Differential Diagnosis

Important Differential Diagnoses for PLAB2 [Medicine, Surgery, Psychiatry, Gynecology & Obstetrics & Pediatrics]

KINGS COLLEGE HOSPITAL LONDON April 2, 2012 Authored by: Dr. Sarmad Kazmi

DDs in Surgery Dysphagia 1. Oesophageal stricture – Could you by any chance have taken something corrosive in your mouth?/ Swallowing substances that harm the lining of the esophagus, such as household cleaners, lye (Caustic Soda), disc batteries, or battery acid 2. Strictures – Are you on any antacid? Could lead to Barrett’s Oesophagus 3. GERD – Did you have burning sensation in chest or under the breastbone after meals/ Feel-

ing that food is stuck behind the breastbone/ Increased by bending, stooping, lying down, or eating/ More likely or worse at night/ Relieved by antacids/ Nausea after eating 4. Achalasia Cardia – Do you bring up water when you drink? 5. Pharyngeal Pouch – How do you feel about your mouth odour/ pillow spoiling in the morning? 6. Myasthenia Gravis – Do you have difficulty in swallowing at the end of the day? 7. Globus Hystericus – Do you have a sensation of lump in your throat if young female 8. Post-procedural (Endoscopy) – Have you recently been gone through any procedure? 9. Ca Oesophagus – Swallowing difficulty for solids and liquids/wt loss/abnormal swellings/smoking history/racing of the heart? 10. Peptic esophagitis – Mostly in immunocompromised.

Abdominal Pain

Important Differentials Diagnose for PLAB2 | 4/2/2012

RIGHT UPPER QUADRANT PAIN 1. Acute Cholecystitis – Are you running a temperature? / Pain radiating to the tip of the shoulder/ pain increased by fatty food? 2. Biliary Colic – Do you vomit which is associated with food/no fever/ pain is in spasms 3. Ascending Cholangitis – Do you have fever with right upper quadrant pain/rigors and shaking 4. Acute Hepatitis (Viral / Alcoholic) – Have you noticed yellowish discolouration of eyes and skin 5. Right Basal Pneumonitis – Fever/cough/breath hurts/ produce phlegm 6. Fracture Rib – Did you hurt yourself by any chance? RIGHT ILIAC FOSSA PAIN 1. Acute Appendicitis – Temp/radiation. Vomiting/ bowl habits 2. Obstructed Hernia – Did u notice a swelling which used to disappear before but not anymore? 3. Irritable Bowel Syndrome – Have you been experiencing symptoms of diarrhoea and constipation? / pain relieve when you open your bowl 4. Ureteric Calculi – History of passing stones? 5. Urinary Bladder Calculi - Lower tummy pain? / How is your urine stream? 6. Urinary Tract Infection - Fever with lower tummy pain with burning sensation while passing urine/vomiting

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Authored by: Sarmad Kazmi 30/03/2011

In Females Ectopic Pregnancy – Are you sexually active? /When was your last Menstrual Period? / Is it normal for you? / Could you be pregnant by any chance? / When did you have your last intercourse/was it protected? /Do you always use safe sex? /Are you on any contraceptives? Pelvic Inflammatory Disease – Fever/Change In discharge down below/pain goes to back? Ovarian Torsion – Severe throbbing pain/ US history of fluid filled sacs In Males – Testicular torsion, Acute Epidydimo-orchitis

LEFT ILIAC FOSSA PAIN ***Same as for right, but replace Appendicitis with Acute Diverticulitis. EPIGASTRIC PAIN 1. Myocardial Infarction 2. Pericarditis 3. GERD – After meal pain gets worse on lying down? 4. Stricture with antacid 5. Acid-Peptic Disease 6. Acute Pancreatitis – pain radiates to the back /changes when you lie down? Vomiting? 7. Dissecting Abdominal Aortic Aneurysm 8. Irritable Bowel Syndrome 9. Trauma

Bleeding Per Rectum (Make Sure About the colour & quantity) Important Differentials Diagnose for PLAB2 | 4/2/2012

*** Anaemia Questions PLUS CA Questions (MUST) 1. Haemorrhoids – have you noticed a painless bright red splash on the pan when you open your bowels? 2. Fissure in Ano – Extreme pain on opening the bowl. Pain is the differentiating factor 3. Rectal Prolapse – Do you feel any abnormal mass coming out from your arse? 4. Colonic Carcinoma – Mixed blood stool plus CA questions 5. Rectal carcinoma – Incomplete sense of evacuation/ Stool covered with blood PLUS CA questions 6. Ulcerative Colitis – Blood with mucus/ skin changes/ eyes changes with abdominal pain 7. Acute Diverticulitis – old age/Rt sided pain and get better with bowl opening 8. Polyps – Family history of polyps 9. Gastric ulcers – possible cause of dark stool 10. Gastroenteritis – fever/ pain / vomiting/ have you eaten outside? / And how are the people who ate with you? 11. Post-procedural (Proctoscopy / Sigmoidoscopy / Colonoscopy) 12. Bleeding Disorders – Have you been diagnosed with any blood disorder/diseases? 13. Medications (Blood thinners) – Are you on any blood thinning medications? 14. Angiodysplasia – often elderly patients/ weakness, fatigue, and shortness of breath due to anaemia/ may not be any signs of bleeding directly from the colon/ occasional mild or severe bleeding episodes with bright red blood coming from the rectum.

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Authored by: Sarmad Kazmi 30/03/2011

Haematuria 1. Renal Calculi - sudden onset of excruciating/cramping pain in low back /or side, groin, or abdomen/Changes in body position do not relieve this pain/ nausea and vomiting./worst pain of their lives/even worse than the pain of childbirth or broken bones/ Kidney stones also characteristically cause blood in the urine/If infection is present in the urinary tract along with the stones, there may be fever and chills/difficulty urinating/urinary urgency/penile pain/ or testicular pain may occur due to kidney stones. 2. Ureteric Calculi - severe colicky loin to groin pain /Pain may radiate into scrotum in men and labia in women /May also cause frequency, urgency and dysuria 3. Urinary Bladder Calculi - lower tummy pain / how is your urine stream?/ In men, pain or discomfort in the penis/ Painful urination/ Frequent urination, especially during the night/ Difficulty urinating or interruption of urine flow/ Blood in your urine/ Cloudy or abnormally dark-coloured urine 4. UTI – Fever with lower tummy pain with burning sensation while passing urine/vomiting 5. Renal Ca. – blood in urine/pain in the flanks/Mass in the flank/wt. loss/fatigue/loss of appetite/fever/night sweet/malaise /anaemia 6. Bladder Ca. – blood in urine/urinary urgency/pain on urination/back or abdominal pain/loss of appetite and weight/ask about profession/smoking has strong association 7. Schistosomiasis – swimming in the lakes 8. Prostatitis - Increased urinary frequency and urgency during day and night /Fever, chills, nausea and vomiting /Pain in the lower abdomen, lower back, pelvis and genital area /Blood in urine /Pain with ejaculation /Pain with bowel movement /Pain or burning sensation when urinating 9. Post-surgery/instrumentations – Have you been gone through any instrumentation recently 10. Bleeding Disorders - Have you been diagnosed with any blood disorder/diseases? 11. Blood Thinners – Are you on any blood thinning medications?

Urinary Obstruction Important Differentials Diagnose for PLAB2 | 4/2/2012

1. Ca. Bladder - blood in urine/urinary urgency/pain on urination/back or abdominal pain/loss of appetite and weight/ask about profession/smoking has strong association 2. Bladder Calculi – lower tummy pain? / how is your urine stream?/ Lower abdominal pain/ In men, pain or discomfort in the penis/ Painful urination/ Frequent urination, especially during the night/ Difficulty urinating or interruption of urine flow/ Blood in your urine/ Cloudy or abnormally dark-coloured urine 3. Benign Prostrate Hypertrophy - Trouble starting a urine stream or making more than a dribble/ Passing urine often, especially at night /Feeling that the bladder has not fully emptied/A strong or sudden urge to urinate/ A weak or slow urine stream/Stopping and starting again several times while passing urine/Pushing or straining to begin passing urine 4. Ca. Prostrate - need to urinate often, especially at night/ intense need to urinate (urgency)

/difficulty in starting or stopping the urine flow /inability to urinate /weak, decreased or interrupted urine stream /a sense of incompletely emptying the bladder /burning or pain during urination /blood in the urine or semen /painful ejaculation 5. U T I - Fever with lower tummy pain with burning sensation while passing urine/vomiting 6. STI - Discharge from the penis, vagina or anus /Pain or discomfort when urinating /Pain during sex /Abnormal or unusual vaginal bleeding /Lumps and bumps on the genitals /Genital sores /genital itching /Genital irritation or pain /Rash on genitals 7. Post-procedural Urethral Stricture – Have you gone through any procedure recently?

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Authored by: Sarmad Kazmi 30/03/2011

8. Drug Induced (Anticholinergic, Antidepressants) – By any chance are you on any medication?

Treatment of UTI: General measures A high fluid intake is essential. Alkaline substances, such as citrates, taken in water might improve symptoms.

Antibiotic therapy Trimethoprim (e.g. Monotrim) is currently the first choice for lower UTI in the UK, because it's costeffective, well tolerated and works in 80 per cent of infections. Cephalosporins, nitrofurantoin and norfloxacin are reserved as second line drugs in patients with lower UTI. But they are the first choices in patients with signs of upper UTI or kidney infection.

Treatment of Kidney Stones: Analgesia Management of pain often requires intravenous administration of NSAIDs or opioids. Orallyadministered medications are often effective for less severe discomfort. Intravenous acetaminophen also appears to be effective. Expulsion therapy The use of medications to speed the spontaneous passage of ureteral calculi is referred to as medical expulsive therapy. Several agents including alpha adrenergic blockers (such as tamsulosin) and calcium channel blockers (such as nifedipine) have been found to be effective. A combination of tamsulosin and a corticosteroid may be better than tamsulosin alone. These treatments also appear to be a useful adjunct to lithotripsy. Surgical Important Differentials Diagnose for PLAB2 | 4/2/2012

A lithotripter machine in an operating room. Other equipment is seen in the background, including an anesthesia machine and a mobile fluoroscopic system (or "C-arm"). Most stones less than 5 millimeters (0.20 in) pass spontaneously. Prompt surgery may, nonetheless, be required with persons with only one working kidney, bilateral obstructing stones, a urinary tract infection and thus, it is presumed, an infected kidney, or intractable pain. Beginning in the mid1980s, less invasive treatments such as Extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, and percutaneous nephrolithotomy began to replace open surgery as the modalities of choice for the surgical management of urolithiasis.

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Authored by: Sarmad Kazmi 30/03/2011

Testicular Torsion Symptoms Testicular torsion is characterized by excruciating one-sided testicular pain, with sudden swelling. Since the cord structures twist (like the strings of a puppet), the testicle elevates as well. Patients may have nausea and vomiting. Patients may also have abdominal pain. There may be a history of previous testicular pain. Fever may also accompany the testicular pain. Testicular torsion is seen most frequently in the 12-18-year-old age group, and most cases occur in men under 30 years of age. However, it can occur at any age, including in new-borns. Exams and Tests The typical physical exam of the torsed testicle reveals a painful scrotum with one-sided testicular swelling and elevation. Lab tests may include a urinalysis and blood count. The scrotum may also be imaged by one or more radiologic studies. Imaging may include a Doppler ultrasound of the testicles or a nuclear scan of the testicles to assess the degree of blood flow. Depending on the physical exam, and/or the time frame, imaging may not be done, since emergent treatment is essential to preserve the testicle. Prevention The orchiopexy should prevent further episodes of torsion.

Testicular Pain Trauma – what were you doing when you experienced this pain? Epidydimo-orchitis – Fever, redness, painful, discharge, history of temperature Testicular Torsion – recent onset of severe pain and stay same while lifting up testes Bladder Calculi – Does your urine stream suddenly stop when you go to loo? U T I – Have you noticed burning sensation while passing water with fever and possible nausea or vomiting? 6. Obstructed Inguinal Hernia – Did you have a swelling in your groins which used to disappear at its own but now it hasn’t gone away for the last few days? 7. Ureteric Colic – Do you feel a severe and restless pain which goes from your loin to groin/tip of your penis or water pipe? 8. Orchitis due to Mumps – Did you have redness of your cheeks and swelling of your face 4-6 weeks ago, either unilateral or bilateral/with fever?/Painful inflammation of the testicles/headache/ may affect either one of both testicles/

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. 2. 3. 4. 5.

***The testes usually get infected about 4-6 days after the mumps infection. The mumps virus has a tendency to spread to other parts of the body and loves to go to the testes. The typical features of a mumps virus induced orchitis include: - concurrent throat infection swelling of scrotum soon after the throat infection - swelling of one side of the scrotum (70% of cases) - both testes affected (30% of cases) besides the mumps virus, numerous other viruses can also cause orchitis. Rarely, mumps orchitis can occur after vaccination with the mumps, measles and rubella vaccine. *** Symptoms of epidydimo-orchitis usually develop quickly - over a day or so. The affected epididymis and testis swell rapidly, and the scrotum becomes enlarged, tender, and red. It can be very painful.

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Authored by: Sarmad Kazmi 30/03/2011

Ulcer / Mole 1.

Malignant Melanoma – Is it dark skin around with shiny & firm nodules/ Wt. loss with anaemia may be or may be not? Asymmetrical skin lesion/Border of the lesion is irregular/Color: melanomas usually have multiple colors/Diameter: moles greater than 6 mm are more likely to be melanomas than smaller moles/Enlarging: Enlarging or evolving /A change in an existing mole A small, dark multi-coloured spot with irregular borders - either raised or flat - that may bleed and form a scab A cluster of shiny, firm dark bumps Having a diameter larger than a pencil rubber

2. Basal Cell Ca. – Is it pearly white in colour? A pearly or flesh-coloured oval bump with a rolled border, which may develop into a bleeding ulcer. A smooth red spot indented in the centre. A reddish, brown or bluish black patch of skin on the chest or back.

3. Squamous Cell Ca. – Does it bleed on touch? A firm, reddish wart-like bump that grows gradually. A flat spot that becomes a bleeding sore that won't heal.

Important Differentials Diagnose for PLAB2 | 4/2/2012

4. 5. 6. 7. 8. 9. 10.

Diabetic Ulcer - Have you been diagnosed with a condition called diabetes? Venous Ulcer – on medial malleolus/associated with varicose veins/ blue discolouration Tubercular Ulcer – Low grade fever/wt. loss/cough/Did you travel to TB rampant area? Pressure sores – Have you been immobile for a long period of time? Post traumatic ulcers – Did you hurt yourself where the ulcers are? H I V – Kaposi’s Sarcoma - Drug and sexual history? Arterial Ulcer (v v v v v rare)

Questions about Ulcers **An astute physician will examine all abnormal moles, including ones less than 6 mm in diameter 1. Where is the ulcer? 2. How did you notice it? 3. How long the ulcer has been there? 4. What is the colour of the ulcer 5. Has the ulcer changed its size? 6. Is it painful? 7. Is there any discharge or bleeding from the site of the ulcer? 8. How is the skin around the ulcer? 9. Is this the first time you had this ulcer? 10. Do you have ulcers anywhere else in your body?

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Authored by: Sarmad Kazmi 30/03/2011

Management 1. 2. 3. 4. 5.

We would like to remove the ulcer. We will remove it with surrounding 5 mm of normal skin. We will send the ulcer to the lab for investigations. Results would come back in 2-4 weeks. Once we have the results we would know whether it contains normal or abnormal tissues and treat you accordingly. 6. Hopefully it will not be serious. 7. If results are not very encouraging then we will do some more tests.

Management of BPH Lifestyle Patients should decrease fluid intake before bedtime, moderate the consumption of alcohol and caffeine-containing products, and follow timed voiding schedules. Medications The two main medications for management of BPH are alpha blockers and 5α-reductase inhibitors.

Important Differentials Diagnose for PLAB2 | 4/2/2012

Alpha blockers (technically α1-adrenergic receptor antagonists) are the most common choice for initial therapy in the USA and Europe. Alpha blockers used for BPH include doxazosin, terazosin, alfuzosin, tamsulosin, and silodosin. All five are equally effective but have slightly different side effect profiles. Alpha blockers relax smooth muscle in the prostate and the bladder neck, thus decreasing the blockage of urine flow. The 5α-reductase inhibitors finasteride and dutasteride are another treatment option. These medications inhibit 5a-reductase, which in turn inhibits production of DHT, a hormone responsible for enlarging the prostate. Antimuscarinics such as tolterodine may also be used, especially in combination with alpha blockers. They act by decreasing acetylcholine effects on the smooth muscle of the bladder, thus helping control symptoms of an overactive bladder. Sildenafil citrate shows some symptomatic relief, suggesting a possible common etiology with erectile dysfunction. Herbal remedies Saw palmetto extract from Serenoa repens is one of the most extensively studied. It showed promise in early studies, though later trials of higher methodological quality indicated no difference from placebo. Minimally invasive therapies Medication is often prescribed as the first treatment option; there are many patients who do not achieve success with this line of treatment. transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). Both of these procedures rely on delivering enough energy to create sufficient heat to cause cell death (necrosis) in the prostate. The goal of the therapies is to cause enough necrosis so that, when the dead tissue is reabsorbed by the body, the prostate shrinks, relieving the obstruction of the urethra.

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Authored by: Sarmad Kazmi 30/03/2011

Surgery If medical treatment fails, and the patient elects not to try office-based therapies or the physician determines the patient is a better candidate for transurethral resection of prostate (TURP), surgery may need to be performed. In general, TURP is still considered the gold standard of prostate interventions for patients that require a procedure. This involves removing (part of) the prostate through the urethra. Post-surgery care often involves placement of a Foley catheter or a temporary prostatic stent to permit healing and allow urine to drain from the bladder.

Complications of BPH Surgery

Important Differentials Diagnose for PLAB2 | 4/2/2012

Erection problems (erectile dysfunction). Urinary incontinence Ejaculation of semen into the bladder instead of out through the penis (retrograde ejaculation) Infertility

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Authored by: Sarmad Kazmi 30/03/2011

DDs in Medicine Hematemesis *** (If there is lot of blood loss then questions about anaemia (racing of heart, fatigue, and cold & pale peripheries) Ask about bright colour or coffee colour vomits 1. Oesophageal Varices (Liver Disease) - alcohol history/Have you been drinking for long? 2. Ca. Oesophagus - CA questions/wt. loss/abnormal swellings/racing of the heart? 3. Mallory Weisz Tear - did you binge drink/did you have retching/ are you on painkillers 4. Ca. Stomach - Fullness and loss of appetite 5. Oesophagitis - Heart burn while lying down 6. Acid Peptic Disease -Tummy pain associated with meals/Painkillers 7. Gastric Erosion - Are you on any painkillers 8. Liver Disease - Have you been diagnosed with liver disease? 9. Bleeding Disorders - Have u been diagnosed or have family history 10. Blood Thinners - Are you on blood thinners 11. Instrumentation -Have you recently been gone through any procedure? 12. Smoking and family history of carcinoma – By any chance do you smoke/What?/how long?

Chest Pain

Important Differentials Diagnose for PLAB2 | 4/2/2012

*** (Patient comfort with Oxygen/Painkillers) 1. Myocardial Infarction – Tight central chest pain >30 minutes which does not go away with rest/radiation 2. Angina - Central & throbbing relieved by rest/Clenched heavy pain radiating to jaw, increases on walking/running. Shortness of breath/nausea/sweating/relieved by rest/GTN 3. Pulmonary Embolism - Localised sharp pain/no radiation & relieved by sleeping on the same side. Aggravated by inspiration/deep breaths or cough/SOB and Wheeze. Long flights, hospitalization, pregnancy and OCPs 4. Pericarditis - Localised sharp pain/no radiation and relieved by leaning forward/worse when breathing 5. Pleurisy - sharp stabbing localised pain/pain breathing in but never gets better 6. Pleural Effusion - Pain & Breathlessness, Gradual onset of pain, gradual onset of shortness of breath/ gets better when lying on the opposite side 7. Pneumonia - Fever/chest pain while breathing in/cough could be dry/productive 8. Tension Pneumothorax- Tall man/sudden pain/sudden onset of SOB 9. Dissecting Aortic Aneurysm -shoulder blade pain but radiating to back 10. Gastroesophageal Reflux Disease - burning sensation/tummy pain/worst on lying down soon after meals 11. Costochondritis - localised pain on pressure 12. Herpes Zoster - sharp pain with dermatome distribution 13. Fracture Rib - Did you hurt yourself? 14. Oesophageal Spasm - Hot or cold drinks and relieved by GTN

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Authored by: Sarmad Kazmi 30/03/2011

Carpal Tunnel Syndrome *** (Numbness and tingling sensation on thumb/index and middle finger) Aetiology 1. Pregnancy - when was your last periods? 2. Obesity - Have you recently gained any weight? 3. Occupational - What do you do for living? 4. Trauma - What do you do for living? 5. Rheumatoid Arthritis- Have you ever been diagnosed with RA? 6. Obesity – Hypothyroidism, Cushing’s, Polycystic Ovarian Disease (P.C.O.S)- Ask relevant questions 7. Acromegaly - Have you noticed change in ring/shoe size/change in facial feature from an old photograph? DDs – Cervical radiculopathy Diabetic neuropathy Ulnar Radiculopathy

Obesity / weight Gain - Have you noticed change in ring/shoe size/change in facial feature from an old photograph? 2. Steroids - Are you on any medication? Called Steroids? 3. Hypothyroidism -feel cold in the same environment/fired and constipation 4. Cushing’s - On long term steroids/facial hair growth/ bluish stria on tummy 5. P.C.O.S - Are you trying to get pregnant? Period history/facial hair growth 6. Pregnancy related - When was your last period? 7. Hereditary - Are others in the family have the same condition 8. Habitual - Have your diet changed recently? Do you exercise normally

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. Acromegaly

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Dry Cough *** Do you bring up any Phlegm? /How much phlegm do you bring? /Any specific smell or odour/ Have you noticed any blood 1. Asthma / Cardiac Asthma – depending on age - Have you been diagnosed with asthma recently? Wheeze associated with cough? Did you have asthma as a child? Cough gets worse when you go to bed? Whistling sensation in your lungs? 2. Smoking - Do you smoke at all? 3. U R T I - Runny nose with fever 4. H I V – Pneumocystis Jerovecii - Have you been diagnosed with HIV? 5. Atypical Pneumonia - travel history/drug abuse/sexual history 6. Allergy - By any chance are you allergic to anything? 7. Occupational - What do you do for Living? 8. ACE-inhibitors (age) - Medication history 9. Post nasal drip - feeling of running something from nose to your mouth/ trickling sensation behind your throat 10. Interstitial lung disease - Occupational/coalmine/shipyard worker Authored by: Sarmad Kazmi 30/03/2011

11. Lymph Node Compression

- Any abnormal swelling?

Hoarseness of Voice * Any loss of weight/racing of your heart/excessively tired/have you noticed any abnormal swellings 1. Smoking History v v v imp. – How long and how much per day? 2. Vocal Abuse -singer, teacher, football match/ concert 3. U R T I - Runny nose, fever and cough? 4. Laryngitis - pain in throat with fever 5. Trauma (Sec to instrumentation or post - surgery) 6. Hypothyroidism - Three questions 7. Ca. Larynx - Wt. loss, swelling and anaemia questions 8. Haematamesis - Coughing blood

Sore Throat 1. 2. 3. 4. 5.

Important Differentials Diagnose for PLAB2 | 4/2/2012

6. 7. 8. 9.

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Mumps – Swelling and redness over the cheeks/low grade fever Measles – Vomiting , diarrhoea and rashes on the body Chicken Pox – Rashes on the body with slight lethargy/comes in crops/fever Glandular Fever (Infectious mononucleosis) – Painful swelling (glands on the neck, armpits and groins) with fever, headache and weakness Bacterial Tonsillitis due to streptococcus – Severe pain on swallowing, redness in the throat, high fever Irritants – Pollen, dust, change of weather, smoking – have you been exposed to them? Allergic conditions – Hay fever – Ask relevant questions? Excessive use of voice – singers & teachers tumours – Back of tongue, throat & Vocal cords

Ear Ache 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Trauma Wax Impaction Foreign Body Mastoiditis Otitis Externa Otitis Media Perichondritis Ramsay Hunt Syndrome Barotrauma Boil and furuncle

- did you hurt your ear by any chance? - pain start after hot shower? - feels like something crawling in your ear? - Is there any pain near the bone on the back of your ear? - fever and warm to touch or painful to touch - fever discharge & decreased hearing - Pain while chewing -Blisters around the ears, change in facial appearance - deep sea diving/travel history -History of diabetes

Authored by: Sarmad Kazmi 30/03/2011

Loss of Consciousness 1. Sub-arachnoid Haemorrhage - Sudden/ severe/ worse occipital pain/ with vomiting/Neck Stiffness 2. Trauma to head – did you hurt yourself? 3. Meningitis - Severe Headache/high grade fever/rash/shying away from light/neck stiffness 4. Epilepsy - Have you been diagnosed with epilepsy? 5. Stroke - Do you have weakness in your body and how long it last for? 6. T I A - Do you have weakness in your body and it lasted for less than 24 hours? 7. Arrythmias - Have you been diagnosed with heart conditions 8. Vasovagal Syncope – Have you been standing for a long time? Did you go pale before you fall? 9. Hypotension - Are you any hypertensive medication?/ ringing sensation with tunnel vision 10. Hypoglycaemia - Diagnosed with diabetes/ Family history? / Excessively thirsty? 11. Diabetic Keto Acidosis – fruity smell with dehydration 12. Alcohol – did you drink too much? 13. Recreational Drugs – Do you take recreation drugs?

Important Differentials Diagnose for PLAB2 | 4/2/2012

Headache

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1. Meningitis - Shy away from light/ fever/ neck stiffness/ rash/ vomiting 2. Sub Arachnoid H’hage – Sudden/ severe/ worse occipital pain/ with vomiting/Neck Stiffness 3. Giant Cell Arteritis - Throbbing pain on the side of head/ visual impairment/ worse on touching 4. Space Occupying Lesion – worsening headache over time/ early morning sickness/ visual impairment/ weakness in the body? Get relieved when you puke? 5. Acute Congestive Glaucoma – Headache in the back of the eyes? / Colourful rings Halos)? / Redness of eye? Get worse by Amytriptrypline? 6. Migraine – Have you been diagnosed with migraine? / Aura/ painkillers 7. Cluster Headache – Specific time? / Night? / Remissions/ relapses/ red eye/ unilateral tearing 8. Tension Headache – Band like pain/ worst towards the end of the day/ stressful job? 9. Sinusitis – Does the pain increase on bending forwards with fever? 10. Trauma – Could you have hurt yourself? 11. Stressful Job – Do you think that you have a busy and stressful job?

Red Eye 1. 2. 3. 4. 5. 6.

Trauma - Did you hurt yourself? Foreign Body - Do you think something has gone in your eyes by chance/accident? Conjunctivitis - did you have matting of your eye/eyes when you woke up this morning? Subconjunctival H’hage - Have you been diagnosed with high blood pressure? Uveitis – Bowl Habits and back pain either due to IBD or Ankylosing spondylitis Acute Congestive Glaucoma- Severe headache/pain in the back of your eyes/nausea and vomiting/ Blurred vision and/or seeing haloes around lights (Haloes and blurred vision occur because the cornea is swollen.)/ profuse tearing *** 7. Rheumatoid Arthritis – Do you have pain in your joints early in the morning? 8. Cluster Headache – Does your headache come after a certain time? 9. Systemic Lupus Erythematosis – Have you noticed any butterfly rash on your face/body?

Authored by: Sarmad Kazmi 30/03/2011

10. Ankylosing Spondylitis – Does your pain go away as the day progresses? Young male patient. 11. Reiter’s – Do you have pain in your joints with trouble passing urine? 12. Inflammatory Bowel Disease – Have you noticed change in bowel habits with skin and joint changes?

Back Ache Remember ‘’DISCTOMA’’ 1. Disc Prolapse – Do you feel numbness in any part of your body? Did you hurt yourself? 2. Infections 3. Secondaries 4. Cauda Equina 5. Trauma 6. Osteoarthritis 7. Multiple Myeloma – Anaemia/ back pain/fatigue 8. Ankylosing Spondylitis 9. Dysmenorrhoea / P I D 10. Dissecting Aneurysm

Fever

Important Differentials Diagnose for PLAB2 | 4/2/2012

Did you measure your temperature? How is the pattern? Any associated symptoms? 1. Meningitis 2. Malaria – Fever/ chills / rigors/did you travel to malaria rampant country at all? 3. Ear Infections 4. U R T I 5. Pneumonia 6. Tuberculosis 7. Gastroenteritis 8. Hepatitis 9. Pelvic Inflammatory Disease 10. Urinary Tract Infection 11. Epidydimo-orchitis

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Calf Pain Remember ‘’BBC DR SET’’ And Do SOCRETES PDA 1. Baker’s Cyst 2. Berger’s Disease 3. Claudication 4. Deep Vein Thrombosis 5. Ruptured Achilles’ Tendon 6. Sciatica 7. Excessive Walking 8. Trauma 9. Sports Injury 10. Cellulitis

Authored by: Sarmad Kazmi 30/03/2011

Haemoptysis ***Assess Anaemia 1. Pulmonary Embolism 2. Pneumonia 3. Tuberculosis 4. Bronchiectasis – months of cupful of pus like sputum per day/crackles/finger clubbing/posture related 5. Cystic Fibrosis – repeated chest infections and diarrhoea 6. C O P D – Long history of cough/breathlessness/wheeze with exacerbation over hours to days with pursed lips 7. Ca. Bronchus 8. Bleeding Disorders 9. Blood Thinners 10. Instrumentation -

Knee Pain **Remember ‘’GHRROSS’’ ***Do SOCRETES PDA 1. Gout 2. Heamarthrosis 3. Reiter’s – red eye and urethritis 4. Reactive Arthritis – history of diarrhoea 5. Osteoarthritis 6. Septic Arthritis – fever/ redness/tenderness/swelling 7. Sports Injury

Important Differentials Diagnose for PLAB2 | 4/2/2012

Elderly Constipation

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Low Fibre Intake Low Fluid Intake Decreased Mobility Medications Faecal Impaction Anal Fissures Intestinal Obstruction Ca. Colon Ca. Rectum Diabetic Neuropathy Hypothyroidism Back Injury

Authored by: Sarmad Kazmi 30/03/2011

Acute Diarrhoea 1. 2. 3. 4. 5. 6.

Gastroenteritis Infectious Diarrhoea Food Poisoning Pseudo Membranous Colitis Medications (Alcohol/ Digoxin/ Laxative abuse) Traveller’s Diarrhoea

Chronic Diarrhoea 1. 2. 3. 4. 5. 6. 7. 8. 9.

Malignancy HIV Inflammatory Bowel Disease Irritable Bowel Syndrome Malabsorption ( Celiac / Chr. Pancreatitis) Parasitic diarrhoea – tummy pain relieved on open bowl Hyperthyroidism Diabetes Neuropathy Lactose intolerance

Important Differentials Diagnose for PLAB2 | 4/2/2012

Weight Loss

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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Malignancy Malnutrition Malabsorption Hyperthyroidism Diabetes Mellitus HIV TB IBS IBD Anorexia Nervosa Bulimia Nervosa Depression

Diplopia Remember ‘’GM4C SHIRT’’ 1. Inflammatory Orbital Myositis - fever/ swelling around eyes/ pain on moving your eyes 2. Refractory Error – Do you wear glasses at all? 3. G C A – Do you feel pain while combing your hair or either by touching your head? 4. Myasthenia Gravis – Do you feel excessively tired towards the end of the day? 5. Multiple Sclerosis – weakness/ coordination/ strength/loss of bladder and bowl control 6. Muscle Palsy – Do you see double in a particular direction? 7. Malignancy – Have you recently lost weight?/Have noticed any abnormal swellings?/any racing of your heart? 8. Cataract (2o to DM or Steroids) – Have you been diagnosed with a condition known as diabetes?

Authored by: Sarmad Kazmi 30/03/2011

9. Space Occupying Lesion – early morning heading worst in the morning and relived by puking? 10. Hyperthyroidism -Do you feel hot in the same environment where others are comfortable? 11. Trauma – Did you hurt yourself by any chance?

Vomiting ***Assess Dehydration ***Feeling more thirsty/Low urine output/Dry lips 1. Pregnancy -*(If female patient) 2. Head Injury 3. Meningitis 4. S O L 5. Migraine 6. Antibiotics 7. Food Poisoning 8. Accidental Poisoning 9. Intestinal Obstruction 10. Gastroenteritis 11. Acute Pancreatitis 12. Diabetic Keto Acidosis 13. Ureteric Colic 14. U T I

Chronic Fatigue Syndrome

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. 2. 3. 4. 5. 6.

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Anaemia Hypothyroidism Myasthenia Gravis Malignancy Depression Shift Workers

Palpitations 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Hyperthyroidism Hyperventilation Hypoglycaemia Cardiac Disorders Arrhythmias Excessive Alcohol Caffeine Stress Fear Anxiety Pheochromocytoma Salbutamol

Authored by: Sarmad Kazmi 30/03/2011

Sore Throat 1. 2. 3. 4. 5. 6. 7. 8. 9.

Mumps Measles Chickenpox Glandular fever Streptococcus A Hay Fever Pollens/ Dust/ Change of weather/ Smoking Ca. (Back of tongue, throat, vocal cords) Excessive use of voice

Anaemia 1. 2. 3. 4. 5. 6. 7. 8.

Malnutrition Malabsorption Malignancy Malaria Bleeding/vomiting/cough/menstruation/bruises/delayed wound healing Chronic renal failure Rheumatoid Arthritis Drugs Antacids/Steroids/Blood thinners

Important Differentials Diagnose for PLAB2 | 4/2/2012

Vertigo

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1. 2. 3. 4. 5. 6. 7. 8.

Meniere’s Disease - Tinnitus/decreased hearing loss/fullness in ear Acoustic Neuroma - Numbness and change in facial features Benign Positional Vertigo Wax Trauma Vertibrobasilar Insufficiency- Due to hyperextension of the neck/shoulders Cereobropontine angle tumour Ototoxicity - Gentamicin/Anticonvulsants

Hot Flushes 1. Natural Menopause 2. Premature ovarian failure – age below 40/ history of surgery/radiotherapy/family history of the same condition 3. Medullary Carcinoma – Neck mass with weight loss 4. CA Pancreas – Painless jaundice, dark coloured urine, pale stools, age>60 5. Brain tumours – Headache, feeling sick worse by cough and sneeze 6. Pheocromocytoma – Headache, palpitations, sweating, High Blood Pressure

Authored by: Sarmad Kazmi 30/03/2011

7. Carcinoid tumours – Flushing after alcohol and coffee 8. Frey’s Syndrome – Redness and sweating on cheeks near angle of ear, occurs when talking and eating certain foods 9. Medications – Ca blockers, Tamoxifen, Reloxifen, Nitrates and nicotinic acid

Osteoporosis (Causes/DD) 1. Family history 2. Early Menopause 3. Steroids (Very Important) 4. Sedentary Life style 5. Smoking 6. Alcohol 7. Rheumatoid Arthritis 8. Thyroid disease 9. Cushing Disease/Syndrome 10. Primary Biliary Cirrhosis

Important Differentials Diagnose for PLAB2 | 4/2/2012

Causes of Elderly Falls

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1. UTI due to confusion 2. Osteoporosis 3. Rheumatoid Arthritis 4. Cushing Disease 5. Thyroid disease 6. Medications – antihypertensive/diuretic/antidepressants 7. TIAs 8. Epilepsy 9. Vasovagal – standing for a long time/going pale/did you lose consciousness 10. Alcohol 11. Multiple myeloma 12. Domestic reasons

Causes of Dysuria UTI BPH Stones

Authored by: Sarmad Kazmi 30/03/2011

DDs in OB-GYN Dysmenorrhoea 1. 2. 3. 4. 5. 6. 7.

Fibroids - dragging sensation and intermenstrual bleeding Adenomas – Adennomyosis/progressive Endometriosis - Do you bleed anywhere else during menstruation Polyps - Postcoital bleeding Pelvic Inflammatory Disease – Fever, discharge and back pain I U C D - Have you been fitted with any contraceptive device down below? Infected Endometrial Ca. (last option, don’t say if you can avoid saying ;))

Menorrhagia

Important Differentials Diagnose for PLAB2 | 4/2/2012

***Assess Anaemia 1. Pregnancy 2. Fibroids 3. Endometriosis 4. Polyps 5. Ca. Endometrium - Weight Loss and HOVAC 6. Ca Cervix - Cervical smear 7. I U C D, Instrumentation 8. Hypothyroidism 9. Bleeding Disorder 10. Medications (Blood Thinners) 11. Dysfunctional Uterine Bleeding 12. Ruptured ovarian cyst - Pain and past medical history 13. Vaginal Atrophy - Painful intercourse

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Amenorrhoea 1. 2. 3. 4. 5. 6. 7.

Pregnancy Post-Pill Amenorrhoea. Lactational Amenorrhoea Uterine – Asherman’s Ovarian – P C O S, Ovarian Failure Endocrine – Cushing’s, Hyperthyroidism, Anorexia, Prolactinoma, Sheehan’s, Stress. Imperforate Hymn

Authored by: Sarmad Kazmi 30/03/2011

Infertility MALE 1. Undescended Testes 2. Mumps/orchitis 3. Medications 4. Medical conditions / Surgeries 5. Tight underwear 6. Trauma 7. torsion of testis 8. hernia 9. UTI FEMALE 1. P C O S 2. Endometriosis 3. Prolactinoma 4. Cushing’s 5. Hyperthyroidism 6. Sheehan’s 7. Asherman’s – any instrumentation/operations down below? 8. PID 9. Premature ovarian Failure

Important Differentials Diagnose for PLAB2 | 4/2/2012

Hyper emesis

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In any case, always assess dehydration and exclude other cause. *** Is this your first pregnancy? 1. Multiple Pregnancy 2. Hydatidiform Mole - Vesicle discharge and past medical history 3. Gastroenteritis 4. U T I 5. D K A 6. Pre eclampcia

Incontinence 1. 2. 3. 4. 5. 6. 7. 8. 9.

True – Fistula Stress Urge Prolapse UTI Habitual Medications – Water tablet? Medical conditions (DM) Atrophic Vaginitis

Authored by: Sarmad Kazmi 30/03/2011

Vaginal Discharge Colour Amount Smell Consistency Pruritus Any blood Pain Fever Relation to cycles Swelling in groin area

Important Differentials Diagnose for PLAB2 | 4/2/2012

2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

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Authored by: Sarmad Kazmi 30/03/2011

DDs in Paediatrics Uncontrolled Epilepsy 1. 2. 3. 4. 5.

Meningitis Head Injury Non Accidental Injury U R T I / U T I / Ear Infections Hypoglycaemia

Excessive Crying 1. 2. 3. 4. 5. 6. 7. 8. 9.

Meningitis Intussusceptions U R T I / U T I / Ear Infections Non Accidental Injury Trauma Hunger Wet Diaper Smoker around / Asthma / Irritation? Infantile Colic

Important Differentials Diagnose for PLAB2 | 4/2/2012

RASH

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* First Assess anaemia – breathlessness/racing of heart/fatigue/pallor 1. Meningitis 2. Non Accidental Injury 3. Anaphylaxis 4. Measles 5. Chicken Pox 6. Scabies 7. Henoch Schonlein Purpura – Abdominal pain/GI bleeding/rash around the buttocks 8. I T P – History of any flu like illness 9. Leukaemia/Anaemia/Von Willie Bran Disease 10. Medications

Head Injury 1. 2. 3. 4.

NAI Accidental Diabetes Mellitus Epilepsy

Authored by: Sarmad Kazmi 30/03/2011

Hypoglycaemic Fit 1. 2. 3. 4. 5.

Meningitis Epilepsy NAI Accidental Injury U R T I / U T I / Ear Infections – does your child cry while passing wee?

Vomiting in Infant *Any sunken part on his head/constipation/ dryness of mouth/ passing less urine than normal) 1. 2. 3. 4. 5. 6. 7. 8. 9.

Meningitis Pyloric Stenosis Duodenal Atresia Intussusceptions Head Injury NAI U R T I / U T I / Ear Infections GERD Over-feeding

Vomiting in Older Child

Important Differentials Diagnose for PLAB2 | 4/2/2012

*Assess dehydration first; (sunken eyes/constipation/ dryness of mouth/ passing less urine

23

than normal) 1. Meningitis 2. Intestinal Obstruction – constipation/ wind passing 3. Diabetic Keto Acidosis – fruity odour 4. Head Injury 5. N A I 6. Gastro-enteritis 7. Accidental Poisoning 8. U R T I / U T I / Ear Infections

Loss of Consciousness 1. 2. 3. 4. 5. 6. 7. 8.

Meningitis Epilepsy Diabetic Keto Acidosis Head Injury Non Accidental Injury Accidental Poisoning Vaso-vagal Syncope Cyanotic Heart Disease

Authored by: Sarmad Kazmi 30/03/2011

Chronic Diarrhoea / Weight Loss 1. 2. 3. 4. 5. 6.

Celiac Disease Cystic Fibrosis – repeated chest infection with diarrhoea Parasitic Infection Lactose Intolerance Long term medications Toddler’s Diarrhoea

Never Walked / Delayed Walking ACUTE 1. Trauma 2. Septic Arthritis – fever/swelling/redness/ tenderness 3. Irritable Hip – history of infections CHRONIC 1. NAI/Trauma – Did he have any trauma in the past? 2. Cerebral Palsy - Any complication during delivery/birth? 3. Congenital Dislocation of Hip – Have you noticed any lump or clicking sound while changing nappies 4. Malnutrition – do you feed him well? 5. Muscular Dystrophy – Family history/child use all four limbs to stand/calf hypertrophy/have you notice any mass on the back of his calf 6. Chronic Infections - recurrent infections/diseases 7. Constitutional Delay – family history of delayed walking 8. Polio – Is he update with all his jabs? 9. Kernicterus – Yellowish discolouration of skin 10. Ricketts – Does he get enough sun exposure? 11. Meningitis -

Important Differentials Diagnose for PLAB2 | 4/2/2012

Febrile Convulsions

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1. 2. 3. 4. 5. 6.

Head injury Meningitis U T I / U R T I / Ear Infections Pneumonia Epilepsy Hypoglycaemia

***Don’t forget to rule out Head Injury

Authored by: Sarmad Kazmi 30/03/2011

Neonatal Jaundice

(First 24 hours is always pathological) *Is he your first child as 2nd child will also be affected 1. 2. 3. 4. 5. 6. 7.

Physiological – do you feed your child with breast milk? Biliary atresia – Vomiting with GREEN COLOURED STOOLS Rh Incompatibility – hepatomegaly/hydrofetalis ABO Blood Groups – ask about the blood group of the father, mother & the baby Sepsis – fever/sign of shock G6 Phosphate deficiency - Familial and run in the family Hypothyrodism – Did you use any hormone during pregnancy?

Vaginal discharge 1. 2. 3. 4. 5. 6. 7. 8.

NAI Foreign body Trauma Candidiasis – common in extreme of ages Poor hygiene Diabetes Immunocompromised – Splenectomy or diabetes possible infections

Important Differentials Diagnose for PLAB2 | 4/2/2012

Cervical lymphadenopathy

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1. Infections – EAR & URTI 2. TB 3. Infectious Mononucleosis – ***Painful lymphadenopathy in the neck, armpits and groin/fever/headache/weakness 4. Leukaemia 5. Lymphoma 6. HIV 7. Medication - Phenytoin

Complications of Measles 1. Diarrhoea 2. Vomiting 3. Conjunctivitis 4. Laryngitis 5. Meningitis 6. Pneumonia 7. Bronchitis 8. Aseptic meningitis 9. Hepatitis 10. Otitis media 11. Sub Acute Sclerosing Encephalitis

Authored by: Sarmad Kazmi 30/03/2011

Complications of Mumps 1. 2. 3. 4. 5. 6.

Orchitis Pancreatitis Encephalitis Meningitis Hearing Loss Miscarriage

Complications of Rubella (German Measles) 1. 2. 3. 4. 5.

Growth retardation Cataract Deafness Congenital Heart Defects Mental retardation

Bracelets “SAD APE” S – Steroids A – Asthma D – Diabetes A – Allergies P – Post Splenectomy E – Epilepsy

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. 2. 3. 4. 5. 6.

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Authored by: Sarmad Kazmi 30/03/2011

DDs in Psychiatry Depression 1. 2. 3. 4. 5. 6. 7.

Manic Depressive Psychosis Dysthymia – low mood for a long time Cyclothymia hypothyroidism Cushing Syndrome Addison’s disease – greyish discolouration of skin Drug and alcohol abuse

Post-Traumatic Stress Syndrome DREAMS 1. D – disinterest in life/detached /emotionally numb 2. R - re-living the incident through intrusive flashbacks, nightmares or vivid memories 3. E - extreme nature of the event 4. A – avoidance of similar circumstances or situations 5. M – months < 6 months 6. S – Sympathetic hyper arousal like hyper vigilance or always on the edge DD – Depression/ GAD/ OCD/ Phobia

Drug Abuse

Important Differentials Diagnose for PLAB2 | 4/2/2012

***Do you do only alcohol or something else i.e. drugs?

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1. C – Cutting Down – Have you ever thought of cutting it down? 2. A – Annoyance – Do you feel that your loved ones and friends feel annoyed by your habits? 3. G – Guilt – Have you ever felt guilty about your habit? 4. E – Eye opener - When do you take your first drink? 5. Q – Have you tried to quit 6. T – Do you have to get more to have the same effect 7. F – Alcohol free period

OR Withdrawal - Do you get the same symptoms if you don’t get it? Dependence – Do you feel the same without it? Tolerance – Do you feel as time passes by you need to increase the amount you take to get the same effect?

Authored by: Sarmad Kazmi 30/03/2011

Suicidal Risk Assessment *Always admit the patient/Always refer the patient to Community Mental Health Team/CAMHT for further assessment Planning? For how long? Did you try to do this before? How did you do it? Any Guilt? Suicide note? Did you take anything else? Mood /anhydonia? HIS FFFF Past Psychiatry History Past Medical History

Obsessive Compulsive Disorders 1. 2. 3. 4.

OCD Phobias Panic attacks GAD

Panic Attacks

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. 2. 3. 4. 5. 6.

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Depression Phobias PTSD GAD OCD Stress

*Include DD of Palpitations

Post Natal Depression 1. Baby Blues – duration is 3-10 days after delivery 2. Post Natal Depression – More than 10 days 3. Post-Partum Psychosis – Intention to kill the baby / hallucinations/delusions/insight/suicidal risk

Anorexia Nervosa 1. 2. 3. 4. 5. 6.

Diabetes mellitus Malignancy Malabsorption Hyperthyroidism Depression HIV

Authored by: Sarmad Kazmi 30/03/2011

Insomnia

Important Differentials Diagnose for PLAB2 | 4/2/2012

1. Depression 2. Mania 3. GAD 4. PTSD 5. OCD 6. Stress 7. Panic Attack 8. Psychosis 9. Grief 10. Caffeine 11. Noise 12. Light 13. Medicine 14. Alcohol 15. Recreational drugs 16. Shift worker 17. Pain/Headache 18. Heart Burn 19. Shortness of Breath 20. Nocturia 21. Cough

29

Authored by: Sarmad Kazmi 30/03/2011

What is urinary tract infection? Urinary tract infection (UTI) is defined as the presence of multiplying micro-organisms (bugs) in the tract through which urine flows from the kidneys via the bladder to the outside world. UTI is 50 times more common in women, with about 5 per cent per year developing symptoms. UTI is uncommon in men below 60 years of age, but the frequency is similar in men and women in older age groups. The condition ranges from cystitis (a mild but distressing inflammation that is limited to the bladder) to severe infections of the kidney, such as pyelonephritis (when the infection has reached the kidney tissue itself). Treatment depends on how and why the infection shows itself. Most patients respond rapidly to antibiotic therapy and are unlikely to have any other urinary tract abnormality.

Good advice UTIs are rare in men, so all cases require investigation. Prostatitis, the infection or inflammation of the prostate (a gland beneath the bladder that produces some components of semen), causes symptoms that can be mistaken for UTI in men.

What causes UTI?

Important Differentials Diagnose for PLAB2 | 4/2/2012

In healthy men, urine is sterile (contains no micro-organisms).

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The most important factor in maintaining the sterility of the urinary tract is emptying the bladder completely and frequently. The cause of most UTIs is bacteria that initially settle (colonise) around the urethra (urine tube), and then ascend into the rest of the urinary tract. Several factors can make this process more likely to occur.

Obstruction: Enlarged prostate Gland urethral stricture (narrowing)

Neurological conditions: Spina bifida Multiple sclerosis Spinal cord injury

Authored by: Sarmad Kazmi 30/03/2011

Structural bladder disease: Diverticula (small sacs or bulges) in the bladder wall Tumour

Abnormal urine drainage: Horseshoe kidney Obstruction by kidney stones or bladder stones Polycystic kidney Bladder reflux disease (usually due to leaky valves between the bladder and ureter tubes that connect to the kidneys)

Foreign body: instrumentation (i.e. during a procedure) Catheters and stents

Underlying disease: Diabetes Steroid therapy. UTIs are classified as either community acquired or hospital acquired. 70 per cent of infections are community acquired, usually caused by the bacteria Escherichia coli (E coli) from the patient's own bowels.

Important Differentials Diagnose for PLAB2 | 4/2/2012

Hospital acquired infections are usually E. Coli, but Pseudomonas and Staphylococci are important causes, particularly when a surgical instrument such as a catheter is used; instrumentation is the predisposing factor.

31

Hospital infections can often be due to multiple organisms, and antibiotic resistance is a common problem.

What are the symptoms of UTI? Symptoms differ, depending on whether the infection affects the lower (bladder and urethra) or upper (kidneys and ureters) parts of the urinary tract. The symptoms of lower urinary tract infection are dysuria (burning on passing urine), frequency (frequent need to pass urine) and urgency (compelling need to urinate). The urine can be cloudy with an offensive odour. In older men, generalised symptoms such as confusion and incontinence can be present. Urine infections are much commoner in the elderly, due to poor bladder emptying, an enlarged prostate, or incontinence associated with stroke or dementia.

Authored by: Sarmad Kazmi 30/03/2011

The symptoms of upper urinary tract infection are the same as lower tract symptoms plus loin (flank) pain, fever and chills. The patient is likely to be ill and might require hospital admission.

How is the diagnosis made? Test strips dipped into a urine sample can detect indirect signs of infection such as blood, protein, white blood cells and nitrites (most common bacteria convert nitrate, which is a chemical normally present in urine into nitrites, which are not usually present). A clean midstream urine sample should be sent to the laboratory for a microscopy examination. A level of 100,000 bacteria per millilitre of urine is regarded as a significant infection, especially if found together with pus or white blood cells (leucocytes) on microscopy. Any infecting bacteria are cultured in the laboratory to assess their sensitivity to common antibiotics.

How is UTI treated? General measures A high fluid intake is essential. Alkaline substances, such as citrates, taken in water might improve symptoms. By making the urine more alkaline, they make the environment more hostile to bacterial growth and improve the results of antibiotic therapy.

Important Differentials Diagnose for PLAB2 | 4/2/2012

Antibiotic therapy

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Antibiotics are the mainstay of treatment. Trimethoprim (eg Monotrim) is currently the first choice for lower UTI in the UK, because it's costeffective, well tolerated and works in 80 per cent of infections. Cephalosporins, nitrofurantoin and norfloxacin are reserved as second line drugs in patients with lower UTI. But they are the first choices in patients with signs of upper UTI or kidney infection. Antibiotics, such as amoxicillin, now have resistance levels of 50 per cent in the community because of widespread use over many years. Based on such experiences, many specialists are concerned about the possible overuse of the more powerful antibiotics as first line therapy in the general community.

Recurrent UTI If UTIs keep occurring, identification and treatment of the underlying cause is essential. Patients who have the same infection coming back can be managed successfully by attending to 'bladder toilet' (drinking 2 to 3 litres of fluid daily and always passing urine at bedtime and after sex). Drinking 250 to 500ml of cranberry juice daily and avoidance of bubble baths may also help. If these measures fail, six months of continuous therapy with low dose antibiotics is usually required.

Authored by: Sarmad Kazmi 30/03/2011

Treatment of Acute Congestive Glaucoma 1. Carbonic anhydrase inhibitors Acetazolamide (Diamox)/Methazolamide (Neptazane)

2. Beta-adrenergic blockers Timolol ophthalmic (Timoptic, Timoptic XE) /Carteolol ophthalmic (Ocupress)/Levobetaxolol (Betaxon)/Levobunolol (AKBeta, Betagan)

3. Alpha-adrenergic agonists Apraclonidine (Iopidine)/Brimonidine (Alphagan, Alphagan-P)

4. Corticosteroids Prednisolone ophthalmic (AK-Pred, Econopred)

5. Ophthalmic agents, miotic Pilocarpine ophthalmic (Pilagan, Pilocar, Pilostat)

6. Hyperosmotics Glycerin (Osmoglyn)/Isosorbide (Ismotic)/Mannitol (Osmitrol)

7. Referral to Eye Surgery

Ovarian Torsion

Important Differentials Diagnose for PLAB2 | 4/2/2012

Definition Ovarian torsion is the twisting of the ovary due to the influence of another condition or disease. This results in extreme lower abdominal pain.

33

Description Ovarian torsion occurs infrequently only in females. In can occur in women of all ages, but most women that experience this are younger. Approximately 70-75% of cases occur in women under 30 years old. About 20% of all reported cases are in pregnant women. It is the fifth most common gynaecological emergency which can include surgical intervention. Ovarian torsion usually arises in only one ovary at a time. They can occur in either normal or enlarged ovaries or fallopian tubes, and occasionally they develop in both.

Causes and symptoms There are a variety of conditions that can cause torsion of the ovary ranging from changes in normal ovaries to congenital and developmental abnormalities or even a disease that affects the tube or ovary. Normal ovaries that experience spasms or changes in the blood vessels in the mesosalpinx can become twisted. For example, if the veins in the mesosalpinx become congested, the ovaries will undergo torsion. Developmental abnormalities of the fallopian tube such as extremely longer-than-normal tubes or a missing mesosalpinx will cause ovarian torsion. Diseases such as ovarian cysts or fibromas, tumour of the ovary or tubes, and trauma to either the ovaries or the tubes will also cause ovarian torsion.

Authored by: Sarmad Kazmi 30/03/2011

The characteristic symptom of ovarian torsion is the sudden onset of extreme lower abdominal pain that radiates to the back, side and thigh. Nausea, vomiting, diarrhoea, and constipation can accompany the pain. The patient may also experience tenderness in the lower abdominal area, a mild fever and tachycardia. Diagnosis The diagnosis of ovarian torsions usually occurs in an emergency room due to the suddenness of extreme pain. Emergency room physicians may consult with another physician specializing in obstetrics and gynaecology. Since 20% of ovarian torsions occur in pregnant women, physicians will order a pregnancy test. Visualization with an ultrasound and CT scan (computed tomography) will help pinpoint the ovarian structures and allow physicians to diagnose. Diagnosis is often confirmed through laparoscopy. Treatment Ovarian torsions need to be repaired. This is done through surgery, and for less severe cases laparoscopic surgery is used. Medications such as NSAIDs are given to control pain. Prognosis If ovarian torsions are diagnosed and treated early, then the prognosis is favourable. However, if diagnosis is delayed, the torsions can worsen and cut off arterial blood flow into and venous blood flow out of the ovary. This results in necrosis (death) of the ovarian tissue. Delayed diagnosis can also result in problems when trying to conceive due to infertility.

Important Differentials Diagnose for PLAB2 | 4/2/2012

Prevention Currently, there are no known methods for prevention of ovarian torsion.

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Authored by: Sarmad Kazmi 30/03/2011

Important Differentials Diagnose for PLAB2 | 4/2/2012

Beck’s Suicide Intent Scale 1974

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1. Isolation Somebody present Somebody nearby, or in visual or vocal contact No one nearby or in visual or vocal contact 2. Timing Intervention is probable Intervention is not likely Intervention is highly unlikely 3. Precautions against discovery/intervention No precautions Passive precautions (as avoiding other but doing nothing to prevent their intervention; alone in room with unlocked door) Active precautions (as locked door) 4. Acting to get help during/after attempt Notified potential helper regarding attempt Contacted but did not specifically notify potential helper regarding attempt Did not contact or notify potential helper 5. Final acts in anticipation of death (will, gifts, insurance) None Thought about or made some arrangements Made definite plans or completed arrangements 6. Active preparation for attempt None Minimal to moderate Extensive 7. Suicide Note Absence of note Note written, but torn up; note thought about Presence of note 8. Overt communication of intent before the attempt None Equivocal communication Unequivocal communication Self-Report 9. Alleged purpose of attempt To manipulate environment, get attention, get revenge Components of above and below To escape, surcease, solve problems 10. Expectations of fatality Thought that death was unlikely Thought that death was possible but not probable

Authored by: Sarmad Kazmi 30/03/2011

Thought that death was probable or certain 11. Conception of method's lethality Did less to self than s/he thought would be lethal Wasn't sure if what s/he did would be lethal Equalled or exceeded what s/he thought would be lethal 12. Seriousness of attempt Did no seriously attempt to end life Uncertain about seriousness to end life Seriously attempted to end life 13. Attitude toward living/dying Did not want to die Components of above and below Wanted to die 14. Conception of medical rescuability Thought that death would be unlikely if he received medical attention Was uncertain whether death could be averted by medical attention Was certain of death even if he received medical attention 15. Degree of premeditation None; impulsive Suicide contemplated for three hours of less prior to attempt Suicide contemplated for more than three hours prior to attempt

Important Differentials Diagnose for PLAB2 | 4/2/2012

Other Aspects (Not included in total score)

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16. Reaction to attempt Sorry it was made; feels foolish; ashamed Accepts both attempt and failure Regrets failure of attempt 17. Visualization of death Life after death, reunion with descendants Never-ending sleep, darkness, end of things No conceptions of or thoughts about death 18. Number of previous attempts None One or two Three or more 19. Relationship between alcohol intake and attempt Some alcohol intake prior to but not related to attempt; reportedly not enough to impair judgment, reality testing Enough alcohol intake to impair judgment; reality testing and diminish responsibility Intentional intake of alcohol in order to facilitate implementation of attempt 20. Relationship between drug intake and attempt Some drug intake prior to but not related to attempt; reportedly not enough to impair judgment, reality testing Enough drug intake to impair judgment; reality testing and diminish Authored by: Sarmad Kazmi 30/03/2011

responsibility Intentional intake of drug in order to facilitate implementation of attempt 15-19 Low Intent 20-28 Medium Intent 29+ High Intent There is also a greater risk of repeated attempts the higher the intent rating

Risk factors for suicide Male gender (3 times more likely than women) Advancing age Unemployed Concurrent mental disorders Previous suicide attempt Alcohol and drug abuse Low socio-economic status Previous psychiatric treatment Certain professions - doctors, students Low social support / living alone Significant life events Institutionalised e.g. prisons, army

Important Differentials Diagnose for PLAB2 | 4/2/2012

Mental disorders and risk of suicide

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The risk of suicide in patients with mental disorders is higher than that for patients without co-existent mental disorders. Although figures as high as 15% have been reported in people with depression, the actual value is much lower. The original 15% represented in patients with severe depression and the actual figure is probably more around 3%. Suicide is a major cause of death in schizophrenic patients and it is thought that up to 1 in 10 patients with schizophrenia will eventually commit suicide.4

Determining a patients risk of suicide Suicidal intent has been found to be a good predictor of a subsequent completed suicide, e.g. a 5 year follow-up study of more than 2500 patients showed that those who scored highly for suicidal intent at the time were at high risk of completed suicide especially within the year after the attempt. There are a number of risk predicting score systems to determine suicidal intent e.g. Beck's Suicidal Intention Scale, Beck's Hopelessness scale and Motives for present parasuicide. The most widely used scales are Pierce Suicide Intent Scale7 and Beck's Suicidal Intention Scale. These contain about 15 items - each one scoring from 0 - 2 points. Part Authored by: Sarmad Kazmi 30/03/2011

of the scale looks at the patient's thoughts and emotions at the time of the attempt and the other questions are about the circumstances around the attempt. The PATHOS score may be used to identify high risk patients after an overdose:

PATHOS - Self-harm assessment 'Have you had Problems for longer than 1 month?' 'Were you Alone in the house when you overdosed?' 'Did you plan the overdose for more than Three hours?' Are you feeling HOpeless about the future - that things will not get much better?' 'Were you feeling Sad for most of the time before the overdose?' The more features present - the greater the likelihood of significant suicidal intent and depression

Important Differentials Diagnose for PLAB2 | 4/2/2012

What to do if a patient expresses suicidal ideation

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Form a good relationship, be empathic and reassure regarding confidentiality. Suicide risk - determine as above. Assess current mental health or physical health difficulties. Determine any support networks available to the patient. Determine risk of further harm or suicide: o History and details of any attempt or are they making plans. o What was/is the intent and are there any precipitating factors, e.g. recent bereavement. o Previous attempts at suicide or deliberate self-harm. o Use of illicit drugs or alcohol dependence. o Social circumstances. o Any concurrent mental health issues, e.g. depression.

Management after initial assessment If the patient is at low risk then they should be offered regular contact (could be by telephone if possible) and counselling. You may need to consider referral to local mental health services for further follow-up. If there are concerns about patient safety or the patient scores highly on the suicide risk score the patient should be referred for urgent mental health assessment. If you are unsure then seek advice from mental health specialists. Usually patients are sent to a designated assessment area and the on-call psychiatrist can direct you as required. One needs to be wary of sending patients to A&E, although most A & E departments have psychiatric liaison staff available on site allowing the patient to be assessed and admitted if necessary. If a patient refuses help then a decision regarding their capacity may need to be made with psychiatric evaluation and detention under the Mental Capacity Act considered.8

Authored by: Sarmad Kazmi 30/03/2011

It is important to remember that scales of risk, although helpful, have a poor predictive value. Therefore, if you have a patient who you are worried about but they score low, then still consider urgent referral for them.

Pierce Suicide Intent Scale 1. Isolation Someone present Someone nearby or on telephone No- one nearby 2. Timing Timed so intervention is probable Intervention unlikely Intervention highly unlikely

3. Precautions against rescue None Passive (alone in the room or doors unlocked) Active precautions 4. Acting to get help Notifies helper of attempt Contact helper doesn’t tell No contact with helper

Important Differentials Diagnose for PLAB2 | 4/2/2012

5. Final acts in anticipation None Partial preparation Definite plans (e.g. will, insurance, gifts)

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6. Suicide note None Note torn up Presence of note 7. Lethality Thought would not kill Unsure if lethal action Believe would kill 8. Stated intent Do not want to die Unsure Wanted to die 9. Premeditation Impulsive

Authored by: Sarmad Kazmi 30/03/2011

Considered less than one hour Considered less than one day Considered more than one day 10. Reaction to act Glad recovered Uncertain Sorry she or he failed 11. Predictable outcome Survival certain Death unlikely Death likely or certain 12. Death without medical interventions No Uncertain Yes

Items (1+2+3+4+5+6) = ‘Circumstances scores’

Items (7+8+9+10) = ‘Self Report Score’

Important Differentials Diagnose for PLAB2 | 4/2/2012

Item (11+12) = ‘Medical risk score’

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Authored by: Sarmad Kazmi 30/03/2011