
Cardiovascular: structural, e.g hypertrophic obstructive cardiomyopathy, arrhythmogenic right ventricular dysplasia, situation syncope (e.g cough syncope, effort syncope, micturition syncope).
Carotid sinus hypersensitivity (precipitated by head turning/shaving).
Vertebrobasilar insufficiency (elderly with cervical osteoarthritis).
PE

Neurological:
neuropathy, e.g MS.
Intracranial haemorrhage (extradural, subarachnoid, subdural).
Drop attack )sudden leg weakness without warning/LOC/Confusion.

Alcohol/drugs use:
Alcohol excess
polypharmacy
Recreational drugs.

Abdominal:
ectopic pregnancy,
Ruptured AAA.

Miscellaneous:
Delirium (secondary to infection). 
Any cause of vertigo above. 
Anaemia
Hypoglycaemia
Eyesight problems 
Arthritis.

Question 6

Common chest histories:

presenting complaint: chest pain.

Answer 6

Cardiac–>
1. Mycardial infaction: Crushing central chest pain.
Radiates to neck/left arm.
Associated nausea/SOB/Sweatiness
Cardiovascular risk factors.
2. Angina: cardiac-type chest pain.
Associated with exertion.
Relieved by rest.
3. Aortic dissection: tearing chest pain of very sudden onset. Radiates to back. Pain in other sites: e.g arms, legs, neck, head.
4. Pericarditis: Retrosternal/precordial pleuritic chest pain.
Relieved by sitting forward. May radiate to trapezius ridge/neck/shoulder.

Respiratory –>

1. Pulmonary embolism: pleuritic chest pain, SOB plus minus haemoptysis, risk factors e.g long hall flight, recent surgery, immobility, malignancy,
2. Pneumothorax: sidden onset pleuritic chest pain. SOB if large enough. Risk factors: (e.g. long haul flight, recent surgery, immobility, malignancy).

Non-cardiorespiratory–>
1. Gastro-oesophageal reflux disease: restrosternal burning chest pain. Related to meals, lying, straining, water brash.
2. Anxiety/panic attack: tight chest pain, SOB, sweating, dizziness, palpitations, feeling of impending doom.
Anxious personality and other symptoms of generalised anxiety disorder.
Recurrent episodes triggered by a stimulus (e.g crowds)
3. Musculoskeletal: sharp chest pain, exacerbated by movement and inspiration, can point to where it is worst. Exacerbated by pressure over area.

Other differentials: costochondritis and Tietze’s syndrome (sharp pleurtitic sternal pain with tenderness), pleurisy (sharp unilateral pleurtitic chest pain), gastritis, myocarditis.