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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 Barretts 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

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.

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?

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.

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 hasnt 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.

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 Kaposis 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?

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 5-reductase inhibitors.

Important Differentials Diagnose for PLAB2 | 4/2/2012

Alpha blockers (technically 1-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 5-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.

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

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

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, Cushings, 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. Cushings
- 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

10

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.

11

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

12

1. Meningitis
- Shy away from light/ fever/ neck stiffness/ rash/ vomiting
2. Sub Arachnoid Hhage 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 Hhage - 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. Reiters 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

13

Calf Pain
Remember BBC DR SET And Do SOCRETES PDA
1. Bakers Cyst
2. Bergers 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. Reiters 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

14

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)
Travellers 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

15

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.

16

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

17

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

Menieres 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. Freys 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

18

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, dont 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

19

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

Pregnancy
Post-Pill Amenorrhoea.
Lactational Amenorrhoea
Uterine Ashermans
Ovarian P C O S, Ovarian Failure
Endocrine Cushings, Hyperthyroidism, Anorexia, Prolactinoma, Sheehans, 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. Cushings
5. Hyperthyroidism
6. Sheehans
7. Ashermans any instrumentation/operations down below?
8. PID
9. Premature ovarian Failure

Important Differentials Diagnose for PLAB2 | 4/2/2012

Hyper emesis

20

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.

21

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

22

* 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
Toddlers 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

24

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

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

***Dont 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

25

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.

26

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
Addisons 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?

27

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 dont 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.

28

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).

30

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

32

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.

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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

Becks 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 doesnt 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