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Long case clinical skills > Symptom histories and differentials > Flashcards

Symptom histories and differentials Flashcards

1
Q

Nine differentials for general fatigue

A

Infection

Anaemia/circulatory compromise

Cancer

Hypothyroidism/hypopituitarism

HONK/DKA

OSA/Sleep disorder

ESRF

Connective tissue disease

Depression/Anxiety/chronic fatigue syndrome

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2
Q

Three Systemic differentials for fatigue/weightloss

A

Infection,

Cancer,

Connective tissue disease

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3
Q

Three Endocrine differentials for fatigue

A

Hypothyroidism,

Hypopituitarism,

DKA/HONK

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4
Q

General questions for fatigue

A

Duration

Loss of appetite and weight

Sweats and chills

Morning/evening variation

Sleep patterns

Exacerbated by activity

Working status, social stressors, smoking, alcohol

Diet

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5
Q

Infection questions

A

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

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6
Q

Three cardiorespiratory differentials for fatigue

A

Heart failure

Anaemia

Respiratory disease

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7
Q

Cardiorespiratory questions

A

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)

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8
Q

Anaemia/bleeding questions

A

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)

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9
Q

Connective tissue disease questions

A

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)

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10
Q

Sleep disorder questions

A

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

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11
Q

Depression/anxiety questions

A

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

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12
Q

Differentials for weight loss

A

Infection

Cancer

Connective tissue disease

Diabetes mellitus

Malabsorptive syndrome

Hyperthyroidism

Addison’s disease Depression

Anorexia nervosa

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13
Q

General history for weight loss

A

Quantity of weight lost

Loss of clothing sizes

Intentional

Appetite changes

Associated fatigue

Smoking, alcohol,

IVDU Social stressors

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14
Q

Malabsorptive history for weight loss

A

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

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15
Q

Cancer supplement

A

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

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16
Q

Broad Differentials for cough

A

Infection

Heart failure

Asthma

GORD

Pulmonary fibrosis

Lung/throat cancer

Medications

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17
Q

Specific differentials for infective cough/dyspnoea

A

Pneumonia

Acute bronchitis

Bronchiectasis

Tuberculosis

Abscess/right heart infective endocarditis

Fungal infection

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18
Q

Specific differentials for asthma cough/dyspnoea

A

Uncontrolled asthma

Workplace related asthma

Hypersensitivity pneumonitis

Allergic bronchopulmonary aspergillosis

Churg-Strauss vasculitis

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19
Q

**Specific differentials for fibrosis related cough/dyspnoea

A

Idiopathic pulmonary fibrosis

Scleroderma,

RA,

SLE

Cryptogenic organising pneumonia

Bronchopulmonary obliterans

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20
Q

Asthma history

A

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

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21
Q

Reflux history

A

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

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22
Q

7 Differentials for haemoptysis

A

Pneumonia

Tuberculosis

PE

Lung/throat Cancer

Bronchiectasis

Pulmonary haemorrhage

Acute alveolitis - Wegner’s vasculitis, Goodpasture syndrome

23
Q

9 Broad differentials for diarrhoea

A

Infective

Drugs

Irritable bowel syndrome

Overflow

Inflammatory bowel disease

Cancer

Malabsorption

Radiation

Endocrinopathies

Spinal cord pathology

24
Q

Infective differentials for diarrhoea

A

Viral gastroenteritis

Bacterial gastroenteritis/colitis

c. difficile colitis

HIV

Amebiosis/giardia

Helminths

25
Q

Drugs that cause GI symptoms

A

NSAIDs

Metformin

Colchicine

Antibiotics

Laxatives

26
Q

Drugs that cause cough and/or fibrosis

A

Beta blockers (SOB)

NSAIDs (SOB, cough)

Methotrexate (SOB, cough)

ACEI (cough)

Amiodarone (cough, SOB)

27
Q

Approach to diarrhoea

A

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

28
Q

13 Broad differentials for abdominal pain

A

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

29
Q

Differentials for upper GI pathology

A

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)

30
Q

Differentials for lower GI pathology

A

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

31
Q

Approach to abdominal pain

A

Assess severity, site, time course

Infective symptom history

Cardiorespiratory history

Menstrual cycle and sexual activity

Previous surgeries/endoscopy

Diet

Alcohol history

32
Q

Broad differentials for dyspnoea

A

Respiratory infection

Pulmonary vascular pathology

Cardiac failure

Obstructive airways disease

Interstitial lung disease

Pneumothorax, pleural and chest wall pathology

Metabolic disturbance

33
Q

Pulmonary embolism screen

A

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

34
Q

6 Pulmonary vascular differentials

A

Pulmonary embolism

Chronic thromboembolic pulmonary hypertension

Pulmonary hypertension in setting of cardiac failure or COPD

Idiopathic pulmonary hypertension

Bronchopulmonary sequestration

AVM

35
Q

7 Chest wall, pleural differentials for dyspnoea

A

Pneumothorax

Pleural effusion

Empyema

Phrenic nerve palsy

Kyphoscloiosis/acute vertebral crush fracture

Acute peripheral neuropathy

Acute myopathy

36
Q

Palpitations History

A

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

37
Q

Differentials for Palpitations

1) Cardiac electrical disturbance
2) Sympathetic disturbance

A

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

38
Q

History for Haematemesis

A

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

39
Q

Differentials for haematemesis

A

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

40
Q

Differentials for Rectal bleeding

A

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

41
Q

History for rectal bleeding

A

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

42
Q

Symptoms and differentials for jaundice

A

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
43
Q

Differentials for back pain

A

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)

44
Q

History for headache

A

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

45
Q

Differentials for headache

A

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

46
Q

Differentials for loss of consciousness

A

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

47
Q

Loss of conscious history

A

(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

48
Q

Differentials for dizziness

A

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)

49
Q

Dizziness history

A

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

50
Q

Differentials for joint pain

A

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

51
Q

History for back pain

A

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

52
Q

History for joint pain

A

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)

53
Q

Differentials for reduced conscious state

A

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

54
Q

Differentials for acute limb

A

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

Long case clinical skills (12 decks)

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