Differential diagnosis and mini-cases : Sore throat, SoB, Chest Pain, Palpitations, Weight gain, Weigh loss, Dysphagia, Neck mass Flashcards Preview

STEP 2 CS Hx Mnemonics > Differential diagnosis and mini-cases : Sore throat, SoB, Chest Pain, Palpitations, Weight gain, Weigh loss, Dysphagia, Neck mass > Flashcards

Flashcards in Differential diagnosis and mini-cases : Sore throat, SoB, Chest Pain, Palpitations, Weight gain, Weigh loss, Dysphagia, Neck mass Deck (78):
1

Sore throat - key history ?

  • Description of CC;
  • Onset; 
  • Fever, infection symptoms; 
  • Other ENT symptoms - ear pain, sinus congestion, runny nose; 
  • Pain, its intensity & radiation; 
  • Odynophagia - pain on swallowing;
  • Dysphagia - difficulty swallowing;
  • Swollen glands ? Cough ? Rash ? Fatigue ?
  • ROS => CRUGS; 
  • Sick contacts, travel; 

2

Sore throat - key physical exam ?

  1. Vital signs;
  2. ENT exam - oral thrush ? tonsillar exudate ? lymphadenopathy ? 
  3. Lung exam;
  4. Abdominal exam - splenomegaly !
  5. Skin exam; 

3

What is your differential diagnosis and workup ?

"26 yo F presents with sore throat, fever, severe fa- tigue, and loss of appetite for the past week. She also reports epigastric and LUQ discomfort. She has cervical lymphadenopathy and a rash. Her boyfriend recently experienced similar symptoms" 

  • Differential diagnosis :
    • Infectious mononucleosis
    • Hepatitis
    • Viral/bacterial pharyngitis
    • Acute HIV infection 
    • Secondary syphilis
    • Toxoplasmosis
    • Cytomegalovirus infection 
  • Workup :
    1. CBC with differential
    2. Monospot test
    3. Throat culture
    4. AST, ALT, bilirubin, alkaline phosphatase 
    5. HIV antibody and viral load
    6. CRP, ESR
    7. Abdominal US 
    8. Acute hepatits serology 
    9. VDRL/RPR
    10. Anti-EBV antibodies

 

4

What is your differential diagnosis and workup ?

"26 yo M presents with sore throat, fever, rash, and weight loss. He has a history of IV drug abuse and sharing needles" 

  • Differential diagnosis :
    • Acute retroviral disease (HIV) 
    • Infectious mononucleosis
    • Viral/bacterial pharyngitis 
    • Hepatitis 
    • Secondary syphilis 
  • Workup :
    • CBC with peripheral smear
    • HIV antibody and viral load
    • CD4 count
    • Monospot test
    • Throat culture
    • VDRL/RPR
    • AST/ALT/bilirubin/alkaline phosphatase

5

What is your differential diagnosis and workup ?

"46 yo F presents with fever and sore throat"

  • Differential diagnosis ?
    • Pharyngitis (bacterial or viral)
    • Mycoplasma pneumonia
    • Acute HIV infection
    • Infectious mononucleosis
  • Workup :
    • Throat swab for culture and rapid streptococcal antigen
    • Monospot test CBC
    • Serologic test (cold agglutinin titer) for Mycoplasma
    • HIV antibody and viral load

6

Cough / SoB - key history ?

  1. Acute/subacute vs. chronic ?
  2. Increased frequency of cough if chronic !
  3. Timing ? 
  4. Presence/description of sputum ?
  5. Presence of hemoptysis ?
  6. Associated symptoms (constitutional, URI, postnasal drip, dyspnea, wheezing, chest pain, heartburn);
  7. Exacerbating and alleviating factors, exposures;
  8. Smoking history ? 
  9. History of lung disease, posttussive emesis, or heart failure ?
  10. Allergies ?
  11. Medications (especially ACE inhibitors) ? 

7

Cough / SoB - physical examination ?

  1. Vital signs ± pulse oximetry;
  2. HEENT/Neck : 
    1. oropharynx : erythema, exudate, postnasal drip;
    2. nasal mucosa : edema, polyps; 
    3. sinus tenderness; 
    4. cervical lymphadenopathy; 
  3. Cardiac : auscultate for murmurs, gallops, rubs; 
  4. Lungs :
    1. Inspection : chest wall abnormalities, accessory muscle use; 
    2. Auscultation : decreased or abnormal breath sounds, wheezing;
    3. Signs of consolidation : dullness, egophony, increased fremitus; 
  5. Abdomen : upper abdominal tenderness - GERD; 
  6. Extremities : peripheral edema, cyanosis, clubbing;

8

What questions should you ask to a patient presenting with chronic cough ?

  1. Could you please describe your cough for me ?
  2. When did your cough start ? (onset)
  3. Is it a dry cough or does it bring up sputum ?
  4. What color is this sputum ? How much sputum do you typicaly cough up (teaspoon, tablespoon) 
  5. Have you ever noticed blood in the sputum ?
  6. Have you ever noticed that something triggers your cough ? Have you ever noticed factors that make the cough become lesser/go away ?
  7. Is there anything that makes it better/worse ?
  8. Have you noticed that something flows in the back of your throat ? / Does mucus drip in the bach of your throat ?
  9. Do you ever get short of breath ? 
  10. Have you noticed wheezing ?
  11. Have you noticed fever ? chills ? night sweats ? weight loss ?
  12. Have you noticed any swollen glands ? on your neck ? around your ears ? elsewhere ? 
  13. Do you sometimes have heartburn ? acid reflux ?
  14. Do you have a history of heart problems ? 
  15. Have you nocites any swelling in your feet 
  16. Have you ever had chest pain ?
  17. On how many pillows do you sleep at night ?
  18. Have you ever woken up being short of breath ? coughing or choking ? 
  19. Do you get short of breath when you lie down ?
  20. Have you ever had lung or heart problems in the past ?
  21. Do you have problems with allergies ? egzema ? rhinitis ? red eyes ? Did you have these problems in the past ?
  22. Do you have HTN ? What medications do you take for that ? (look for ACEI !) 
  23. Is there anyone in your family with asthma ?
  24. What kind of work do you do ?
  25. Do you have smoking hx ?
  26. Have you traveled outside US recently ?

9

What workup do you have to consider in a patient presenting with chronic cough ?

  1. Lung tests : 
    1. Structural : CXR, CT scan 
    2. Functional : pulmonary function tests, arterial blood gas analysis 
  2. Arterial blood gas analysis 
  3. ECG, echocardiogram 
  4. Esophagram 

10

What questions will you ask a patient with dyspnea ?

  1. Tell me about your problem with breathing.
  2. How long has this shortness of breath been going on?
  3. Do you have a history of cardiac problems?
  4. Do you smoke?
  5. What is your occupation?
  6. Have you had a recent period of prolonged immobilization?    
  7. Do you have a history of cancer or lower extremity weakness?    
  8. Are you taking birth control pills or estrogen?    
  9. Do you have diabetes, high blood pressure, high cholesterol, or heart disease?    
  10. Has anyone in your immediate family had a serious heart condition? At what age?    
  11. Have you had unintentional weight loss, night sweats, or fatigue?    
  12. Do you have any other medical problems?
  13. Have you traveled in the past year? Have you travelled to foreign countries ?
  14. Do you have any known allergies to foods, insects, or latex ?
  15. Have you been taking your prescribed medications, and in the proper doses?    
  16. Have you recently started taking any new medications (eg, β-lactam antibiotics, angiotensin-converting enzyme inhibitors)?    
  17. Is your chest tight, or does it take an increased amount of effort to breathe?
  18. Do you feel that your breathing is rapid and/or shallow?
  19. Does your breathing only get heavy with activity?    
  20. Do you feel as if your throat is closing or that air can't get all of the way in to your lungs?
  21. Do you have shortness of breath when lying flat?    
  22. Does lying on one side or the other cause increasing shortness of breath?
  23. Can you exercise for some time before getting short of breath?
  24. Do you have chest pain?
  25. Do you have any itching or hives? Are your lips or tongue swelling?
  26. Have you had a fever?
  27. Have you been coughing?
  28. Do you have swelling in your legs or abdomen?
  29. Have you lost weight?
  30. Have you had fainting spells?
  31. Do you have rashes or joint pains?
  32. Do you have weakness in your arms or legs or difficulty speaking or swallowing?
  33. Do you have any numbness or tingling in your fingertips?
  34. Did you feel a sense of impending doom or extreme fear?    

 

11

What is your differential diagnosis and workup ?

"30 yo M presents with shortness of breath, cough, and wheezing that worsen in cold air. He has had several such episodes in the past 4 months" 

 

  • Differential diagnosis
    1. Asthma
    2. GERD
    3. Bronchitis
    4. Pneumonitis
    5. Foreign body
  • Workup 
    • CBC
    • CXR
    • Peak flow measurement
    • PFTs
    • Methacholine challenge test

12

What is your differential diagnosis and workup ?

"56 yo F presents with shortness of breath and a pro- ductive cough that has lasted for at least 3 months each year over the past 2 years. She is a heavy smoker"

 

  • Differential diagnosis :
  1. COPD / Chronic bronchitis
  2. Bronchiectasis
  3. Lung cancer
  4. Tuberculosis
  • Workup 
    • Chest XR or Chest CT
    • Pulmonary function tests - PFTs
    • Arterial blood gasometry
    • CBC with differential 
    • Sputum examination - cytology and gram stain, culture 
    • PPD

13

What is your differential diagnosis and workup plan ?

"58 yo M presents with 1 week of pleuritic chest pain, fever, chills, and cough with purulent yellow sputum. He is a heavy smoker with COPD" 

 

  • Differential diagnosis :
    1. Pneumonia
    2. COPD exaccerbation 
    3. Lung abcess
    4. Tuberculosis
    5. Lung cancer
    6. Pericarditis, Pleuritis 
  • Workup 
    • chest XR, chest CT
    • PFTs 
    • Sputum gram stain and culture 
    • CBC with differential 
    • PPD
    • Arterial blood gasometry 
    • ECG

14

What is your differential diagnosis and workup ?

"25 yo F presents with 2 weeks of nonproductive cough. Three weeks ago she had a sore throat and a runny nose" 

 

  • Differential diagnosis : 
    1. Atypical pneumonia
    2. Reactive airway disease
    3. Upper Airway Cough Syndrome (UACS) 
    4. Post-infectious cough 
    5. Upper airway inflammation/infection
    6. Asthma
    7. GERD 
  • Workup :
    • CBC
    • Induced sputum Gram stain and culture CXR
    • IgM detection for Mycoplasma pneumoniae
    • Urine Legionella antigen

15

What is your differential diagnosis and workup ?

"65 yo M presents with worsening cough for the past 6 months accompanied by hemoptysis, dyspnea, weakness, weight loss. He is a heavy smoker" 

 

  • Differential diagnosis : 
    1. Lung cancer
    2. Tuberculosis
    3. Lug abcess
    4. Bronchiectasis
    5. Chronic bronchitis / COPD
    6. Vasculitis
    7. Pneumonia
    8. Interstitial lung disease 
    9. CHF
  • Workup 
    • CBC
    • Sputum Gram stain, culture, and cytology
    • CXR
    • CT—chest
    • PPD
    • ANCA
    • Bronchoscopy
    • Echocardiography

16

What is your differential diagnosis and workup ?

"55 yo M presents with increased dyspnea and spu- tum production for the past 3 days. He has COPD and stopped using his inhalers last week. He stopped smoking 2 days ago" 

 

  • Differential diagnosis : 
    1. COPD exaccerbation
    2. Lung cancer 
    3. Pneumonia
    4. Upper respiratory infection
    5. Lung abcess
    6. Congestive lung failure
    7. TB
    8. Bronchiectasis
  • Workup :
    • CBC
    • CXR
    • ABG
    • PFTs
    • Sputum Gram stain and culture
    • CT—chest
    • Echocardiography

17

What is your differential diagnosis and workup ?

"34 yo F nurse presents with worsening cough of 6 weeks’ duration accompanied by weight loss, fatigue, night sweats, and fever. She has a history of contact with tuberculosis patients at work" 

 

  • Differential diagnosis :
    1. Tuberculosis
    2. Pneumonia
    3. Lung abcess
    4. Vasculitis
    5. Lymphoma
    6. Metastatic cancer
    7. Lung cancer
    8. HIV/AIDS
    9. Sarcoidosis
  • Workup : 
    • CBC
    • PPD/QuantiFERON Gold
    • Sputum Gram stain, acid-fast stain, and culture
    • CXR
    • CT—chest
    • Bronchoscopy
    • HIV antibody
    • Lymph node biopsy

18

What is your differential diagnosis and workup ?

"35 yo M presents with shortness of breath and cough. He has had unprotected sex with multiple sexual partners and was recently exposed to a patient with active tuberculosis" 

 

  • Differential diagnosis :
    1. Tuberculosis
    2. Pneumonia
    3. Bronchitis
    4. Acute retroviral disease
    5. Asthma
    6. Pulmonary embolism
    7. Acute coronary syndrome
    8. Cardiomyopathy/CHF 
  • Workup : 
    • CBC
    • PPD/QuantiFERON Gold
    • Sputum Gram stain, acid-fast stain, silver stain, and culture
    • CXR
    • HIV antibody
    • Echocardiography

19

What is your differential diagnosis and workup plan ?

"50 yo M presents with a cough that is exacerbated by lying down (orthopnea) at night and improved by propping up on 3 pillows. He also reports exertional dyspnea"

  • Differential diagnosis :
    1. CHF
    2. Cardiac valvular disease
    3. GERD
    4. Pulmonary fibrosis
    5. COPD
    6. Upper Airway Cough Syndrome
  • Workup plan :
    • CBC
    • CXR
    • ECG
    • Echocardiography
    • PFTs
    • BNP
    • CT—chest

20

What is your differential diagnosis and workup plan ?

"60 yo M presents with worsening dyspnea of 6 hours’ duration and a cough that is accompanied by pink, frothy sputum"

  • Differential diagnosis :
    1. Pulmonary edema - left heart failure
    2. Acute coronary syndrome with left CHF
    3. Mitral valve stenosis
    4. Arrythmia
    5. Alveolitis
    6. Acute respiratory distress syndrome
    7. Pulmonary embolism
    8. Pneumonia
  • Workup : ECG, CXR, CBC, ABG, PFTs, BNP

21

Key history - hemoptysis ?

  1. Onset, timing, precipitating factor, past occurence;
  2. Description of a typical episode; 
  3. Intensity : amount, frequency;
  4. Quality : sputum ? amount, color, structure;
  5. Aggreviating and alleviating factors ?
  6. Associated symptoms : SoB, chest pain, fever, chills, night sweats, weight loss, appetite, chronic cough, fatigue, palpitations, dysphagia, nausea, vomiting;
  7. ROS : CRUGS : CV, Respiratory, Urinary, GI, Sleep;
  8. PMH : Heart, Lung, Hematologic, Oncologic; 
  9. SAD : Smoking, Alcohol, Drugs;
  10. HITS : Hospitlizations, Immobility, Trauma, Surgieries; 
  11. Medications known to accecerbate bleeding !
  12. Sexual - unprotected, multiple contacts ?
  13. Sick contacts ? Recent travel ? 
  14. Occupation ? Housing ?

22

What questions will you ask to the patient with hemoptysis ?

  1. When did you first start coughing up blood ?
  2. How often are you coughing up blood ?
  3. What does it look like ? Bright or dark ? Small streaks or large amounts ? Rust colored ?
  4. How much sputum are you coughing up ? How much sputum are you coughing up ?
  5. Do you have breathing problems ?
  6. Have you had chest pain ? 
  7. Have you had fever or chills ?
  8. Have you had sweats at that that soak you clothes ?
  9. Do you have cough, fever, dyspnea, arthralgias, or skin rash?
  10. Do you have hematuria, sinusitis, otitis, or skin lesions?
  11. Have you lost weight ?
  12. Have you been exposed to sick people ? Have you been exposed to TB ? 
  13. Have you travelled recently ? 
  14. Have you been diagnosed with other medical conditions ?
  15. Have you had severe or recurrent pneumonia (including tuberculosis)?
  16. Do you chronically produce large amounts of purulent sputum?
  17. Do you take any medications ?
  18. Does anyone in your family have significant lung disease ? 
  19. What kind of work do you do ?
  20. Do you smoke ? At what age did you start and how many ciggaretes a day have you been smoking ?
  21. Do you drink alcohol ? What type ? How much ? How often ? 
  22. Have you ever used recreational drugs ?

23

List main causes of hemoptysis !

  1. Pulmonary :
    1. Bronchitis
    2. Lung cancer
    3. Bronchiectasis
  2. Cardiac
    1. Pulmonary embolism
    2. Mitral stenosis 
    3. Left ventricular failure with acute pulmonary edema
  3. Infectious
    1. Tuberculosis
    2. Lung abcess
    3. Bacterial pneumonia
    4. Aspergillosis
  4. Hematologic 
    1. Coagulopathy
  5. Vascular 
    1. Vasculitis
    2. Pulmonary embolism
    3. Arteriovenous malformation
  6. Miscallenous 
    1. Granulomatosis with polyangitis
    2. Goodpasture syndrome
    3. Trauma 
    4. Cocaine abuse 

24

What physical examination will you perform to a patient with hemoptysis ?

  • HEENT :
    • mouth expection, teeth, oropharynx
    • nasal passages
  • Neck 
    • lymphadenopathy
    • JVD
  • Lungs 
    • inspection - chest size and shape, skin, accessory muscle use, respiratory distress
    • palpation - pain, symmetrical fremitus
    • percussion - resonance, dulness ?
    • auscultation of breath sounds
  • Heart 
    • auscultation : m/g/r - murmurs, gallops , rubs
  • Extremities 
    • clubbing, cyanosis, edema, rash 

25

What is your workup plan for a patient with hemoptysis ?

  1. Chest XR, chest CT 
  2. CBC with differential - look for anemia, infection signs, platelet count
  3. Trothrombin time, partial thromboplastin time - clotting abnormalities
  4. High sensitivity d-dimers - pulmonary embolism 
  5. Sputum gram stain, culture, acid-fast smear 
  6. Arterial blood gas analysis 

26

Chest pain - key history ?

  1. Location, quality, severity, radiation, duration ?
  2. Context (exertional, postprandial, positional, cocaine use, trauma) ?
  3. Associated symptoms (sweating, nausea, dyspnea, palpitations, sense of doom, fever) ?
  4. Exacerbating and alleviating factors (especially medications) ?
  5. History of similar symptoms ?
  6. PMH : known heart or lung disease or history of diagnostic testing ? Chronic liver disease? Peptic ulcer disease? Renal disease?
  7. Cardiac risk factors (hypertension, hyperlipidemia, smoking, family history of early MI) ?
  8. Pulmonary embolism risk factors (history of DVT, coagulopathy, malignancy, recent immobilization) ?
  9. Vascular surgeries or tracheotomy ? 

27

Chest pain - most important differential diagnosis ?

  • Is the chest pain pleuritic or nonpleuritic ? => Truly pleuritic chest pain is worsened by respiration;
  • Nonpleuritic chest pain :
    1. Cardiac: myocardial ischemia/infarction, myocarditis.
    2. Esophageal: spasm, esophagitis, ulceration, neoplasm, achalasia, diverticula, foreign body.
    3. Referred pain from subdiaphragmatic GI structures :
      1. Gastric and duodenal: hiatal hernia, neoplasm, PUD.
      2. Gallbladder and biliary: cholecystitis, cholelithiasis, impacted stone, neoplasm.
      3. Pancreatic: pancreatitis, neoplasm.
      4. Dissecting aortic aneurysm.
    4. Pain originating from skin, breasts, and musculoskeletal structures: herpes zoster, mastitis, cervical spondylosis.
    5. Mediastinal tumors: lymphoma, thymoma.
    6. Pulmonary: neoplasm, pneumonia, pulmonary embolism/infarction.
    7. Psychoneurosis.
    8. Chest pain associated with mitral valve prolapse.
  • Pleuritic chest pain : 
    1. Cardiac: pericarditis, postpericardiotomy/ Dressler’s syndrome.
    2. Pulmonary: pneumothorax, hemothorax, embolism/infarction, pneumonia, empyema, neoplasm, bronchiectasis, pneumomediastinum, TB, carcinomatous effusion.
    3. GI: liver abscess, pancreatitis, esophageal rupture, Whipple’s disease with associated pericarditis or pleuritis.
    4. Subdiaphragmatic abscess.
    5. Pain originating from skin and musculoskeletal tissues: costochondritis, chest wall trauma, fractured rib, interstitial fibrositis, myositis, strain of pectoralis muscle, herpes zoster, soft tissue and bone tumors; 
    6. Collagen vascular diseases with pleuritis.
    7. Psychoneurosis.
    8. Familial Mediterranean fever.

28

What are the most important diagnosis and their differential features ??

  1. Coronary artery disease :
    • substernal 
    • radiation to arm, jaw, neck and shoulder
    • precipitated by exertion 
    • relieved by rest or nitroglycerin 
  2. Pulmonary/pleuritic - pleurisy, pneumonia, pericarditis, PE : 
    • sharp/stabbing pain 
    • worse with inspiration 
    • pericarditis : worse when lying flat 
    • PE, pneumothorax : respiratory distress, hypoxia 
  3. Aortic - dissection, intramural hematoma 
    • sudden, severe tearing pain 
    • radiates to the back 
    • elderly men 
    • hypertension, risk factors for atherosclerosis
  4. GI/esophageal 
    • nonexcertional
    • relieved by antacids 
    • upper abdominal and substernal 
    • associated with regurgitation, nausea, dysphagia
    • nocturnal pain 
  5. Chest wall/musculoskeletal 
    • persistent, prolonged pain 
    • worse with movement or position change 
    • often follows repetitive activity 

29

Chest pain - what questions will you ask ?

  1. Can you please describe your pain for me ? 
  2. Have you ever had pain like this before ?
  3. If so, what was the outcome ?
  4. Do you still have the pain or has it resolved ? How is it now compared to before ?
  5. What were you doing when this pain began ?
  6. Can you think of anything that may have caused this pain ?
  7. If past episodes : how often ? how long do they last ? what brings the pain on ? how far can you walk before you develop pain/SoB ? Can you describe your last episode ?
  8. Point to where the pain is present ? Show me where do you feel the pain ? 
  9. Do you feel it anywhere else ? Does it move anywhere ? Can you please show it to me ?
  10. On a scale from 1 to 10, how strong is this pain ?
  11. Describe the quality of pain for me : sharp, stabbing, burning, crushing, squizzing, heavy ?
  12. Is there anything that makes the pain worse / better ?
  13. Have you noticed any other symptoms taking place together with the pain ? - SoB, palpitations, nausea, sweating, lightheadedness ?
  14. Have you had a fever ? 
  15. Have you had a cough ? 
  16. Do you have swelling in the legs ?
  17. Do you have leg pain while walking ?
  18. Ask about risk factors of PE : unilateral leg pain/swelling, immobilization, recent surgery, clotting disorders ?
  19. Have you been diagnosed with othe rmedical conditions ? => hypertension, diabetes, heart problems, hypercholesterolemia ?
  20. Is there anyone in your immediate family with heart disease ?
  21. Do you smoke ? At what age did you start and how much do you smoke ?
  22. Do you drink alcohol ? How much ? How often ?
  23. Do you use recreational drugs ? 
  24. ROS : 
    1. Pulmonary : cough, wheezing, hemoptysis ?
    2. Cardiovascular : palpitations, tachycardia, edema, orthopnea ?
    3. GI : heartburn, esophageal reflux, hematemesis, nausea/vomiting ?

30

Chest pain - what physical examination will you perform ?

  1. Vital signs ± BP in both arms;
  2. Patient position and ody habitus; 
  3. Complete cardiovascular exam : carotid pulse, carotid bruits, jugular venous pressure, PMI - location and character, heary sounds : S1 and S@, m/g/r, chest wall tenderness, heart sounds, abdominal aorta - bruits or enlargement; 
  4. Lung : work on breathing, accessory muscle use, lung sounds, signs of consolidation : egophony, dullness; 
  5. Abdominal exams : epigastric tenderness, liver/gall bladder enderness : Murphy's sign; 
  6. Extremity exam : peripheral pulses, lower extremity edema, shoulder examination, signs of DVT; 

31

What diagnostic tests are worth performing in patients with chest pain ?

 

  1. ECG
  2. Chest XR
  3. Pulse oximetry 
  4. ABGs
  5. High sensitivity D-dimer
  6. CT pulmonary angiogram or ventilation/perfusion scan
  7. Echocardiogram
  8. CT scan of the chest 
  9. Barium esophagram 
  10. Upper GI endoscopy 
  11. Liver / gallbladder US 

32

What will be your differential diagnosis and workup plan ?

"60 yo M presents with sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, nausea. He has a history of hypertension, hyperlipidemia, and smoking"

  • Differential diagnosis :
    1. Acute coronary syndrome
    2. GERD
    3. Stable angina
    4. Costochondritis
    5. Aortic dissection
    6. Heart failure
    7. Pulmary embolism
    8. Pericarditis 
    9. Pneumothorax
    10. Aortic aneurysm type A 
  • Workup plan :
    • ECG
    • Troponins x3, CKMB 
    • Chest XR
    • CBC, CRP, ABGs
    • Glucose, electrolytes 
    • Clotting - INR, aPTT, PT
    • Blood group 
    • High sensitivity D-dimer 

33

What will be your differential diagnosis and workup plan ?

"20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management"

  • Differential diagnosis :
    1. Acute chest syndrome (SCD)
    2. Acute myocardial syndrome 
    3. Pulmonary embolism 
    4. Pneumothorax
    5. Pneumonia 
    6. Costochondritis
    7. Aortic dissection
    8. Panic attack 
  • Workup plan : 
    • ECG
    • Troponins x3, CKMB
    • Chest XR
    • CT chest angiogram 
    • Glucose, electrolytes 
    • ABG, CBC with reticulocyte count & peripheral smear, CRP
    • LDH, billirubin 

34

What will be your differential diagnosis and workup plan ?

"45 yo F presents with a retrosternal burning sensa- tion that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids"

  • Differential diagnosis :
    • GERD
    • Esophagitis
    • PUD
    • Esophageal spam
    • Acute gastritis
    • Stable angina, CAD
    • Cholangitis
  • Workup plan :
    • Upper GI endoscopy 
    • Barium swallow
    • 24h pH-metry monitoring
    • ECG, proBNP, Echocardiography
    • Chest XR 
    • abdominal US 
    • CBC, CRP, electrolytes

35

What will be your differential diagnosis and workup plan ?

"55 yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest and is not related to food intake"

  • Differential diagnosis :
    1. Stable angina
    2. Esophageal spasm
    3. Esophagitis
  • Workup plan :
    • ECG, CPK-MB, troponin
    • CXR
    • CBC, Electrolytes
    • Exercise stress test
    • Upper endoscopy/pH monitor
    • Cardiac catheterization

36

What will be your differential diagnosis and workup plan ?

"34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago"

  • Differential diagnosis :
    • Pericarditis
    • Aortic dissection
    • MI
    • Costochondritis
    • GERD
    • Esophageal rupture
  • Workup plan :
    • ECG
    • CPK-MB, troponin
    • CXR
    • Echocardiography
    • CBC, CRP, ESR
    • Upper endoscopy

37

What will be your differential diagnosis and workup plan ?

"33 yo F presents with stabbing chest pain that wors- ens with deep inspiration and is relieved by aspirin. She had a URI 1 week ago. Chest wall tenderness is noted"

38

What will be your differential diagnosis and workup plan ?

"70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain. She also pres- ents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery"

  • Differential diagnosis :
    1. Pulmonary embolism
    2. Pneumonia
    3. Costochondritis
    4. MI
    5. CHF
    6. Aortic dissection
  • Workup plan :
    1. D-dimer, ECG, CPK-MB, troponin
    2. CBC
    3. CXR
    4. ABG, Electrolytes, BUN/Cr, glucose
    5. CTA—chest with IV contrast
    6. Doppler U/S—legs

39

What will be your differential diagnosis and workup plan ?

"55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a history of uncontrolled hypertension"

40

Palpitations - key history

  1. Gradual vs. acute onset/offset; 
  2. First episode or history of previous episodes;
  3. Typical episode description - detailed description of palpitations, ask patient to ap out the rythm; 
  4. Context, precipitating factors (exertion, caffeine, anxiety, drug use, alcohol);
  5. Associated symptoms (lightheadedness, presyncope, syncope, loss of consciousness, chest pain, dyspnea, fever, sweating, pale skin, flushing, diarrhea, polyuria);
  6. Hyperthyroid symptoms;
  7. History of bleeding or anemia;
  8. History of heart disease, hypertension, diabetes; 
  9. Family histroy of SCD, arrhythmia;
  10. Use of medications known to prolong QT or cause tachycardia; 
  11. Detailed psychiatric history - history of anxiety, depression, bipolar disorder, posttraumatic stress disorder, panic disorder, somatization;

41

What is a broad differential diagnosis of palpitations ?

  1. Structural heart disease : alvular heart disease, cardiomyopathy
  2. Cardiac conduction disease : atrial fibrillation, supraventricular arrythmia/ectopy, ventricular arrythmia/ectopy
  3. Metabolic disorder : hyperthyroidism, hypoglycemia, pheochromocytoma, anemia
  4. Neuropsychiatric disorder : anxiety disorders, insomnia
  5. Medications : stimulants, vasodilators, bronchodilators, anticholinergics 
  6. Other substances : caffeine, alcohol, cocaine, amphetamines

42

Give examples of questions you will ask a patient presenting with palpitations.

  1. Please describe what your palpitations feel like.
  2. Could you please try to tap out the rythm of your heart during your palpitations - the way you feel it.
  3. Do you have any additional symptoms while having palpitations ? Do you have any additional symptoms ?
  4. Have you ever passed out ? Yes ? Could you please describe it for me ? What were the circumstances in which you passed out ?
  5. When did these episodes begin ?
  6. How often are they happening ?
  7. How long do they last ?
  8. What are you doing when you have these episodes ?
  9. Does anything seems to be triggering them ?
  10. Do you drink coffee ? How much ?
  11. Have you had any breathing problems ?
  12. Have you noticed any swelling in your feet ?
  13. Have you noticed any belly discomfort ?
  14. Have you beed diagnosed with any ohter medical conditions ?
  15. Do you take any medications - including over the counter medications ? 
  16. Are there any heart conditions in your immediate family ?
  17. Did anyone in your family die unexpectedly at a young age ?
  18. Do you smoke ? At what age did you start to smoke ? How much do you smoke ?
  19. Do you drink alcohol, including beer ? How much ? How often ? 
  20. Have you ever used recreational drugs ?
  21. What are you most concerned about ? What do you believe may be causing your symptoms ? 

43

What parts of physical examination will you perform in a patient presenting with palpitations ?

  1. Neck - examine thyroid for enlargement and presence of nodules; 
  2. Lungs - aucultate for breath sounds and adventitious sounds; 
  3. Heart - inspect neck veins and precordium, palpate carotid and peripheral pulses, palpate precordium for displaced point of maximal impulse; Auscultate for m/g/r; Repeat with valsalva;
  4. Neurologic - evaluate DTR's, examine for han tremor; 
  5. Extremities - examine for peripheral edema; 
  6. Skin - examine for warmth, flushing, diaphoresis; 

44

What diagnostic tests are worth performing ?

  1. 12-lead ECG
  2. Holter monitor
  3. CBC 
  4. Electrolytes
  5. Glucose
  6. TSH 
  7. Chest XR to assess cardiac silhouette

45

What will be your differential diagnosis and workup plan ?

"70 yo diabetic M presents with episodes of palpita- tions and diaphoresis. He is on insulin"

  • Differential diagnosis :
    1. Hypoglycemia 
    2. Cardiac Arrythmia
    3. Acute myocardial infarction
    4. Hyperthyroidism
    5. Hyperventilation episode
    6. Septic shock
    7. Panic attack
    8. Shock secondary to electrolyte disturbance
    9. Rhabdomyolysis
    10. Pheochromocytoma
    11. Carcinoid syndrome
  • Workup plan :
    1. Glucose, electrolytes, BUN 
    2. CBC
    3. ECG, Holter monitor
    4. Chest XR
    5. TSH, T4 
    6. Troponin x3, CKMB
    7. CPK 
    8. Blood cultures 
    9. 24-hour urinary catecholamines
    10. 5-HIAA 

46

What will be your differential diagnosis and workup plan ?

"35 yo M presents with several episodes of palpitations, sweating, rapid breathing. Episodes occur unexpectedly, and he does not recall any triggers. He has had 4–5 episodes per month for several months. Each episode lasts 2–3 minutes. He does not have any history of psychiatric illness except for separation anxiety as a child"

  • Differential diagnosis :
    1. Panic attacks, Anxiety 
    2. Cardiac arrythmia
    3. Generalized anxiety disorder
    4. Acute stress disorder 
    5. Specific phobia
    6. Substance abuse, dependence
    7. Mitral valve prolapse
    8. Pheochromocytoma
    9. Hyperthyroidism 
    10. Carcinoid syndrome
  • Workup plan :
    • CBC, electrolytes, glucose
    • ECG, CXR 
    • 24-hour urinary catecholamines
    • TSH, fT4
    • 5-HIAA
    • Echocardiography
    • Urine toxicology

47

What will be your differential diagnosis and workup plan ?

"19 yo F presents with episodic palpitations, especially during presentations in front of her class. Episodes include heart pounding, facial blushing, hand tremor. She also experiences excessive sweating and rapid breathing. She complains of intense worry and trouble sleeping for days or weeks before an upcoming social situation. Now she avoids all social events because she is afraid of humiliating herself"

  • Differential diagnosis :
    1. Speciphic phobia - social 
    2. Avoidant personality disorder
    3. Generalized anxiety disorder 
    4. Panic attacks 
    5. Hyperthyroidism
    6. Miral valve prolapse
    7. Substance abuse
  • Workup plan :
    • Glucose, electrolytes 
    • CBC
    • ECG
    • Echocardiography 
    • TSH, fT4 
    • Urine toxicology 
    • Mental status exam

48

What will be your differential diagnosis and workup plan ?

"34 yo F presents with episodic palpitations accompanied by lightheadedness and sharp, atypical chest pain"

  • Differential diagnosis :
    1. Mitral valve prolapse
    2. Hyperthrophic cardiomyopathy
    3. Cardiac arrythmia
    4. Pheochromocytoma
    5. Aortic stenosis
    6. Atypical angina, CAD
    7. Panic Attack
    8. Hypoglycemic spells
    9. Substance abuse  
  • Workup plan :
    • Chest XR, Echocardiography, ECG 
    • Holter monitor
    • CBC, glucose, electrolytes
    • Urine toxicology screen 
    • 24-hours urine catecholamines

 

49

Weight loss - key history

  1. Amount, duration, intention - voluntary or involuntary;
  2. Note the patient's age; 
  3. Diet, anorexia, exercise history;
  4. Body image, anxiety or depression;
  5. ROS, constitutional symptoms - esp. pulmonary and digestive systems;
  6. Hyperthyroid symptoms (palpitations, tremor, diarrhea);
  7. Family history of thyroid disease;
  8. HIV risk factors;
  9. Tobacco, alcohol, and drug use;
  10. Medications;
  11. History of cancer; blood in urine or stool;
  12. Munchausen syndrome - patients voluntarily lose weight to get attention;

50

Give examples of focused questions you will ask a patient presenting with weight loss.

  1. Is your appetite increased ? => hyperthyroidism, malabsorption, diabetes;
  2. Have you lost the desire to eat ? => cancer, psychiatric, CHF, COPD, chronic infection, HIV, AIDS, chronic inflammatory disorder; 
  3. Do you have any fevers, chills, or night sweats ? => infection, hematologic malignancy;
  4. Do you exercise excessively ? => Eating disorder;
  5. Are you overly concerned with the way you look ? => Eating disorder;
  6. Are your menstrual periods irregular ? => Anorexia nervosa; 
  7. Have you ever used self-induced vomiting, water pills, laxatives, enemas to control your weight ? => Bulimia;
  8. Do you have little interest or pleasure in doing things ? => depression;
  9. Do you have frequent bowel movements or diarrhea ? => Malabsorption;
  10. Does your fear of abdominal pain make you not want to eat ? => Mesenteric ischemia, IBS; 
  11. Are you pregnant ? => Hyperemesis gravidarum;
  12. Do you have abdominal pain, early satiety, blood in stool or trouble swollowing ? => GI cancer; 
  13. Do your symptoms change with different foods ? => Malabsorption; 
  14. Have you ever injected drugs, had unprotected sex, or received blood transfusions ? => HIV, chronic hepatitis, cirrhosis; 
  15. Do you use recreational drugs ? => drug-induced weight loss; 
  16. Did the onset pf weight loss correlate with starting new medications ? => drug-induced anorexia or increased metabolism; 
  17. Do you feel nervous, sweaty or warm ? => hyperthyroidism; 
  18. Do you feel thirsty or that you need to use the toilet to pee more frequently ? => Diabetes mellitus;
  19. Do yu expierience facial flushing or dizziness when you stand ? => pheochromocytoma;
  20. Do you have any new rashes, joint pain, joint swelling ? => Connective tissue disease or autoimmune disorder; 

51

Name common treatable causes of involuntary weight loss in older adults.

MEALS ON WHEELS

  1. Medication effects
  2. Emotional problems - esp. depression
  3. Anorexia nervosa, alcoholism
  4. Late-life paranoia
  5. Swallowing disorders
  6. Oral factors - poorly fiting dentures, cavities
  7. No money
  8. Wandering and other dementia-related problems
  9. Hyper-/hypothyroidism, hyperparathyroidism, hypoadrenalism
  10. Enteric problems - malabsorption
  11. Eating problems - inability to feed self
  12. Low-salt, low-cholesterol diets
  13. Social issues - social isolation, inability to obtain preferred foods

52

What is a basic differential diagnosis for fatigue and weight loss ?

  1. Infection - HIV, tuberculosis, chronic infectious disease
  2. Metabolic disorder - hyperthyroidism, diabetes, adrenal insufficiency 
  3. Malignancy - solid tumor, hematologic malignancy
  4. GI - malabsorption, hepatitis, cirrhosis, pancreatic insufficiency 
  5. Other - depression, anorexia, anxiety, medication side effect

53

What is your differential diagnosis and workup plan ?

"42 yo F presents with a 15.5-lb (7-kg) weight loss within the past 2 months. She has a fine tremor, and her pulse is 112"

  • Differential diagnosis : 
    1. Hyperthyroidism
    2. Cancer 
    3. HIV infection 
    4. Dieting
    5. Medication-induced weight loss
    6. Anorexia nervosa
    7. Malabsorption
    8. Manchausen syndrome
  • Workup plan :
    1. TSH, FT4
    2. CBC
    3. Electrolytes
    4. HIV antibody
    5. Urine toxicology

54

Weight gain and obesity - key history ? 

  1. Amount, duration, timing (relation to medication changes, smoking cessation, depression);
  2. Diet and exercise history;
  3. Hypothyroid symptoms (fatigue, constipation, skin/hair/nail changes);
  4. Menstrual irregularity,
  5. Hirsutism;
  6. Medical history;
  7. Alcohol and drug use.
  8. Obesity ? => complications ? comorbidities ?

55

What are the main 4 goals of patient's history in case of weight gain/obesity ?

  1. You must distinguish between weigt gain being a result of water retention and fat accumulation;
  2. You must look for secondary causes of weight gain such as endocrinological conditions - hypothyroidism, hypercortisolism, hyperinsulinemia etc. 
  3. You must screen for serious medical complications caused by weight gain/obesity; 
  4. Screening for comorbid conditions : like diabetes;

56

What is a differential diagnosis in case of obesity/weight gain ?

  1. Primary weight gain / obesity
  2. Menopause - HA DOC => Hot flashes, Atrophy of vagina, Dryness of vagina, Osteoporosis, Coronary artery disease
  3. Smoking cessation
  4. Increased caloric intake
  5. Decrease in physical activity level
  6. Sleep deprivation
  7. Pregnancy
  8. Medication : GCS, Sulfonylureas, Insulin, Valproate, Atypical antipsychotics, TCA, SSRI, OCPs
  9. Endocrinological : Cushing's, hypothyroidism, hyperinsulinemia, PCOS, Hypogonadism

57

What will be your initial assessment of obesity ?

  1. History and symptoms of obesity and obesity-related complications ? 
    1. Back pain 
    2. Osteoarthritis 
    3. Artherosclerotic cardiovascular disease 
    4. Sleep apnea
  2. Biometric measurements 
    1. Blood pressure and pulse
    2. Weight and height
    3. BMI 
    4. Waist circumference
  3. Lab studies : 
    1. Glucose
    2. Electrolytes
    3. TSH
    4. Lipids
    5. Hepatic enzymes 

58

List questions one should ask in obesity case !

  1. Tell me about your weight gain / obesity (open-ended question);
  2. When did it start ? => avoid interrupting; 
  3. How has your weight gain progressed over time ?
  4. How long have you been gaining weight ?
  5. How many pounds have you gained ? 
  6. Can you think of any reason for this weight gain ?
  7. How is your appetite ?
  8. How many meals do you eat during the day ?
  9. Describe your typical daily menu / meal.
  10. Have you changed your dietary habits?
  11. Do you eat snacks between your meals ?
  12. How often do you eat out or eat fast food? Has this changed?
  13. How often do you engage in planned physical activity? Has this pattern changed?
  14. Are you currently trying to lose weight? When did you start? How much weight did you lose?
  15. Have you tried diets or weight loss programms in the past ?
  16. Do you snore excessively or have problems with breathing during the night ? 
  17. Do you feel cold when those around you are warm ?
  18. Do you have joint pains ?
  19. Women : When was your last menstrual period ? Have your periods been regular ? Screen for pregancy !
  20. Do you have other medical conditions ? 
  21. Have you had your cholesterol checked recently ?
  22. Do you take any medications ? 
  23. Have you been taking any steroid medication recently ?
  24. Is there obesity in your family ?
  25. Do any of your immediate-family members have heart disease, diabetes, thyroid disorder ?
  26. What concerns do you have about your current weight / weigh gaining / obesity ?
  27. Have you noticed any recent changes in your life such as a recent stressful event, marriage, pregnancy ?
  28. Have you ever been depressed? How would you describe your mood ?
  29. Have you been under a lot of stress lately? Do you find yourself eating when you are not hungry to relieve stress ?
  30. Do you ever go on eating binges ? Have you ever taken diuretics or laxatives to help you lose weight ? Have you ever made yourself vomit ?
  31. Do you smoke ? When did you start and how much do you smoke ?
  32. Do you drink alcohol ? How much and how often ?
  33. Have you used illicit drugs ? 

59

What questions will be useful to screen for : Cushing's disease, hypothyroidism, hypogonadism, hyperinsulinemia, PCOS ?

  1. Cushing's 
    1. Have you noticed disproportionate accumulation of fat in the face, trunk, stomache ?
    2. Have you noticed any thinning of the skin, reddish purple streaks on the belly or easy bruising ?
    3. Do you have high blood pressure ? 
    4. Do you have high glucose level ? 
    5. Do you have irregular menstrual cycle ?
    6. Have you noticed increasing facial hair or acne ?
  2. Hypothyroidism => ABCD HV 
    1. Have you noticed any recent appetite change ?
    2. Would you say there was some change in your bowel movements recently ? Have you been more constipated recently ? 
    3. Do you sometimes feel cold while others are comfortable ?
    4. Have you been depressed lately ? How is your mood ? Would you say you were more sad recently ?
    5. Have you noticed any change in you hair, nails, skin ? 
    6. Have you noticed any voice change ?
  3. Hyperinsulinemia :
    1. Have you ever been experiencing episodic confusion, headaches, seizures, visual changes when fasting / when not eating for a longer period of time ?
    2. Have you had palpitations, sweating or tremors while not eating for a longer period of time ?
  4. PCOS : 
    1. Do you have irregular or infrequent menstrual periods?
    2. Have you had difficulty becoming pregnant?
    3. Have you noticed increasing facial hair or acne?
  5. Hypogonadism : 
    1. Have you had a decrease in libido?    
    2. Have you had difficulty obtaining erections ? / Has there been a change in the pattern of your menstrual cycle? 
    3. Have you noted thinning of body and pubic hair? 
    4. Have you been experiencing hot flashes?
    5. Have you been experiencing insomnia?
    6. Is intercourse uncomfortable or painful?

60

What alarm symptoms and serious diagnoses must be kept at the back of your head when tackling a patient with weight gain ?

  1. Increased weight over days to weeks => cogestive heart failure, kidney failure, liver failure;
  2. Difficulty breathing or coughing at night => congestive heart failure;
  3. Inability to sleep lying flat => congestive heart failure;
  4. A recent increase in waist or pant size => ascites;
  5. Yellowing of the skin or whites of the eyes => chronic liver disease;
  6. Tea-colored urine => chronic liver disease; 
  7. Prolonged or excessive bleeding => chronic liver disease, renal failure;
  8. Decrease in how much you urinate => renal failure;
  9. Nausea, vomiting, generalized itching => renal failure, chronic liver disease;
  10. Swelling in the ankles, feet, legs => congestive heart failure, renal failure, chronic liver disease;
  11. Increase in thirst or urination => DM
  12. Blurry vision => DM 
  13. Chest tightness or pressure brought on by excertion or emotional stress => Coronary heart disease; 
  14. Snoring or stop breathing during the night => Sleep apnea;

61

What are the hey physical examinations you would perform on a patient presenting with weight gain / obesity ?

  1. GA : assessment of general habitus, gait, ambulation;
  2. HEENT - lid lag and exopthalmos; 
  3. Neck - thyroid exam;
  4. Chest and heart - auscultation of the lungs and heart;
  5. Abdominal exam - looking for organomegaly - liver enlargement, stomachache;
  6. Extremities => examine for cyanosis, clubbing, peripheral edema; 

62

What will be most important in closing the "obesity/weight gain" encounter ?

  1. Adress patients primary concerns ! => cosmetic issue ? weight-related comorbidity ? 
  2. Start by restating and claryfing patient's concerns;
  3. Review severity of patient's obesity and any complications or additional findings on physical examination; 
  4. Counseal ! 
  5. Remain empathetic and nonjudgemental;

63

What test will you order / consider ordering in a obesity-weight gain encounter ?

  1. CBC with differential 
  2. CRP / ESR
  3. ABGs 
  4. TSH, fT4
  5. 24-hour urine cortisol 
  6. Glucose and Hb-A1c
  7. Liver function tests - ALT, AST, bilirubin 
  8. Creatinine 
  9. pro-BNP

64

What is you differential diagnosis and workup plan in the following case : 

"44 yo F presents with a weight gain of > 25 lbs (11.3 kg) within the past 2 months. She quit smoking 3 months ago and is on amitriptyline for depression. She also reports cold intolerance and constipation"

  • Differential diagnosis :
    1. Hypothyroidism
    2. Smoking-quiting associated weight gain
    3. Medication-associated weight gain
    4. Cushing's disease
    5. PCOS
    6. Depression-associated weight gain / Mood disturbance associated weight gain
    7. Diabetes mellitus
  • Workup plan : 
    • TSH, fT4 
    • Amitryptiline blood level ?
    • 24-hour urine cortisol 
    • Dexamethasone supression test 
    • Beck's depression inventory 
    • CBC 
    • Glucose, HbA1c 
    • Electrolytes, ABGs 

65

What is your differential diagnosis and workup plan ?

"30 yo F presents with weight gain over the past 3 months. She also reports tremor, palpitations, anxiety, and hunger that is relieved by eating. She exhibits proximal muscle weakness and easy bruising"

  • Differential diagnosis : 
    • Insulinoma
    • Reactive postpranial hyperinsulinemia
    • Cushing's disease 
    • Polymiositis
    • Liver disease 
    • Hyperthyroidism
  • Workup plan :
    • Glucose and serum insulin levels
    • Glucose tolerance test
    • 24-hour urine free cortisol 
    • CPK, mioglobin 
    • AST, ALT, billirubin
    • TSH, fT4 

66

Dysphagia - difficulty swallowing - key history ?

  • REMEMBER => not dysphagia, but difficulty swallowing !
  • Solids or liquids vs. both solids and liquids ?
  • Progression ?
  • Problem occurring at the beginning or middle of swallow ? 
  • Any constitutional symptoms (especially weight loss) ?
  • Hoarseness ? 
  • Drooling, regurgitation of liquids vs. undigested food ? 
  • Odynophagia - pain while swallowing ?
  • GERD symptoms - burning, pain ? 
  • Medications ?
  • HIV risk factors ?
  • History of anxiety ? 
  • Globus ? => sensation of a lump or tightness in the throat unrelated to swallowing ? 
  • Smoking ? 
  • Raynaud’s phenomenon ? 

67

How would you describe the following terms to the patient ? => dysphagia, globus, mechanical disorder, motor disorder, odynophagia, oropharyngeal dysphagia ?

  1. Esophageal dysphagia - difficulty in passage of a bite from the upper part of your GI tract to the stomach/into your belly; 
  2. Globus - sensation of a lump, mass, tightness in the throat, this is unrelated to swallowing; 
  3. Mechanical disorder - physical barrier in the esophagus / tube used to trasport food from your mouth into your stomach 
  4. Motor disorder - problem in movement of your esophagus - your esophageal contractions losse their coordination 
  5. Odynophagia - pain with swallowing
  6. Oropharyngeal dysphagia - difficulty to start swallowing - difficulty to move the food from your mouth into yout pharynx 

68

What is a simple differential diagnosis of dysphagia ?

  1. Esophageal cancer
  2. Esophageal stricture
  3. Esophagitis (CMV, HSV, HIV, pill-induced)
  4. Eosinophilic esophagitis (EE)
  5. Achalasia
  6. Amyotrophic lateral sclerosis
  7. Systemic sclerosis
  8. Post-stroke dysphagia
  9. GERD
  10. Zenker’s diverticulum
  11. Plummer-Vinson syndrome
  12. Mitral valve stenosis

69

What is a more advanced differential diagnosis of oropharyngeal and esophageal dysphagia ?

  • Oropharygneal dysphagia : 
    • neuromuscular causes : stroke, cerebral palsy, multiple sclerosis, myasthenia gravis, ALS, Parkinson's, Myopathies, Polymiositis/dermatomysistis; 
    • structural causes : Zenker's diverticulum, head and neck tumors, cervical spondylosis, vertebral osteophytes, pharyngeal webs - Plummer-Winson syndrome;
    • iatrogenic causes : radiation therapy, corrosive pill injury, anticholinergic medications; 
  • Esophageal dysphagia : 
    • Motor : achalasia, diffuse esophageal spasm, Nutcracker esophagus, scleroderma, Sjorgren's syndrome, Chagas disease;
    • Mechanical : tumors, strictures, lower esophageal rings, esophageal webs and rings, eosinphilic esophagitis, foreign body;
    • Mechanical, extrinsic : right-sided aorta, left atrial enlargement, aberrant vessels, mediastinal lymphadenopathy, substernal thyroid; 
    • Iatrogenic : pill esophagitis - doxycycline, NSAIDs, alendronate, potassium chloride tablets; 
    • Infectious : candidal esophagitis, herpes esophagitis, CMV esophagitis; 

70

What questions will you ask to a patient presenting with difficulty swallowing ?

  1. Could you please describe to me how does your difficulty swallowing look like ?
  2. Tell me what happens when you swallow ?
  3. When did you first notice that you have some difficulty swallowing ?
  4. Is it constant, meaning that you have difficulty swallowing all the time ? 
  5. Would you say your symptoms are getting worse or better ?
  6. Could you please try to describe for me what happens when you try to swallow solid foods ? try to drink sth / fluids / liquids ? 
  7. Do you cough, choke, or sense food coming back through your nose after swallowing?
  8. Does it feel as if food is getting stuck within the first few seconds of swallowing?
  9. Is food sticking or getting stuck after you swallow?
  10. Have you experienced nasal regurgitation?
  11. Do you have difficulty initiating a swallow?
  12. Do you choke or cough when you try to swallow?
  13. Do you feel like you have bad breath?
  14. Do you regurgitate old foods?
  15. Is it painful to swallow?
  16. Do you experience chest pain?
  17. Do you ever have to bear down or raise your arms over your head to help a food bolus pass?
  18. Are your symptoms worse with very hot or cold liquids?
  19. Do you have a long-standing history of heartburn?
  20. Are your symptoms relieved by repeated swallows?
  21. Have you ever experienced the sudden onset of dysphagia after swallowing pieces of meat?
  22. Do you suffer from food allergies or have other allergic diseases (eg, asthma)?
  23. Does your difficulty swallowing affect your daily living / activities ? 
  24. What concerns you most about your difficulty swallowing ? I ask because I would like to address your needs the best way I can. 
  25. What do you think may be causing your difficulty swallowing ? I ask because I want to respond to your concerns / needs. 
  26. Do you have any medical conditions diagnosed ? 
  27. Have you ever had stroke ? neurologic problems ? Reflux - that is a condition when acid substance from your stomache goes into your esophagus and your feel this unpleasant burning sensation.
  28. Do you take any medications ? (remember about pill-induced esophagitis)
  29. Do you take your medications with fluids?
  30. Do you take your medications immediately before going to bed?
  31. Have you noticed any weight loss / bleeding / fevers / chills / sweats ?
  32. Do you use tobacco products ? Do you drink alcohol ? Do you sometimes use recreational drugs ?
  33. Have you received radiation therapy in the past?
  34. Now I want to ask you some routine questions I ask every patient about your private life - is that alright ? 
    1. Are you sexualy active ? 
    2. With how many partners are you active at the moment ? What about the recent year ?
    3. Are your partners females, males or both ?
    4. Do you use any from of protection ?
    5. Have you ever been diagnosed with a sexually transmitted disease ? 
  35. Do you have a medical condition that suppresses your immune system (eg, human immunodeficiency virus [HIV], chronic steroid use, chemotherapy)?
  36. Have you noticed that your mouth or eyes are very dry ? Do you need to use eye drops often ?

71

What parts of physical exam will you perform in a patient with history of difficulty swallowing ?

  1. Vital signs;
  2. Head and neck exam;
  3. Heart, lung, abdominal exams;
  4. Skin exam (for signs of scleroderma/CREST);

72

What is your differential diagnosis and workup plan ?

"75 yo M presents with dysphagia that started with solids and progressed to liquids. He is an alcoholic and a heavy smoker. He has had an unintentional weight loss of 15 lbs (6.8 kg) within the past 4 months" ?

  • Differential diagnosis : 
    1. Esophageal carcinoma
    2. Esophageal ring
    3. Esophageal stricture
    4. Achalasia
    5. Esophagitis
    6. Systemic sclerosis 
    7. ALS
  • Workup plan :
    • Upper GI endoscopy with biopsy
    • Barium upper GI studies 
    • Immune studies - anti-Jo1 
    • CBC
    • CT-chest
    • Electromyography
    • Nerve conduction studies

73

What is your differential diagnosis and workup plan ?

"45 yo F presents with dysphagia for 2 weeks accom- panied by mouth and throat pain, fatigue, and a craving for ice and clay" ?

  • Differential diagnosis :
    1. Plummer Vinson syndrome
    2. Achalasia 
    3. Esophageal spasm
    4. Esophageal cancer
    5. Esophagitis
    6. Nutritional deficiency 
    7. Systemic sclerosis
    8. Mitral valve stenosis
  • Workup plan :
    • CBC
    • Serum iron, ferritin, TIBC
    • Barium swallow
    • Upper endoscopy
    • Video fluoroscopy

74

What is your differential diagnosis and workup plan ?

"48 yo F presents with dysphagia for both solids and liquids that has slowly progressed in severity within the past year. It is associated with difficulty belching and regurgitation of undigested food, especially at night. She has lost 5.5 lbs (2.5 kg) in the past 2 months" ?

  • Differential diagnosis :
    1. Achalasia
    2. Plummer-Vinsonsyndrome
    3. Esophageal cancer
    4. Esophagitis
    5. Systemic sclerosis
    6. Mitral valve stenosis
    7. Esophageal stricture
    8. Zenker’s diverticulum
  • Workup plan : 
    • CXR
    • Upper endoscopy
    • Barium swallow
    • Esophageal manometry
    • XR—neck

75

What is your differential diagnosis and workup plan ?

"38 yo M presents with dysphagia and pain on swal- lowing solids more than liquids. Exam reveals oral thrush" ?

  • Differential diagnosis :
    1. Esophagitis (CMV, HSV, HIV, pill-induced)
    2. Systemic sclerosis
    3. GERD
    4. Esophageal stricture
    5. Zenker’s diverticulum
  • Workup plan : 
    • CBC
    • Upper endoscopy
    • Barium swallow
    • HIV antibody and viral load
    • CD4 count

76

Neck mass - key history ?

  1. Onset, size, location, mobility, pain, movement with swallowing;
  2. Obstructive symptoms (dysphagia, shortness of breath);
  3. Other masses;
  4. Associated symptoms (constitutional, hematologic, GI, endocrine, pulmonary);
  5. Sick contacts ?

77

Neck mass - Key Physical Exam ?

  1. Vital signs;
  2. HEENT exam;
  3. Exam of lymph nodes, spleen, and tonsils;
  4. Heart, lung, abdominal exams.

78

What is your differential diagnosis and workup plan ?

"39 yo F presents with a single 2-cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing, or abdominal pain. Her husband was recently discharged from prison, and her mother has a history of gastric cancer"

  1. Differential diagnosis :
    1. Hodgkin’s/non-Hodgkin’s lymphoma
    2. Tuberculosis
    3. Thyroid nodule
    4. Gastric carcinoma
  2. Workup : 
    1. CBC with differential
    2. Electrolytes
    3. ESR, CRP
    4. Lymph node biopsy
    5. PPD
    6. CXR
    7. TSH
    8. U/S—thyroid
    9. Upper endoscopy