Symptom histories and differentials Flashcards
Nine differentials for general fatigue
Infection
Anaemia/circulatory compromise
Cancer
Hypothyroidism/hypopituitarism
HONK/DKA
OSA/Sleep disorder
ESRF
Connective tissue disease
Depression/Anxiety/chronic fatigue syndrome
Three Systemic differentials for fatigue/weightloss
Infection,
Cancer,
Connective tissue disease
Three Endocrine differentials for fatigue
Hypothyroidism,
Hypopituitarism,
DKA/HONK
General questions for fatigue
Duration
Loss of appetite and weight
Sweats and chills
Morning/evening variation
Sleep patterns
Exacerbated by activity
Working status, social stressors, smoking, alcohol
Diet
Infection questions
Loss of appetite, weight loss
Sweats chills rigors (sepsis)
Nausea and vomiting (Sepsis, hepatitis, cholecystitis, cholangitis)
Diarrhoea/loose stools, abdominal pain (Gastroenteritis, diverticulitis, colitis, proctitis, abscess, typhoid, hepatitis)
Coryzal symptoms - sore throat, runny nose, sore ears (acute bronchitis, sinusitis, conjunctivitis viral illness, HIV, EBV)
Cough, Shortness of breath, chest pain (pneumonia, empyema, effusion, lung abscess)
Myalgias/body aches, rashes, joint pain (Influenza, meningococcaemia, septic arthritis/OM/nec. faciscitis, streptococcal sequelae, malaria/dengue)
Urinary frequency and urgency, pain on urination (UTI, pyelonephritis, prostatitis, urinary TB)
Headache, neck stiffness photophobia (meningitis, influenza, malaria)
Overseas travel, (malaria, dengue, typhoid)
IVDU, (IE, Hep B/C, HIV)
Sexual contact, (proctitis, HIV, Hep B, C, gonorrhoea, chylamidia)
Animal contact, (Q fever, Brucellosis, Pasturella, vibrio)
Prostheses, dental procedures (Infective endocarditis, prosthetic infection)
Previous exposure/contact TB, Hep B/C
HIV, immunosuppressive meds (PCP, Candida)
Recent needlestick injury
Recent hospital contact (MRSA, pseudomonas)
Immunisation
Sick contacts
Three cardiorespiratory differentials for fatigue
Heart failure
Anaemia
Respiratory disease
Cardiorespiratory questions
Shortness of breath/exercise tolerance (heart failure, angina)
dizziness/lightheadedness with/without exercise (aortic/pulmonary outflow obstruction, arrthymia)
Loss of consciousness (arrthymia, aortic/pulmonary outflow obstruction)
Chest pain/discomfort (MI, pericarditis, PE, Boorhaeve’s)
History of smoking (MI, angina)
HTN, dyslipidaemia, T2DM, previous MI (MI, angina)
Previous coronary angiograms, stress tests, echocardiograms
Shortness of breath lying flat at night, number of pillows (left ventricular failure)
Cough and breathlessness at night sleeping (left ventricular failure, asthma, OSA)
Swelling in feet and legs (Right ventricular failure, left ventricular failure)
Palpitations (arrythmia, sympathetic stimulation)
Family history of sudden death (arrythmia, HCOM)
Anaemia/bleeding questions
Change in bowel habits, loss of appetite/weight (Bowel cancer)
Smoking, bloody cough (Lung ca)
Epigastric pain (gastritis, gastric/oesophageal ca)
Blood in urine and stool (Bleeding disorder, bladder ca, renal ca, prostate ca)
Intake of red meat, type of diet (IDA, B12 deficiency)
Periods and amount of bleeding (IDA)
Alcohol consumption (alcohol related, B12 deficiency)
New medications from doctor, other health practitioner (haemolytic anaemia)
Night sweats (leukaemia, lymphoma, solid cancer)
Lumps, bumps, bony pain (leukaemia, lymphoma, myeloma)
Rashes
Blood clots, previous miscarriages (Paroxysmal nocturnal haemoglobinuria)
Family history of blood disorders, ethnicity (thallasaemia, VWD, haemophilia)
Connective tissue disease questions
Joint pains, associated swelling, variation during day (OA, RA, gout, seronegative arthritis, viral arthralgia)
Morning stiffness of joints and duration (inflammatory arthritis
Clicking, locking, giving way, thickening of cartilage (meniscal tear, ligament/tendon injury, relapsing polychondritis)
Back pain, chronic diarrhoea (Ankylosing spondylitis, seronegative RA)
Pain in leg muscles, standing from chair, walking up stairs, lifting hands above head (dermatomyositis, polymyositis)
Rashes on face, worse with sunlight, on skins, on hands (SLE, erythema nodosum, gottron’s papules, vasculitis)
Medications from doctor, OTC (drug induced SLE)
Skin tightness (scleroderma)
Eye grittiness, eye pain (Sjogrens, RA)
Difficulty swallowing (Scleroderma)
Reflux (scleroderma)
Discolouration of fingers in cold (scleroderma, dermatomyositis, SLE, RA)
Sleep disorder questions
Sleepiness during day - during driving, watching TV, during conversation, after lunch
Duration and time of sleep
Waking during night
Known snorer shortness of breath/choking during night
Morning headache
Pain during sleep/tingling of feet
Uncontrollable urge to move legs
Previous partner concerns/injuries during sleep
Shift work
Depression/anxiety questions
Feelings of ongoing guilt sadness
Loss of concentration, fogginess
Desire to end life, active planning
Current social stressors
Feelings of fear
Particular behaviours of avoidance
Differentials for weight loss
Infection
Cancer
Connective tissue disease
Diabetes mellitus
Malabsorptive syndrome
Hyperthyroidism
Addison’s disease Depression
Anorexia nervosa
General history for weight loss
Quantity of weight lost
Loss of clothing sizes
Intentional
Appetite changes
Associated fatigue
Smoking, alcohol,
IVDU Social stressors
Malabsorptive history for weight loss
Diarrhoea, frequency of stools
Colour, floating stools
Diarrhoea with certain meals
Abdominal pain
Current diet
Volume of stools
Associated bloating
Alcohol history, pancreatitis history, gallstones Prior small bowel surgery
Previous coeliac disease history
Previous overseas travel, tropical regions
Rashes, bruising, swelling of limbs
Cancer supplement
Changes to bowel habit
Ongoing feeling of faecal urge
Difficulty swallowing
Previous cancer history
Back pain
Pain at night
Smoking history
Exposure to industrial dyes, asbestos
Previous radiation therapy or exposure
Broad Differentials for cough
Infection
Heart failure
Asthma
GORD
Pulmonary fibrosis
Lung/throat cancer
Medications
Specific differentials for infective cough/dyspnoea
Pneumonia
Acute bronchitis
Bronchiectasis
Tuberculosis
Abscess/right heart infective endocarditis
Fungal infection
Specific differentials for asthma cough/dyspnoea
Uncontrolled asthma
Workplace related asthma
Hypersensitivity pneumonitis
Allergic bronchopulmonary aspergillosis
Churg-Strauss vasculitis
**Specific differentials for fibrosis related cough/dyspnoea
Idiopathic pulmonary fibrosis
Scleroderma,
RA,
SLE
Cryptogenic organising pneumonia
Bronchopulmonary obliterans
Asthma history
Diagnosis of asthma
Precipitants
Changes to symptoms in workplace
Use of puffers
Frequency of exacerbations
Shortness of breath, variation day/night
Nocturnal cough, wheeze
Previous ICU
Reflux history
Duration of symptoms
Postprandial symptoms worse with lying
Types of food associated
Previous gastroscopy
Previous Barrett’s
Difficulty or pain on swallowing
Sensation of food obstruction
7 Differentials for haemoptysis
Pneumonia
Tuberculosis
PE
Lung/throat Cancer
Bronchiectasis
Pulmonary haemorrhage
Acute alveolitis - Wegner’s vasculitis, Goodpasture syndrome
9 Broad differentials for diarrhoea
Infective
Drugs
Irritable bowel syndrome
Overflow
Inflammatory bowel disease
Cancer
Malabsorption
Radiation
Endocrinopathies
Spinal cord pathology
Infective differentials for diarrhoea
Viral gastroenteritis
Bacterial gastroenteritis/colitis
c. difficile colitis
HIV
Amebiosis/giardia
Helminths
Drugs that cause GI symptoms
NSAIDs
Metformin
Colchicine
Antibiotics
Laxatives
Drugs that cause cough and/or fibrosis
Beta blockers (SOB)
NSAIDs (SOB, cough)
Methotrexate (SOB, cough)
ACEI (cough)
Amiodarone (cough, SOB)
Approach to diarrhoea
Assess need for cardiopulmonary resus from severity
Assess chronicity
Determine frequency, volume, colour/floating
Postprandial, and time after
Night diarrhoea
Consider general fatigue questions
Infective history
Drug history
Cancer history
Connective tissue disease history
Malabsorptive history
Endocrine history
13 Broad differentials for abdominal pain
Acute GI infection
Acute genitourinary infection
Upper GI pathology
Lower GI pathology
Ischaemic gut
Renal calculi
Myocardial infarct
Pneumonia
Ruptured AAA
DKA
Hypercalcaemia
Ectopic pregnancy
Cancer
Differentials for upper GI pathology
Cholecystitis (febrile, RUQ tenderness, positive murphy’s, NV and dehydration)
Choledocholithiasis (Jaundice, biliary colic, positive murphy’s)
Cholangitis (fever, jaundice, RUQ tenderness, positive murphy’s, NV and dehydration)
Peptic ulcer (RUQ/epigastric tenderness, haematemesis, dehydration)
Acute hepatitis (RUQ pain, fevers, malaise +/-, ascites, jaundice, asterixis, reduced GCS, peripheral oedema, bruising, hepatic faetor, NV and dehydration)
Acute pancreatitis (central abdominal pain, lipase +, RUQ pain, low Ca, dehydrated, febrile, low BP)
Myocardial infarct (ECG changes, troponin, prior reflux symptoms, CVD risk factors)
Oesophageal ishaemia (Chest and epigastric pain, odynophagia/dysphagia, recent procedure, febrile, NV haematemesis, creps auscultation, SC crepitus)
Oesophageal rupture (as ischaemia, low BP, crepitus, RR high, low sats)
Differentials for lower GI pathology
Appendicitis
Diverticulitis
Small bowel obstruction
Large bowel obstruction
Bowel perforation
Ischaemic gut
AAA rupture
peritonitis
Abscess
Renal calculus
Pelvic inflammatory disease
Bleeding renal cyst
Retroperitoneal incarcerated hernia
Approach to abdominal pain
Assess severity, site, time course
Infective symptom history
Cardiorespiratory history
Menstrual cycle and sexual activity
Previous surgeries/endoscopy
Diet
Alcohol history
Broad differentials for dyspnoea
Respiratory infection
Pulmonary vascular pathology
Cardiac failure
Obstructive airways disease
Interstitial lung disease
Pneumothorax, pleural and chest wall pathology
Metabolic disturbance
Pulmonary embolism screen
Previous DVT, PE
History of cancer
Previous surgery, immobility
Current estrogen supplementation
Recent long haul flights or car trips
Family history of clotting disorders
Calf pain or swelling
Smoking
6 Pulmonary vascular differentials
Pulmonary embolism
Chronic thromboembolic pulmonary hypertension
Pulmonary hypertension in setting of cardiac failure or COPD
Idiopathic pulmonary hypertension
Bronchopulmonary sequestration
AVM
7 Chest wall, pleural differentials for dyspnoea
Pneumothorax
Pleural effusion
Empyema
Phrenic nerve palsy
Kyphoscloiosis/acute vertebral crush fracture
Acute peripheral neuropathy
Acute myopathy
Palpitations History
Duration, frequency and rhythm
Occurrence with activities (before, during, after)
Associated dizziness, loss of conscious, lightheadness
Associated shortness of breath or chest discomfort
Nausea vomiting, chills, sweats, rigors, coryzal symptoms
Hunger (at time of palpitations), tremor, heat intolerance, prior diarrhoea
Menstrual history (last period/irregular cycles, vaginal dryness, irritability, sweats/flushes)
Caffeine, alcohol intake, smoking
Social stressors, anxiety
Family history of sudden death, MI
PHx dyslipidaemia, HTN, T2DM, long QT, COPD, heart failure
Guilt, sadness, suicidal ideation
Differentials for Palpitations
1) Cardiac electrical disturbance
2) Sympathetic disturbance
1) Cardiac electrical disturbance
- AF, flutter
- Supraventricular Tachycardia
- Ventricular tachycardia/ectopics
- HCOM
2) Systemic sympathetic disturbance
- Caffeine, alcohol
- Anxiety
- Infection
- Dehydration/hypovolaemia
- Thyrotoxicosis
- Hypoglycaemia
- Phaechromocytoma
History for Haematemesis
Nature, colour, amount, consistency
Distinguish coughing from vomiting and vomiting without blood present, prior nausea
Abdominal pain and discomfort prior, heartburn w/ acid brash
Malaena, PR bleeding
Dizziness, lightheadedness, shortness of breath
Loss of weight, loss of appetite, night sweats, dysphagia
Bleeding elsewhere - cough w/ haemoptysis, haematuria, epistaxis, easy bruising
Liver symptoms - RUQ pain, jaudice/yellow skin, ankle, abdominal swelling
Meds - NSAIDs, anticoagulants, bisphosphonates, steriods
Recent ingestion of corrosive material
Recent abdominal trauma
Prior history of GORD, cirrhosis, aortic graft repair, hepatitis B,C, HIV, cancer, IVDU, overseas travel
Prior endoscopies, CT scans
FHx oesophageal cancer, gastric cancer
Differentials for haematemesis
Bleeding gastric or duodenal ulcer
NSAID/bisphosphonate/GCS/stress associated gastritis
Oesophageal or gastric fundal varicies in setting of cirrhosis
Mallory-Weiss Tear
Oesophageal strangulation and rupture (Boerrhave’s)
Aortoenteric fistula
Gastric/duodenal AVM
Bleeding diathesis
Differentials for Rectal bleeding
Colitis - infective, ischaemic
Inflammatory bowel disease - ulcerative colitis
Colorectal cancer
Proctitis - Radiation, infective, inflammatory, traumatic
Upper GI bleed
Haemorrhoids
Divericular bleed
Anal fissures
Anal trauma, foreign bodies
Anorectal prolapse and ulceration
History for rectal bleeding
Amount, mixed with stool/around stool, dripping, on toilet paper
Colour - dark/bright
Time course and duration
Dizziness, lightheadedness, shortness of breath/fatigue
Abdominal pain, back pain
Diverticular bleed, haemorrhoids- Bowel habits, hard stools, constipation, use of laxatives, straining when going to toilet
Anal fissure/ulcer - Anal pain
Cancer, IBD - Tenesmus/faecal urgency
New mass in rectum
Faecal incontinence
Chills/sweats rigors, nausea vomiting
Recent sick contacts, take-away foods, BBQs, uncooked meat, unwashed salads/vegetables, overseas travel
Arthralgias, rashes, eye pain, back pain, oral ulcers
Loss of weight loss of appetite, night sweats
PMHx - IBD, anorectal surgeries, radiotherapy, AF/IHD, constipation/diverticulitis, cancer, previous colonoscopies
NSAIDs, anticoagulants
Smoking, alcohol
Symptoms and differentials for jaundice
Biliary disease (cholangitis, choledocholithiasis, gallstone pancreatitis, cholangiocarcinoma, pancreatic Ca, Biliary stenosis, primary sclerosing cholangitis)
- RUQ pain, pale stools, dark urine, itch, nausea, vomiting, poor oral intake, loss of weight
- PHx previous gallstones, cholecystectomy, previous endoscopies/stents
Hepatitis/decompensated cirrhosis (Viral hepatitis, drug associated hepatitis, autoimmune hepatitis, biliary cirrhosis, acute fatty liver of pregnancy)
- IVDU, hep B/C/HIV history, tattoos/piercings, foreign travel, needle stick injury, sexual partners
- Arthralgia, rashes, eye pain/gritty eyes, vitiligo
- Nausea, vomiting
- abdominal distension, leg swelling
Hepatic congestion (Right heart failure - TR, right MI, Budd-Chiari)
- RUQ pain, history of blood clots, history of myeloproliferative disorders, MI
Haemolytic anaemia (Autoimmune, mechanical/valve related, G6PD, congential cause, DIC/TMA)
- chest pain on exertion/SOB, bruising, heart valves
Differentials for back pain
Muscular strain/sprain (central palpation, vertebral movement, FABER)
Facet joint osteoarthritis
Vertebral disc prolapse
Vertebral crush fracture (central palpation)
Spondylolysthesis
Sacroiliitis - Ankylosing spondylosis, IBD (Sacroiliac tenderness)
Discitis/vertebral osteomyelitis (central palpation, febrile, flushed, tachycardic, loss of power and reflexes, lactate)
Aortic dissection (radioradial and radiofemoral delay, abdominal tenderness, expansile mass, diastolic murmur at RUSE, low BP, lactate)
Vertebral metastasis (central palpation, cachexia, lymphadenopathy, conjunctival pallor, abdominal mass/localised wheeze/breast lump, icterus)
Renal calculi/pyelonephritis (Flank tenderness, lower abdominal tenderness, febrile)
Colitis/diverticulitis/appendicitis/retroperitoneal incarcerated hernia (abdominal tenderness, peritonism, febrile, lactate)
Kyphosis/scoliosis (Curvature of spine, reduced chest expansion)
History for headache
Site - unilateral/bilateral, neck involvement
Time of onset, duration, painfree periods; intermittent, continuous progressive
Rapid onset - instant; worst severity experienced
Exacerbating factors - worse early morning/evening, after bright lights, moving head/neck, touching scalp, with coughing
Nausea, vomiting, loss of appetite
Visual aura - spots/images before eyes
Neck stiffness, rash, fevers/chills/rigors, photophobia
Discomfort with chewing (temporal arteritis, trigeminal neuralgia), short duration (trigeminal neuralgia)
Severe, pain around one eye, tears (cluster)
Use of analgesics
PHx cancer, migraines, smoking, alcohol, caffeine, hypertension
FHx - berry aneurysms, malignancy
Differentials for headache
Primary headache (Tension headache, migraine, cluster headache, analgesic headache)
Meningitis
Haemorrhage (subarachnoid, intracranial)
Temporal arteritis
Trigeminal neuralgia
Raised intracranial pressure (hydrocephalus, neoplasm)
Ice-pick headache, benign sex headache
Flu-like illness/upper respiratory tract infection
Differentials for loss of consciousness
Cardioneurogenic reflex (vasovagal syncope, micrition syncope, carotid sinus hypersensitvity)
Cerebral hypoperfusion (arrhythmia, aortic outflow stenosis, hypovolaemia)
Seizure (tonic/clonic, atonic (drop attack), clonic, complex partial)
Hypoglycaemia
Basilar artery TIA, subclavian steal syndrome, posterior circulation giant cell arteritis
Loss of conscious history
(Obtain collateral history)
Events prior to, during and after event
fall and subsequent pain and trauma, head trauma
Footwear, use of gait aid, visual aids, lights on or off
Symptoms of dizziness, lightheadedness, palpitations, shortness of breath (cardiac)
Palpitations, chest pain (arrhythmia)
Prior aura - epigastric sensation, de ja vu (generalised seizure)
Sudden instability, weakness in limbs, double vision (posterior circulation insufficiency, atonic seizure/drop attack)
Tongue bitten/bleeding, urinary/faecal incontinence (tonic/clonic seizure, syncope)
Confused for 15-20mins following (generalised seizure, hypoglycaemia)
tremor, hunger, lethargy (hypoglycaemia)
Neck turning, shaving, neck extension (carotid sinus hypersensitivity, vertebral artery occlusion)
Exercising (outflow stenosis, subclavian steal, posterior GCA)
Dizziness on standing from sitting/lying (hypovolaemia/orthostatic hypotension)
Appetite, prior nausea and vomiting, fever, chills, rigors, diarrhoea (hypovolaemia/sepsis)
Headache, worse with coughing, worse in morning/when waking (Raised intracranial pressure)
History of epilepsy, IHD, HTN, T2DM, on insulin, smoking, alcohol, stroke
Differentials for dizziness
Faintness/lightheadedness (Cerebrovascular insufficiency, anaemia, hypoglycaemia, arrhythmias)
Vertigo (BPPV, labyrinthitis/vestibular neuronitis, vestibular migraine, medication toxicity, meniere’s disease, brainstem infarct)
Lateral instability (stroke, cerebellar disease, Parkinson’s disease, sensory peripheral neuropathy, myasthenia gravis)
Dizziness history
Allow patient to define dizziness - lightheadness, rotational, difficulty walking
Time course and duration
Worse with walking, lying/sitting, turning head
Worse after exercise
Hearing loss, tinnitus, nausea, vomiting
Previous URTI, ear infections, pain from ear, blood from ear
Headache, motor weakness, sensory weakness, visual disturbance, speech difficulties
Chills, sweats and rigors, infective Hx
PHx stroke, IHD, AS, heart failure
Smoking, alcohol
Differentials for joint pain
Osteoarthritis
Gout/pseudogout/hydroxyapetite crystal arthropathy
Rheumatoid arthritis
Infective arthritis
Haemarthrosis
Soft tissue injury
Viral arthralgia,rheumatic fever
SLE, jaccoud’s arthropathy
Seronegative arthritis - psoriatic arthritis, reactive arthritis, enteropathic arthritis
Mixed connective tissue disease
Haemachromatosis
Relapsing costocondritis
History for back pain
Site, radiation, duration
Worse with lying, sitting, standing, walking, coughing bending
Use of analgesics
Abdominal pain, groin pain, dysuria, flank pain (aortic dissection, renal calculi)
Numbness/tingling down leg and calf (lumbar nerve compression)
Bilateral numbness, tingling, weakness bilaterally, recent changes to bowel and bladder habits, anal tingling (spinal cord compression, conus medularis compression, lumbar nerve root compression)
Pain at night, constant, night sweats, loss of weight, appetite (crush fracture, metastasis)
IVDU, needlestick injury, fevers chills rigors (Osteomyelitis, discitis)
Recent back trauma
Abdominal pain, changes to bowel habit, PR bleeding (colitis, diverticulitis, appendicitis, retroperitoneal hernia)
Smoker, alcohol, social circumstances
History for joint pain
Site/sites of joints involved, swelling, redness
Ability to move joint
Recent trauma, injections, prostheses (septic arthritis)
Chills/sweats/rigors, nausea, vomiting
Loss of weight, malaise, fatigue, general unwell (chronic infection, connective tissue disease)
Catching/locking or giving way (meniscal/ligamentous rupture)
Morning stiffness
Movement better/worse, better worse at beginning/toward end, improvement/worsening with rest, limitation of movement on ADLs
Numbness, tingling at night, improved with hanging hand over bed (Carpal tunnel syndrome complication)
Nodules, raynauds (Rheumatoid)
Pitted nails, PHx psoriasis (psoriatic arthritis)
Dry eyes and mouth (showgren’s)
Chronic diarrhoea, blood in stool, eye pain (IBD)
Ulcers in mouth or genitals (RA, Bechet’s)
Chest pain, cough, shortness of breath on exertion (RA, CREST)
Differentials for reduced conscious state
Hypotension
Hypoxia
Hypoactive delirium
Hypoglycaemia/hyperglycaemia
Acute intracranial haemorrhage
Meningoencephalitis
Non-convulsive status epilepticus
Alcohol, benzodiazepine, opioid intoxication
Hyperkalaemia/hypokalaemia, hypercalcaemia/hypocalcaemia
Renal or liver failure
Sleep disorder
Differentials for acute limb
Referred pain - MI, Renal calculi, AAA, radiculopathy, neuropathy
Compartment syndrome
Arterial insufficiency
Necrotising fascitis/cellulitis
Myonecrosis
Septic arthritis
DVT
Abscess
Gout
Fracture/osteonecrosis
Neuropathic pain
