Histories Flashcards

Question

Burn history

Answer 1

IMIST from ambulance What burnt patient - fire, electricity, oil, gas Duration of contact Ignition of clothing? Closed environment? ALOC VIolent movement / trauma associated when falling What PPE worn AMPLE ABCDE - EMST Want to do secondary survey + assess which burns are deep dermal or full thickness, or partial derma Capillary vasodilatation and recruitment closed capillary loops --> major extravasation of plasma to all interstitial tissues --> persists in areas under burn --> shock Deep tissue death + vascular thrombosis = worsens this Compartment syndrome highly likely Without skin = rapid cooling with exposure --> raise room temperature + glad wrap Bicarbonate to alkalinise urine making pigments water soluble (haemochromogens) 4thj degree = deep to subcutaneous fat Watch for ARF and sepsis

Answer 2

Ddx Lower GI - Haemorrhoids, fissure, diverticular, CRC, angiodysplasia, proctitis (radiation, IBD, infection), ischaemic colitis Upper GI - PUD, varices, fistula Small bowel - Crohn's, Meckel's, GIST/Carcinoid/Adenocarcinoma Vascular - Coagulopathy, thrombocytopenia, HHT Hx: SOCRATES Where when how often blood Painful/painless/colour Chronicitity Mucous/pus Diarrhoea/frrequency Constipation before episode Symptoms better or worse after food Fevers/rigors/sweats/suspicious food/unintentional weight loss Recent travel Fatigue/Dizziness on sitting or standing/Palpiations FmHx auto-immune/IBD/Cancer FOBT/Colonoscopy Recent NSAID or anticoagulant use Radiation/SMoking/Alcohol Liver disease/yellow skin H pylori/dyspepsia/ Easy bruising/bleeding elsewhere/petechiae Skin lesions Systems review MUST EXAMINE INCLUDING DRE Ix: FBC, UEC - urea, iron studies, LFT, CRP Colonoscopy CT angiography Capsule endoscopy

Answer 3

Spinal canal disease Sciatia Peripheral neuropathy Risk factors Smoking diabetes, HTN, Genetic Dyslipidaemia Aetiology - Atheroscloeris, buergers, vasculitis, arterial trauma, adventitial disease,

Answer 4

DDx Respiratory - Lung cancer, tuberculosis, COPD, interstitial lung disease, pulmonary fibrosis, pulmonary embolism, metastatic cancer Cardiovascular - Heart failure, pulmonary hypertension, endocarditis Infectious - Tuberculosis, HIV/AIDS, chronic fungal infections Haem - Lymphoma, anaemia, leukaemia Metabolic/Endocrine - Hyperthyroidism, adrenal insufficiency, diabetes Autoimmune - Sarcoidosis, rheumatoid lung disease, systemic lupus erythematosus (SLE) Hx Nature and severity of shortness of breath After how much Exertion How rapidly did this develop Rest, during night, when lies flat (how many pillows, wake up sob) Cough, productive, blood Weight loss Fevers/rigros/sweats Smoking history Asbestos Family hsitory Foreign travel Family history other cancers Previous blood clots or DVT Hoarseness of voice Difficulty swallowing FBC, UEC, CMP, LFT CXR ABG Sputum MCS, AFB, Cytology

Answer 5

DDx: Hx: SOCRATES Rule out hypertensive crisis - irritability, headache, visual disturbances, confusion, altered consciousness, seizures Renal disease - polyuria, nocturne, dysuria, thirst, haematuria, colic, lethargy, general malaise Phaeo- sweating, palpitations, anxiety, tremor - in paroxysms Cushings - truncal weight gain, thinning of skin, easy bruising, proximal myopathy, striae, hirsutism Heart failure symptoms Back pain Chest pain NSAIDS, OCP, HTN drugs, Steroids, Antidepressants Tobacco, alcohol, illicit drugs Family history Known renal disease, pre-eclampsia when pregnant, known arterial disease Thyroid disease

Answer 6

Ddx - head trauma, tumour, mets, stroke, CNS infection, metabolic disorder - hypoglycaemia, hyponatraemia, hyperclacaemia, medication, drug withdrawal Risk factors - non-compliance, viral, abuse of alcohol, sleep deprivation How did seizure start, any aura Any focal or lateralising features at seizure onset Seizure duration Time taken to recover What happened before, during and after Any witnesses FmHx, associated symptoms (fevers) Past history head trauma, neurological illness, cardiovascular, cancer, drug and alcohol consumption

Answer 7

FINISH THIS Sudden onset or gradual Any associated pain at all Any preceding trauma, stretch, peripheral nerve injury Any weakness in any other limb or region on the same side Any back pain Any symptoms on the other side as well Any fevers/rigors/sweats Any unexplained weight loss Any headache, any nausea or vomiting - particularly in the morning or when's training Any seizures Any visual symptoms, weakness, numbness anywhere else, Bowel and bladder disturbance Any autoimmune disease Any immunosuppression or diabetes Family history of anything to do with brain, norves, brainstemV

Answer 8

Need to distinguish whether they are lightheadded for which Ddx - Cardiac arryhtmia, postural hypotension, anaemia, hypoglycaemia, loss of consciousness (syncope or epilepsy) Otherwise vertigo - world spinning around them - spontaneous, recurrent, changes in posture Need to clarify whether peripheral or central - vertebrobasilar ischaemia, dyelinatioatn, cerebellar disease, migraine, vasculitis CNS, neuromyelitis optica - temporal lobe epilepsy - cerebelloponine angle tumour - deafness, ataxia, facial sensory loss Peripheral - BPPV, vestibular neuronitis, meniers disease, middle ear dieseae Vestibular apparatus vs vestibular nuclei and connections Hearing loss Vision loss, Tinnitus New weakness / change in sensation / difficulty walking or balancing What brings on symptoms How long for Fevres/rigors/sweats Headache or any pain N+Vomiting, tongue biting or incontinence Cardiac risk factors and diseases Family history and personal history of any neurological diseases, migraines, tumours FINISH THIS

Answer 9

DDx Vascular - Intermittent claudication - Chronic venous insufficiency MSK - Joint disease - Muscle/ligament injury - Stress fracture Neurogenic - SCiatica - Spinal canal stenosis - Cauda equina syndrome How long Any associated pain Is it shooting - how far down does it go (if not further than knee probs not sciatica) Any associated weakness / change of sensation Any bowel or bladder changes Any fevers/rigors/sweats , recent infection Any loss of weight, constitutional symptoms, neurological disease/tumoru FmHx Any clots / vascular issues Cardiac issues Hx FINISH THIS

Answer 10

Site Quality Severity - effect on life Time course ?insidious Context - recent illness, STI, trauma, travel Aggravating factors Relieving factors Fevers/rigors/sweats Sensory/Weakness Sore throat Weight loss Headache Gait disturbance Rashes ulcers Genital discharge Dysuria Sicca symptoms Raynauds Diarrhoea Autoimmune, IBD, OP, bleeding disorder IVDU/smoking/eTOH Occupation

Answer 11

Structural - associated pain, bulge, constitutional symptoms, onset, family history - Hernia - Cancer - Appendicitis - Intusseception - IBD? Dietary - Alcohol - Caffeine - Dehydration Medications - Opioids - Anti-histamines - Laxative use - Anti-diarrhoeals Metabolic/Endocrine - Hypercalcaemia - Hyperparathyroidism - Hypothyroidism Neuromuscular - Parkinson's - Cauda Equina Congenital - Hirschprung's - Cystic fibrosis FINISH THIS

Answer 12

DDx Arterial Neuropathic Pressure Venous Other Ddx same as leg laceration Hx: SOCRATES Location, pain Leg swelling, aching, heaviness, itching Varicose veins, DVT, obesity, prolonged standing, previous venous surgery Severe pain worsening with elevation, claudication, rest pain, cold feet Smoking, diabetes, hypertension, dyslipidaemia, PVD, Painless, numbness, tingling, burning Diabetes, alcoholism, spinal cord disease Fevers/rigors/sweats Immobility, malnutrition, sensory loss Exam: Location Margins, exudate Surrounding skin Peripheral pulses Capillary refill Complete neurological exam - monofilament and vibration testing Confirmatory tests Doppler USS ABI CT angiography HBA1c May require imaging to rule out deep infection such as CT

Answer 13

Ddx: Traumatic Sharp force Blunt force Crush Avulsion Bite wounds Non-traumatic Infectious - Nec fasc - Cellulitis - Mycobacterial or fungal infection - Cutaneous anthrax Ulcer - Venous, arterial, neuropathic, pressure AUtoimmune/Derm - Pyoderma gangrenosum - Epidermolysis bullosa - Vasculitis - Lichen sclerosis SCC/BCC/Melanoma History: SOCRATES Foreign material, what object, how, dirty, tetanus, occupation Pain - out of proportion? Wound progressionl Walk / cold feet / neurological symptoms Anywhere else Fevers/rigors/sweats Risk factors for causes - ulcers, skin condition, skin cancer, auto-immune, derm, Unintentional loss of weibght / radiation Auto-immune Recent travel Previous TB MUST EXAMINE including neurological exam Ix: Wound swab!!, BSL at bedside!! FBC - infection UEC - Risk for PAD CRP - Inflamamtory/INfection Blood cultures - infection HBA1c - diabetic LFT - Albumin ?poor healing Autoimmune panel X-ray for gas CT? ABI/USS/ MRI for OM Punch vs excision biopsy

Answer 14

DDx Renal - stone, RCC, pyelo, abscess, infarction, trauma, obstructive uropathy GI - Appendix, diverticulitis, IBD, Gall bladder, Pancreatitis Vascular - AAA, Retroperitoneal haemorrhage MSK - Muscle strain, vertebral pathology, herpes zoster Reproductive - Torsion - ovary and testicular, endometriosis, PID Neurological - Radiculopathy, spinal cord compression, diabetic Hx: SOCRATES LUTS, haematuria, dysuria Fevers/rigors/sweats/loss of weight Bowel habit, Malaena, Jaundice, Pruritus Previous surgeries of bowel, kidney, reproductive Leg pain on walking, Previous easy bruising/bleeding, anticoagulation Strain, previous issues with back, trauma, burning followed by pain and rash on one side of body Periods / scrotal pain / discharge Any trouble with sensation around anus, any weakness/change in sensation I WOULD EXAMINE Ix: Urine dip + MCS, BSL/ECG if required but unlikely FBC, UEC, CRP, LFT, Coag CT depending otherwise USS repro

Answer 15

Ddx: Urological TCC/Prostate cancer/RCC UTI Stones BPH Trauma Radiation cystitis Iatrogenic Schistosomiasis Non-urological Systemic - Coagulopathy, vasculitis, sickle cell Vascular - Renal artery dissection, malignant hypertension, aneurysm rupture Renal - PCKD, Glomerulonephritis Drug induced - abx, ibuprofen, cyclophosphamide Pseudo - jaundice, rhabdo, porphyria, beeturia, drugs (rifampicin) Hx: SOCRATES Painful vs painless - Smoking, occupation, exposure to paints/dyes Infective vs non-infective Constitutional symptoms LUTS Previous urological and fmHx of urological/kidney/other cancer or no cancer Pelvic radiation stones / neck mass / constipation Bleeding / bruising / epistaxis / bleeding anywhere else Trauma Travel overseas Hypertension / headache/blurry vision Medications Cough/chest infection/swelling in legs After finish Hx - do systems review --> Notice skin yellow, recent long run / long lie, eating beetroot, weakness/change in sensation Examine patient Ix: Urine dip + MCS Urine cytology x3 Urine red cell morphology FBC, UEC, CRP, Coag, PSA, LFT if suspicion of pseudo/coagulopathy, autoimmune panel if worried about auto-immune, sickle cell screening CT IVP/RTUS Flexible cystoscopy

Answer 16

Ddx Urological Torsion / torsion of appendage Epididymo-orchitis SCrotal trauma Fournier's Iatrogenic Tumour Kidney stone Varicocele/Spermatocele/Hydrocele Idiopathic Non-urological Hernia Parasitic infection Lymphadenopathy Oedema Hx: SOCRATES Sudden onset and when Pain and if so - Constant / coming and going Able to get over or not Testes in origin or scrotum LUTS? Haematuria? Dysuria? Fevers/rigors/sweats/unintentional weight loss FmHx cancer Trauma Flank pain / previous kidney stones Heavy lifting / previous hernia Recent overseas travel / any travel Swelling anywhere else in body Lumps or bumps anywhere else Examine!! - Able to get over / under, transilluminate, prehn, cremasteric, Ix: Urine dip + MCS Urine STI screen USS FBC - anaemia/wcc, CRP - inflammatory/infection, UEC - stone AFP, LDH, Beta HCG CT CAP if feels obvious tumour or CT AP if large hernia

Answer 17

Ddx Cardiac - MI, Pericarditis, Tamponade Pulmonary - PE, PTX, Pneumonia GI - Oesophageal rupture, GORD, PUD MSK - pre-existing Surgical - related to laparoscopy or thoracotomy etc. Anxiety LUQ Abdominal pain - Pancreatitis, Haemorrhage, Mesenteric ischaemia, splenic infarct or pain, aortic dissection, kidney stone, herpes zoster: Hx: SOCRATES Acute vs chronic Pre-op or only post op Insidious Related to breathing? Exertional? Sitting up or lying down? After or before food? SOB / cough / coughing up blood Fevers/rigors/sweats Cardiac risk factors - Previous MI, FmHx, Diabetes, Dyslipidaemia, HTN Leg swelling or pain Palpitations or dizziness especially on sitting or standing Previous blood thinners / previous DVT Ix: ECG Trop, ABG (alkalosis), FBC, CRP, Coag CXR - PTx, Pneumonia, Widened mediastinum or mediastinal air CTPA/Gastrograffin swallow Echocardiogram

Answer 18

DdX: Viral/bacterial/antibiotic/parasitic - gastroenteritis IBD IBS Cancer Bile acid diarrhoea / CLD Coeliac/Lactose/Pancreatitis related/SIBO Endocrine / Metabolic - Hyperthyroidism, Carcinoid, VIPoma, Addison's Medication induced Post surgical - short bowel/fistula/dumping syndrome Hx: SOCRATES How many stools Acute / chronic Watery/Bloody Tenesmus, fevers/rigors/sweats/unintentional weight loss Abdominal pain ?relieved by diarrhoea Recent travel FmHx CRC/IBD/Autoimmune Iron deficiency / steatorrhea, after dairy ingestion/gluten Yellow skin, pruritus, Liver disease, biliary surgery, gall bladder Tremors/AF/Loss of hair/Heat insensitivity/ Hyperpigmentation of skin and low blood pressure (dizziness on sitting and standing) Flushing/dehyrdration Antibiotics/Laxatives/PPI/Metformin Recent surgery Stool culture + MCS, calprotectin FBC, CRP, TTG IGA, LFT, UEC for dehydration, consider lipase, May require colonoscopy especially if overdue ACTH and cortisol if Addisons'

Answer 19

Ddx: RUQ - Cholecystitis, Cholangitis, hepatitis, Liver abscess, Pyelo, Kidney stone LUQ - Gastritis, PUD, Pancreatitis, Splenic infarction or rupture, Pyelo, Kidney stone Epigastric - GORD, MI, Aortic dissection RLQ - Appendicitis, Crohn's, Torsion/cyst rupture, ectopic LLQ - UC, Ovarian, Diverticulitis Generalised or vascular - Mesenteric ischaemia, AAA, Peritonitis, Cystitis, Any malignancy - Kidney, Bowel, Liver, Other Hx: SOCRAATES When start Radiate Fever/vomiting/diarrhoea/weight loss/blood in stool/change in bowel habit Previous surgeries, CVD, Smoking, NSAIDS Urinary symptoms, dysuria Medications - NSAID, Opoid Stones Gynaecological hx, urological hx Autoimmune/IBD FmHx any of above including any cancers Previous gallstones/pancreatitis Jaundice, pruritus, liver disease things Sexual hx, discharge Muscular strain Must examine!!! Including DRE Ix: FBC, UEC, CRP, LFT, Lipase CT AP

Answer 20

Ddx Respiratory PE Bronchial artery rupture Lung cancer TB Pneumonia Abscess Aspergillosis COVID, Influenza, viral pneumonia COPD SLE/Vasculitis Bronchiectasis Non-respiratory Coagulopathy. TTP AAA Mitral stenosis Heart failure Ensure not haematemesis Iatrogenic Hx: SOCRATES How much and since when Fresh or dark red Blood streaked sputum? Fevers/night sweats/weight loss Smoking, TB, Travel Surgery OCP Pleuritic chest pain, shortness of breath, leg swelling Orthopnoea, PND Nosebleeds brusing, bleeding gums, epistaxis Haematuria, joint pain, rash Autoimmune Anticoagulant EXAMINE Ix: Sputum MCS, ECG FBC, Coag, UEC (urea), CRP Depending on Hx could do D-dimer/ANCA/Anti-GBM and LFT CXR at a minimum Otherwise CT Chest/CTPA Bronchoscopy? Endoscopy?

Answer 21

Ddx: Skin cancers - BCC, SCC, kaposi Benign skin lesion - seborrheic keratosis, blue/spitz nevus, solar lentigo, pigmented dermatofibroma Pre-malignant - atypical naves, lentigo maligns, actinic keratosis Addison's disease, PIH, Drug eruption, tattoo Hx: SOCRATES - Raised, flat, vascular, changing with time, itchy, bleeding, crusting Trauma or irritation Sun exposure, occupation, whether wear sunscreen or not (and where), tanning bed, moles Often get sunburnt, fair skin, red/blond hair FmHx Other skin lesions Previous skin cancers Fevers/rigors/sweats/unexplained weight loss Bony pain, persistent headache, vision changes Autoimmune diseases or immunosuppression Do you feel weak, tired, episodes of fainting or light headedness on standing, hyperpigmentation, N+V or diarrhoea Systems review Ix: EXAMINE Dermascopy Excisional biopsy Could do FBC, CRP ensure not infected lesion, Coags if indicated

Answer 22

DDx Expected post-operative Wound and soft tissue complication - infection/haematoma/seroma/dehiscence Abscess/peritonitis/NF Post-operative haemorrhage, compartment syndrome, ischaemia nerve injury, neuropathic pain Pneumothoraxi, Bowel obstruction, urinary retention MI / PE / DVT Pneumonia Ileus Hx: SOCRATES Fever, erythema, wound discharge Dizziness sitting and standing, cool peripheries Abdominal distention N+V SOB/chest pain hypoxia Leg swelling, redness, diaphoresis Previous cardiac history if chest pain Diabetes obesity smoking immunosuppression EXAMINE - bladder scan, DRE - pelvic abscess, DVT Ix: Urine dipstick + MCS, ECG, FBC, CRP - inflammation infection UEC - post op ileus electrolyte Trops LFT - bile leak liver dysfuction Coag - DIC ABG - acidosis - ischemia, sepsis CTPA/Doppler USS Wound MCS CXR for pneumonia CT for anastomotic leak

Answer 23

DDx/Risk Immobilisation Malignancy Pregnancy Thrombophilia/Antiphospholipid syndrome Recent surgery Previous DVT Nephrotic syndrome Ortho/Abdominal/pelvic surgery/neurosurgery/>3 hour surgery OCP Wells - Active cancer (treatment ongoing or within 6 months) +1 Paralysis, paresis, or recent immobilization of a limb +1 Bedridden for ≥3 days or major surgery in past 4 weeks +1 Localized tenderness along deep venous system +1 Swelling of entire leg +1 Calf swelling >3 cm compared to other leg +1 Pitting edema +1 Collateral superficial veins (non-varicose) +1 Alternative diagnosis more likely -2 Virchow - stasis, hypercoagubility, Endothelial Hx: SOCRATES Leg pain, swelling, redness Immobilisation Chest pain, SOB, Haemoptysis Neurological deficits (PFO), stroke like Weight loss, night sweats, unexplained fatigue, Previous DVT PE History of clots - factor 5 protein C/S, APLS Smoking OCP, HRT Recent surgery EXAMINE Ix: D Dimer Coags Thrombophilia Venous doppler USS CTPA Echo

Answer 24

Ddx: Infective - Pneumonia, UTI, wound, Sepsis of other cause, post-operative Metabolic - hypoxia, hypoglycaemia, electrolyte, uraemia Neurological - stroke, seizure, haematoma, pre-existing dementia Medications - opioids, benzodiazepines, anti-cholintergics, polypharmacy, alcohol withdrawal, anaesthetic related Cardiovascular - hypotension, hypertensive crisis, MI Uncontrolled pain, psychosis, surgical stress response Ensure not psychiatric, dementia, POCD Hx: SOCRATES Fluctuating or persisitent Lucid? Fever/rigors/sweats Tachycardia/cough/dyspnoea/chest pain/weakness/change in sensation/agitation/rtremors/dehydration/pain Urinary symptoms Wound Post-operative course DVT/PE Drugs given New medications previous Delirium Pre-existing cognitive impairment Bowels Systems review EXAMINE - bladder scan, DRE Ix: ECG, BSL FBC, CRP, UEC, LFT (hepatic encephalopathy) Blood cultures, CXR, Urine MCS ABG Tox screen CT Brain RTUS USS doppler

Answer 25

Ddx: Medications - anticoagulant, anti-platelet, NSAID, SSRI, Corticosteroid Platelet disorders - thrombocytopenia, platelet dysfunction, congenital platelet disorder Coagulation factor deficiency - Hemophilia A/B, Liver disease, Vitamin K deficiency (warfarin, prolonged antibiotics, malabsorption) Vascular fragility - Euler's Danos, Marfan Systemic - CKD, Liver disease, MM Nutritional - Vitamin C and K Cushings/Diabetes/CKD/Age/Hematologic Amyloidosis/DIC sepsis related Hx: SOCRATES Spontaneous, trauma, mucosal bleeding, petechiae, haemarthrosis, haematoma Location, Epistaxis, GI bleeding, haematuria Liver disease, anticoagulants Medications CKD/Cushing's Fatigue, weight loss, fevers, rigors, sweats Weight gain, moon face, buffalo hump Skin changes Autoimmune disorder Infective signs - Chest, urine, skin - chronic infections Neurological signs? Food alcohol intake Smoking EXAMINE Ix: FBC, Blood film, Clotting, LFT, UEC - CKD, D-dimer, Von willebrand, Factor 8 and 9, Vitamin C and K Cortisol CT/Brain MRI? Abdominal USS - Hepatosplenomegaly Bone marrow biopsy

Answer 26

Ddx Hypertrophic pyloric stenosis (early) Intestinal atresa Malrotation with midgut volvulus Metabolic disorder - GORD Food intolerance Infections Intra-cranial pressure Gastroenteritis Increased intracranial pressure Appendicitis Toxin ingestion Liver disesase Metabolic disorder (urea cycle defect), organic academia Hx: SOCRATES Projectile or not Bilious or not Bloody or coffee ground Feeds Morning Abdominal distension or pain/constipation Weight loss, dehydration, ltheragy Drawing up of legs Bulbing fontanelle, seizures Fever, poor feeding, irritability, neck stiffness Unintentional loss of weight FmHx cancer N+V Smelly urine, Diarrhoea, Premature, issues with pregnancy Pre-eclampsia FmHx GI issues Yello0w, scratching, EXAMINE - pyloric mass, ICP, bulging fontanelle, fluid status Ix: Glucose, urinalysis FBC, CRP UEC - electrolyte LFT, Ammonai, Gas - alkalosis = stenosis, acidosis sepsis/shock/inborn errors Bilirubin/LOFT - neonatal liver disease

Answer 27

DDx Stress - weak pelvic floor (previous complicated birth), cachexia, previous prostatic surgery, pelvic organ prolapse, rectal prolapse Urge - infection, detrusor overactivity, TCC at trigone Overflow incontinence - HPCUR, BOO (cancer or non-cancer) Functional incontinence - Dementia, stroke Neurological - MS, Parkinson's stroke, spinal cord injury Metabolic - DM, Hypercalcaemia with nephrogenic DI medications - diuretics, anticholinergics, opioids Mixed Hx: SOCRATES SUI/UUI LUTS - haematuria Rule out infection, fevers/rigors/sweats/flank pain/rUTI's FmHx prostate cancer / PSA Unintentional loss of weight Smoking, occupational exposures, blood thinners, pelvic radiation Prolapse of organs Pregnancy history Surgical history Weakness/change in sensation anywhere Obesity Mediations COPD/Cough Situational Stones / constipation / abdominal pain EXAMINE INCLUDING DRE and PV exam UROFLOW Ix: FBC, CRP, UEC (HPCUR), HBA1c, Calcium (hypercalcium), PSA blood test Urine dipstick + MCS RTUS + Cystoscopy MRI spine if neurological cause Further down the track urodynamics to diagnose detrusor overactivity Rule out reversible causes Pelvic floor physio Bladder training Medication - Anti-cholinergics, oestrogen, ISC Sling/botox/sacral nerve stimulation/TURP

Answer 28

DDx Blood loss - GI bleeding, menorrhagia, post surgical, haematuria, blood donation Malabsorption - Coeliac, H pylori, gastrectomy, IBD, bariatric Dietary deficiency - Vegetarian, vegan, pregnancy Increased demand - Children/Pregnancy Chronic liver disease/Crhonic kidney disease IDA Mimics - Chronic disease, thalasaemia, lead poisoning, sideroblastic Hx: SOCRATES Fatigue, weakness, exercise tolerance Dizziness on sitting/standing Pallor Pain any where? Radiating to back Bowel symptoms Bladder symtptoms Swelling anywhere Recent surgery Craving for ice/dirt/starch NSAIDS/Epigastric pain/reflux Periods! Chronic diarrhoea, GI surgery H pylori What diet RA/CKD/Chronic Autoimmune Loss of weight / fevers/rigors/sweats Recent infection Yellow/liver/kidney/ EXAMINE Ix: FBC, Iron sudies Coeliac, breath test, LFT if chronic liver disease Stool cal pro / colonoscopy/endoscopy CT AP CXR

Answer 29

Ddx: Anterior EXT ABD - FOOSH Posterior INT ADD - Seizure, electrocution, FOOSH Inferior ARM above - high energy trauma, hyperabduction Other causes Fractures Rotator cuff injury Labral tear AC joint Brachial plexus Septic arthritis Shoulder impingement See shoulder pain for Hx IX Important for axillary nerve and radial pulse 3 view x-ray Humeral head where is it Hill sachs - cortical defect for choronic Glenoid rim fracture - Recurrent instability CT/MRI

Answer 30

Ddx Systemic/Malignancy - GI, Lung, Haematological, RA/SLE, Chronic infection (TB, HIV, Endocarditis) GI - Coeliac, IBD, Pancreatitis, PUD, gastropareasis, stricture/cancer of oesophagus Endocrine - Hyperthyroidism, Adrenal, DM, CKD Psychiatric - Eating disorder, depression/anxiety, dementia/ALS, Substance use TB/HIV/Parasite Medication - Stimulants, Chemotherapy, metformin, SSRI's Post GI surgery, Radiation heart failure COPD Hx: SOCRATES Amount Intentional vs not intentional Normal appetite but weight loss, loss of appetitie, early satiety, difficulty swallowing, painful swallowing Diarrhoea, steatorhea Fevers/night sweats/rigors Abdominal pain, rectal bleeding Tremor, heat intolerance, palpitations, skin changes including hyperpigmentation, salt craving, dementia, memory loss, weakness/change in sensation Family history cancers - lung, liver, bowel, prostate, breast, blood Alcohol, drugs, smoking Recent travel Medication - suppressant, chemo, SSRI Heart failure COPD Systems review EXAMINE including BMI Ix: FBC - anaemia, WCC infection CRP - infection, malignancy LFT - malignancy, albumin UEC - Electrolyte imbalance from metabolic, CKD CMP - malnutrition paraneoplastic TFT , ACTH, Serology (coeliac, HIV) Stool examination, culture, calprotectin CXR/Abdominal USS/CT AP Endoscopy/Colonoscopy

Answer 31

Ddx Atelectasis, Aspiration, Pneumonia, SIRS, UTI, Central line, drug fever, wound, DVT/PE, C difficile, Deep surgical infection, Endocarditis, HITS Normal inflammatory response Undiagnosed malignancy/lymphoma Hx: Onset, recurrent, level Sustained, spiking Feeling of hot Rigors/sweats Cough/runny nose/sob Deep breathing post-op, sitting out of bed Dysuria/frequency/flank pain Redness, pain, discharge at wound site Diarrhoea, nausea+vomiting Leg swelling, redness of leg, calf pain, previous clot in leg Abdominal pain Mobilising Eating Rash anywhere on body Systems review Confusion? EXAMINE Ix: Urine dipstick, ECG (right heart strain) FBC, CRP - infection UEC - dehydration/kidney function in setting sepsis LFT - drug reaction Blood cultures/urine cultures/sputum culture/wound swab/Faecaes PCR CXR Doppler USS vs CTPA

Answer 32

Ddx Congenital - branchial cleft, thyroglossal, dermoid, cystic hygroma, teratoma Infectious (MOST COMMON) - Reactive, bacterial, tuberculous, mycobacterial, cat stretch, viral, fungal, septic thrombophlebitis, abscess Inflammatory - Kawasaki, JIA, Sarcoidosis Neoplastic - Lymphoma, leukaemia, neuroblastoma, thyroid, salivary gland tumour Vascular - AVM, Haemangioma Neuroblastoma Hx: SOCRATES Pain, onset, stable, soft/fim, mobile/fixed Fever/sore throat/weight loss/night sweats Dysphagia, hoarseness, cough, skin changes, SOB Skin changes Recent infections, travel Cat scratch/animal exposure Immunosuppresion Family history of cancer/autoimmune disease Conjunctivitis/rash Thyroid symptoms Exposure to smoking Weakness/chagne in sensation/Dizziness Bleeding bruising Ix: EXAMINE FBC, CRP - infection Viral panel / serology Throat swab / blood culture LDH / USS +/- FNA CXR

Answer 33

DDx Lymphadenopathy - Reactive, granulomatous disease, lymphoma, metastatic (stomach, pancreas, colon breast on left, thoracic lung and oesophagus breast on right), leukaemia Infectious - TB, Lymphadenitis (Staph/Strep), Cat scratch, fungal, vira Congenital - Cyst - branchial or thyroglossal Vascular - Carotid body tumour, subclavian artery aneurysm, jugular vein DVT Cancer - Thyroid cancer, Salivary gland, sarcoma Goitre/Sarcodiosis Hx: SOCRATES Fixed, hard vs mobile Painful Warm/red Growing Night sweats/fevers/unintineional loss of weight/rigors Which side Sore throat, recent travel, TB, skin infections, dental infections Cough, blood, sob Difficulty breathing, N+V, early steatite, vomiting blood, maelaena Easy bruising/infections Breast lump - pain, discharge Thyroid symptoms Radiation Other malignancies Immunosuppressed Smoking/alcohol/HPylori/Reflux Weakness/ change in sensation/numbness down either arm or anywhere Cool peripheries Ulcers/skin changes Ix: EXAMINE Lymph node, thyroid, neck, abdominal, respiratory, breast FBC, CRP infection, malignancy, LFT in case GI origin, UEC - urea bleeding, baseline uec Optional TB/HIV/EBV/CMV CEA/Ca19.9, AFP, PSA, TFT USS +/- FNA X-ray if resp CT staging

Answer 34

DDx Viral - HSV, VZV, HPV, HIV Bacterial - Syphilis, TB Fungal - Candidaisis, immunocompromised Inflammatory - Aphthous, behcet's disease, IBD, Reiter's (reactive arthritis) Benign - Papilloma/fibroma/haemangioma Premalignant - leukoplakia/erythroplakia Malignant - SCC, lymphoma, kaposi Metabolic - CKD Stomatitis, IDA/B12 Drug - Chemo/Bisphosnophate/NSAID Hx: SOCRATES How long for Healing or not Painful or painless Lymphadenopathy Fevers/rigors/sweats/loss of weight Smoking / Alcohol / FmHx cancer / Tongue Any other lumps anywhere else Immunosuppression / DM / IBD / Autoimmune disease Joint pain / issues with urinating (pain) / red eyes infected Skin lesions in genital area Final infection / viral infection Vaccinations Previous Herpes / potential new risk (new sexual contact) Previous TB / cough / sob Recent travel What medications Any cancer Dizziness sitting standing EXAMINE - Neck + ENT Ix: FBC, CRP - infection UYEC - Uraemiec stomatitis IDA/VItamin B12/Folate HBA1c Autoimmune panel potentially PCR swab / MCS / Syphilis / fungal culture Quantiferon test USS +/- Xray if dental involvement or CXR if chest CT vs MRI depending on that FNAC vs biopsy

Answer 35

Ddx MSK - OA, FAI, Labral tear, Greater trochanter, AVN, Hip/Stress fracture, Muscle strain, Snapping hip, Legg-Calve Perthes, SCFE Neurological - SCiatica, Piriformis, Lumbar spinal stenosis, femoral neuropathy, meralgia paresthetica Inflammatory - IBD, RA, Gout/Pseudogout Infective - Septic, OA, Tuberculosis, Lyme Referred- Lumbar, inguinal hernia, SI joint, Pelvic (prostate appendix ovary) Vascular - Claudication, DVT Trauma Neoplastic - Primary, mets, lymphoma Hx: SOCRATES Onset Worsened by activity or better with it Clicking / locing Corticosteroid use/alcohol.trauma/deep persistent pain Morning stiffness Weakness/change in sensation Where pain going to Other joints Red, swollen Fevers/rigors/swetas/weight loss Functional status, occupation, Bowel / bladder /saddle anaesthesia Recent travel, recent infection with urethritis and conjunctivitis Abdominal pain, hernia, Back pain, Numbness Pain with exertion relieved by rest with cool peripheries, ulcers on legs DVT, Clotting issues Respiratory / urinary symptoms Autoimmune disease Ix Joint aspirate FBC, CRP - infection UEC - baseline prior to NSAIDs LFT - ALP Uric/CMP - gout/pseudogout / PTH RF/Anticcp Vitamin D X-Ray USS CT/MRI

Answer 36

DDx Patellofemoral syndrome Patellar tendinitis Quadriceps tendinopathy Osgood-Schlatter disease Meniscus MCL Pes anserine IT band Baker's cyst Hamstring Other Arthritis - OA, Septic, RA, inflammatory, reactive DVT / Popliteal artery entrapment Gout / Psuedogout Metastases, MM PVD Hx: SOCRATES Pivot / contact injury Red /fevers/rigors/sweats/untentional loss of weight/warm knee Pop sound Swelling Locking/clicking Worse with stairs/squatting OR jumping Runner / occupation Morning stiffness, crepitus, worsens with activity or sitting Knee extension Bilateral / systemic symptoms / other joints / skin changes / nail changes Recent illness including GI/GU with conjunctivitis and urethritis Previous gout / issues with kidney stones Shooting pain / weakness/change in sensation / cool peripheries DVT / clotting / calf Pain on walking / CVD / Lipids/diabetes Hypothyroidism related pain Neck mass / constipation / confusion EXAMINE: Neurovascular + joint above and below Consider ABI Ix: BSL, Joint aspirate FBC, CRP infection Anti-RA + Anti CCP Blood cultures CMP, uric acid ANA/DsDNA, HLAB27 HBA1c Vitamin D TSH LFT - ALP for bony mets USS / X-ray MRI

Answer 37

Ddx - Rotator cuff pathology, biceps tendonitis, arthritis (OA, septic, RA), inpingment, deletion, AC, Clavicle fracture, nerve entrapment, referred pain from neck, frozen shoulder (diabetes and hypothyroidism), polymyalgia rheumatic, cardiac, gallbladder, lung Thoracic outlet syndrome - first rib Thrombosis / aneurysm HX: SOCRATES Trauma/overuse Night pain Morning pain Stiffness Other joints Overhead activities Occupation Previous dislocation Functional activities? Clicking Numbness/weakness/change in sensation Facial flushing when raise arms up Drooping eyelid Fevers/rigors/sweats/unintentional loss of weight Chest pain / SOB / diaphoresis / issues with gallbladder / skin yellow Cough / Issues with lungs / Smoker / Recent Cool arm / weak pulses / clotting issues Diabetes . Hypothyroidism/ Lipids/ Hyperthyroidism laparoscopic surgery EXAMINE + shoulder + neck/elbow/neurovascular assessment Ix: Joint aspiration / BSL / ECG (ensure no cardiac cause) FBC, CRP if infection Troponin if indicated X-ray Consider TFT + HBA1c USS / MRI after that Nerve conduction studies

Answer 38

Ddx: Heel pain - Plantar fasciitis, Achilles tendonitis, calcanea stress fracture, tarsal tunnel Arch/midfoot - flatfoot, lisfranc, tibialis posterior dysfunction, stress fracture Forefoot - morton's neuroma, stress fracture, metatarsalgia Toe - Gout, bunion, hammer toi, freiberg Generalise - Peripheral neuropathy, arthritis, vascular, infection, reactive Hx: SOCRATES Trauma / fall / twisting injury Weight bear? Fevers/rigors/sweats/Unintentional weight loss/redness/swelling Other joint pain Morning stiffness / worse on movement / exertion / improves with activity? Worse with weight bearing? Tight shoes? Sudden pain, previous gout or pseudo gout Diabetes / Alcohol intake / Smoker Foot drop / weakness / change in sensation / tingling Any skin lesions Any conjunctivitis / urethritis / recent viral infection Autoimmune disease PVD / CVD/ HTN/LIpids DVT/clots/PE EXAMINE Ix BSL / wound aspirate if indicated / wound mCS FBC, CRP infection UEC, CMP - electrolyte related X-Ray - trauma, arhtiritis MRI - if soft tissue/stress fracture USS for DVT/PAD

Answer 39

Ddx Lumbar spine pathology - Herniated disc, spinal stenosis Nerve entrapment - diabetic neuropathy MSK - SI joint dysfunction, hamstring pain, hip pathology Vascular - PAD, DVT Referred pain - Hip osteoarthritis, pelvic tumour, endometriosis Metastatic cancer / primary cancer Localised infection Trauma Hypothyroidism Hx SOCRATES Sharp, radiating pain Worsening with bending or improving with lying down Worsen with walking relieved by bending forward Radicular symptoms Bilateral leg weakness / urinary retention / saddle anaesthesia / constipation Aggravated by sitting Burning / tingling / numbness / stocking-glove pattern Foot drop / lateral leg numbness / worse with prolonged crossing legs Diabetes / nutritional deficiency / alcohol use Muscle strain / over-use of muscles Infection / trauma / skin cut / pus Issues with hip joint or any other joint Leg pain with walking, CVD, Relieved by rest or hanging leg over bed Unilateral calf swelling, pain, redness, DVT/PE, Clotting issues Abdominal pain / fevers / rigors/swetas/unintentional loss of weight Endometriosis? - cyclic pain and pain before menstruation Other cancers - previously treated Hypothyroidism? Any issues with lung / prostate / liver / bowel - systems review Renal disease / neck mass - hyperparathyroidism EXAMINE - straight leg test, FABER, ABI Ix: BGL X-ray spine vs MRI EMG Doppler USS FBC, CRP - infection / autoimmune disorder Vitamin - B12 if alcoholic or HBA1c UEC, CMP - muscle spasm LFT - for ALP Blood cultures if sepsis RA Anti-CCP TSH

Answer 40

Ddx Vascular - PAD, Popliteal artery entrapment, buergers - ensure not CLI Neurological - spinal stenosis, sciatica, cauda equina MSK - Chronic extensional compartment, myositis, tendonitis Venous- Chronic venous insufficiency, DVT Haematologic - Sickle cell, polycythemiae, Electrolyte Other rare - cystic adventitial, iliac artery endofibrosis Hx: SOCRATES Leg pain with exertion Diminished pulses ,cool peripheries Smoker, raynaud's, unilateral vs bilateral Diabetes, HTN, Lipids Relieved by lower leg vs relieved by bending forward Radiating pain from back to leg Sensory loss, weakness Saddle anaesthesia, urinary retention Proximal vs distal pain, fevers/rigors/sweats, unintentional loss of weight Leg swelling ++, worsening with standing and improving with elevation Previous DVT, clotting issues, PE Recent crush injury / long lie / burn / etc. Intermittent painful crises in other areas too, muscle cramps, weakness, arryhthmia, sickle cell disease in family Occupation / Endurance athlete EXAMINE make sure not compartment syndrome - Normal resting pressure <10mmHg If resting pressure >30-40 then diagnostic OR Delta P <30mmHg (Diastolic - Compartment = Delta P) Ix: ABI, ECG + BSL if vasculopathic FBC, CRP - inflammatory Blood film sickle cell UEC, CMP ensure not metabolic disturbance cramp Doppler USS - arterial vs venous disease CT angiography Spinal MRI if spinal disease

Answer 41

Ddx Inflammatory arthritis RA, psoriatic arthritis, gout, pseudo gout Septic arthritis Hemochromatosis, acromegaly, hyperparathyroidism SLE, Scleroderma Reactive arthritis Charcot joint Mets, MM, primary bone cancer Hx: SOCRATES Other joints, how long Weight bearing joints, morning stiffness, asymmetric, worsens with activity History of trauma, obesity, joint overuse, metabolic disorders Fevers/rigors/sweats/unintentional loss of weight Painless joint swelling, deformity, sensory loss Skin plaques, auto-immune conditions Conjunctivitis, urethritis following GI/GU infection, recent other illness, recent travel Sacroilitis/axial stiffness Gout / sudden severe pain Kidney stones / constipation / neck mass / kidney issues Issues swallowing / fingers go red easily Ix: FBC, CRP for infection X-ray - joint space narrowing, osteophytes, subchondral sclerosis Could do RF, Anti-CCP, ANA, Anti-DSDNA if suspected Joint aspiration also possible

Answer 42

Ddx Vascular - CVD/PVD, HTN, Diabetes, Smoking Neurological - Peripheral neuropathy, MS, Spinal cord injury, stroke Hormonal - Hypogonadism, hyperprolactinaemia, thyroid dysfunction Psychogenic - Anxiety, depression, performance anxiety, relationship issues Medication induced - Anti-hypertensives, SSRI's, antipsychotics, opioids Structural - Peyronie/Trauma Lifestyle - Obesity, sedentary, alcohol, drug use Hx: SOCRATES Libido / Ejaculation / Situational / Morning erections / Masturbating / Able to penetrate Onset acute or chronic DM, HTN, Heart disease, PVD, Lipids Weakness / change in sensation / stroke previously/ spinal cord injury Previous surgery / trauma / radiation Skin lesions Fatigue, muscle loss, depression, galactoraea, heat/cold intolerance, weight gain or loss History of depression/anxiety/stress with partner Finish history- ask about antipyschotics SSRI antihypertensives, recreational drugs Skin lesions / curve / painful erection Other illnesses, fevers, sweats, rigors, loss of weight Ix: Testosterone Prolactin TSH Glucose Lipid USS

Histories Flashcards

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