Core presentation differentials

Question 1

Acute Confusional State (ACS) Differentials

Answer 1

D rugs
E yes/Ears and Endocrine
L ow O2
I ctal
R estraints/Retention
I  nfections
U ndernutrition
M etabolic
S troke/Subdural/Sleep deprivation

Question 2

Acute Confusional State (ACS) Drug Causes

Answer 2

D opamine agonists
R ecreational
O piates
A nticonvulsants
A ntidepressants
A nticholinergics 
N euroleptics
S edatives

Question 3

Acute Confusional State (ACS) Hypoxic Causes

Answer 3

AMI, ARDS, PE, CHF, COPD

Question 4

Acute Confusional State (ACS) Endocrine Causes

Answer 4

Hyperthyroid, hypothyroid, Addison’s disease, diabetic pre-coma, hypoglycaemia

Question 5

Acute Confusional State (ACS) Infective Causes

Answer 5

Systemic-Pneumonia, UTI, wounds, IV lines

Intracranial- Meningitis, encephalitis, cerebral abscess

Question 6

Acute Confusional State (ACS) Metabolic Causes

Answer 6

Electrolyte disturbances (eg. severe hyponatraemia, acute hypercalcaemia); hepatic, renal, cardiac or respiratory failure; hypoxia, hypercapnia, anaemia

Question 7

Acute Confusional State (ACS) Nutritional Causes

Answer 7

Thiamine, nicotinic acid, B12 deficiency

Question 8

Acute Confusional State (ACS) Intracerebral Vascular Causes

Answer 8

Stroke, MI; brain haemorrhage (subdural, extradural, intracerebral, subarachnoid), venous sinus thrombosis

Question 9

Acute Confusional State (ACS) Eight Assessable Signs

Answer 9

All acute onset
D isordered thinking
E uphoria, fearful, angry or depressed
L anguage impaired
I llusions/delusions/hallucinations
R eversal of sleep-wake cycle
I nattention
U naware/disoriented
M emory deficit

Question 10

Acute Confusional State (ACS) Examination

Answer 10

General Observation + Vitals (signs of sepsis, cardiac/resp failure)

MMSE - abbreviated: [10 points,

Question 11

Acute Confusional State (ACS) Investigations

Answer 11

Driven by history and examination.

Standard: Blood Glucose, Electrolytes, FBE, ABG, Urine M/C/S, CXR, ECG

Specific: Brain imaging, EEG, Septic source, Endocrine function, Plasma drug concentrations

Question 12

Altered Bowel Habit Differentials

Answer 12

CD CD MIG

Change in diet 
Drug induced
Cerebral/spinal cord lesion 
Depression 
Metabolic 
Immobility / Infection
Gastrointestinal

Question 13

Altered Bowel Habit Gastrointestinal Causes

Answer 13

Ask: context blood, pain on defecation/relief on defecation/effect of food/weight loss/pallor

Carcinoma of colon and rectum, Irritable Bowel Syndrome (IBS), Diverticular disease, Inflammatory Bowel Disease (UC, Chron’s), rectal dyschezia, irritable colon

Question 14

Altered Bowel Habit Drug Causes

Answer 14

Ask recent drug history

Constipating drugs (opiods, hypotensive agents, aluminium alkalis), purgative dependence, antibiotics (change in colonic bacterial flora)

Question 15

Altered Bowel Habit Metabolic Causes

Answer 15

Ask Heat/cold intolerance, change in appetite, lump in neck; moans, stones, groans, polyuria, polydipsia; palpitations

Hypothyroidism, hyperthyroidism, hypercalcaemia, hypokalaemia

Question 16

Altered Bowel Habit Examinations

Answer 16

Abdominal Exam, DRE

Question 17

Altered bowel habit Neurological Causes

Answer 17

Ask Neurological symptoms (parasthesia/dysasthesia) +/-abnormal sphincter tone and anal sensation

MS, Spinal Cord Lesion, Cerebral lesion

Question 18

Altered bowel habit Investigations

Answer 18

Standard: Stool inspection, proctoscopy, sigmoidoscopy; FBE, UEC, LFTs; Abdo Xray and CT
Specific: Colonoscopy with biopsy, barium enema, CT/MRI CNS, thyroid function tests, serum Ca, K, etc.

Question 19

Acute Abdomen Differentials

Answer 19

SAUCED HIPPO
S trangulation of Bowel
A ppendicitis
U lcer perforation
C holangitis
E ctopic pregnancy
D iverticulitis

H aemorrhage
I schaemia (mesenteric, splenic)
P ancreatitis
P elvic inflammatory disease
O bstruction

Question 20

Abdominal Pain: RLQ

Answer 20

APPENDICITIS

A ppendicitis / Abscess
P ID/Period
P ancreatitis
E ctopic/Endometriosis
N eoplasia
D iverticulitis
I ntussusception
C hron's Disease/Cyst
I BD
T orsion (ovarian)
I rritable Bowel Syndrome
S tones

Question 21

Abdominal Pain: RUQ

Answer 21

HD CRAAP

H epatitis
D uodenal ulcer

C ongestive hepatomegaly
R ight pneumonia
A cute cholecystitis
A ppendicitis
P yelonephritis

Question 22

Abdominal Pain: LUQ

Answer 22

GRAPPL

G astric ulcer/Gastritis
R uptured spleen
A ortic aneurysm
P erforated colon
P yelonephritis
L eft pneumonia

Question 23

Abdominal Pain: Periumbilical

Answer 23

MA, IDEA!

M esenteric thrombosis
A ortic aneurysm

I ntestinal obstruction
D iverticulitis
E arly appendicitis
A cute pancreatitis

Question 24

Abdominal Pain: Lower Midline

Answer 24

EPICC FOAM

E ndometriosis
P ID
I BS
C ancer (uterine)
C ystitis

F ibroids
O varian cancer
A ortic aneurysm
M enstrual pain

Question 25

Abdominal Pain: LLQ

Answer 25

CT PRESSUReS Crohn’s Tubo-ovarian abscess ``` Perforated colon Renal/ureteric stone Endometriosis Sigmoid diverticulitis Salpingitis Ulcerative Colitis Ruptured Ectopic Strangulated hernia ```

Question 26

Abdominal Pain: History Questions

Answer 26

Nature of Pain (site (+ radiation), severity, quality, time course (onset, constancy), context, aggravating/relieving factors) --Effect of respiration, food, movement, micturition, menstruation, defecation Vomiting: onset, frequency, content Change in Defecation: constipation/diarrhoea- onset, frequency, content Infection: Fever, rigors, Immunisations, Contacts, Travel, Occupation, Animals, Drugs, Sexual contacts Constipation: Distension Cancer/Chronic infections: Systemic symptoms (weight loss, tiredness, anorexia, night sweats) PMHx: previous surgery, recent trauma, menstrual history

Question 27

Abdominal Pain: Examination

Answer 27

Vitals (raised pulse and temperature in inflammatory conditions) Chest Examination Abdominal, Rectal and Vaginal Examinations

Question 28

Abdominal Pain: Investigations

Answer 28

Standard: FBE, UEC, LFTs, serum amylase/lipase, MSU, CXR, AXR, US Specific: ECG, BSL, serum calcium, betaHCG, IVU, gastrograffin enema, angiography, CT

Question 29

Microcytic Anaemia: DDx

Answer 29

Find Those Small, Plump Cells ``` Fe deficiency Thalassaemia Sideroblastic anaemia Pb poisoning Chronic disease ```

Question 30

Microcytic Anaemia: History Questions

Answer 30

Blood loss: Menstrual history, PR bleed Iron deficiency: PUD - malaena, reflux, poor diet Thalassaemia: FHx, Mediterranean origin PMHx: Chronic disease

Question 31

Microcytic Anaemia: Investigations

Answer 31

Standard: FBE (thalassaemia has much lower MCV), film, iron studies (serum Fe, Ferritin, Total Iron Binding Capacity) Specific: Hb electrophoresis

Question 32

Macrocytic Anaemia: DDx

Answer 32

FAT Dumb RBC Foetal Alcohol Thyroid (Hypothyroid) Drug (AZT, cytotoxic, phenytoin, barbituates)/Dysplasia Reticulocytosis B12/folate deficiency Cirrhosis and Chronic liver disease

Question 33

Macrocytic Anaemia: History

Answer 33

Med Hx: Autoimmune disease eg. primary hypothyroidism, vitiligo, etc; Malabsorption, surgery Dietary history (including alcohol) Pregnancy, lactation Drugs: Phenytoin, barbiturates, methotrexate Symptoms of liver disease, hypothyroidsm and haemolysis (jaundice?)

Question 34

Macrocytic Anaemia: Investigations

Answer 34

Standard: FBE, film, serum B12 and folate Specific: Intrinsic factor antibody, TFTs, Urine-urobilinogen, Bone marrow biopsy

Question 35

Normocytic Anaemia: DDx

Answer 35

``` Anaemia of chronic disease (eg. rhematoid arthritis, hypogonadism, etc) Chronic renal failure Anaemia of pregnancy Hypothyroidism Haemolysis Bone marrow failure ```

Question 36

Normocytic Anaemia: History

Answer 36

Med Hx of chronic disease, renal failure Uraemic symptoms (fatigue, weight loss, tremors, muscle wasting) Pregnancy Symptoms of hypothyroidism (reduced appetite, weight gain, puffy eyes, constipation, etc), haemolysis, pancytopaenia (bruises, infections, etc)

Question 37

Normocytic anaemia: Investigations

Answer 37

FBE, UEC, iron, B12, folate, TFTs, bone marrow biopsy

Question 38

Anorectal Pain: DDx

Answer 38

Acute: thrombosed hemorrhoids, perianal hematoma, anal fissure, perianal abscess, trauma, anorectal gonorrhea, herpes Chronic: proctalgia fugax, hemorrhoids, anorectal malignancy, rectal ulcer, anal fistula, chronic perianal sepsis

Question 39

Anorectal Pain: History

Answer 39

``` Pain (time course (onset, duration), context, aggravating/relieving factors, associated features (defecation, tenesmus, blood, itching, discharge, spasms, abdominal pain, diarrhea)) Any changes in bowel habit, fever, weight loss PMHx: hemorrhoids, trauma Sexual Hx (anal sexual exposure) ```

Question 40

Anorectal Pain: Examination

Answer 40

Rectal Examination (external examination including buttocks; digital rectal examination)

Question 41

Anorectal Pain: Investigations

Answer 41

Standard: FBE, proctoscopy (swab), sigmoidoscopy Specific: endo-anal US, MRI

Question 42

Arthritis: DDx

Answer 42

Monoarthritis: septic arthritis, trauma, crystal arthropathies (gout/pseudogout), osteoarthritis, monoarticular presentation of a polyarticular disease (e.g. RA), psoriatic and reactive arthritides Polyarthritis: viruses, RA, OA, spondyloarthritides (seronegative), connective tissue diseases (e.g. SLE), crystal arthropathies, post-streptococcal reactive arthritis

Question 43

Arthritis: Hx

Answer 43

Site, severity, quality, time course (onset, duration), context, aggravating/relieving factors Associated features (swelling, weakness, instability, neurological symptoms (numbness/tingling), deformity, stiffness) Systemic symptoms (fever, eye or skin involvement, lungs, kidneys (dysuria), heart, GI (mouth ulcers, bloody diarrhea, CNS)) PMHx: recent trauma, infection, OA, past trauma, RA, gout Drugs: pain medications (past/present), side effects or concerns

Question 44

Arthritis: Investigations

Answer 44

Standard: FBE, RF, XR Specific: blood culture, joint aspiration, arthroscopy, CT/MRI, serum uric acid, CXR

Question 45

Back Pain: DDx

Answer 45

DISK MASS D egeneration (DJD, osteoporosis, spondylosis) and Drugs I nfection/Injury S pondylitis K idney M ultiple Myeloma and other neoplasms/Metabolic A bdominal pain/Aneurysm S kin (HSV)/Strain/Scoliosis and lordosis S lipped disk/Spondylolisthesis

Question 46

Back Pain: Neoplastic causes

Answer 46

Mets from breast, prostate, bronchus, kidney, thryoid, colon Direct invasion from oesophagus, myeloma, leukaemia, lymphoma, meningioma, glioma, lipoma, neurofibroma, osteoblastoma, hamangioma and osteoid osteoma

Question 47

Back pain: Drug Causes

Answer 47

Steroids, methysergide

Question 48

Back pain: Metabolic Causes

Answer 48

osteoporosis, osteomalacia, Paget’s, hypre and hypoparathyroidism

Question 49

Back pain: Hx Questions

Answer 49

Pain (site (+ radiation + localisation, underlying bone pathology or malignancy), severity, quality, time course (onset, constancy), context, aggravating/relieving factors, pattern of pain) Fever, rigors, night sweats Age of patient!!! Systemic symptoms (weight loss, tiredness, anorexia, night sweats) Urinary symptoms and changes in defecation PMHx: previous surgery, recent trauma, malignancy Meds: corticosteroids

Question 50

Back pain: Examination

Answer 50

Vitals (raised pulse and temperature in inflammatory conditions) Spine: Fixed deformities eg kyphosis Spinal tilt/scoliosis Haematoma ``` Neuro: • Peripheral neuropathy • Cauda equina • Loss of knee jerk (L3,4) • Loss of big toe extension (L5) • Upgoing plantars • Test sensation in saddle area S3-5 Signs of steroid use ie. Cushingnoid facies ``` Cardio - Look for aortic aneurysm/dissection ``` GI: • Signs of pancreatitis • Tenderness under right costal margin • Polycystic kidneys • DRE ```

Question 51

Back pain: investigations

Answer 51

Standard: FBE, UEC, LFTs (ALP), serum amylase/lipase, ESR, CRP, spinal XR, calcium, PTH Specific: PSA, CT abdomen, pelvis, CXR, breast US, BMD-DEXA, Bence Jones protein, bHCG, MRI if spinal compression suspected, Vit D, HLA-B27 testing, blood cultures, blood film, KUB, gastroscopy for IBD, lumbar puncture.