Differential diagnoses Flashcards
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1
Q
DDx
Abdominal pain
- Constant
- Colicky
- Pain on eating
A
- Inflammation, ischaemia
- Obstruction of a viscus
- Peptic ulcer, pancreatitis, cholecystitis, mesenteric ischaemia
2
Q
DDx
Epigastric pain
A
- Peptic ulcer
- Pancreatitis
- Reflux oesophagitis
- Acute gastritis
- Malignancy: gastric, pancreatic
- Pain from adjacent areas: RUQ, central abdo pain, cardio/pulm/pleural pathology
- Functional disorders: nono-ulcer dyspepsia, IBS
3
Q
DDx
RUQ pain
A
- Gall bladder path: cholecystitis, biliary colic, cholangitis
- Liver path: hepatitis, hepatomegaly (CCF, Budd-chiari syndrome); hepatic tumours, hepatic/subphrenic abscess
- Pain from epigastrum (pancreatitis, peptic ulcer), RIF, loin pain, pulm/pleural path (pneumonia, empyema, pulm infarction)
- Appendicitis in pregnant women
- Colonic cancer in hepatic flexure
- Herpes Zoster
- Fitx-hugh curtis syndromerare - complication of pelvic inflammatory disease
4
Q
DDx
RIF pain
A
- GI: appedicitis, IBD, colonic cancer, constipation IBD
- Repro: Females: ovarian cyst tortion/rupture/haemorrhage, ectopic pregnancy, salpingitis/pelvic inflammatory disease, endometriosis
- Males: seminal vesiculitis, cancer in undescended testis
- Renal: UTI, ureteric colic (renal stones)
- Pain from adjacent areas: RUQ, suprapubic, central abdo pain, groin pain, hip pathology, psoas abscess, rectus sheath haematoma, right-sided lobar pneumonia
5
Q
DDx
Suprapubic pain
A
- Urinary retention
- Cystitis
- Pain from adjacent areas - RIF/LIF
6
Q
DDx
LIF pain
A
- GI: diverticulitis, IBD, colonic cancer, constipation, IBS
- Repro:
- Females: ovarian cyst tortion/rupture/haemorrhage, ectopic pregnancy, salpingitis/pelvic inflammatory disease, endometriosis
- Males: seminal vesiculitis, cancer in undescended testis
- Renal: UTI, ureteric colic (renal stones)
- Adjacent areas: LUQ, suprapubic, central abdo, hip path, psoas abscess, rectus sheath haematoma, left sided lobar pneumonia
7
Q
DDx
LUQ pain
A
- Splenic rupture, splenic infarction, splenomegaly
- Subphrenic abscess
- Pain from adjacent areas: epigastric, LIF, loin pain, cardio/pulm/pleural path (MI, pericarditis, pneumonia, empyema, pulm infarction)
- Colonic cancer in splenic flexure
- Herpes zoster
8
Q
DDx
Central abdo
A
- GI: intestinal obstruction, early appendicitis, gastroenteritis
- Vascular: AAA (ruptured), mesenteric ischaemia
- Medical: DKA, uraemia
- Adj areas: epigastric, iliac
9
Q
DDx
Loin pain
A
- Infection: UTI, perinephric abscess/pyonephrosis
- Obstruction: renal stones
- Renal disease: tubulointerstitial nephritis, IgA nephropathy, renal vein thrombosis, renal carcinoma, polycystic kidney disease
- Haemorrhagic adrenal infarction
- Aortic dissection (type B)
- Pain from vertebral column
10
Q
DDx
Groin pain
A
- Renal stones (pain radiating from loin to groin)
- Testicular pain - tortion, epididymo-orchitis
- Hernia - inguinal
- Hip path
- Pelvic fractures
11
Q
DDx
Diffuse abdo pain
A
- Gastroenteritis
- Peritonitis
- Intestinal obstruction
- IBD
- Mesenteric ischaemia
- Medical causes - DKA
- CVS/resp: MI, pneumonia
- Metabolic: DKA, addisonian crisis, HerCa, uraemia, porphyria,paheo, lead poisoning, hereditary angioedema
- Neuro: herpes zoster, tabes dorsalis
- Haem: sickle cell crisis, retroperitoneal haemorrhage, lymphadenopathy
- Inflammatory: vasculitis
- Infections: intestinal parasites, TB, malaria, typhoid fever
- IBS
- IBS
12
Q
DDx
Abdo distention
A
- Fat
- Fluid
- Flatus (intestinal obstruction - small bowel: adhesions, herniae, intussusception, CD, tumour, TB; large bowel: cancer, volvulus, diverticulitis, faeces), perf viscus
- Faeces
- Fetus
- Giant organomegaly
13
Q
DDx
Metabolic Acidosis
A
- Normal anion gap:
- ^GI bicarb loss: diarrhoea, fistula (biliary, intestinal, pancreatic), ileostomy
- t1 renal tubular acidosis: dec H+ secretion
- T2 RTA: dec HCO3 reabsorption
- T4 RTA: suppression of ammonia excretion hyperK
- High anion gap:
- Ketoacidosis: DM, excess alcohol, starvation
- Lactic acidosis -> tissue hypoxia, drugs (metformin, ethanol, methanol, zidovudine), short gut syndrome, leukaemia, lymphoma, liver failure, G6PD
- Renal failure
- Salicylate poisoning
14
Q
DDx
Respiratory Acidosis
A
- CNS:
- Organic disease involving resp centre (vasc, infection, inflammatory, trauma, tumour)
- Drugs: opiates, BZD, barbiturates
- Lungs: severe asthma (uncommon), COPD, large airway obstruction, Obs sleep apnoea
- Neuromuscular:
- Motorneurone: Guillain-Barre syndrome, motor neurone disease, polomyelitis, acute porphyria
- NMJ/muscle: myasthenia gravis, muscular dystrophy, muscle relaxant, diaphragmatic paralysis
- Chest wall: severe kyphoscoliosis, severe obesity, traumatic flail chest
15
Q
DDx
Metabolic alkalosis
A
- GI loss of H+: vomiting, laxative abuse, villous adenoma, VIPoma
- Renal loss of H+: hyperaldosteronism
- Excess glucocorticoids: cushing’s sydnrome, liquorice
- ^ Na delivery to distal nephron: diuretics thiazides and loop diuretics
- Intercellular shift of H+: hypokalaemia
- Others: compensation for resp acidosis
- Excessive alkali ingestion, fulminant hepatic failure
16
Q
DDx
Respiratory Alkalosis
A
- Hyperventilation:
- Physiological (anxiety, pain, fever, pregnancy, high altitude)
- Mechanical overventilation
- Resp failure: type 1 - asthma, COPD, pneumonia, pulm oedema, pulm embolism, ARDS, fibrosing alveolitis
- CO poisoning
- CNS disease: stroke, infection, tumour, trauma
- Others: liver failure, GN septicaemia
17
Q
DDx
Macrocytic Anaemia
A
- Alcohol
- Folate/B12 deficiency
- Haemolytic anaemia
- Hypothyroidism
- Liver disease
- Myelodysplasia
- Drugs: methotrexate, hydroxyurea, azathioprine, zidovudine
18
Q
DDx
Microcytic anaemia
A
- IDA: blood loss (GI, urogenital, hookworm, malabsorption, ^ demands, decreased intake
- Thalassaemia
- Sideroblastic anaemia - x-linked, alcohol, drugs, lead, myelodysplasia
- Lead poisoning
- Anaemia of chronic disease
19
Q
DDx
Normocytic anaemia
A
- Anaemia of chronic disease (chornic infection, inflamm/connective tissue diseases, malignancy)
- Haemolytic anaemia
- Hypothyroidism
- Pregnancy
- Renal failure
- Bone marrow failure
20
Q
DDx
Haemolytic anaemia
A
- Hereditary:
- Haemoglobinopathies: sickle cell and thalassaemia
- Membrane defects: spherocytosis, elliptocytosis
- Metabolic defects: pyruvate kinase deficiency, G6PD
- Acquired:
- AI: warm Ab (SLE, lymphoma), cold Ab (EBV, lymphoma)
- Alloimmune: transfusion
- Drugs: penicillin, quinidine
- Microangiopathic haemolytic anaemia: TTP, HUS, DIC, malignant HTN
- Artificial heart valves
21
Q
DDx
Aplastic anaemia
A
- Idiopathic:
- Inherited: fanconi anaemia, dyskeratosis congenita
- Acquired: drugs, chemicals, radiation, viral infection (B19 parvovirus, HIV, hepatitis, measles)
22
Q
Causes of Aortic regurg:
A
- Valve leaflet abnormalities: infective endocarditis, RhF, trauma, bicuspid aortic valve
- aortic and valve ring dilatation: aortic dissection, aortitis, arthritides (RhA, ankspond) ^ BP
- Others: Marfan’s syndrome, pseudoxanthoma elasticum, Ehlers-Danlos syndrome, osteogenesis imperfecta, IBD
23
Q
Causes of Aortic stenosis
A
- Stenosis secondary to RhHD
- Calcification of a congenital bicuspid AV
- Calcification/degeneration of a tricuspid AV in elderly
24
Q
DDx
Increased APTT
A
- Haemophilia
- vWD
- Liver disease
- Warfarin therapy, vitamin K def
- Heparin
- DIC
- Antiphospholipid syndrome
25
DDx
Hypoxia and
1. Normal/low PaCO2
2. High PaCO2
1. Resp Failure T1:
1. Asthma
2. COPD
3. Pulm embolism
4. Pulm oedema
5. Pneumonia
6. Pulm fibrosis
7. R -\> L shunt
8. ARDS
2. Resp Failure T2:
1. CNS:
1. Organic disease involving resp centre
2. Drug: opiates, BZD, Barb
2. Lungs:
1. Severe asthma
2. COPD
3. Large airway obstruction
4. Obstructive sleep apnoea
3. Neuromuscular:
1. Motor neurones: GBS, MND, poliomyelitis, acute porphyria
2. NMJ/muscle: myasthenia gravis, muscular dystrophies, uscle relaxants, diaphragmatic paralysis
4. Chest wall: severe kyphoscoliosis, severe obesity, traumatic flail chest
26
DDx
Ascites
1. Transudate:
1. Cirrhosis
2. Cardiac failure/constrictive pericarditis
3. Nephrotic syndrome, renal failure
4. Rare: Meigs' syndrome, ovarian hyperstimulation
2. Exudate:
1. Malignancy (abdo, pelvic, peritoneal mesothelioma)
2. Infection: TB, pyogenic
3. Pancreatic
4. Myxoedema (hypothyroidism)
5. Budd-Chiari syndrome (hepatic vein obstruction), portal vein thrombosis
6. Chylous ascites - obstruction of lymphatics
3. Haemorrhagic ascites:
1. Tumour
2. Trauma
3. Acute pancreatitis
27
DDx
Left axis deviation
1. L ant hemiblock
2. MI in inferior wall
3. Wolff-parkinson-white syndrome
4. Ventricular tachycardia
5. Obesity, pregnancy, congenital heart defects
28
DDx
Right axis deviation
1. R ventricular hypertrophy, pulm embolism
2. MI to antero-lateral
3. Wolff-parkinson-white syndrome - left sided accessory pathway
4. Dextrocardia
5. Left post hemiblock - rare
29
Causes of B12 deficiency
1. Decreased absorption:
1. Decreased IF (pernicious anaemia, gastroscopy)
2. Terminal ileal surgery/disease (coeliac disease, crohn's disease, TB, bacterial overgrowth, lymphoma, pancreatic insufficiency)
3. Drug induced malabsorption - metformin
2. Decreased intake: vegans
3. Other: transcobalamin deficiency, nitrous oxide
30
DDx
Back pain
1. Trauma/fractures, strenuous activity
2. Younger pts \<40
1. Prolapsed disc
2. Ankspond
3. Spondylolisthesis
4. (alkaptonuria)
3. Older pts \>40
1. Osteoarthritis, osteoporosis
2. Spinal stenosis, spinal claudication
3. Paget's
4. Herpes Zoster
4. Serious causes:
1. Infection (TB, bacterial osteomyelitis)
2. Malignancy (metastasis, multiple myeloma)
3. Cord compression
4. Fracture
5. Vascular/GI/Pelvic
1. Aortic aneurysm
2. Peptic ulcer, pancreatic cancer
3. Renal disease, rectal cancer, uterine tumours
4. Pelvic inflammatory disease, endometriosis, ovarian cyst
5. Retroperitoneal fibrosis
31
DDx
Blackouts
1. Cardiovascular:
1. Arrhythmia: bradycardia, tachycardia
2. Outflow obstruction: aortic stenosis, hypertrophic obstructive cardiomyopathy, pulm embolism, pulm stenosis
3. Postural hypotension: hypovolaemia, autonomic neuropathy, antihypertensive meds
4. MI, aortic dissection
2. Neurological:
1. Epilepsy
2. Stroke/TIA
3. Vasovagal (reflex bradycardia):
1. Prolonged standing esp. in warm surroundings
2. Other causes of vagal overactivity: micturition, cough, carotid sinus hypersensitivity
3. Metabolic: hypoglycaemia
32
DDx
Breathlessness
1. Acute (mins):
1. Pulm embolism
2. Pneumothorax
3. Foreign body
4. Anaphylaxis
5. Anxiety
2. Subacute (hrs)
1. Left ventricular failure - pulm oedema)
2. Asthma
3. COPD
4. Chest infection
5. Metabolic acidosis
3. Chronic (days-wks):
1. Anaemia
2. Recurrent pulm emboli
3. Cardiac disease (HF, arrhythmia, valvular heart disease)
4. Asthma
5. COPD
6. Chest infection/bronchiectasis
7. Lung cancer
8. Pulm fibrosis
9. Pulm HTN
10. Hepatorenal syndrome
11. Cirrhotic hydrothorax
12. NM disorders, chest wall deformities
33
DDx
Bundle Branch block
1. LBBB:
1. IHD
2. Cardiomyopathy
3. Left ventricular hypertrophy - aortic stenosis, HTN
4. Conduction system fibrosis
2. RBBB:
1. IHD
2. Cardiomyopathy
3. Massive pulm embolism
4. Atrial septal defect, Ebsteins anomaly
34
DDx
Chest pain
1. Cardiac large vessels: angina pectoris, MI, pericarditis, aortic dissection, rupture of thoracic aortic aneurysm, bleeding into atheroma
2. Resp: PE, pneumothorax, pneumonia, connective tissue disease
3. GI: reflux oesophagitis, oesophageal spasm, hiatus hernia, peptic ulcer, pancreatitis
4. MSK: Teitze's syndrome, fractured rib
5. Neuro: herpes zoster, nerve root compression
Pleuritic:
1. PE
2. pneumothorax
3. pneumonia
4. pericarditis
5. connective tissue disease
6. Malignancy involving pleura
35
DDx
CXR - bilat hilar lymphadenopathy
1. TB
2. Sarcoidosis
3. Lymphoma
4. Others: bronchial carcinoma, metastatic tumours, recurrent chest infections, AIDS, berylliosis, silicosis
36
DDx
CXR - Cavitating lung lesions
1. Abscess - staph aureus, klebsiella, p aeruginosa, TB, histoplasmosis
2. Tumour - squamous cell carcinoma, lymphoma
3. Infarct
4. Inflammatory: rheumatoid nodule, wegner's granulomatosis
37
DDx
CXR: coin lesions
1. Tumours: bronchial crcinoma, met deposit
2. Infection: TB, pneumonia, abscess, hydatid cyst
3. Infarction
4. Encysted pleural effusion
5. Rheumatoid nodule
6. Vasculitides
7. AV malformation
38
DDx
CXR: Airspace/alveolar shadows
1. Pus - consolidation
2. Fluid - pulm oedema
3. Blood - pulm haemorrhage
4. Cells - lymphangitis carcinomatosis, alveolar cell carcinoma
39
DDx
Reticulonodular shadowing
1. Pulm fibrosis:
1. Cryptogenic fibrosing alveolitis
2. Connective tissue disease: scleroderma, SLE, sarcoidosis, RhA, ankspond
3. Drugs (amiodarone, NFT), radiation
4. Extrinsic allergic alveolitis
5. Pneumoconioses
2. Upper zone: TB, allergic bronchopulm aspergillosis, radiation, ext allergic alveolitis, ankspond, sarcoidosis
3. Middle zone: sarcoidosis
4. Lower zone: cryptogenic fibrosing alveolitis, drugs, asbestosis, RhA, scleroderma
40
DDx
CXR: White hemithorax
1. Large pleural effusion
2. Pneumonectomy
3. Congenital absence of lung/extensive hypoplasia
4. Collapse
41
DDx
Increased Creatine Kinase
1. MI, myocarditis
2. Meds: statins, azathioprine, alcohol
3. Surgery, trauma, burns, haematoma, IM injections, defib
4. Rhabdomyolysis, rigorous exercise, seizures
5. Dermatomyositis, polymyositis, muscular dystrophy
6. Bowel ischaemia
7. Myxoedema
42
DDx
Clubbing
1. Congenital
2. Acquired:
1. CVS:
1. Congential cyanotic heart disease
2. Infectiv endocarditis
3. Atrial myxoma
2. Resp:
1. Cancer: bronchial, mesothelioma
2. Fibrosis
3. Suppurative lung disease
4. Cryptogenic organising pneumonia
3. GI:
1. Cirrhosis
2. IBD
3. GI lymphoma, malabsorption
4. Others: thyroid acropachy, unilat clubbing: axillary artery aneurysm, brachial AV malformations
43
DDx
Decreased Consciousness
1. Hypoglycaemia
2. Hypoxia: cardiac arrest, shock (hypovolaemic, septic), resp failure
3. Vascular: intracranial haemorrhage/iinfarction
4. Infection: meningitis, encephalitis
5. Inflammation
6. Trauma
7. Toxic:drugs - opiates, alcohol
8. Metabolic: liver/renal failure, electrolyte (Na/K/Ca/Mg) disturbances, andocrinopathies
9. Epilepsy
44
DDx
Constipation
1. Diet: low fibre, inadequate fluid intake
2. Drugs: opiates, anticholinergic, iron
3. Immobility
4. Old age
5. Surgical/GI:
1. Anorectal disease
2. Intestinal obstruction
3. IBS
4. Post op
6. Endo: hypothyroidism, hyperCa, hypokalaemia, porphyria, lead poisoning
7. Neuro/muscular: autonomic neuropathy, spinal/pelvic nerve injury, scleroderma
45
DDx
Cough
1. URTI
2. Pulm causes: all lung diseases: asthma, COPD, PE, infection, bronchiectasis, malignancy, interstitial lung disease, sarcoidosis, pneumoconiosis
3. Other causes:
1. Post-nasal drip
2. GORD
3. ACEi
4. HF
5. Psychogenic
46
DDx
Auscultation: Crackles
1. Fine crackles: pulm fibrosis, pulm oedema
2. Coarse crackles: Brochiectasis, consolidation, COPD
47
DDx
Cranial Nerve lesions: III
1. Brainstem: demyelination, infarction, tumour, basilar aneurysm
2. Posterior communicating artery aneurysm
3. Inflammation/infiltration of basal meninges: TB, sarcoidosis, lymphoma, carcinoma, syphilis
4. Cavernous sinus: aneurysm, thrombosis, tumour
5. Sup orbital fissure/orbit: tumour, granuloma
6. Medical 3rd nerve palsy - pupil spared: infarction in nerve trunk 2ry to DM, HTN, SLE, polyarteritis nodosa, GCA
7. Migraine
8. Tentorial herniation
48
DDx
Cranial nerve lesion: IV
1. Brainstem: demyelination, infarction, tumoour
2. Head trauma
3. Inflammation/infiltration of basal meninges: TB, sarcoidosis, lymphoma, carcinoma, syphilis
4. Cavernous sinus: aneurysm, thrombosis, tumour
5. Superior orbital fissue/orbit: tumour, granuloma
6. Infarction to nerve trunk 2ry to DM, HTN, SLE, polyarteritis nodosa, GCA
49
DDx
Cranial Nerve lesions: V
1. Sensory involvement: trigeminal neuralgia, herpes zoster, nasopharyngeal carcinoma
2. Brainstem: demyelination, iinfarction, tumour
3. Cerebellopontine angle: acoustic neuroma, meningioma
4. Inflammation/infiltration of basal meninges: TB, sarcoidosis, lymphoma, carcinoma, syphilis
5. Petrositis
50
DDx
Cranial nerve lesions VI
1. Damage to nerves blood supply: DM, HTN, Wernicke-Korsakoff syndrome
2. Brainstem: demyelination, infarction tumour
3. False localising sign of raised ICP
4. Cerebellopontine angle tumour
5. Inflammation/infiltration of basal meninges: TB, sarcoidosis, lymphoma, carcinoma, syphilis
6. Petrositis
7. Orbital tumour
51
DDx
Cranial nerve lesions causing multiple palsies
1. Brainstem lesions (stroke, tumour)
2. Basal meningeal infiltration: carcinoma, TB, sarcoid, lymphoma, leukaemia
3. Trauma
4. Guillain-Barre syndrome
5. Botulism
6. Mononeuritis multiplex
7. Arnold-Chiari malformation
8. Paget's disease
52
DDx
Increased Creatinine
1. Decreased GRFR, high muscle mass, rhabdomyolisis
2. Tranient/minimal increase: after exercise, high meat meal
3. Decreased tubular secretion; trimethoprim, cimetidine
53
DDx
Decreased creatinine
1. Increased GFR - pregnancy
2. Low muscle mass
54
When in CRP elevated?
1. Infection
2. Inflammation
3. Malignancy
55
DDx
Increased WCC in CSF
1. Predominantly lymphocytes:
1. Infective meningitis: viral meningitis/meningoencephalitis, TB, fungal, listerial, syphilis
2. Inflammatory diseases: Behcet's disease, sarcoidosis, SLE, MS
3. Malignancy: lymphoma, leukamia, other tumours
4. Drugs: NSAIDs, trimethoprim
2. Predominantly neutrophils
1. Bacterial meningitis
2. Brain abscess eroding into ventricles
3. Initial phase of viral meningitis
56
DDx
Decreased glucose in CSF
1. Bacterial meningitis
2. TB meningitis
3. Fungal meningitis
4. Occasionally mumps meningitis and herpes encephalitis
5. Sarcoidosis, CNS vasculitides, carcinomatous meningitis
57
DDx
Central and peripheral cyanosis
1. Central:
1. Decreased O2 transfer due to lung disease: fibrosing alveolitis, severe pneumonia, COPD, massive PE
2. R-\>L shunt (cyanotic congenital HD)
3. methaemaglobinaemia, sulfhaemoglobinaemia
4. Acute: asthma, pneumothorax, inhaled foreign body LVF
2. Peripheral
1. same as central cyanosis
2. Cold exposure
3. Raynauds phenomenon
4. Arterial occlusion
5. Decreased cardiac output
58
DDx
Deafness: sensorineural or conductive
1. Conductive:
1. Wax in canal
2. Eardrum: perforation, cholesteatoma
3. Ostosclerosis, ossicular abnormality
4. Middle ear effusion
2. Sensorineural:
1. Infection: measles, mumps, meningitis, syphilis
2. Trauma: noise, head injury, surgery
3. Tumour: acoustic neuroma
4. Toxic: aminoglycosides, cytotoxic drugs, frusemide
5. Congenital: maternal rubella, eclampsia, perinatal hypoxia
6. Genetic: Alport syndrome/Waardenburg syndrome
7. Degenerative: presbyacusis
8. Others: Meniere's disease, Paget's disease
59
DDx
Dehydration
1. Decreased fluid intake: severe illness, anorexia, malnutrition
2. Pyrexia/excess sweating
3. GI loss: D/V
4. Polyuria - DM, DI, hyperCa
60
DDx
Delirium
1. Hypoxia - resp/cardiac failure
2. Hypoglycaemia
3. Toxic: alcohol withdrawal, Wernicke's encephalopathy
4. Drugs: opiates, Anticholinergics, anxiolytics, anticonvulsants, corticosteroids, digoxin, dopaminergic agonists, recreatioonal drugs
5. Metabolic: Liver/renal failure, electrolyte imabalances (hypoNa, HyperCa), endocrinopathies, nutritional def (B12, nicotinic acid, thiamine)
6. Vascular: intracranial bleeding, infarction, venous sinus thrombosis
7. Infection: intracranial (meningitis/encephalitis), extracranial: chest infection, urinary infection, surgical wounds, IV lines
8. Inflammation: vasculitis
9. Trauma: head injury, subdural haematoma
10. Tumour: space occupying lesions
11. Hypertensive encephalopathy
12. Epilepsy: status epilepticus, post-ictal states
61
DDx
Dementia
1. Alzheimers
2. Vascular: multiple infarctions
3. Infection: HIV, syphilis, Whipple's disease
4. Inflammation: vasculitis, SLE, sarcoid, MS
5. Trauma: head injury, subdural haemorrhage
6. Tumour: frontal, post fossa, brain mets and paraneoplastic
7. Toxic: alcohol, lead, barbiturates
8. Metabolic: myxoedema, vit B12 def, hypoglycaemia
9. Inherited: Wilson's disease, huntington's chorea
10. Degenerative: Parkinson's, Pick's disease, prion disease, Lewy body dementia
62
DDx
Diarrhoea
1. Infection:
1. Viral: rotavrius, adenovirus
2. Campylobacter, Salmonella
3. Shigella, E coli
4. Yersinia enterocolitica
5. Staph aureus
6. Clostridium botulinum/perfringens/difficile
7. Virbrio cholerae/parahaemolyticus
8. Parasites: Giardia, cryptosporidium, entamoeba histiolytica
9. AIDS: enteropathy, cryptosporidia, microsporidia, CMV
2. IBD
3. Malabsorption: small intestine disease/resection, pancreatic insufficiency
4. Medication: laxatives, Abx
5. Overflow diarrhoea: 2ry to constipation
6. Endocrine: thyrotoxicosis, carcinoid syndrome, DM, VIPomas
63
DDx
Bloody diarrhoea
1. Infective colitis: campylobacter, haemorrhagic E coli, entamoeba histiolytica, salmonella, shigella- CMV in immunocompromised
2. IBD
3. Ischaemic colitis
4. Diverticulitis
5. Malignancy
64
DDx
Dullness at base of lung
1. Pleural effusion
2. Pleural thickening - old TB, empyema, mesothelioma
3. Basal collapse
4. Raised hemidiaphragm - hepatomegaly, phrenic nerve palsy
65
DDx
Dysarthria - difficulty with speech
1. Cerebellar disease: slurred, scanning speech
2. Bulbar palsy: nasal speech
3. Pseudobulbular palsy: slow, indistinct, effortful - spastic speech
4. Extrapyramidal disease: soft, monotonous
66
DDx
Dyspepsia
1. GORD, oesophagitis
2. Peptic ulcer, hiatus hernia, gastritis, duodenitis, gastric cancer
3. Chronic cholecystitis
4. Non-ulcer dyspepsia
67
DDx
Dysphagia
1. Intraluminal: foreign body
2. Intramural:
1. Achalasia
2. Benign stricture: oesophageal webs/rings
3. Cancer - oesophageal, gastric, pharyngeal
4. Diffuse oesophageal spasm
5. Oesophagitis: infection - candidiasis, HSV, CMV, HIV, inflammation (GORD, corrosives, radiotherapy)
6. Others: scleroderma, chagas' disease
3. Extramural:
1. Lung cancer
2. Lymphadenopathy
3. Retrosternal goitre
4. Pharyngeal pouch
5. Paraoesophageal hiatus hernia
6. Aortic aneurysm
7. Aberrant SCA
8. Left atrial enlargement
4. Neuromuscular:
1. Stroke
2. Guillain Barre
3. Bulbar/pseudobulbar palsy
4. Myaesthenia gravis
5. Inflammatory myositis
6. Motor neurone disease
7. Syringobulbia
68
DDx
Dysphasia
1. Broca's expressive: lesions affecting inferolateral frontal lobe
2. Wernicke's reeptive: lesions afecting posterior superior temporal lobe
3. Conduction dysphasia
69
DDx
Dysuria
1. UTI: cystitis, urethritis, acute pyelonephitis
2. Urethritis: chlamydial, gonococcal; trichonomas vaginalis, candida albicans, herpes simplex
3. Vaginitis: candida albicans, trichonomas vaginalis, bacterial vaginosis
4. Prostatitis
5. Interstitial cystitis
6. Female urethral syndrome
70
DDx
ESR
1. Increased:
1. Infection
2. Inflammatory/connective tissue diseases
3. Malignancy
4. metabolic - phaeo
2. ^ESR with normal CRP
1. SLE
2. UC
3. Myeloma
4. Recovery from infection
71
DDx
Unilateral facial palsy
1. Bell's palsy/pathologies along course of nerve
1. brainstem: infarction, demyelination, tumour
2. cerebellopontine angle: acoustic neuroma
3. Basal meningeal inflammation/infiltration: TB, sarcoidosis, lymphoma
4. Middle ear: infection or herpes zoster
5. Face/parotid: surgery/trauma
72
DDx
Bilateral facial nerve palsy
1. Congenital facial diplegia
2. Guillain-Barre
3. Sarcoidosis
4. Motor neurone disease
5. Myasthenia gravis
6. Muscular dstrophy
7. Infections: lyme disease and HIV
73
DDx
Facial pain
1. Neuro:
1. GCA
2. Trigeminal neuralgia
3. Glossopharyngeal neuralgia
4. Migrainous neuralgia and migraine
5. postherpetic neuralgia
2. Local causes:
1. Post traumatic
2. Sinusitis
3. Orbital and ocular disease, optic neuritis, retroorbital disease
4. Dental/oral disease
5. TMJ dysfunction
6. Ear and parotid disease
7. Nasopharyngeal tumours
8. Referred cardiac pain
9. Atypical facial pain
74
DDx
Facial swelling
1. Periorbital oedema
1. Infection - peri/orbital cellulitis, trichinosis
2. Allergy - anaphylaxis
3. Hypo/erthyroidism
4. Nephrotic syndrome, hypoalbuminaemia
5. Cavernous sinus thrombosis
6. Dermatomyositis
2. Other causes:
1. Dental/sinus infection
2. Trauma, burns
3. Subcut emphysema
4. SVC thrombosis
5. Cushing's syndrome, obesity
75
DDx
Faecal incontinence
1. Diarrhoea
2. Overflow - faecal impaction, neoplasm
3. Pelvic floor abnormality: accidental injury, traumatic childbirth, rectal prolapse
4. Neurological: epilepsy, spinal cord compression, stroke, MS, trauma and tumours, peripheral neuropathy, dementia, parkinson's
5. Congenital: meningomyelocele, anorectal abnormalities
76
DDx
Fatigue
1. anaemia
2. endocrine/metabolic: DM, hypo/erthyroidism, addison's disease, uraemia
3. HF
4. infection
5. inflammatory/connective tissue diseases
6. malignancy
7. drugs - b-blockers
8. depression
9. chronic fatigue syndrome
77
DDx
Ferritin- high or low
1. High:
1. Acute phase response: infection, inflammation, malignancy
2. Haemochromatosis
3. Repeated transfusions in thalassaemia, iron therapy
4. Still's disease
5. Sideroblastic anaemia
6. anaemia of chronic disease, chronic haemolysis
2. Low: IDA
78
DDx
Fever in travellers
1. Hep A
2. Malaria
3. Typhoid
4. Leptospirosis
5. Dengue
6. haemorrhagic fevers
7. Longer incubation:
1. malaria
2. typhoid
3. TB
4. brucellosis
5. leishmaniasis
6. amoebic abscess
79
DDx
Finger pain
1. Vascular: vasospasm, vasculitis, PVD, emboli
2. Nerve/root compression: carpal tunnel syndrome, radiculopathy
3. Infeciton: paronychia, tendon sheath inection, pulp space infection
4. Inflammation/connective tissue disease: RhA, gout, scleroderma
5. Trauma: fx, subungual haematoma
6. Tumour: bone tumour, glomus tumour
80
DDx
Flaccid paralysis
1. Anterior spinal artery syndrome
2. Anterior horn cells: poliomyelitis, enterovirus, echovirus, adenovirus, west nile virus
3. Nerve root: polyradiculopathy, tabes dorsalis, cauda equina
4. Peripheral nerves: GBS
5. Myoneural junction: myasthenia gravis, lambert-eaton syndrome
6. Myopathy
81
DDx
Folate deficiency
1. Increased demand: pregnancy/lactation, malignancy, chronic inflammation, chronic haemolytic anaemia, haemodialysis
2. Decreased absorption: jejunal disease (coeliac, tropical sprue, whipple's disease, small intestinal resection
3. Decreased intake: alcoholics, elderly, anorexia
4. Drugs: phenytoin, trimethoprim, sulphasalazine
82
DDx
Foot drop
1. Neuro:
1. Common peroneal nerve lesion: mononeuritis multiplex (DM)
2. L5 root lesion
3. Rare: motor neuron disease, MS, stroke
2. Musc:
1. injury to dorsiflexors
2. Compartment syndrome
83
DDx
Foot pain
1. Deformities, strain
2. Skin: cellulitis, warts, corns, callosities
3. Bone: fracture, osteomyelitis, osteochondritis (metatarsal head and navicular), tumours
4. Joints: septic arthritis, gout, RhA, osteoarthritis
5. Periarticular: plantar fasciitis, tendonitis, bursitis
6. Vascular: ischaemia, ulcers
7. Neuro: L4/5/S1 root pain, morton's metatarsalgia, tarsal tunnel syndrome
84
DDx
Nocturia, Urinary frequency
1. Polyuria
2. Frequent passage of small amounts of urine:
1. UTI
2. Bladder (stone, tumour, compression by pelvic mass)
3. Prostate enlargement (BPH, cancer)
4. Genuine stress incontinence
5. Detrusor instability
6. Sensory urgency
85
DDx
GI bleeding
1. Upper:
1. Peptic ulcer
2. Gastritis/gastric erosions, duodenitis, oesophagitis
3. G-O varices
4. Mallory-Weiss tear
5. Medications: NSAIDs, anticoag, steroids, thrombolytics
6. Oesophageal/gastric cancer
7. Rare:
1. Bleeding disorders, hereditary haemmorrhagic telangiectasia, Dieulafoy gastric vascular abnormality
2. Lower GI:
1. Anal: haemorrhoids, fissure
2. Angiodysplasia
3. Bowel cancer, polyps
4. Colitis: inflammative (UC), infective, ischaemia, radiation
5. Diverticulae (colonic)
6. Excessive GI (upper) bleeding
7. Other: bleeding disorders, aortoenteric, fistula, meckel's diverticulum, solitary renal ulcer
86
DDx
Gaze palsy - horizontal and vertical
1. Horizontal:
1. Ipsilat pontine or contralat frontal lobe lesions
1. Vascular, tumour, demyelination, infection
2. Vertical:
1. Superior midbrain lesions:
1. Vascular, tumours (mets), demyelination, infection, metabolic, neurodegen
87
DDx
Glossitis
* Iron def
* Def of folate, B12, niacin (B3, thiamine (B1), riboflavin, Zinc
* Candidiasis
* Syphilis - rare
88
DDx
increased GGT
Liver disease:
* Cholestasis
* alcohol-induced damage
89
DDx
Glycosuria
1. DM - 1 and 2
2. Pregnancy
3. Chronic renal failure
4. Renal tubular dysfunction/damage
90
DDx
Goitre
1. Simple goitre - euthyroid: puberty, pregnancy
2. Thyrotoxicosis: Graves, toxic adenoma, toxic multinodular goitre with palpable nodule, thyroiditis
3. Hypothyroidism: hashimoto's
4. Lithium, anti-thyroid drugs, iodine def/excess, dyshormogenesis
5. thyroid cyst
6. thyroid carcinoma: papillary, follicular, anaplastic, medullary, lymphoma
91
DDx
Gynaecomastia
1. Physiological: puberty, elderly
2. Pseudogynaecomastia - obese men
3. Drugs: spironolactone, chlorpromazine, oestrogens, digoxin, drugs of abuse - marijuana/heroin
4. Chronic liver disease
5. Chronic renal failure
6. Hypogonadism
7. Hyperthyroidism
8. Tumours: ectopic hCG, oestrogen producing
9. Unilat:
1. Breast carcinoma
2. Lipoma, lymphangioma, neurofibroma, haematoma, dermoid cyst
92
DDx
Haematuria
1. Kidney, bladder, ureter or urethra:
1. Trauma
2. Infection: UTI, (TB), schistosomiasis
3. Stones
4. Tumours
5. Others: glomerulonephritis, IgA nephropathy, interstitial nephritis, cystic renal disease, emboli, renal vein thrombosis, vascular malformation, drugs, excessive exercise
6. Prostate: BPH, prostate cancer, prostatitis
7. General: haematological disorders, anticoags
2. Other causes of urine discolouration:
1. Food: beetroot
2. Drugs: senna, rifampicin
3. Haemoglobinuria/myoglobinuria
4. Porphyria
93
DDx
Haemoptysis
1. Lung:
1. Infection - TB, pneumonia, absces, bronchitis, bronchiectasis
2. PE
3. Malignancy
4. Vasculitis - Wegner's granulomatosis, Goodpasture's
5. Trauma
6. Foreign body
2. Heart: Mitral stenosis
3. Rarer: arteriovenous malformation, amyloidosis, sarcoidosis
94
DDx
Hallucination
1. Psych:
1. Schizophrenia/schizoaffective disorder
2. Mania with psychosis
3. Severe depression with psychosis
4. Dementia
5. Delirium
6. Puerperal psychosis
7. Alcoholic hallucinosis
2. Organic:
1. Cerebrovascular
2. Infection
3. toxic/metabolic - alcohol, hallucinogens
4. Drug-induced psychosis - amphetamine, cocaine
5. Sensory organ disease
6. Seizures
95
DDx
Headache - acute/subacute
1. Head injury
2. Meningitis/encephalitis
3. Subarachnoid haemorrhage, cerebral venous thrombosis
4. Carotid/vertebral artery dissection
5. Acute angle closure glaucoma
6. GCA
7. Pit apoplexy
8. Other: Increased BP, drugs (GTN, CCB), infections, hypoNa, hyperviscosity syndromes
96
DDx
Chronic/recurrent headaches
1. Raised ICP: space occupying lesion - tumour/abscess, hydrocephalus, benign intracranial HTN
2. Reduced ICP: post LP
3. Migraine
4. Migrainous neuralgia
5. Tension headache, rebound headache
6. Sinusitis
7. Others: carvicogenic, hypnic headache, meningeal infiltration - malignancy/sarcoidosis; refractive errors, Paget's, acromegaly, antiPL syndrome
97
DDx
Loud heart sounds - S1, S2
S1:
1. Mitral stenosis
2. Atrial myxoma
3. Tachycardia
4. Hyperdynamic circulation
5. Decreased PR interval - preexcitation syndromes
Variable S1 intensity:
1. AF
2. AV block
3. nodal/ventricular tachycardia
S2:
1. Systemic HTN
2. Tachycardia
3. Pulm HTN
98
DDx
Soft heart sounds - S1, S2
S1
1. Mitral Regurgitation
2. Aortic regurgitation
3. Long PR interval
4. LBBB
5. Severe HF
S2
1. Aortic stenosis
2. Pulmonary stenosis
99
DDx
Extra heart sounds - S3, S4
S3
1. Normal in under 35s
2. Ventricular failure
3. Mitral regurg
4. Tricuspid Regurg
5. VSD
6. Constrictive pericarditis
7. Restrictive cardiomyopathy
S4
1. Aortic stenosis
2. HTN HD
3. Hypertrophic cardiomyopathy
4. MI
5. Pulm stenosis
100
DDx
S2 abnormalities: splitting - wide, reversed splitting and single S2
1. Wide:
1. Delayed activation of RV:
1. RBBB
2. LV pacing/pre-excitation - WPWS
2. Prolonged RV ejection time:
1. Pulm stenosis
2. Pulm HTN
3. Decreased LV ejection time:
1. Mitral regurg
2. VSD
4. Wide fixed splitting: ASD
2. Reversed splitting:
1. Delayed action of LV:
1. LBBB
2. RV pacing/preexcitation
2. Prolonged LV ejection time:
1. Aortic stenosis
2. HOCM
3. HTN
4. PDA
3. Single S2:
1. Apparent: obesity, COPD, pericardial effusion
2. Absent a2: severe aortic stenosis, severe aortic regurg
3. Absent p2: absent pulm valve, pulm atresia, pulm stenosis, Fallot tetralogy
4. Fusion of a2 and p2: Eisenmenger's syndrome
101
DDx
Hemiparesis/hemiplegia
1. Vascular: stroke
2. Infection: brain abscess from local or distant infections
3. Inflammation: MS, cerebral vasculitis
4. Trauma: extradural/subdural haemorrhage
5. Tumour
6. Metabolic: hypoglycaemia causes tranisent
7. Others: epileptic seizures, migraine
102
DDx
Hepatomegaly
1. Cancer: 2ry mets, hepatoma, liver cell adenoma
2. Cirrhosis: alcoholic, 1ry biliary cirrhosis
3. CCF
4. Budd-Chiari (hepatic vein thrombosis)
5. Polycystic liver disease
6. Infection: Hep A/B/C, EBV, CMV, toxoplasmosis, leptospirosis, abscess, hydatid cyst
7. Infiltration: fatty (alcohol), haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
103
DDx
Hepatosplenomegaly
1. Myeloprolif disorders: CML, myelofibrosis, polycythaemia rubra vera, essential thrombocythaemia
2. Lymphoprolif disorders: lymphoma, CLL, myeloma, ALL, hairy cell leukaemia
3. Portal HTN
4. Megaloblastic anaemia - pernicious
5. Infection: Hep B/C, EBV, CMV, leptospirosis, toxoplasmosis, TB, brucellosis, malaria, schistosomiasis, leishmaniasis
6. Other: amyloidosis, storage disorders, infantile polycystic disease
104
DDx
Horner's syndrome
1. Brainstem/cervical spinal cord: tumour, infarction, syringomyelia/bulbia
2. T1 root: brachial plexus lesion, neurofibromatosis
3. Cervical sympathetic chain: pancoast tumour
4. Internal carotid artery: dissection, occlusion
5. Migraine, cluster headaches
105
DDx
Hyperaldosteronism
1. 1ry:
1. Adenoma (conn's),
2. bilat adrenal hyperplasia,
3. glucocorticoid-remediable aldosteronism
2. Hyperaldosteronism:
1. Increased Renin: tumour
2. Renal artery stensosi
3. Cirrhosis
4. HF
5. diuretics
6. Bartter's syndrome
106
DDx
hyperbilirubinaemia
1. Unconjugated:
1. Haemolysis
2. ineffective eryhtropoesis
3. Decreased glucuronidation - Gilbert's
2. Conjugated: Jaundice - hepatocellular and obstructive
107
DDx
Hypercalcaemia
1. HyperPTH - 1ry and 3ry
2. Malignancy: multiple myeloma, bone mets (prostate, kidney, thyroid, breast, lung), bronchial squamous cell carcinoma, lymphoma
3. Excess vit D: self-admin, sarcoid, TB
4. Immobility
5. Others:
1. Increased Ca intake
2. Drugs: lithium, thiazides
3. Endocrine disease: hyperthyroidism, phaeo, acromegaly, Addison's
4. Familial hypocalciuric hypercalcaemia
108
DDx
Hypercalciuria
1. Hypercalcaemia
2. Idiopathic hypercalciuria
3. Increased Ca intake
4. Renal tubular acidosis
5. X linked hypercalciuria
109
DDx
Hyperglycaemia
1. Stress - acute/severe illness
2. DM:
1. Type 1 and 2
2. 2ry to
1. steroids
2. Endocrine: Cushing's syndrome, acromegaly, phaeo, glucagonomas, somatostatinomas
3. Pancreatectomy, chronic pancreatitis, haemochromatosis
110
DDx
Hyperhidrosis
1. Endocrine: thyrotoxicosis, acromegaly, phaeo
2. Chronic infection: TB, brucellosis
3. Malignancy: lymphoma
4. Medications: opiates, drugs with cholinergic properties, sympathomimetics
5. Acute: acute febrile illness, MI, hypoglycaemia, hypotension
111
DDx
Hyperkalaemia
1. Released from cells: acidosis, rhabdomyolysis, suxamethonium
2. Renal failure
3. Renal tubular acidosis type 4
4. ACEi
5. Addison's
6. Amiloride and other K sparing diuretics
7. Increased intake
8. PsuedohyperK - haemolysis, leucocytosis, thrombocytosis
112
DDx
Hyperlipidaemia
1. diabetes
2. Drugs: alcohol, OCP, steroids, thiazides
3. Myxoedema
4. Nephrotic syndrome, renal impairment
5. Obesity
6. Obstructive jaundice
113
DDx
Hypernatraemia
1. **_Dehydration_**
2. Decreased fluid intake: elderly, confused, unconscious
3. Increased fluid loss:
1. GI: diarrhoea, vomiting
2. Renal: diabetes insipidus, osmotic diuresis
3. Skin: excessive sweating
4. Hyperosmolar non-ketotic coma
5. Excess Na admin
6. Excess mineralocorticoids: hyperaldosteronism
114
DDx
Hyperphosphataemia
1. Renal failure
2. Psuedo/HypoPTHism
3. Rhabdomyolysis
4. Tumour lysis syndrome
5. Acromegaly
6. Excessive phosphate intake/admin
7. Vit D intox
115
DDx
Hyperprolactinaemia
1. Physiological: pregnancy, lactation, stress
2. Prolactinoma, rarely ectopic prolactin
3. Decreased DA transport to ant pit: pit tumour compressing pit stalk
4. Drugs:
1. Depletion of central DA stores: reserpine, methyldopa
2. DA receptor blockers: haloperidol, metoclopramide, domperidone
5. Increased TRH secretion stimulates PL release
6. Oestrogens: HRT/OCP, PCOS
7. Chest wall injury
8. Other: Liver failure, decreased DA synthesis/release from hypothalamus (tumour, inflammation, arteriovenous malformation)
116
DDx
HTN
1. Essential
2. Renal disease: chronic glomerulonephritis, chronic pyelonephritis, cystic kidney disease, renal carcinoma
3. Drugs: oestrogen containing OCPs, steroids
4. Endocrine disease: cushing's, conn's, phaeo, acromegaly, 1ry hyperPTH
5. Vascular: coarctation of aorta, renal artery stenosis
6. Pre-eclampsia
117
DDx
Hyperuricaemia
1. Decreased renal excretion:
1. Idiopathic
2. Drugs: ciclosporin, aspirin, nicotinic acid, thiazides, loop diuretics, ethambutol, alcohol, pyrizinamide
3. Chronic renal disease
2. Increased intake/production:
1. Increased dietary intake
2. Increased synthesis: Lesch-Nyhan syndrome
3. Increased nucleic acid turnover: lymphoma, leukaemia, polycythaemia vera, psoriasis
118
DDx
Hypoalbuminaemia
1. Decreased synthesis:
1. Acute phase reaction
2. Liver disease
3. Malnutrition
2. Increased loss:
1. Nephrotic syndrome
2. Protein-losing enteropathy - coeliac disease, IBD, sprue, whipple's disease, intestinal lymphoma, intestinal lymphangiectasia
3. Burns
4. Bullous skin lesions
3. Haemodilution: sample from IV infusion arm, pregnancy
4. Rare: familial idiopathic dysproteinaemia
119
DDx
Hypocalcaemia
1. Hypoparathyroidism
1. Congenital - digeorge's
2. autoimmune
3. surgical
4. PseudohypoPTHism
5. Decreased Mg, Fe overload, increased copper
2. Vit D def:
1. decreased dietary intake/malabsorption
2. Lack of sunlight
3. liver disease
4. anticonvulsants
5. Renal failure
6. vit D resistance
3. Increased PO4: chronic renal failure, phosphate therapy
4. Pancreatitis
5. Resp alkalosis
6. Hypoalbuminaemia
7. Others: artifact, iatrogenic: bisphosphonates, calcitonin, citrated blood
120
DDx
Hypoglycaemia
1. Excess insulin, sulphonylureas, salicylate, pentamidine, quinine
2. Insulinomas, hepatomas, sarcomas
3. alcohol
4. Addison's
5. Renal failure
6. Liver failure
7. Malaria
8. Post-gastrectomy
121
DDx
Hypokalaemia
1. GI loss:
1. Vomiting
2. Diarrhoea
3. Villous adenoma
4. VIPoma
5. Fistulae
6. Ileostomies
2. Renal loss:
1. Excess mineralocorticoids (increased excretion):
1. Hyperaldosteronism
2. Increased glucocorticoids: cushing's, liquorice
3. Congenital adrenal hyperplasia
2. Increased Na delivery to distal nephron (increased Na absorption and K secretion)
1. Osmotic diuresis
2. Diuretics: thiazides and loop diuretics
3. Bartter's syndrome, Gitelman's syndrome
3. Others:
1. Hypomagnesaemia
2. Renal tubular acidosis
3. Renal tubular damage
4. Liddle's syndrome
3. Redistribution into the cells: insulin, beta agonists, alkalosis
122
DDx
Hypomagnesaemia
1. decreased intake or GI losses:
1. Malnutrition, alcoholism, diarrhoea, malabsorption, intestinal resection, intestinal fistulae
2. Renal losses:
1. Diuretics
2. Alcohol abuse
3. Drugs: nephrotoxins
4. DM, hyperCa, hyperthyroidism, hyperaldosteronism, tubular dysfunction
3. Other: post-op, post parathyroidectomy, pancreatitis, foscarnet
123
DDx
Hyponatraemia
1. Pseudohyponatraemia:
1. Hyperproteniaemia, hypertriglyceridaemia
2. hyperglycaemia
2. Artifactual: taking blood frm the arm into which low Na solution is infused
3. Hypervolaemic pts: cirrhosis, CCF, nephrotic syndrome, renal failure
4. Hypovolaemic pts: renal loss - diuretics, renal tubular acidosis, salt losing nephropathy, adrenal insufficiency
1. Extra-renal loss: diarrhoea, vomiting, burns, pancreatitis
5. Euvolaemic pts: hypothyroidism, adrenal insufficiency, SIADH
124
DDx
Hypophosphataemia
1. Redistribution into cells:
1. Increased insulin: recovery from DKA, refeeding
2. Resp alkalosis
3. Hungry bone syndrome: due to marked deposition of Ca and PO4 in bone
2. GI:
1. PO4 binders
2. Diarrhoea - chronic
3. Decreased dietary intake
3. Renal:
1. HyperPTH 1ry, 2ry: increased urinary excretion
2. Vit D deficiency/resistance: by decreased GI absorption and causing hypoCa and 2ry hyperPTH
3. Hereditary hypoPO4 rickets, tumour induced Osteomalacia
4. Osmotic diuresis
5. Fanconi syndrome
125
DDx
Hypotension
1. Septicaemia
2. Hypovolaemia:
1. Haemorrhage
2. GI loss
3. Renal loss (diuretic, DM, DI, post-obstructive diuresis, acute renal failure)
4. Cutaneous loss (exudative lesions, burns)
5. Adrenal insufficiency
6. Cardiovascular: any condition that decreased CO (arrhythmias), decreased diastolic filling (pericardial disease), myocardial disease, outflow obstruction
126
DDx
Postural hypotension
1. Volume depletion
2. Autonomic neuropathy:
1. Metabolic: DM, amyloidosis, drugs (TCA, L DOPA)
2. Inflammation: GBS
3. Infection: HIV, syphillis
4. Tumours: paraneoplastic, hypothalamic
5. Degenerative: Parkinson's, multpile system atrophy, shy-drager syndrome
6. Familial dysautonomia
3. Drugs: antihypertensives, diuretics, nitrates, antidepressants, sedatives
4. Leg vein insuffiency
127
DDx
Impotence
1. Psych
2. Drugs: alcohol, antidepressants, b-blockers, cannabis, diuretics, major tranq
3. Endocrine disorders: hypogonadism/androgen deficiency, hyperthyroidism, prolactinoma, acromegaly
4. Neurological: autonomic neuropathy, nerve damage after bladder neck/prostate surgery, MS
5. Vascular disease
128
DDx
Infertility
1. Female:
1. anovulation - 1ry/2ry hypogonadism
2. obstructed fallopian tubes - adhesions
3. uterine cavity abnormalities - fibroids, endometriosis
4. chromosome abnormalities
5. antiphospholipid syndrome
2. Male
1. Hypogonadism 1ry/2ry
2. Varicocoele
3. Immotile sperm
4. obstruction of epididymis, vas deferens
5. coital disorders
129
DDx
Increased ICP
1. vascular: haemorrhage (extradural, subdural, subarachnoid, intracerebral)
2. Infection: meningitis/encephalitis, abscess
3. Trauma: head injury
4. Tumours
5. Benign intracranial HTN, hydrocephalus, cerebral oedema
130
DDx
Jaundice
1. Pre-hepatic:
1. Haemolysis
2. ineffective erythropoiesis
3. decreased glucuronidation (gilbert's)
2. Hepatocellular:
1. Viral: Hep ABC - other infections: CMV, EBV, toxoplasmosis, leptospirosis, Q fever
2. Drugs: paracetamol, anti-TB drugs, statins, Na valproate, toxins, herbal meds
3. Alcoholic hep
4. Autoimmune hep
5. Cirrhosis, hep mets, hep abscess
6. Wilson's, haemochromatosis, alpha1-antitrypsin def, Budd-chiari syndrome
7. Septicaemia
8. Dubin-johnson syndrome, rotor syndrome
3. Obstructive:
1. Gallstones
2. Carcinoma of head of pancreas/ampulla of vater/bile duct
3. Lymphadenopathy at porta hepatic
4. Benign stricture
5. Drugs: ABx, OCP, chlorpromazine, sulphonylureas
6. Primary schlerosing cholangitis, primary biliary cirrhosis
7. Parasites: schistosomiasis, pancreatitis, AIDS cholangiopathy
131
DDx
Increased JVP
1. RHF
2. Tricuspid regurg
3. Pericardial effusion, constrictive pericarditis
4. Fluid overload
5. Obstruction of SVC
6. a waves - cannon waves
1. Regular: nodal rhythm, paroxysmal nodal tachycardia, partial heart block with very long PR interval
2. Irregular: complete heart block, multiple ectopic beats
132
DDx
Ketonuria
1. diabetes
2. Starvation
3. Increased metabolic requirements: fever, pregnancy, thyrotoxicosis
4. Glycogen storage diseases
133
DDx
Enlarged Kidneys
1. Cystic kidney
2. Carcinoma
3. Hydronephrosis, pyonephrosis
4. Hypertrophy
5. Perirenal haematoma
6. Congenital anomaly
134
DDx
Swelling of knee
1. Septic arthritis
2. trauma, haemarthosis
3. pseudo/gout
4. RhA, OA
5. Seronegative athritides - reactive arthritis, enteropathic arthrits, ankspond, psoriatic arthritis
6. Systemic: SLE, sjogren's, sarcoidosis, Behcet's, vasculitidies
7. Malignancy
8. Localised swellings:
1. Ant:
1. Prepat bursa
2. Infrapat bursa
3. Osgood-schlatter disease
2. Lat/medial:
1. lat/med meniscus cyst
2. Exostosis
3. Post:
1. Semimembranous bursa
2. Baker's cyst
3. Popliteal aneurysm
135
DDx
Kussmaul's sign
(paradoxical rise in JVP on inspiration, or a failure in the appropriate fall of the JVP with inspiration)
1. Pericardial effusion
2. Constrictive pericarditis
3. Restrictive cardiomyopathy
136
DDx
Increased LDH
1. MI
2. Haemolysis
3. Hepatocyte damage
4. Pulm Embolism
5. Lymphoma, tumour necrosis
137
DDx
Leg pain
1. Vascular: aterial occlusion - acute/chronic, DVT
2. Neurological: lumbar canal stenosis radiculopathy, plexopathy, peripheral neuropathy
3. MSK: soft-tissue injury, muscle spasm
4. Arthritis
138
DDx
Leg swelling
1. Bilat:
1. HF
2. Liver failure - other causes of hypoalbuminaemia (malnutrition, malabsorption, nephrotic syndrome)
3. Renal failure
4. Hypothyroidism
5. Iatrogenic: oestrogens, CCB, fluid overload
6. Venous insufficiency: acute/chronic
7. Venous obstruction
2. unilat:
1. Acute:
1. DVT
2. Cellulitis
3. Compartment syndrome, trauma
4. Baker's cyst rupture
2. Chronic:
1. Varicose veins
2. Lymphoedema: primary, LN involvement (RT, infection)
3. Immobility
139
DDx
Deranged LFTs
(raised AST, ALT, ALP)
1. AST:
1. hepatocyte damage
2. haemoysis
3. MI
4. Skeletal muscle damage
2. ALT:
1. Hepatocyte damage
2. Shock
3. ALP:
1. Liver disease: cholestasis
2. Bone disease: growth in adolescence, healing fx, paget's, osteomalacia, bone mets, hyperPTH, renal failure
3. Placenta: pregnancy
4. Other: RHF, Polymyalgia rheumatica, thyrotoxicosis
140
DDx
FEV1/FVC ratio
1. Obstructive \<75%:
1. Asthma, COPD
2. Restrictive \>75%
1. Pulm fibrosis:
1. Idiopathic fibrosing alveolitis
2. Connective tissue diseases: scleroderma, SLE, sarcoidosis, RhA, ankspond
3. Drugs: amiodarone, nitrofurantoin, radiation
4. Extrinsic allergic alveolitis
5. Pneumoconioses
141
DDx
Lymphadenopathy
1. Infection:
1. Bacterial, TB, less commonly: brucellosis, syphilis
2. Viral: HIV, EBV, CMV, rubella, measles
3. Toxoplasmosis, filariasis, fungal
2. Inflammatory/connective tissue disease: RhA, sarcoidosis, SLE
3. Malignancy: mets, lymphoma, leukaemia
4. Rare: thyrotoxicosis, psoriasis, eczema, phenytoin
142
DDx
Macroglossia
1. Hypothyroidism
2. Amyloidosis
3. Acromegaly
4. Mucopolysaccharidosis
5. Down's syndrome
6. Chronic infections TB
7. Space-occupying lesions - rhabdomyosarcomas
143
DDx
Megacolon
1. IBD
2. Ischaemic colitis
3. Pseudomembranous colitis
4. Amoebic colitis
5. CMV colitis
6. Trypanosomiasis
144
DDx
Miosis
1. Reactive to light:
1. Old age
2. Horner's
2. Non-reactive:
1. Drugs: pilocarpine eye drops, opiates, organophosphate
2. Argyll robertson pupil
3. Anterior uveitis
4. Pontine lesion
145
DDx
Monoarthralgia
1. Articular:
1. Infection: septic arthritis
2. trauma, haemarthrosis
3. Gout/pseudogout
4. RhA, OA
5. Seronegative arthitides
6. Systemic: SLe, sjogren's syndrome, sarcoidosis behcets, vasculitides
7. Malignancy
2. Extra-articular:
1. Bursitis
2. Tenosynovitis
3. Cellulitis
146
DDx
Murmurs (systolic and diastolic)
1. Systolic:
1. Ejection:
1. Aortic area: aortic stenosis, aortic sclerosis
2. Pulm area: innocent, atrial septal defect, pulm stenosis
2. Pansystolic:
1. Mitral Regurg, VSD
2. Tricuspid regurg
2. Diastolic:
1. Early: aortic regurg, pulm regurg
2. Mid diastolic: mitral stenosis, tricuspid stenosis
3. Continous: patent ductus arteriosus
147
DDx
Mydriasis
1. Drugs: mydriatic eye drops, OD (cocaine, amphetamine), poisoning
2. Trauma: post traumatic iridoplegia, iridectomy, lens implant
3. Third nerve palsy
4. Holmes-Adie pupil
5. Acute angle closure glaucoma
6. Deep coma, cerebral death
148
DDx
Nasal discharge
1. Allergic rhinitis
2. vasomotor rhinits
3. Infection - viral, sinusitis
4. Inflammation polyps, wegner's granulomatosis, sarcoidosis, midline granuloma
5. Trauma: foreign body, fx of anterior fossa
6. tumours
149
DDx
Neck swelling
1. Midline:
1. thyroid gland swelling
2. thyroglossal cyst
3. LN
4. Manubrium swelling:
1. Soft: lipoma
2. Hard: bony tumour
3. Pulsatile: eroding aortic aneurysm
2. Ant triangle:
1. LN
2. Cold abscess
3. salivary gland swelling
4. branchial cyst
5. carotid body tumour/aneurysm
6. sternomastoid tumour
3. Post triangle:
1. LN, cold abscess
2. cystic hygroma
3. subcalvian artery aneurysm
4. tumour of clavicle
150
DDx
Night sweats
1. Infections: chronic - TB, subacute bacterial infections, HIv histoplasmosis
2. Malignancy: lymphoma, solid tumours
3. Menopause
4. Meds - GnRH agonists, antidepressants
151
DDx
Nystagmus
1. Physiological = extreme lat gaze
2. Pendular: congenital
3. Jerky:
1. Acute labyrinthitis, other inner ear diseases - meniere's, BPPV, vestibular neuronitis, acoustic neuroma = NB: hearing loss, tinnitus and vertigo may be present
2. Brainstem/vestibular nuclei: vascular (stroke), inflammation (MS/tumours). toxic (alcoholism)
3. Cerebellar disease
4. Drugs -phenytoin
4. Rotary nystagmus: lesion in labyrinth or brainstem
5. Vertical nystagmus: drugs or brainstem lesion
152
DDx
Oedema in ankles
1. Pitting/bilat:
1. HF
2. LF, or hypoalbuminaemia: malnutrition, malabsorption, nephrotic syndrome, protein losing enteropathy
3. Renal failure
4. hypothyroidism
5. iatrogenic: oestrogens, CCB, fluid overload
6. Venous insufficiency: acute, chronic
7. Venous obstruction: pelvic mass, pregnancy
2. Non-pitting:
1. Lymphoedema: 1ry, LN involvement: RT,infection, malignant infiltration, excision
153
DDx
Optic disc atrophy
1. Optic neuritis
2. ^ ICP: 2ry to papilloedema
3. Toxic/met/drugs: tobacco, alcohol, vit B12 def, diabetes, ethambutol
4. Infection/infiltration: spread from sinuses, syphilis, sarcoid
5. Compression: intraorbital, tumour of pit/sphenoid sinus, carotid aneurysm
6. Ant ischaemic optic neuropathy
7. Trauma: orbital fracture, indirect trauma
8. Retinal disease: retinitis pigmentosa, macular degeneration
9. Occlusion of retinal artery
10. ^ pressure inside eye
11. Hereditary - leber's optic atrophy, hereditary ataxis
154
DDx
Osler's nodes
1. subacute bacterial endocarditis
2. SLE
3. Haemolytic anaemia
4. gonococcal infection
155
sources of O2 sat errors
1. hypoperfusion
2. improper probe placement
3. intensive ambient light
4. motion artifact
5. MRI
6. Nail polish
7. Skin pigmentation
8. Abnormal Hb
9. Venous congestion/pulsations
156
DDx
P wave
1. Absent:
1. AF
2. Hyperkalaemia
3. Sinoatrial block, junctional rhythm
2. Tall:
1. Pulm HTN
2. Pulm stenosis
3. tricuspid stenosis
157
DDx
Painful red eye
1. Scleritis
2. Anterior uveitis
3. Acute angle closure glaucoma
4. corneal ulcer/bacterial keratitis
158
DDx
High arched palate
1. Marfan's
2. Homocytinuria
3. MEN2b
4. turner's syndrome
5. Noonan's syndrome
6. friedrich's ataxia
7. Fragile x syndrome
159
DDx
Palmar erythema
1. Liver disease
2. Alcoholism
3. RhA
4. Thyrotoxicosis
5. Pregnancy
6. Chornic leukaemia
160
DDx
Palpitations
1. fever, exercise, anaemia, pregnancy
2. Drugs - caffeine, nicotine salbutamol, anticholinergics, vasodilators, cocaine
3. Cardiac: arrhythmias - AF/SVT/VT, pacemaker, valvular disease, cardiac shunts, cardiomyopathy, atrial myxoma
4. Endocrine: thyrotoxicosis, phaeo, hypoglycaemia, mastocytosis
5. Psych: panic attacks, generalised anxiety disorder, depression
161
DDx
Pancytopaenia
1. Aplastic anaemia
1. Congenital: fanconi's
2. Radiation
3. Chemicals: benzene, insecticides
4. Drugs: chloramphenicol, gold
5. Infection: HIV, viral hep, measles
6. Idiopathic
2. Megaloblastic anaemia
3. Marrow infiltration
1. Lymphoma, leukaemia, metastasis, myeloma, myelofibrosis
4. SLE, sepsis, hypersplenism, paroxysmal nocturnal Hburia
162
DDx
Paraesthesia
1. Peripheral neuropathy: DM, alcoholism
2. Peripheral nerve entrapment/compression - carpal tunnel, disc herniation
3. Spinal cord disease - MS
4. Hypocalcaemia
163
DDx
Parotid enlargement
1. Bilat:
1. Sjorgens
2. sarcoidosis
3. lymphoma
4. anorexia
5. acromegaly
6. alcoholics
7. diabetics, hypertriglyceridaemia
8. Infection: mumps, HIV
2. Unilat:
1. Tumours
2. Calculi
3. Cysts
4. Bacterial infection
164
DDx
Percussion notes - dull, hyperresonant
1. Dull:
1. Pleural effusion
2. Collapse
3. Consolidation
4. Fibrosis
5. Pleural thickening
2. Hyperresonant:
1. Pneumothorax
2. COPD (hyperinflation)
165
DDx
Pericarditis
1. Idiopathic
2. Infection: viral - EBV, varicella, mumps, HIV; bacterial - strep, TB; fungal
3. Inflammatory: RhA, SLE
4. MI
5. Malignancy
6. Myxoedema
7. Uraemia
8. Radiotherapy
9. Surgery/trauma
10. Drugs: hydralazine, isoniazid
166
DDx
Decreased platelets
1. Decreased production:
1. Bone marrow failure:
1. Myeloma, myelofibrosis, marrow infiltration, anaemia, leukaemia
2. Drugs: cytotoxics, chloramphenicol, alcohol
3. Decreased megaaryocytes: chemicals, drugs, viral infection
2. Increased destruction/consumption:
1. Autoimmune - ITP
2. SLE, CLL, lymphoma
3. Infections (malaria, viral: HIV)
4. Drugs: Analgesics, abx, anticonvulsant, anti-diabetics, heparin, quinine
5. DIC, TTP, HUS
6. Sequestration: splenic pooling due to splenomegaly
7. Dilutional loss
8. Artifactial
167
DDx
Increased platelets - thrombocytosis
1. 2ry:
1. blood loss
2. infection
3. inflammation
4. malignancy
5. splenectomy
6. trauma/surgery
2. 1ry
1. essential thrombocythaemia
2. polycythaemia vera
3. myelofibrosis
4. myelodysplasia
5. CML
168
DDx
Pleural effusion
1. Exudate:
1. infection: TB, bacterial, pneumonia
2. inflammation/connective tissue: SLE, sarcoidosis
3. Malignancy: bronchial carcinoma, mesothelioma
4. Pulmonary infarction
5. post-MI
6. pancreatitis
2. Transudate:
1. Cardiac failure
2. Hypoproteinaemia
3. hypothyroidism
4. constrictive pericarditis
5. Meigs' syndrome
169
DDx
Polyarthralgia
1. Infection: disseminated septic arthritis, viral, rheumatic fever, lyme disease, TB
2. Pseudo/gout
3. RhA, OA
4. Seroneg arthritis - reactive (reiters), enteropathic, ankspond, psoriatic
5. Systemic diseases: SLE, sarcoid, sjogrens, behcets, primary vasculitides, polymyalgia rheumatica
6. Other: haemochromatosis, sickle cell, malignancy
7. Migratory polyarthralgia:
1. Gonococcal arthritis
2. Rheumatic fever
170
DDx
Polycythaemia
1. Reactive: dehydration, Gaisbock's syndrome
2. True:
1. Polycythaemia rubra vera
2. Appropriate increase in EPO:
1. Chronic hypoxia - high altitude, chronic lung disease, cyanotic heart disease
1. Inappropriate increase EPO: renal cell carcinoma/cysts, hepatoma, cerebellar haemangioblastoma, fibroids
171
DDx
Polyuria
1. DM
2. DI:
1. Central: tumour, trauma/surgery, infiltration (TB, sarcoid, histiocytosis X)
2. Nephrogenic: hyperCa, hypoK, lithium
3. Diuretics
4. Diuretic phase of acute RF/chronic RF
5. Post-obstructive diuresis
6. Psychogenic polydypsia
172
DDx
Portal HTN
1. Prehepatic: portal/splenc vein thrombosis
2. Hepatic: cirrhosis, granulomata, schistomiasis
3. Post-hepatic: budd-chiari syndrome, CCF, constrictive pericarditis
173
DDx
PR interval
1. Long: 1st degree AV block
2. Short: Wolff-parkinson-white syndrome; HOCM, Duchenne's muscular dystrophy
174
DDx
Proteinuria
1. Pregnancy
2. DM
3. HTN
4. UTI
5. Inflammation - SLE, glomerulonephitis
6. Multiple myeloma
7. Amyloidosis
8. Other: fever, exercise, CCF
175
DDx
Increased Prothrombin time
1. Warfarin/vit K deficiency
2. Liver disease
3. DIC
4. Hepparin
5.
176
DDx
Proximal muscle weakness
1. Toxic/metabolic: steroids, cushing's syndrome, thyrotoxicosis, hypothyroidism, OM, alcohol, heroin
2. Inflammatory: dermatomyositis, polymyositis
3. Infectio: staph myositis, parasites, viral
4. Inherited: muscular dystrophies, metabolic/mitochondrial myopathies, familial periodic paralysis, acid maltase deficiency
177
DDx
Pruritis
1. Cutaneous:
1. Eczema, allergic reactions
2. Lichen planus
3. Scabies, herpes simplex/zoster, parasites
4. Dermatitis herpetiformis
5. Psoriasis
6. Nodularr prurigo
7. prurigo preganancy
2. Systemic disease
1. Metabolic: LF, chronic renal failure
2. Endocrine: hyperthyroidism, hypothyroidism, DM
3. Haematological: polycythaemia, IDA, hodgkin's lymphoma
4. Psych: parasitophobia, anxiety
5. Tropical infection: filariasis, hookworm
6. Drugs: alkaloids
178
DDx
Puritus ani
1. Incontinence, diarrhoea, poor hygeine
2. Infection: threadworm, fungal (candidiasis, tinea cruris), scabies
3. Anal disease: haemorrhoids, fissure, fistula, wart
4. Skin disease: contact dermatitis, eczema, psoriasis, lichen sclerosis
5. Other: anxiety, tight pants
179
DDx
Ptosis
1. 3rd nerve palsy
2. Horner's syndrome
3. Myasthenia gravis
4. Myotonic dystrophy
5. Ocular myopathy
6. Congenital
7. syphilis
180
DDx
Puberty - delayed or precocious
1. Delayed:
1. constitutional growth and puberty delay
2. hypogonadism of prepubertal onset
2. Precocious:
1. Complete:
1. Congenital: hydrocephalus, brain malformation
2. Acquired: tumours, trauma, radiation, infiltrations
2. Incomplete:
1. Premature pubic/axillary hair development: excess androgens
2. Leydig cells simulated by hCG - hepatoma, pineal/hypothalamic teratomas
3. Leydig cells premature activation due to mutation in LH receptor
4. Leydig cell tumour
5. McCune-albright syndrome
6. Excess androgens from adrenal tumours, CAH
7. Exogenous sex steroids
3. Premature breast development - excess oestrogens:
1. Ovarian cyst
2. hypothyroidism
3. Ovarian neoplasm
4. McCune-Albright
181
DDx
Pulmonary HTN
1. 1ry
2. 2ry:
1. L heart disease - mitral valve disease, LVF, left atrial myxoma
2. COPD
3. Recurrent PE
4. Increased pulm blood flow - VSD, ASD, patent ductus arteriosus
5. Connective tissue disease - SLE, scleroderma
6. Drugs: fenfluramine
7. HIV
182
DDx
Irregular/Bounding/Unequal or delayed pulse
1. Irregular:
1. Sinus arrhythmia
2. Irreg irreg: AF, mutliple ectopic beats, atrial flutter with variable block
3. reg irreg: 2nd degree heart block, ventricular bigemini
2. Bounding
1. Peripheral vasodilation: CO2 retention, sepsis, liver failure, thyrotoxicosis
2. Increase SV: aortic regurg, patent ductus arteriosus, large AV fistulas thyrotoxicosis, severe anaemia, exercise
3. Unequal/delayed:
1. Atherosclerosis, thromboembolic disease
2. Aortic dissection
3. Aortic aneurysm
4. Arteritis: large vessel vasculitis
5. Subcalvian steal syndrome
6. Supravalvular aortic stenosis
183
DDx
Increased/decreased Pulse pressure
1. Increased:
1. Aortic regurg
2. Thyrotxicosis
3. Pregnancy
4. Patent ductus arteriosus
5. High-output HF
2. Decreased:
1. Aortic stenosis
2. Shock
3. Pericardial effusion, constrictive pericarditis
184
DDx
Pyoderma gangrenosum
1. IBD, autoimmune hepatitis
2. RhA, seroneg arthritides
3. Haematological: leukaemia, myeloma, polycythaemia rubra vera
4. Wegner's granulomatosis
5. Idiopathic
185
DDx
Pyrexia of unknown origin
1. Infection: abscesses
1. Bacterial: infective endocarditis, osteomyelitis, UTI, biliary infection
2. TB, brucellosis, viral infections: HIV, CMV EBV, malaria
2. Inflammation/CTD: RhA, SLE, sarcoidosis, vasculitides, polymyalgia rheumatica
3. Malignancy: lymphomas, leukaemia, renal cell carcinoma, hepatocellular carcinoma, pancreatic carcinoma
4. DrugS: sulphonamides, isoniazid, aspirin
5. Familial mediterranean fever, familial periodic fever
186
DDx
Q waves
1. Normal: \<25% of height of following R wave, or \<2mm deep
1. Septal q waves in lat leads
2. Common in III, V5-V6
3. MI
4. Left ventricular hypertrophy
5. BBB
187
DDx
QRS complexes
1. Axis deviation
2. BBB
3. Low QRS
1. incorrect standardisation
2. Obesity
3. COPD
4. Pericardial effusion
5. Myxoedema
4. Wide QRS
1. Ventricular extrasystoles, ventricular tachycardia, complete AV block, BBB - L/R
2. Dominant R waves in V1
188
DDx
QT interval
1. Long:
1. Hypothermia
2. HypoCa/Mg/K
3. Congenital: Romano-Ward syndrome, jervell-lange-nielsen syndome
4. Drugs: TCA, chloroquine, class Ia anti-arrhythmics
5. Acute MI, acute myocarditis
6. Cerebral injury
2. Short:
1. Hyperthermia
2. Hypercalcaemia
3. Digoxin
189
DDx
R wave dominant in V1
1. RV hypertrophy, RBBB, pulm embolism
2. Post MI
3. Myocarditis
4. WPW syndrome
5. Misplaced pacemaker
190
DDx
Raynaud's phenomenon
1. Idiopathic
2. Occupational
3. Connective tissue disease: slceroderma, SLe, sjogren syndrome, RhA, dermatomyositis
4. Cold agglutinins
5. Cryoglobulinaemia, macroglobuniaemia
6. cervical rib
7. drugs - b blockers
8. vascular disease
191
DDx
Rectal discharge
1. Common:
1. Haemorrhoids
2. Anal fissure
3. Rectal prolapse
4. Proctitis
5. Perianal warts
2. Occasional:
1. Rectal carcinoma
2. anal fistula
3. Perianal IBD
4. Solitary rectal ulcer syndrome
5. villous adenoma
192
DDx
Red eye
1. Conjunctivitis - allergic, viral, bacterial, chlamydial
2. Episcleritis
3. Scleritis
4. Iritis
5. Acute angle closure glaucoma
6. Other: inflamed pinguecula, subconjunctival haemorrhage
193
DDx
Absent red reflex
1. Cataract
2. corneal oedema
3. vitreous haemorrhage
4. retinal detachment
194
DDx
RAPD
1. Optic neuritis
2. Optic nerve compression
3. Central retinal artery occlusion
4. Retinal detachmment
5. Unilat glaucoma
195
DDx
Resp Rate -\> increased/decreased
1. Increased:
1. Physiological: exercise, anxiety
2. Lung disease: pneumothorax, PE, obstructive disease, restrictive disease, infection, inflammation, malignancy
3. Elevation of diaphragm: ascites, diaphragmatic paralysis
4. met acidosis
2. Decreased:
1. Physiological: well-conditioned athletes
2. CNS disease: infection (meningitis, encephalitis), trauma, tumour, drugs, coma
196
DDx
+ve rheumatoid factor
1. Sjogren's
2. RhA
3. SLE
4. Scleroderma
5. Mixed connective tissue disease
6. mixed cryoglobulinaemia
7. Poly/dermatomyositis
8. Infection/inflammatory disease - TB, infectious mono, subacute bacterial endocarditis, chronic hepatitis
197
DDx
Roth's spots
1. Infective endocarditis
2. leukaemia
3. anaemia
4. vasculitis: SLE, PAN
198
DDx
Seizures
1. Adults:
1. Vascular: infarction, haemorrhage, cortical venous thrombosis, vascular malformation
2. Trauma: head injury
3. Tumours
4. Toxic: alcohol, drugs, lead, CO
5. Metabolic: hypoxia, hypoglycaemia, electrolyte disturbances, renal/hepatic failure, endocrine disorders (hypopit, hypo/erPTH, addison's disease, insulinoma), vit deficiency
6. Infection: meningitis, encephalitis, abscess, TB, cysticercosis, HIV
7. Inflammation: MS, vasculitis, SLE, sarcoidosis
8. Degen disorders: alzheimer's, prion disease
9. HTN
2. Children;
1. Congenital anomaly
2. Tuberous sclerosis
3. Metabolic storage diseases
199
DDx
Sore throat
1. Pharyngitis
2. Strep tonsilits
3. Infectious mono
4. Gonococcal pharyngitis
5. Diptheria
6. With pharyngeal ulcers:
1. Herpes simplex
2. Herpangina
3. Vincent's angina
4. cadidiasis
200
DDx
Splenomegaly
1. Massive:
1. CML, myelofibrosis
2. tropical infections: malaria, leishmaniasis, schistosomiasis, tropical splenomegaly
3. Gaucher's disease
2. Moderate:
1. Haematological - haemolytic anaemia, lymphoma, leukaemia, myeloprolif disorders
2. Portal HTN
3. Infection: infective endocarditis, infectious mono, TB, brucellosis
4. Inflammatory/connective tissue diseases: RhA, SLE, sarcoidosis, amyloidosis
201
DDx
Splinter haemorrhages
1. Trauma
2. Infective endocarditis
3. Vasculitis
4. Psoriasis
5. Mitral stenosis
202
DDx
Purulent sputum
1. Upper resp source - acute sinusitis, rhinitis, bronchitis
2. Infection: pneumonia, TB, lung abscess
3. Bronchiectasis
4. Bronchopleural fistula
203
DDx
ST segment - depression, elevation
1. Depression:
1. MI - posterior
2. Myocardial ischaemia
3. Drugs - Digoxin, quinidine
4. Ventricular hypertrophy
2. Elevation:
1. MI - acute
2. Pericarditis
3. Prinzmetal angina
4. Left ventricular aneurysm
5. Brugada syndrome
6. High take off
204
DDx
Short stature
1. CGPD, familial
2. Syndromic: turner's syndrome, achondroplasia, prader-willi
3. Psychosocial factors: child abuse, anorexia nervosa, emotional deprivation
4. Endocrine factors:
1. Decreased growth hormone - hypopit
2. Mutations: pit1, PROP1, GHRH receptor
3. Cushing's syndrome and excess endogenous corticosteroids
4. Biologically inactive GH
5. GH resistance
6. Low levels of IGF1 (laron dwarfism)
7. decreased thyroid hormones
5. nutritional factors
6. Systemic illness:
1. GI: malabsorption - coeliac disease, milk protein intolerance, IBD
2. CV: Congenital cyanotic heart disease
3. Resp: CF
4. Renal: chronic renal failure
205
DDx
Tall stature
1. Familial
2. Syndromic:
1. Klinefelter's syndrome
2. Marfan's syndrome
3. Homocystinuria
3. Endocrine:
1. Excess GH
2. Excess thyroid hormones
3. Excess sex steroids/precocious puberty
206
DDx
Steatorrhoea
1. Small bowel disease/resection:
1. Bacterial overgrowth
2. coeliac disease
3. crohn's disease
4. ileocaecal TB
5. parasite infection
6. intestinal lymphoma
7. radiation enteritis
2. Pancreatic insufficiency
1. Chronic pancreatitis
2. Pancreatic cancer
3. CF
3. Biliary insufficiency:
1. Biliary obstruction
2. 1ry biliary cirrhosis
207
DDx
Striae
1. Cushing's syndrome
2. Systemic steroids
3. Physiological:
1. Pregnancy
2. Adolescence
3. weightlifters
208
DDx
Stridor
1. Partial obstruction of upper airways
2. Intraluminal:
1. foreign body, tumour
3. Intramural:
1. Infection: epiglottitis, croup in children, resp papillomata
2. Laryngeal oedema/carcinoma
3. cricoarytenoid RhA
4. Tracheal stenosis
4. Extramural:
1. Goitre
2. Lymphadenopathy
209
DDx
T waves - tall, small, inverted
1. Tall:
1. HyperK
2. Acute MI
3. Normal variant
2. Small
1. HypoK
2. Pericardial effusion
3. hypothyroidism
3. Inverted:
1. V1-V3/4:
1. Normal variant in children and black people
2. RBBB
3. PE
2. V2-V5
1. Non-Q wave MI
2. Hypertrophic cardiomyopathy
3. Subarachnoid haemorrhage, lithium
3. V4-V6 and lateral
1. Left ventricular hypertrophy
2. Myocardial ischaemia
3. associated with LBBB
210
DDx
Tachycardia: Sinus, SVT, AF, VT
1. Sinus tachy:
1. Fever, exercise, anxiety, anaemia, drugs (caffeine, salbutamol, catecholamines, nicotine), pregnancy
2. Hypotension
3. Cardiac: MI, CCF, constrictive pericarditis
4. Pulm: PE, asthma, chronic lung disease
5. Endocrine: hyperthyroidism, phaeo, hypoglycaemia
2. SVT:
1. Idiopathic
2. WPW
3. AF/flutter:
1. Idiopathic
2. Thyrotoxicosis
3. alcohol abuse
4. pulm: embolism, infection, cancer
5. pericarditis, cardiomyopathy, IHD, Rheumatic heart disease, mitral stenosis
4. Ventricular tachycardia:
1. Idiopathic
2. IHD/MI
3. Hypertensive heart disease, cardiomyopathy, myocarditis
4. long QT syndrome, drugs
211
DDx
Testicular pain and swelling
1. Testicular torsion
2. epidydimo-orchitis
3. TB, sarcoid
4. leukaemia
5. polyarteritis nodosa
6. renal vein thrombosis
212
TFTs
DDx
1. Normal T3/4/TSH = euthyroid
2. Normal T3/4 and low TSH = subclinical hyperthyroidism
3. Normal T4/3 and high TSH = subclinical hypothyroidism
4. Low T3/4, high TSH = 1ry hypothyroidism
5. Low T3/4, low/normal TSH = 2ry hypothyroidism, sick euthyroid syndrome
6. High T3/4, low TSH = primary thyrotoxicosis
7. high t3/4/tsh = 2ry hyperthyroidism
8. High T4/3, normal TSH - increased serum Thyroxine binding globulin
9. Familial dysalbuminaemic hyperthyroxinaemia
10. anti-T4 Ab
213
DDx
Thyrotoxicosis
1. Graves disease
2. toxic mutlinodular goitre
3. toxic adenoma
4. thyroiditis
5. gestational thyrotoxicosis
6. Rare causes:
1. 2ry hyperthyroidism
2. follicular carcinoma of thyroid
3. choreocarcinoma
4. struma ovarii
5. drugs: amiodarone, surreptitious thyroxine consumption
6. TSH-receptor mutations, McCune albright syndrome
214
DDx
Tracheal deviation
1. Collapse
2. Tension pneumothorax
3. large pleural effusion
215
Increased Tumour markers (8)
1. alpha-fetoprotein: hepatoma, germ cell tumour, pregnancy, hepatitis, cirrhosis, open neural tube defects
2. CA 125: ovarian cancer, other malignancy (breast, endometrial, lung, pancreas), benign conditions (endometriosis, fibroids, pelvic inflammatory disease, peritonitis, cirrhosis)
3. CA 15-3: breast cancer, benign breast disease
4. CA 19-9: pancreatic cancer, colorectal cancer, cholestasis
5. CEA: colorectal cancer, medullary thyroid carcinoma, cirrhosis, panceatitis, smoking
6. HCG: pregnancy, germ cell tumours, hydatidiform mole, choriocarcinoma
7. PLAP: seminoma, smoking, pregnancy, ovarian carcinoma
8. PSA: prostate cancer, BPH, prostatitis, DRE
216
DDx
U wave
1. Normal
2. HypoK
3. HyperCa
4. Hyperthyroidism
217
DDx
Mouth Ulcers
1. Trauma, aphthous ulcers
2. GI diseases: crohn's, coeliac
3. Infection: herpes simlex, acute ulcerative stomatitis, candidiasis TB, syphilis
4. Exclude: leukaemia, agranulocytosis
5. Inflammatory: behcets, reactive arthritis, SLE
6. Skin diseases: pemphigus, pemphigoid, erythema multiforme, lichen planus
7. Malignancy: squamous cell carcinoma
8. Other: strachan's syndrome
218
DDx
Genital ulcers
1. Infection:
1. Painful: herpes simplex, haemophilus ducreyi
2. Painless: Syphilis (treponema pallidum), chlamydia trachomatis, granuloma inguinale
2. Behcet's disease
3. Crohn's
4. Reiter's syndrome
5. Erythroplasia of Queyrat, squamous cell carcinoma
6. trauma
7. Other genital rashes: fixed drug eruption, eczema, psoriasis, scabies
219
DDx
Orogenital ulcers
1. Infectious:
1. Herpes simplex, syphilis
2. Inflammatory diseases:
1. Behcet's disease, reiter's syndrome
3. Skin diseases
1. Pemphigus, erythema multiforme
4. GI: Crohn's
5. Other: Strachan's diseases
220
DDx
Leg ulcer
1. Venous: superficial venous insufficiency, DVT
2. Arterial: atherosclerosis
3. Diabetic: ischaemia, neuropathic
4. Vasculitis: RhA, 1ry vasculities
5. Sickle cell anaemia
6. Pressure
7. Pyoderma gangrenosum
8. Malignancy
221
DDx
Decreased urea
1. Increased GFR (pregnancy)
2. Low-protein diet, starvation, liver failure
3. SIADH
4. Drugs: Na valproate
222
DDx
Increased urea
1. Impaired glomerular filtration rate
2. High protein diet, GI haemorrhage, catabolic states
3. Dehydration
4. Drugs: steroids, tetracycline
223
DDx
Urgency
1. UTI
2. Bladder: stone, tumour, compression by pelic mass
3. Prostate enlargement (BPH, cancer)
4. Genuine stress incontinence
5. Detrusor instability
6. sensory urgency
224
DDx
Urinary stress incontinence
1. females:
1. Pelvic floor weakness/bladder neck descent (pregnancy, vaginal delivery, obesity, menopause)
2. Males:
1. Prostate surgery
225
DDx
Urge incontinence
1. Detrusor instability
1. Idiopathic,
2. 2ry to bladder outflow obstruction
3. Stroke, MS, cord compression
2. Bladder stone, tumour, infection (cystitis)
226
DDx
Continous incontinence - urinary
1. Chronic retention/overdistention/overflow
1. Outflow obstruction
2. Bladder atonia due to damage to S2-4, parasympathetic fibres in lower spinal cord, cauda equina or pelvis, diabetic autonomic neuropathy
3. Fistula 2ry to obstructed labour, surgery, malignancy, radiotherapy
227
DDx
Acute urinary retention
1. Males:
1. Prostatic hyperplasia/carcinoma
2. Obstruction of urethral lumen/bladder neck
3. Post-op
4. Medications: anticholinergic, antidepressants, alcohol
5. Neurological: MS, spinal cord disease, diabetic autonomic neuropathy, herpes zoster
2. Females:
1. Pelvic mass: fibroids, ovarian mass, pregnancy
2. Obstruction of urethral lumen/bladder neck
3. Post-op
4. Medication: anticholinergics, antidepressants, alcohol
5. Neurological: MS, spinal cord disease, diabetic autonomic neuropathy, herpes zoster
228
DDx
Urinary tract obstruction
1. Lumen:
1. stones, tumours, blood clots
2. Wall: stricture, defective peristalsis, neuropathic bladder
3. Pressure from the outside: postatic/pelvic mass, retroperitoneal fibrosis, phimosis
229
DDx
Uveitis
1. Inflammatory/connective tissue diseases:
1. Seroneg spondyloarthropathies (reactive arthritis, IBD, ankspond, psoriatic arthritis)
2. Sarcoidosis
3. Behcet's disease
4. juvenile chronic arthritis
2. Infection:
1. CMV
2. Toxoplasmosis
3. Post-op infection
4. Fungal, herpetic, TB, syphilis
3. Ocular disease
230
DDx
Vertigo
1. Labyrinth:
1. Acute labrynthitis
2. BPV
3. Meniere's disease
4. 2ry to middle ear disease
2. Vestibular nerve
1. Herpes zoster
2. Acoustic neuroma
3. Ototoxic drugs
3. Brainstem:
1. Ischaemia/bleeding
2. MS, tumours
4. Other: migraine, vertiginous epilepsy
231
DDx
Sudden visual loss
1. Unilat:
1. Amaurosis fugax
2. Central retinal vein/artery occlusion
3. Vitreous haemorrhage
4. Retinal detachment
5. GCA
6. Optic neuritis
7. Ischaemic optic neuropathy
2. Bilat:
1. Severe bilat papilloedema
2. Rapid progression of lesion compressing the optic chiasm
3. Bilat infarcts of occipital lobes
4. Bilat optic neuritis
232
DDx
Gradual visual loss
1. Cataracts
2. Glaucoma
3. Diabetic retinopathy
4. Macular degeneration
5. optic nerve compression
233
DDx
Vomiting
1. Drugs, poisoning, alcohol
2. Abdo pathology - GI, hep, gynae
3. Metabolic/endocrine: DKA, addisonian crisis, hyperCa, uraemia, pregnancy
4. Neurological: increased ICP, acute labyrinthitis
5. Acute angle closure glaucoma
234
DDx
Weight loss
With appetite loss and increase
1. Voluntary: diet, exercise
2. Increased appetite:
1. Increase in physical activity
2. Malabsorption syndrome
3. Endocrine: hyperthyroidism, uncontrolled DM, phaeo
3. Decreased appetite:
1. Chronic systemic illness:
1. Infections
2. Malignancy
3. cardiopulm disease
4. GI disease
5. Endocrine disease
2. Psychiatric: depression, eating disorder
3. Drugs: antidepressants, L-dopa, digoxin, metformin NSAIDs, alcohol, opiates, amphetamine, cocaine
235
DDx
Weight gain
1. Pregnancy
2. Excessive calorific intake
3. Endocrine: PCOS, cushing's syndrome, hypothyroidism, hypothalamic disease, acromegaly
4. Drugs: steroids, OCPs, androgenic steroids, antidepressants, anticonvulsants
5. Depression
6. Increased fluid: CCF, RF, cirrhosis, excess IV fluids, lymphatic obstruction
7. Cessation of smoking
236
DDx
Wheeze
1. Anaphylaxis
2. Asthma, allergic bronchopulm aspergillosis
3. COPD
4. Pulm oedema
5. Aspiration
6. PE
7. Bronchiolitis:
1. Infection
2. Connective tissue diseases
3. Transplant
4. Toxic fume inhalation
5. UC
6. Idiopathic
8. Carcinoid syndrome
9. Lung cancer
10. Lymphangitic carcinomatosis
11. Bronchiectasis, CF
12. Parasitic infections
237
DDx
Neutrophilia
1. Infection - bacterial
2. Inflammation/connective tissue diseases/vasculitis
3. Tissue damage: trauma/surgery, burns, MI
4. HAemorrhage/haemolysis
5. Myeloprolif disease - polycythaemia, CML
6. Meds: steroids
7. Malignancy - solid/necrotic tumours
238
DDx
Neutropaenia
1. Pancytopaenia
2. Infection: viral, typhoid, TB, brucellosis
3. Drugs: sulphasalazine, sulphonamides, carbimazole
4. Immune: AI neutropaenia, SLE, felty's
5. Benign racial: black africans
6. Congenital: kostmann's syndrome
239
DDx
Eosinophilia
1. Allergic diseases: asthma, urticaria, eczema, hay fever, food allergy
2. Drugs
3. Parasitic infections
4. Addison's disease
5. Blistering skin disease: pemphigus, pemphigoid, erythema multiforme
6. Hodgkin's lymphoma
7. mstocytosis
240
DDx
Increased lymphocytes
1. Infections: viral, TB
2. CLL, prolymphocytic leukaemia, ALL, hairy cell leuk
3. NHL
4. Thyrotoxicosis
241
DDx
Decreased lymphocytes
1. Pancytopaenia
2. Infections: AIDS, legionnaires'
3. Steroids
4. SLE
5. Uraemia
