What are the differentials in a patient presenting with bone pain/tenderness, which investigations might you use to help differentiate them?
- Trauma/fracture (steroid increase risk)
- Myeloma and other primary malignancy e.g. sarcoma
- Metastatic spread e.g. Breast, Lung, Kidney, Prostate, Parathyroid
- osteonecrosis
- osteomyelitis
- hydatid cyst (bone is a rare site)
- osteosclerosis
- paget’s disease of bone
- sickle cell anaemia (vaso-occlusive ‘painful’ crises)
- renal osteodystrophy
- CREST syndrome/ sjrogrens syndrome
- Hyperparathyroidism
Tests: PSA (prostate cancer), ESR, Calcium, LFT, Electrophoresis.
Treatment: Treat the cause, bisphosphonates and NSAIDs may control symptoms.
What are the differentials of a women presenting with a breast lump? What investigations might you use to help differentiate them?
Causes:
- pagets disease of breast
- breast carcinoma
- fibroadenoma/fibroadenosis
- Simple cysts
- Abscess
- Galactocele
Investigations: Urgently refer all breast lumps for triple assessment.
What are the differentials of a patients presenting with TATT (Fatigue), and what investigations might you use to differentiate them?
Differential Diagnoses:
- Depression
- Obesity
- Obstructive sleep apnoea
- Poor sleep pattern
- Iatrogenic e.g. Sedatives
- Chronic fatigue syndrome
- Anaemia
- Malignancy
- Renal disease
- Liver disease
- Heart failure
- Hypothyroidism
- Diabetes
- Autoimmune disease
Red flags:
- unexplained weight loss
- Lymphadenopathy with signs of malignancy (e.g. A lymph node that is non-tender, firm, hard, larger than 2cm across, progressively enlarging, supracalvicular, or axillary).
- Any other symptoms or signs of malignancy (e.g. Haemoptysis, dysphagia, rectal bleeding, breast lump, post-menopausal bleeding)
- Focal neurological signs
- Symptoms and signs of inflammatory arthritis, vasculitis (e.g. GCA or PMR), or connective tissue disease
- Symptoms or signs of cardiorespiratory disease (e.g. Angina, asthma, COPD, heart failure)
- Sleep apnoea
Important History Questions:
- Define exactly what is meant by tired or fatigue
- note the duration of the problem
- Ask about previous levels of energy
- Any other symptoms
- Recent changes in medication? (Beta-blockers may cause fatigue)
- Weight gain/loss?
- Polyuria or nocturia? (Diabetes)
- Mensturation? Blood loss?
- Change in bowel habit?
- Sleep? (Early morning waking sign of anxiety/depression)
Tests:
- Urinalysis for glucose and albumin (renal disease)
- Bloods: FBC for anaemia, U+E (renal disease), blood glucose, LFTs, TFTs, consider IgA tissue transglutaminase for coeliac, bone profile.
- ECG if considering cardiac cause.
What are the differentials for a child presenting with Failure to Thrive, and what investigations might you use to help differentiate them?
Failure to thrive means poor weight gain in infancy (falling across centile lines).
Causes:
- 95% are due to not enough food being given, may be problems with feeding.
- CF, Metabolic disease, hypothyroidism, anaemia, endocrine disorder, abuse, IBD, congenital heart disease.
Investigations:
- check feeding technique
- Consider MSU, U+E, Glucose, LFT, Ca2+, proteins, immunoglobulins, CRP, TSH, FBC, Sweat test, urinary amino +/- organic acid chromatography, stools MC+S, CXR, renal or CNS ultrasound. Skeletal survery for dwarfism or abuse. Jejuno biopsy (IBD), ECG, ECHO
Describe Infertility, it’s causes, important history questions, investigations.
Investigate patients complaining of infertility in couples have regular intercourse for at least a year.
Causes: Idiopathic (27%), anovulatory causes (21%), Male factors (24%), Tubal causes (14%)
Important History Questions:
- how long trying, how regular
- any other pregnancies (primary or secondary), partner any other children.
- menstrual history, periods regular (oligomenorrhea in PCOS) pelvic pain or dysmenorrhea (?endometriosis), miscarriages, any surgery? Discharge (STI)
- contraception?, hormonal therapy, terminations? Appendicectomy?
- medications unsafe for pregnancy? Rubella status, HIV, Hep B/C
Investigations:
- general (BMI, Goitre, Anaemia, Hirsutism), abdominal (masses, cushings) and pelvic examinations
- semen analysis (volume more than 1.5ml, sperm more than 15million/ml, Motility (ABCD A+B more than 32%), morphology more than 4% normal. Cause of poor semen analysis (Varicocele, infection, exposure to heat, mumps)
- Day 5 FSH (less than 35U/L) and L
- serum mid-luteal progesterone (7 days before expected period) more than 30nmol/L suggests ovulation
- consider Prolactin and TFTs as differentials
- testosterone should be less than 2.7nmol/L (measure Free Androgen Index as some testosterone bound to Sex Hormone Binding Globulin (SHBG) testosterone X 100 / SHBG. If raised DHEA checks for adrenal involvement.
- imaging US then consider hysterosalpingogram or laparoscopy and dye.
What are the differentials for a Pregnancy woman presenting with breathlessness, and what investigations might you perform to differentiate them?
Differentials:
- Physiological changes of pregnancy
- Respiratory: Pulmonary embolism, Asthma, Pneumothorax, Pneumonia, Pulmonary oedema
- Cardiac: Cardiomyopathy, pulmonary hypertension, valvular disease, anaemia
- Amniotic Fluid Embolism
History + Examination:
- Symptoms: Duration, Pre-existing (e.g. Asthma + Cardiac) Chest pain, Sputum, Fever, Family members sick, FH thromboembolic disease, previous pregnancies? (Any issues)
- Obs: RR (Does not change in Physiological), HR (may be raised but over 100 usually abnormal e.g. in PE), O2 sats, Peripheral Oedema (may be normal, also occurs in right heart failure or pre-eclampsia)
Investigations:
-CTPA, ECG (sinus tachy), CRP, FBC, PEF (normal in physio), ABG, CXR
What are the differentials of a woman presenting with pelvic pain, and what investigations might you use to differentiate them?
Differentials:
- Pregnancy
- Appendicitis
- Ovarian Torsion
- Ectopic pregnancy
- Mittelschmerz
- PID
History + Examination:
-Symptoms: Acute or Chronic?, Character of pain (appendicitis begins with general visceral pain migrating to somatic pain in RIF), Peritonism?, Fever (Favouring Appendicitis/ PID). Pain worse on coughing? Anorexia?, Relation to period? LMP? PV Bleeding (Prune juice in ectopic). Ever had it before?
Investigations:
-Pregnancy test, FBC, CRP, U+E, USS (fluid in pouch of Douglas points to ruptured ectopic), vaginal swab (chlamydia).
What are the differentials of a child presenting with vomiting, and what investigations might you use to distinguish them?
Effortless regurgitation of milk is common during feeds ‘posseting’. Vomiting between feeds is also common. Ask about carpets: Significant committing in a bay will have caused lots of damage, no damage unlikely to pathological. Try to observe feeding to establish severity. Bilious vomiting requires urgent help. Is the baby gaining weight, wetting nappies? Fever?
Differentials:
- GORD
- Over feeding (150mL/Kg.day is normal)
- pyloric stenosis (projectile vomiting)
- UTI
- Pharyngeal pouch
- metabolic conditions
- General illness
- Obstruction or volvulus (Bilious green vomiting)
- GI malformations (Bilious green vomiting)
Investigations:
-Sats, Temp, NG tube, AXR, Endoscopy, Clean-catch urinalysis.
What are the differentials for a lady presenting with nipple discharge, and what investigations might you use to differentiate them.
Causes:
- Mastitis
- Lactation, Galactorrhoea
- Duct ectasia
- Breast Cancer
- Duct papilloma
Investigations: Colour, Consitency?, Unilateral or Bilateral, Spontaneous or elicited. Unilateral spontaneous nipple discharge should raise suspicion of DCIS. Green nipple discharge could be due to Duct ectasia.
What are the differentials of a pregnant woman presenting with reduced foetal movements, and what investigations might you use to differentiate them?
Maternal perception of foetal movements is one of the first signs of life, they are first perceived between 18-20wks of gestation and rapidly acquire a regular pattern. A reduction in foetal movements is a significant warning sign of impending foetal death. (55% of women with stillbirth reported a reduction in foetal movements prior to diagnosis.
Causes:
- sleep cycle, usually last 20-40 minutes and rarely last more than 90.
- sedating drugs which cross the placenta such as alcohol, benzodiazepines, methadone, opiates.
- Foetal Hypoxia (large head, small abdomen)
Investigations:
- CTG monitoring/ FHR monitoring (normal foetal heart rate does not exclude chronic hypoxia)
- assess risk factors for stillbirth e.g. Diabetes control, Pre-eclampsia, IUGR, placental insufficiency, extremes of age, primips tity, smoking, obesity.
- USS scan + MCA, Uterine, Umbilical Doppler Assessment
What are the differentials of a patient that presents with a genital ulcer, and what investigations might you use to help differentiate them?
Causes:
- Genital herpes (painful, dysuria, discharge, tender glands, new sexual partner)
- Primary syphilis (Chancre, painless)
- Chancroid
- Lymphogranulare Venereum (painful lymphadenopathy)
- Behcets disease (painful ulcers, mouth ulcers)
- granuloma inguinale (donovanosis)
Examination:
-Pain? Induration? Nodes? Number?
Investigations: Swab, STI screen, FBC,
What are the differentials of a patient presenting with an ulcer, and what features might help differentiate them?
Typical Causes:
- gravity/stasis/pressure
- neuropathy (painless/diabetes)
- Venous (less painful, poorly circumscribed, shallow)
- Arterial (painful punched out well demarcated)
- Trauma
Rarer Causes:
- Pyoderma gangrenosum (UC, Crohn’s)
- Sickle-cell disease
- vasculitis (SLE, RA)
- Cryoglobulinaemia
- malignancy
- leishmaniasis
What are the differentials of patient presenting with Blackouts and what features and investigation of might help one differentiate between them.
Causes:
- Vasovagal Syncope
- situational syncope
- epilepsy
- stokes-Adams attacks
- drop attacks
- hypoglycaemia
- orthostatic hypotension
- anxiety
Important History Questions:
- LOC? Witnessed? Gap in memory?
- Any injuries? Patient hit head?
- Any movements after blackout, clonic jerks may occur with syncope but tonic-clonic movements is suggestive of epilepsy
- Any incontinence? Suggestive of epilepsy but can occur in others
- Tongue biting? Suggestive of epilepsy
- Post-ictal drowsiness (Epilepsy) Or rapid recovery? (Vasovagal)
- Any aura or pre syncope? What were they doing at the time?
- any muscle ache, can suggestive tonic-clonic seizures.
Investigations:
- cardiac, neurological BP lying and standing
- ECG, U+E, FBC, Glucose, tilt-table test
What are the differentials for a patient presenting with shortness of breath, and how might one differentiate between them?
Causes:
- cardiac e.g. MI, pulmonary oedema, arrhythmia, valvular disease, heart failure, anaemia
- pulmonary e.g. Pneumonia, pneumothorax, PE, asthma, COPD, lung cancer, pulmonary fibrosis
- metabolic e.g. Thyroid disease, obesity, DKA,
- neuromuscular e.g. Guillian-barre, myasthenia gravis
- anxiety
History:
- Acute vs chronic
- cough? Chest pain? Weight loss? Haemoptysis? Polyuria? Dizziness? Diurnal variation? Medications?
Investigations:
- cardiac and respiratory examination, fever?
- spirometry
- CXR, Echo
- Bloods: FBC, TFT, BNP, CRP
What are the differentials for a patient presenting with jaundice, and what features and investigations might help one distinguish between them?
Pre-hepatic causes (Unconjugated hyperbilirubinaemia):
- overproduction i.e. Haemolysis e.g. Malaria, DIC
- Impaired hepatic uptake e.g. Contrast agents, Rifampcin, right heart failure
- impaired conjugation e.g. Gilbert’s, Crigler-Najjar (neonate)
- physiological neonatal jaundice is a combination of the above.
Hepatic causes:
-Hepatitis B/C, EBV, CMV, Paracetamol OD, MAOi, Valproate, Statins, alcoholic hepatitis, cirrhosis, haemochromatosis, neoplasm, abscess, autoimmune hepatitis, alpha1-antitrypsin deficiency, wilsons disease.
Post-hepatic causes (Conjugated Hyperbilirubinaemia):
-primary biliary cirrhosis, primary sclerosing cholangitis, flucoxacillin, sulfonylureas, ascending cholangitis (common bile duct stones), pancreatic carcinoma, cholangiocarcinoma.
History questions:
- Pale stools dark urine? (Obstructive jaundice)
- Blood transfusions/IVDU/high risk sexual activity (Hepatitis B/C)
- Travel abroad (Malaria, leptospirosis)
- FH (haemochromatosis = autosomal recessive, IBD?, autoimmune?)
- alcohol use, obese (Alcoholic hepatitis, NAFLD, cirrhosis)
Investigations:
- FBC (Haemolysis), U+E, Clotting (DIC), Blood film (Malaria), LFT (if AST over 1000 likely viral hepatitis), Hep B/C serology.
- US (dilated bile ducts over 6mm = obstruction), hepatic metastases? Pancreatic mass?
- ERCP if bile ducts dilated and LFT not improving
- liver biopsy if US normal
- CT if suspect malignancy
What are the differentials for a patient presenting with haemoptysis and how might one differentiate between them.
Causes:
- Bronchitis
- Pulmonary Tuberculosis (Night sweats, cyclical fever)
- Lung abscess (febrile)
- Pneumonia (SOB, Cough, febrile)
- Primary lung cancer (Weight loss, lymphadenopathy, chronic cough)
- Lung metastatises
- Anticoagulants
- bronciectasis (pruluent sputum, multiple past infections, CF
- PE (sudden onset, pleuritic chest pain)
- Mitral valve stenosis (Murmur)
- LVF (SOB)
- thrombocytopenia/ DIC
- AV malformation
- airway trauma
- aspergillosis
Management:
- CXR
- ABCDE
- interventional radiology if severe
- FBC, Coag, culture
What are the differentials of a patient presenting with a motor peripheral neuropathy?
Guillian-Barre
Chronic Inflammatory Demyelinating Polyneuropathy
Charcot-Marie-tooth
Drugs e.g. Lead, vincristine, metronidazole, nitrofuratoin
What are the differentials for a patient presenting with gynaecomastia?
Drug induced: -digoxin, spironolactone, sex hormones, anti-androgens, methyldopa, antihistamines, Alcohol Cirrhosis Hypo/Hyperthyroidism Hypoadrenalism Cancer
What are the differentials for a patient presenting with proximal myopathy?
Inherited myopathies:
- muscular dystrophies e.g. Duschennes, Beckers, FSH
- Biochemical defects causing myopathy e.g. Glycogen storae disorders, mitochondrial myopathy
Acquired myopathies:
- Immunological e.g. Polymyositis, dermatomyositis, SLE, RA, polyarteritis nodosa, PMR
- Non-Inflammatory e.g. Hyperthyroidism, hypothyroidism, cushings, DM, sarcoid
- Drug induced e.g. Steroids, statins, zidovudine
- infection e.g. HIV, toxoplasmosis, influenza, Lyme disease.
What are the differentials for a patient presenting with haematochezia (PR bleeding)?
Diverticular disease Colonic angiodysplasia Colorectal cancer Internal haemorrhoids Anal Fissue IBD -Crohn's/UC Infectious colitis Ischaemic colitis Vasculitis Rectal Variceal Endometriosis
What are the differentials for a patient presenting with lymphadenopathy?
Viral: URTI, Glandular fever, CMV, Rubella, Varicella, Measles, HIV, Hep A and B, Roseola infantum (HHV-6), dengue fever, adenovirus
Bacterial: Septicaemia, typhoid fever, TB, syphilis, Lyme disease, brucellosis
Protozoan: toxoplasmosis, leishmaniasis, Chagas’ disease
Autoimmune: Juvenile idiopathic Arthritis, SLE, drug reactions (phenytoin, allopurinol)
Storage disease: gaucher’s, niemann-pick
Neoplastic: Leukaemia, lymphoma, neuroblastoma, castlemans
What are the differentials of a patient who on examination has hepatomegaly?
Common causes: Hepatitis, Malignancy, Right Heart failure
Other causes:
- congenital: liver cysts
- infective: viral hepatitis, malaria, glandular fever, abscess
- neoplastic: mets, leukaemia, HCC
- inflammatory: sarcoidosis, amyloidosis, haemochromatosis, PBC
What are the causes of macroglossia?
Hypothyriodism Acromegaly Amyloidosis Duchenne muscular dystrophy Mucopolysaccharidosis e.g. Hurler Syndrome -IDA
(Patients with Down’s syndrome are thought to have apparent macroglossia due to a combination of med-face hypoplasia and hypotonia)
What are the differentials for a patient presenting with Pyrexia of Unknown Origin?
Defined as pyrexia over 38.3 for over 3weeks, with no obvious source despite appropriate investigations e.g. 3 days in hospital or 3 outpatient visits.
Causes:
- Infection (23%) e.g. abcesses, empyema, bacteria, rheumatic fever, TB, IE.
- Connective Tissue Diseases (22%) e.g. RA, PMR, Still’s disease, GCA, SLE, PAN, Kawasaki
- Neoplasms (20%) e.g. Lymphoma, Solid tumours (e.g. GI, Renal)
- Drug-related (3%) - (Associated with eosinophilia
- Miscellaneous (14%) - PE, IBD, Amyloid, Sarcoid, Hyper IgD syndrome.
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