CAM202 Clinical > Presenting complaint > Flashcards

Presenting complaint Flashcards

(39 cards)

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1
Q

Upper abdominal pain ddx

A

Gastrointestinal

  • gastritis
  • peptic ulcer
  • reflux esophagitis
  • pancreatitis
  • cancer (gastric, pancreatic)
  • Booerhaarve’s disease (esophageal rupture)
  • dyspepsia
  • irritable bowel syndrome

Pain from nearby areas

  • abdominal: central, RUQ pain
  • cardiac: e.g. myocardial infarction, pleuritis
  • pulmonary: e.g. pneumonia, pleurisy
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2
Q

Right upper abdominal pain ddx

A

Gall bladder

  • biliary colic
  • cholecystitis
  • cholangitis

Liver

  • hepatitis
  • hepatomegaly (e.g. liver congestion in right heart failure)
  • hemorrhage into hepatic tumour
  • trauma
  • hepatic or subdiaphragmatic abscess
  • Fitz-Hugh-Curtis syndrome (periphepatitis due to PID)

Other gastrointestinal

  • appendicitis with high appendix (e.g. pregnancy)
  • perforated or penetrating duodenal ulcer
  • colon cancer

Pain from nearby areas

  • abdominal: epigastric, central, RIF, loin, groin pain
  • right lower lobe pneumonia, pleurisy or other lung disease
  • subphrenic abscess
  • acute pyelonephritis
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3
Q

Left upper abdominal pain ddx

A
  • pancreatitis
  • subphrenic abscess
  • diverticulitis
  • ruptured spleen
  • acute pyelonephritis
  • leaking aneurysm of the splenic artery
  • acute gastric distention
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4
Q

Right iliac fossa pain

A

Gastrointestinal

  • appendicitis
  • crohns disease
  • inflamed meckels diverticulum
  • cholecystitis with low gall bladder
  • mesenteric adenitis
  • epiploic appendagitis
  • colon cancer
  • constipation
  • irritable bowel syndrome

Reproductive (female)

  • ectopic pregnancy
  • acute ovarian event (cyst rupture, hemorrhage, torsion)
  • Mittelschmerz (ovulation pain mid-cycle)
  • Pelvic inflammatory disease
  • Endometriosis

Reproductive (male)

  • seminal vesiculitis
  • undescended testicle pathology

Urinary

  • renal colic
  • UTI

Pain from nearby areas

  • abdominal: RUQ, central, groin pain
  • hip pathology
  • psoas abscess
  • rectus sheath hematoma
  • right lower lobe pneumonia
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5
Q

Suprapubic abdominal pain ddx

A
  • urinary retention
  • cystitis
  • uterine in origin (e.g. PID, fibroid, menstruation)
  • origin from RIF and/ or LIF causes
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6
Q

Flank abdominal pain ddx

A

Renal tract

  • infection e.g. pyelonephritis
  • obstruction, e.g. renal colic
  • renal carcinoma
  • renal vein thrombosis
  • polycystic kidney disease
  • adrenal hemorrhage

Other

  • retroperitoneal hemorrhage
  • retroperitoneal infection
  • vertebral pathology
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7
Q

Referred abdominal pain ddx

A
  • Herpes zoster
  • Pneumonia
  • Thoracic spine disease
  • AMI
  • Pericarditis
  • Testicular torsion
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8
Q

Abdominal pain hx

A
  • Age
  • Pain HX (SOCRATES)
  • Associated (GIT history symptoms): focus on nausea, vomiting, bowel motion changes
  • Constitutional symptoms
  • PMHx (surgery especially)
  • Medications
  • FHx (colon Ca, diabetes, HTN, IBD)
  • SHx (alcohol, travel, occupation)
  • Menstrual history (if appropriate)
  • Sexual history (if appropriate)
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9
Q

General abdominal pain ddx

A
  • Uraemia
  • Hypercalcaemia
  • Diabetic ketoacidosis
  • Sickle cell disease
  • Pb poisoning
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10
Q

Abdominal pain examinations

A
  • Full GIT examination, plus relevant CVS/Resp/renal
  • PR
  • Vaginal
  • Urine analysis
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11
Q

General examinations for abdominal pain

A

FBC, ESR

Low Hb can show peptic ulcer, malignancy. High WCC indicates infection/inflam. High ESR can indicate Crohn’s or TB.

U&Es

Urea and Creatinine up will provide insight into uraemia.

LFTs

Thinking cholangitis and hepatitis or acute cholecystitis.

Serum amylase

Pancreatitis. Perforated peptic ulcer or bowel infarct can raise also.

MSU

Blood, protein, culture epositive in pyelonephritis. Red cells in ureteric colic. Must think of glomerular disease also.

CXR

Perforated viscus (gas under diaph.) or lower lobar pneumonia.

AXR

Obstruction (dilated loops of bowel). Local ileus (sentinel loop) – pancreatitis, acute appendicitis. Toxic dilation of UC or Crohn’s. Renal calculi. Calcified aorta aneurysm. Radio-opaque gallstones.

US

Abscesses (appendix, diverticular). Fluid in peritonitis. Aortic aneurysm. Ectopic pregnancy. Gallstones. Kidney cysts/tumours.

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12
Q

Specific examinations for abdominal pain

A
  • Blood glucose (diabetic ketoacidosis)
  • ABGs (metabolic acidosis)
  • Beta HCG (pregnancy)
  • ECG (AMI, or electrolyte/K disturbance)
  • IVP (Kidney stones)
  • CT (aneurys, pancreatitis, malignancy)
  • Barium enema (colon Ca, obstructions)
  • Colonscopy (tumours, diverticular, colitis)
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13
Q

Constipations differential diagnosis

A

Congenital

  • Hirschsprung’s disease

Obstruction

  • Colonic Ca
  • Diverticular disease
  • Extrinsic compression - Pregnancy, tumours

Anal pain

  • Anal fissure
  • Perianal abscess
  • Haemorrhoids
  • Post surg.

Adynamic bowel

  • Paralytic ileus
  • Ischaemic colitis
  • Senility
  • Spinal injury

Endocrine

  • Diabetic autonomic neuropathy
  • Hyperparathyroidism

Drugs

  • Codeine
  • Morphine
  • Atropine
  • Tricyclic antidepressants

Other

  • IBS
  • Diet
  • Anxiety
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14
Q

Relevant history constipation

A

Age

Explore timing, relieving/excacerbating and previous episodes

? Pain Hx (SOCRATES)

Associated (GIT history symptoms)

  • Focus on nausea, vomiting, bowel motion changes in past

Constitutional symptoms

PMHx (surgery and trauma especially)

Medication

FHx (colon Ca, diabetes, HTN, IBD)

Menstrual history (if appropriate)
Sexual history (if appropriate)
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15
Q

Examinations constipation

A
  • Full GIT examination, plus relevant CVS/Resp/renal
  • PR
  • Vaginal
  • Urine analysis
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16
Q

General investigations for constipation

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A

FBC, ESR

Hb low can be anaemia with Ca, WCC high can be diverticular disease. High ESR can be Ca

U&E

High urea with dehydration

Sigmoidoscopy

Tumour or Hirschsprung disease

AXR

Obstruction

17
Q

Diarrhoea ddx

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A

Infective enteritis

  • Bacterial (Escherichia coli, Shigella spp., Vibrio cholera, Clostridium difficile, Campylobacter spp., Salmonella spp., Staphylococci, Yersinia enterocolitica)
  • Viral

Inflammatory

  • UC
  • Crohn’s

Malabsorption

  • Coeliac disease
  • Radiation

Neoplastic

  • Ca
  • Non-neoplastic polyps

**Pancreatic **

  • Chronic pancreatitis
  • Cystic fibrosis
  • Ca

Drug

  • Abx
  • Laxatives
  • Mg antacids
  • Chemo

Other

  • Diverticular disease
  • IBS
  • Ischaemic colitis
  • Anxiety
  • Diet
18
Q

History for diarrhoea

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A
  • Age
  • Pain Hx (SOCRATES)
  • Associated (renal/GIT): focus on nausea, vomiting, cramping
  • Constitutional symptoms (fever, dehydration)
  • PMHx (surgery and trauma especially)
  • Medication
  • SHx (travel)
  • FHx (colon Ca, diabetes, HTN, IBD)
  • Menstrual history (if appropriate)
  • Sexual history (if appropriate)
19
Q

Examinations for diarrhoea

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A
  • Full GIT examination, plus relevant CVS/Resp/renal
  • Vitals for infection
  • PR
  • Vaginal
  • Urine analysis
20
Q

Investigations for diarrhoea

Study These Flashcards
A

FBC, ESR

  • Hb low can be anaemia with Ca bleeding or other cause. High PCV in dehydration. WCC high from infection or diverticular disease. High ESR can be Ca or inflam.

Stool culture and microscopy

  • Infectious causes

U&E

  • High urea with dehydration, low K in dehydration

LFTs

  • Liver mets. from colon Ca ALP will be high

Sigmoidoscopy

  • Tumour, IBD, pseudomembranous colitis

Colonscopy

  • Tumours, colitis, diverticular

Barium enema

  • Tumours, colitis, diverticular disease
21
Q

Specific investigations for diarrhoea

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A

Duodenal/jejunal biopsy

Coeliac disease

22
Q

Jaundice differential diagnosis

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A

Preheptic

  • Congenital
    • Gilbert’s disease
  • Haemolysis
    • Hereditary spherocytosis
    • Sickle cell disease
    • Thalassaemia
    • Malaria
    • Incompatible blood transfusion
    • Autoimmune
    • Haemolytic disease of newborn

Hepatic

  • Acute hepatic disease
    • Viral hepatitis (A, B, C, EBV, CMV)
    • Drugs (paracetamol)
    • Toxins
  • Chronic hepatic disease
    • Chronic viral hepatitis
    • Autoimmune hepatitis
    • ESLD (alcohol, cirrhosis, haemochromatosis, Wilson’s disease)
    • HCC

Posthepatic

  • Lumen
    • Gallstones
    • Infection infestation
  • In the wall
    • Congenital biliary atresia
    • Cholangiocarcinoma
    • Stricture
    • Cholangitis (ascending)
  • Outside the wall
    • Ca of pancreas
    • Chronic pancreatitis
23
Q

History for jaundice

Study These Flashcards
A

Age

? Pain Hx (SOCRATES)

Associated (GIT history symptoms)

  • Focus on nausea, vomiting

Constitutional symptoms (weight loss, malaise)

PMHx

Medication

FHx (Liver disease)

SHx (Alcohol, travel and occupation)

24
Q

Examination for jaundice

Study These Flashcards
A
  • Full GIT examination, plus relevant CVS/Resp/renal
  • Vitals for infection
  • PR
  • Vaginal
  • Urine analysis
25
General investigations for jaundice
**FBC, ESR** * Hb low can be anaemia due to malignancy, haemolysis. WCC high from infection (hepatitis, cholangitis). High ESR can be Ca or inflam. **Reticulocyte count** * Haemolysis **LFTs** * VITAL (see table below) **Viral antibodies** * Viral hepatitis **US** * Gallstones, dilated bilary tree, cirrhosis. **CT** * Ca of pancreas, liver mets.
26
Specific investigations for jaundice
Specialty serum tests for specific markers * Iron and copper (haemochromatosis and Wilsons + others)
27
Differential diagnosis chest pain
**Cardiovascular** * Angina (stable/unstable) * AMI * Acute aortic dissection * Pericarditis **GIT** * Oesophageal reflux * Peptic ulcer * Gastritis **Respiratory** * Pneumonia * PE * Pneumthorax **Musculoskeletal** * Trauma * Herpes zoster
28
Relevant history chest pain
Age Pain HX (SOCRATES) * _Character of pain_ Associated (CVS history symptoms) * _Focus on palpitations, pain Hx_ Constitutional symptoms PMHx Medications FHx (colon Ca, diabetes, HTN, IBD) SHx (alcohol, travel, occupation)
29
Examination for chest pain
* Full CVS and/or respiratory examination, plus relevant GIT * Vitals very important
30
General examinations chest pain
**FBC** * WCC high in infection **Cardiac enzymes** * AMI **ECG** * Angina or AMI **CXR** * Pneumonia, pneumophorax, PE, aortic dissection, trauma
31
Specific investigations chest pain
V/Q scan * Mismatch (PE)
32
Differential diagnosis dyspnoea
**Sudden** * Pneumothorax * Pulmonary oedema * PE * Aspiration * Anaphylaxis * Anxiety * Trauma **Acute** * Asthma * Pneumonia * Tumours * Pleura effusion * Metabolic acidosis **Chronic** * COPD/Emphysema * Heart failure * Anaemia * Arrhythmia * Valvular heart disease * Cystic fibrosis * Pulmonary HTN Interstitial diseases
33
Relevant history for dyspnoea
Age _Explore the Hx: Onset, precipitating factors, relieving factors, happened before_ _Associated (Resp. history symptoms)_ * _Focus cough, wheeze, chest pains_ _Constitutional symptoms_ PMHx Medications FHx _SHx (SMOKING AND OCCUPATION)_
34
Examination dyspnoea
Full respiratory and/or CVS examination, plus relevant GIT. JVP important. Percussion and auscultation vital. Vitals very important
35
General investigations dyspnoea
**FBC** * Low Hb for anaemia as primary cause **Peak expiratory flow rate** * Asthma or COPD **CXR** * Hyperinflation in emphysema, asthma. Consolidation in pneumonia. Fibrosis in interstitial disease. Heart failure with cardiomegaly. Lung collapse. Pneumothorax. Masses: Ca **ECG** * Angina or AMI or arrhythmias or PE **ABGs** * Severity and metabolic acidosis. Respiratory failure.
36
Specific investigations for dyspnoea
Cardiac enzymes * AMI? V/Q scan * Mismatch (PE) Serum and blood cultures * Pneumonia? Spirometry * Restrictive or obstructive disease and severity. Obstructive: reduced FEV1 to FVC ratio with normal VC (asthma, COPS, bronchiectasis, CF) FVL will show plateau in expiration. Restrictive: normal FEV1 to FVC ratio with reduced VC (pulmonary fibrosis, infiltrative lung disease) Bronchoscopy * Foreign body aspiration or biopsy for pneumonia or Ca CT thorax * Only if unsure Echocardiogram * Heart failure of valvular pathology. PE: RSHF and elevated pulmonary a. pressures. Elevated pulmonary a. pressures can also be pulmonary HTN.
37
Differential diagnosis for vomiting
**Central vomiting (direct vomiting centre stimulation)** * Drugs (narcotic analgesics and chemo) * Acute infections (children) * Pregnancy * Diabetic ketoacidosis * Addison’s * Intracranial pressure * Motion sickness * Psychiatric disorders (bulimia) * Offensive sights/smells **Reflex vomiting (afferent fibres to vomiting centre)** Inflammation * Appendicits * Cholecystitis * Pancreatitis * Peptic ulcers * Biliary colic Obstruction * Pyloric stenosis * Small/colon obstruction Irritants * Bacteria (Campylobacter and Salmonella) * Drugs (NSAIDS, Fe, abx) * Alcohol * Poisons * Emetics Other * AMI * Severe pain * Irradiation * Coughing attack
38
Haematemsis/melaena ddx
Swallowed blood Oesophagus * Varices * Reflux oesophagitis * Oesophageal Ca * Mallory Weiss tear Stomach * Peptic ulcer * Gastritis erosions * Ca Small intestine * Merckel’s diverticulum Bleeding disorders Liver disease associated Thrombocytopenia Haemophilia Drugs Anticoagulants Asprin NSAIDS Steroids
39
Left hypochondrium pain
Gastrointestinal * diverticulitis * colitis * colon cancer * constipation * irritable bowel syndrome Reproductive (female) * ectopic pregnancy * acute ovarian event (cyst rupture, hemorrhage, torsion) * Mittelschmerz (ovulation pain mid-cycle) * Pelvic inflammatory disease * Endometriosis Reproductive (male) * seminal vesiculitis * undescended testicle pathology Urinary * renal colic * UTI Pain from nearby areas * abdominal: LUQ, central, groin pain * hip pathology * psoas abscess * rectus sheath hematoma * left lower lobe pneumonia
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