Gold Standard Vs 1st Line Investigation Flashcards
Renal Colic
1st: X-Ray KUB + USS
GOLD: Non-Contrast CT KUB
Stroke / TIA
1st: CT Head (MRI is often unavailable or contraindicated
GOLD: MRI
Coeliac Disease
1st:
IgG Tissue-Transglutaminase (BEST)
IgG Anti-Endomysial Antibody (LESS SPECIFIC)
GOLD (And required by NICE):
Endoscopy + Duodenal biopsy
Crohn’s Disease
1st: Calprotectin++ (Tells you it is Crohn’s/UC)
GOLD: Endoscopy + Biopsy
Ulcerative Colitis
1st: Faecal Calprotectin++ (Tells you it is Crohn’s/UC), P-anca +ve
GOLD: Colonoscopy + biopsy
Osteoarthritis
1st and GOLD: X-Ray (Think L.O.S.S)
Rheumatoid Arthritis
1st line for progression: X-Ray + Other Imaging.
GOLD: Anti-Cyclic-Citrullinated-Peptide++
Pericarditis
1st: ECG:
Widespread “Saddle” ST-Elevation
Minor PR depression.
Suppressed QRS waves
2nd: Imaging: Echo or CT.
GOLD: Cardiac Catheterisation
Acute Pancreatitis
1st and GOLD: Pancreatic Enzymes++ (Lipase/Amylase)
2nd: Other bloods + calculate PANCREAS score. (Enzymes in PANCREAS score are ALT/AST)
Sjogren’s Syndrome
1st: Schirmer’s test - tears travel <10mm
2nd: Serum antibodies (SSA+?/SSB+?/CCP-?/RF?)
Anti-RO (SSA) most common
Anti-LA (SSB) most specific
GOLD: Minor salivary-gland biopsy
Gout
1st and GOLD: Joint aspiration for needle (-)birefringent crystals.
Assume it is septic arthritis until proven otherwise
Pseudogout
1st and GOLD: Joint aspiration for rhomboid (+)birefringent crystals.
Assume it is septic arthritis until proven otherwise
Septic Arthritis
1st and GOLD: Joint aspiration and culture
Do this BEFORE starting broad-abx so there is no interference with the culture.
Osteomyelitis
1st: Plain X-Ray (Not very sensitive, progress to CT)
GOLD: Bone biopsy (Only if pt is clinically stable, do this BEFORE abx)
Systemic Lupus Erythematosus (SLE)
1st: Serum Anti-Nuclear-Antibodies (ANA)
Inflammatory markers: raised ESR, normal CRP
GOLD: Anti-Double-Stranded-DNA (Anti-dsDNA)
Myocardial Infarction
1st and GOLD: ECG + Serum Troponin
Cardiac Failure
1st: Serum-B-Type Natriuretic Peptide (BNP)
GOLD: Echocardiogram (Ejection fraction + structure)
Valvular Heart Disease
1st: ECG + Auscultation
GOLD: Echocardiogram (Doppler + structure)
Congenital Heart Diseases
VSD/ASD/TetFalot
1st: ECG + Ascultation
GOLD: Transthoracic Echocariogram
Primary Sclerosing Cholangitis
1st: ALP/GGT, AST/ALT, Billirubin, Albumin, pANCA
GOLD: MRCP (Magnetic-Resonance Cholangio-Pancreatography)
Myasthenia Gravis
1st: Serum Anti-ACh-Antibodies (Sensitivity 50-95%)
2nd: Edrophonium (Tensilon) test
GOLD: There is no adequate gold standard.
Testicular Cancer
1st: Hormones such as ßHCG (Seminoma) / ∂FP (Non-Seminoma) + examination.
GOLD: Testicular Ultrasound
Bowel obstruction
(Before specifying what the cause is)
1st: Abdominal X-Ray or DRE if distal.
GOLD: Not-contrast CT abdomen
Diabetes Insipidus
1st: 24-hour urine collection (Confirm polyuria)
GOLD: Water Deprivation + Desmopressin Test
Fibromyalgia
1st: Serum CRP/ESR/ACCP/ANA to rule out others.
GOLD: No gold standard. Diagnosis via exclusion. 11 out of 18 tender spots.
Hypertension
1st: Clinical BP monitoring (>150 = >80 / >140 = <80)
GOLD: Ambulatory Monitoring (ABPM)
Abdominal Aortic Aneurysm
1st and GOLD: Abdominal Ultrasound (Screening men >65 too)
For further investigations, you would do a CT.
Duchenne Muscular Dystrophy
1st: rise in serum creatinine kinase
2nd: genetic testing
(combined 1st and 2nd diagnoses 95% of cases)
GOLD: muscle biopsy - absence of dystrophin
Giant cell arteritis
1st: raised ESR and CRP
GOLD: temporal artery biopsy
Cushing’s
1st: Cortisol Levels
GOLD: Overnight Dexamethasone Suppression Test
ACTH levels to work out primary or secondary
Addison’s
1st: Serum electrolytes decreased Na, increased K
GOLD: Synacthen test - ACTH stimulation test - no response = Addison’s.
HCC
GOLD: Ultrasound of Liver
1st: Enzymes / Hx
Lung Cancer
1st: CXR
GOLD: CT Chest (Biopsyis ultimately gold, but can only be done if CT shows it is acessible)
Spinal Cord Compression / Damage
1st: Spine X-Ray (Quick and cheap)
GOLD: MRI Spine
Gullian Barre
1st: Lumbar puncture (Essential- Raised proteins)
GOLD: Nerve conduction study
Brugada
1st: ECG
GOLD (Not perfect): Na+ Channel-Blocker Test
Diabetes Mellitus
Gold: Any of the following
Random plasma glucose >11.1 + Symptoms
Fasting plasma glcose >7
HbA1c > 48
Pancreatitis
1st: Serum amylase / lipase
GOLD: 2 out of 3 of:
Epigastric pain, raised amylase, abnormal CT scan pathology
Autoimmune hepatitis
1st: Autoantibodies: ANA, ASMA (most specific), p-ANCA
GOLD: liver biopsy
Screening:
Cervical Cancer
25-64 years old
-Cell biopsy
Screening:
Aortic Aneurysm
> 65 years old
-Abdominal Ultrasound
Screening:
Bowel Cancer
60-74 years old
-Faecal sample kit.
-Soon to expand to 56-year-olds.
Screening:
Breast Cancer
50-70 years old
-X-Ray Mammogram.
Screening:
Diabetic Eye
All diabetics >12 years old.
Screening:
Prostate Cancer
TRICK QUESTION: THIS IS NOT DONE
-Although, it is controversial.
Klinefelter’s
1st: Low testosterone and high FSH/LH at puberty.
GOLD: Karyotype (Ideally from an amniotic biopsy).
Aortic Dissection
1st: CT Scan (Often all you need)
GOLD: MRI
Thyroid cancer
1st: Blood - T3 and T4 levels
GOLD: Fine-needle aspiration
Multiple sclerosis
1st and GOLD: MRI head
Other: Lumbar puncture
Ascending cholangitis
1st: bloods - inflammatory markers & LFTs
2nd: USS - thick walled gallbladder & stones
GOLD: contrast CT
Beta thalassemia
1st and GOLD: Hb electrophoresis
Other: X-ray - “Hair-on-end” appearance
Prostate Cancer
First-line: Multi-Parametric MRI (Has now replaced TRUS Biopsy)
Gold Standard: TRUS Biopsy
(But MRI is ALWAYS done first; some cancers are not clinically significant)
Multiple Myeloma
- (FBC, U&Es etc)
Protein Electrophoresis:
-Serum: ++igA/G
-Urine, ++igA/G (Bence Jones)
Gold Standard: Bone-marrow biopsy (Plasma cells raised significantly)
Imaging: Full-body MRI for lytic lesions and infiltration of bone-marrow.
Achalasia
1st line: Endoscopy (To rule out malignancy, not very sensitive)
2nd line: Barium swallow (May miss early disease)
GOLD: Manometry (Measure pressure at different levels while patient attempts to swallow)
