Approach To Common Medical Symptons

APPROACH
Approach Type Qs
As discussed in the class the “key thing” is to think about the
Differential………if D/D type Q

OR
PD…….if /P/D type Q
DON’T TRY TO “mug up” these answers “MUKHOSTO” korte jeo na!!!
Just look at the approach of answering this type of Qs {as discussed in the class}
1
22 year old male presented with fever for 5 days, progressive loss of consciousness and 3 episodes of convulsion
probable causes?? Diagnostic approach to pinpoint diagnosis?? Management of this patient?
(Think of a 1 single pathology/disease which explains ALL 3)
Probable causes-
1. CNS infection affecting Brain function/structure 2. Infection elsewhere, but affecting brain function
Complicated Falciparum Malaria-cerebral Malaria (CM) a. Acute Hepatic failure (AHL)- Viral Hepatitis
Meningitis
Encephalitis
Brain Abscess
Approach= 1.Clinical→ history+ examination 2. Investigations

History-Important points with their significance are
a. Type/pattern of fever- may give an idea about the underlying disease
b. level of consciousness/ pattern of convulsion- to be assessed
c. Associated symptoms- may help to predict type of the disease
1. headache/Neck stiffness-CNS infection
2. Photophobia- Meningitis
3. Focal neurodeficit- brain abscess/meningitis
4. Behaviourial disturbance- encephalitis/ hepatic encephalopathy
5. h/o Presence of jaundice- AHL/CM
6. Symptoms of focal infection- which may be complicated by Meningitis
7. Oliguria- AKI due to CM
8. Cola coloured urine- Intravascular hemolysis-CM
Examination- Important points with their significance
a) level of GCS- to be assessed
b) Neck rigidity- Meningitis
c) UMN signs-brain abscess
d) Flapping tremor- hepatic encephalopathy
e) Hepatomegaly- AHL
f) Signs of ENT infection- meningitis
g) Rash- meningitis/coagulopathy due to AHL or DIC due to CM
h) Jaundice- AHL/CM
i) Splenomegaly- CM
Investigations-
Preliminary- Important ones with relevant diagnostic clues they give
Blood-
a) TC/DC/CRP- high in any infection but remarkably in bacterial infection
b) Leukopenia- may be in Acute viral Hepatitis/malaria
c) MP with Malarial antigen-+ve in CM
d) Blood C/S- may be +ve in Pyogenic infection
e) LFT- very high transaminase/Bilirubin- AHL
f) Hepatitis serology- +ve in AHL
CT Brain- to r/o brain abscess
Special investigations- nature depends on tentative preliminary diagnosis
Preliminary diagnosis special investigation
Meningitis/encephalitis CSF study
AHL USG abdomen/ ascitic fluid analysis
Management (remember actual and our own ''ABCD''!!)

2
A. Admit; Airway- to be secured, if required intubate
B. Breathing= O2/ ventilatory support; Bed Sore prevention- Regular change of position
C. Circulation- IV fluid ; Catheterisation
D. Drugs- 1. Antibiotic- If meningitis/brain abscess is suspected- empirical Antibiotic- Ceftriaxone. May be altered
according to CSF C/S or Blood C/S results
2. Antimalarial- ACT if Cerebral malaria
3. Antiviral- Acyclovir if Encephalitis is suspected
4. Lactulose/Rifaximin- if AHL is suspected
5. Antipyretic/Analgesic- Paracetamol
Diet- Nutritious diet through Ryle’s tube
DVT prevention- Prophylactic Heparin/ DVT stocking
A male patient aged 22 years has been admitted due to sudden onset of convulsion with fever and jaundice of 5 days
prior to admission. What are the possibilities? How do you approach to this case?
Probable causes- conditions causing fever + jaundice with CNS involvement as pt developed convulsion, therefore I
will think about-
1.Acute Hepatic failure (AHF) due to Acute Viral Hepatitis
2.Complicated Falciparum Malaria-Cerebral Malaria (CM)
3.Leptospirosis
History-Important points with their significance are
a.Pattern of fever- low grade- Hepatitis
High with chill/rigor- Malaria/Leptospirosis
b.Level of consciousness/ pattern of convulsion- to be assessed
c.Associated symptoms- may help to predict type of the disease
1.RUQ discomfort- Hepatitis
2.Juandice preceded by nausea/vomiting- Hepatitis/CM
3.Focal neurodeficit- Hepatic Encephalopathy
4.Behaviourial disturbance- Hepatic encephalopathy/CM/Leptos
5.Severe headache- CM/Leptospirosis
6.Red eye- Leptospirois
7.Oliguria- AKI due to CM/ Leptos
8.Hematuira- ?Intravascular hemolysis-?CM
9.Any risk factors of Hepatitis- to be looked for
10.Any occupational risk factors for Leptospirosis: veterinarians/farmers/sewerage workers
Examination- Important points with their significance
a.level of GCS- to be assessed
b.Flapping tremor- Hepatic encephalopathy
c.Conjunctival suffusion- Leptospirosis
d.Rash- Leptospirois
e. Low GCS- Encephalopathy due to AHL/CM
f.Tender Hepatomegaly- Viral Hepatitis
g.Neck rigidity- Leptospirosis can cause meningtitis
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Investigations-
Preliminary- Important ones with their diagnostic significance
Blood-
a.TC/DC/CRP- remarkably high in bacterial infection
b.Leukopenia - may be in Acute viral Hepatitis/Malaria
c. MP with Malarial antigen - +ve in CM
e. LFT-
Very high Transaminase/Bilirubin - AHL/Leptospirosis
Mildly raised Bilirubin +/- mildly raised Transaminase- CM/Leptos
CT Brain- to rule out any Brain lesion- usually done any pt with convulsion
Special investigations- to confirm diagnosis
Nature of these tests depend on initial provisional diagnosis
1.Hepatitis serology- Anti HAV- IgM/ Anti HEV- IgM/ HBs-Ag
2.USG abdomen/ ascitic fluid analysis
3.Leptospira serology/
A 16yr old boy with high fever, headache, bodyache, vomitting and subconjunctival haemorrhage. what will be the
D/Ds and approach?
D/D-
1.Viral Hgic.Fever 2.Non Viral diseases
Dengue Hemorrhagic Fever Meningococcemia
Eblola Hgic fever Leptospirosis
Bunya virus disease
Chikungunya
Yellow Fever
Approach includes 1.Clinical approach= History & Examination 2. Investigations
History- Important points with diagnostic clues they give are
1.Natue of the fever- to be assessed
2.Associated symptoms
a.severe bodyache- Dengue
b.severe headache- can caused by any of them
c.Neck pain/stiffness-Meningococcemia/ Leptospirosis
d.Rash- Dengue/Meningococcemia/Chikungunya
e.Oliguria/anuria- AKI due to Leptospiroiss/Meningococcemia
f.Jaundice-Leptospirosis
g.Altered sensorium- Meningococcemia/Dengue/Leptospirosis
h.Red eye- Chikungunya
i.Recent H/o of travel- Latin America/Africa- Ebola/YF/Bunya to be considered
Examination- Imp. points with diagnostic clues they give are
1.Rash- Pupuric- Meningococcemia
Maculopapular- any of the viral fever
2. Iridocyclitis/Uveitis- Chikungunya
3.Jaundice- Leptospirois
4.Neck rigidy- Menigococcal meningitis/Leptospirosis
5.Hepatomegaly- Leptospirosis
6.Signs of dehydarion- Dengue
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Investigations
1.Preliminary
1.FBC- Low platelet- dengue
High TC/DC/CRP- Meningococcemia/Leptosporosis
2.Ur.Cr.- High- AKI- Dengue with renal failure/ Leptospirosis/Meningococcemia with severe sepsis
3. LFT- deranged- Leptospirosis
4. Dengue NS1/Dengue IgM- +VE in Dengue
5. Blood C/S- may be +ve in Bacterial infections
2.Special- Nature depends on Preliminary diagnosis
Preliminary diagnosis Special Investigation
Meningococcal Meningitis CSF study
Viral Fever Blood viral serology tests
A 19 yr college student presents to you with h/o jaundice, high colored urine for 3 days preceded by fever, nausea,
malaise and myalgia for 4 days. He gives an h/o academic trip for 1 month before his present illness.
Provisional diagnosis? What are the D/Ds? Briefly discuss the approach? Management of the most likely cause.
(Think of a single disease which explains all 5)
Ans 1. P/D- Acute Viral Hepatitis
Ans 2. D/D
1. Acute Viral Hepatitis-h/o travel, so Hep A/E
(Most likely)
2. Malaria
4. Leptospirosis
5. GB stone disease with ascending cholangitis
Ans 2. Approach= Clinical= (history & examination) Investigations
History-Important points with their relevance are
History What they suggest
1. Severe nausea Hepatitis
2. Jaundice-painless- medical cause
-with RUQ pain- surgical cause
3.Pattern of fever
low grade Hepatitis
High with chill/rigor Cholangitis/malaria/Leptos
4. Associated symptoms
Disorientation Fulminant hepatic failure
Cerebral Malaria
Haematuria- Malaria
Severe headache- Malaria/Leptospirosis
Red eye Leptospirois
Pre existing GB stone- Cholangitis
Jaundice in fellow travellers- Hepatitis
Examination- Important points with their relevance are
Findings what they suggest
Conjunctival suffusion Leptospirosis
Rash Leptospirois
Low GCS Encephalopathy due to FHF/CM
Flap Encephalopathy due to FHF
Tender Hepatomegaly Viral Hepatitis
Murphy’s sign+ve Cholecystitis
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Investigations- with their relevance
Preliminary
Blood
a.Hb,TC,DC,CRP-
High-in cholangitis/Leptospirosis
Leukopenia- Acute viral hep.
b.LFT -↑↑Transaminase & ↑Bilirubin-Acute Viral hep.
c. Albumin↓/P.Time& INR↑- FHL due to Viral Hep.
c.MP with +VE Malarial Antigen- Malaria
e.BloodC/S- may be +ve in cholangitis with Bacteremia
USG abdomen- GB/CBD pathology
Special-type depends on provisional diagnosis

a.Hepatitis Serology- Anti HAV- IgM/ Anti HEV- IgM/ HBs-Ag
b. Leptospira serology
c. MRCP
Ans 3. Management (remember actual& our''ABCD''!!)
A.Admit, if required
Airway- to be secured if comatose, if required intubate
B. Breathing= O2/ ventilatory support, if in coma
Bed Sore prevention-if comatose- Regular change of position
Blood Biochemistry- monitor regularly- INR/Albumin/LFTs
C. Circulation- IV fluid
Catheterisation- to monitor urine output
D. Drugs
Avoid hepatotoxic drugs
Bowel cleansers-Lactulose/Rifaximin- if encephalopathy
Diet- Nutritious diet orally/if comatose through Ryle’s tube
-Protein restriction if encephalopathy
E. Encephalopathy- look for/prevent/treat if occurs
F. Fluid- IV fluid should Dextrose containing
Fulminant Hepatic failure- consider Liver transplantation
(G.Ganges water, if dies inspite of doing A to F!!)
26 year old with gum bleeding, fever and purpuric rashes, fever for 3 days-approach?
Important causes to be considered are
1. Haematological diseases- Pancytopenia due to
1. Intrinsic Marrow disorder-
Aplastic Anaemia
MDS (Myelofibrosis- unlikely given young patient, to be included if middle aged/ elderly patient)
BM infiltration-AML/CML/ALL/Lymphoma
2. Non BM diseases: Hypersplenism/HIV/Post Viral hepatitis/PNH/Vit B12/ Folate deficiency
2. Non Haematological diseases (infection with Hgic complications) a. Dengue hgic fever b. Septicemia with DIC
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History-Important points with relevance/suspected causes are
1. Detailed h/o fever- to assess the fever
2. Symptoms of focal infection-to localise type of infn
3. Bleeding from any other sites
4. Distribution/type of rash- to assess the rash
5. Associated symptoms/history- may give a clue about the underlying disease
a. severe body ache/Viral Prodorme- Dengue
b. Ongoing severe infection- septicemia
c. abdominal discomfort- Organomegaly- Leukemia/Lymphoma
d. Bony tenderness- Leukemia
e. Lymph node enlargement-Lymphoproliferative disorder
f. Whether a known case of CML/AML/Lymphoma
h. Drug History-? Cytotoxic or Myelosupperessive drugs
Examination-Important points with diagnostic clues
1. Pallor- Bone marrow failure
2. Throat ulcers- Neutropenia
3. Rash-Nonpalpable purpuric-Thrombocytopenic purpura/ Dengue/ DIC
-Palpable purpura-Vasculitis due to septicemia
4. Sternal/iliac tenderness- AML/CML
5. Hepatosplenomegaly- AML/CML
6. Lymphadenopathy- ALL/Lymphoproliferative disorders
Investigations-
1. Blood-
1. FBC- Pancytopenia- bone marrow failure
2. WBC- Very high- CML
3. Smear- Blasts-Acute Leukemia
-Morphological abnormalities- Myelodysplastic syndrome
4. Serology- Dengue/HIV/Hepatitis should be checked depending on the clinical background
5. LDH/Bilirubin- to look for hemolysis- PNH
6. Vit B12/Folate- to L/F deficiency- can cause Pancytopenia
7. Uric acid- may be high in haemato/ lymphoproliferative disorders
8. FDP/Fibrinogen level- if DIC is suspected
9. Sepsis screen-CxR/Urine r.e/m.e/c.s/Blood C/S- to localise infection
2.USG- Hepatosplenomegaly- Myelo/Lymphoproliferative disease
Special
1. Bone Marrow Aspiration and Trephine biopsy with Immunohistochemistry & cytogenetic- if initial investigations
suggest a primary bone marrow disease
2. Endoscopy- if hypersplenism due to Portal Hypertension is suspected
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Approach of Pancytopenia
The problem “Pancytopenia” can be disguised as followings:
a. 26 year old with gum bleeding, fever and purpuric rashes, fever for 3 days-approach?
b. 25 yr old male with fever and skin rash for 3 days and presented with haematemesis and malena in the
emergency
c. 78 yr old lady presented with anaemia ( or “progressive fatigue, lethargy, dizziness & palpitation”) for last few
weeks & has developed purpuric rashes in last few days.
d. 78 yr old lady presented with high grade fever. She is anaemic ( or “progressive fatigue, lethargy, dizziness &
palpitation” for last few weeks) & has developed purpuric rashes in last few days.
In all these the “mother problem” is basically the same- directly or indirectly the story says about CYTOPENIAS-
anaemia+ thrombocytopenia+ neutropenia (fever could be infection secondary to undiagnosed neutropenia)
So the answer will be more or less the same….Pancytopenia!! .however depending on the scenario some additional
DDs need to be considered which you will see whilst reading the “approach Q& A”
Pancytopenia approach
Causes may be divided into bone marrow failure or peripheral consumption:
Bone marrow failure Peripheral consumption
Stem cell defect Idiopathic PNH
 Aplastic anaemia Hypersplenism
Ineffective haemopoiesis drugs/viral Autoimmune diseases- SLE
 MDS
Alternative way to classify causes of pancytopenia!!!
 Megaloblastic Anaemia
Bone marrow infiltration ( as mentioned in the Q&A)
 Haematological malignancy Intrinsic Marrow disorder- Non BM diseases-
 Non-haematological malignancy Aplastic anaemia Hypersplenism
Myelofibrosis MDS PNH
Bone marrow suppression Cytotoxic/antibiotic Myelofibrosis Vit B12/ Folate def
BM infiltration: Leukemia/Lymphoma
Approach=
1. Clinical→ history+ examination 2. Investigations
History-Important points with relevance/suspected causes are
1. Detailed h/o fever- to assess the fever d. Bony tenderness- Leukemia
2. Symptoms of focal infection-to localise type of infn e. Lymphadenopathy-Lymphoproliferative disorder
3. Bleeding from any site f. joint pain/red eye/photosensitivity- SLE
4. Distribution/type of rash, if any- to assess the rash g. Whether a known case of CML/AML/Lymphoma
5. Associated history- clue of underlying disease h. Known CLD- Hypersplenism
a. Recent h/o fever- viral fever/febrile neutropenia i. D/H- BM suppressives- cytotoxic/antibiotic
b. Ongoing severe infection- due to neutropenia
c. abdominal discomfort- Organomegaly- Leukemia/Lymphoma/Myelofibrosis/MDS

1. Pallor- Anaemia 4. Sternal/iliac tenderness- AML/CML
2. Throat ulcers- Neutropenia 5. Hepatosplenomegaly- AML/CML
3. Rash-purpuric-Thrombocytopenic purpura 6. Lymphadenopathy- ALL/Lymphoproliferative
Malar rash/discoid rash- SLE disorders
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Investigations-
2. FBC- Pancytopenia- bone marrow failure; WBC- Very high- CML
3. Smear- Blasts-Acute Leukemia
-Morphological abnormalities- Myelodysplastic syndrome
- High MCV- Megaloblatic anaemia
4. Serology- HIV/Hepatitis should be checked depending on the clinical background
5. LDH/Bilirubin- to look for hemolysis- PNH
9. USG- Hepatosplenomegaly- Myelo/Lymphoproliferative disease
Special
1. Bone Marrow Aspiration + Trephine biopsy with cytogenetic- confirms primary marrow disease
35yr old female refractory anaemia, how will you approach for diagnosis.
Technically a wrong Q, as RA is a very specific entity…therefore I think the Q meant “anaemia where the cause is not
obvious”…so we will deal this topic differently for Short notes and approach type Q purpose!!!
Refractory anaemia…Short note
RA is a clonal disorder of totipotent stem cell or multipotent myeloid progenitor cell characterised by ineffective
hemopoiesis and dyserythropoiesis. It’s a preleukemic condition, carrying a 10-20% probability of evolving into
leukemia.
WHO classification- RA with no or rare blasts in the peripheral blood

RA with Excess Blast (RAEB)
C/F
In RA there is hypercellular marrow & anemia and/or leukopenia and/or thrombocytopenia, but these features do
not represent a diagnostic requirement.
1. f/o anaemia “ abcdef ”….notes
2. f/o Leukopenia…notes
3. f/o Thrombocytopenia….notes
Investigations
FBC- Hb usually low +/- low TC+/- low Platelet
Bone marrow
1. Evidence of Dyserythropoiesis- megaloblastoid changes/multinuclearity/ nuclear fragmentation
2. Ringed Sideroblast/blast
3. Cytogenetics No specific chromosome marker, however deletion of long arm of chromosome 5 may be found in
many RA pts.
Treatment- supportive
Blood transfusion in patients with symptomatic anemia
Anemic patients with low serum erythropoietin- recombinant EPO
Chemotherapy- Lenalidomide; Azacitidine
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35 yrs old female refractory anaemia, how will you approach for diagnosis.
Assuming the term “refractory” means anaemia where the cause is not obvious, the important underlying causes of
such an anemia would be
1. Iron deficiency but NO OBVIOUS blood loss: Occult bleed/nutritional
2. Hemolytic anemias
3. Megaloblastic anaemia
4. Anaemia of chronic disease
5. Bone marrow diseases
a. Stem cell defect Idiopathic c. Bone marrow infiltration
 Haematological malignancy
 Aplastic anaemia  Non-haematological malignancy
drugs/viral {{
b. Ineffective haemopoiesis

 MDS
 Megaloblastic Anaemia
c. Myelofibrosis
Approach= 1. Clinical: history+ examination 2. Investigations
History-Important points with suggestive underlying causes
1. h/o black stool- occult blood loss
2. h/o epigastric pain-PUD 12. Abdominal discomfort- Organomegaly-
3. h/o wt. loss- GI/ hematological malignancy Leukemia/Lymphoma/Myelofibrosis/MDS
4. h/o appetite loss- GI disease 13. Bony tenderness- Leukemia/Myeloma
5. h/o menorrhagia- cause of anaemia 14. Lymphadenopathy-Lymphoproliferative disorder
6. poor dietary history- nutritional cause 15. joint pain/red eye/photosensitivity- Chronic
7. bleeding tendency- Thrombocytopenic- BM autoimmune disease
disease 16. Whether a known case of CML/AML/Lymphoma
8. Jaundice- haemolysis 17. Known CLD- Hypersplenism
9. Any chronic disease- CKD/RA/SLE 18. D/H- BM suppressives- cytotoxic/antibiotic
10. fever- may be febrile neutropenia- BM disease 19. Family h/o anaemia- Hemolytic disease
11. Rash- could be Thrombocytopenic- BM disease
1. Throat ulcers- Neutropenia-BM disease 4. Jaundice- hemolytic disease
2. Rash-purpuric-Thrombocytopenia-BM disease 5. Hepatosplenomegaly-
Malar rash/discoid rash- AML/CML/MF/MDS/hemolytic disease
autoimmune disease 6. Lymphadenopathy- Lymphoproliferative
3. Sternal tenderness- Acute Leukemia disorders/ALL
7. Koilonychia (hmm!!)- iron deficiency
8. Beefy red tongue-megaloblastic anaemia
9. Glossitis/angular cheilosis- iron deficiency
10. Neuropathy-vit B12 deficiency
Basic Investigations
1. FBC-confirms anaemia; Any accompanying leukopenia or thrombocytopenia if present- BM problem
2. PB film-
 Microcytosis- IDA/underlying Thalassemia
 Normocytosis- may be anaemia of chronic disease
 Macrocytosis- B12/Folate def
 Blast cells- Acute Leukemia
 Leukoerythroblastic picture with Teardrop poikilocytosis-MF
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3. ESR-Very high- Myeloma
4. Urea/Cr- High- Myeloma( can lead to CKD) or CKD (due to any cause)
5. Reticulocyte count
 Increased- marrow response to the anaemia- suggestive of either ongoing blood loss or haemolysis
 Low- production problem in the bone marrow
6. LDH/Haptoglobin/ unconjugated Bilirubin/Coomb’s test- Screen for Haemolysis
Further investigations will depend on clinical assessment and the results of these preliminary tests
Suspected cause Special test

Megaloblastic anaemia Serum B12/Folate level
Hemoglobinopathy Hb Electrophoresis
IDA Ferrtin/Iron level/GI investigations
BM disease BM aspiration+ biopsy with cytogenetic study
Myeloma Protein electrophoresis
Fever with Maculopapular rash/Exanthematous rash

’ An exanthem is any eruptive skin rash that may be associated with fever or other systemic symptoms
Important causes
Acute Viral exanthems-Measles/Rubella/Rubeola/Dengue/Infectious Mononusleosis(IM)/Chikungunya
(Additional cause for Paed- Parvovirus (Erythema Infectiosum)/Adeno/Roselola Infantum)
Bacterial infections-Enteric/Scarlet Fever/Meningococcemia
Collegen vascular diseases- Connective tissue disease-SLE/Dermatomyositis/Still’s disease/RA
Vasculitis-HSP/WG/MPA/PAN
Drug eruption-SJS/TEN
Exotic infection-Rickettsial infections
History-Important ones with their significance are
1.Fever- Acute/Hectic rise-any viral or bacterial illness
Low Grade-Vasulitis/CTD
Step ladder pattern rise-Enteric
2.Rash-
Simultaneousuly with fever- CTD/Vaculitis/Meningococcemia…however in these conditions
Rash may precede or follow fever.
Definite chronological relation with fever….. (Very Sick Person Must Take Double Tablets)
1st day- Varicella…………….although mainly vesicular but may start as maculopapular
2nd day-Scarlet fever
3rd day-Small Pox……………..not applicable as it has been eradicated!!
4th day-Measles
5th day-Typhus
6th day-Dengue
7th day-Typhoid
Distributon of the rash-may give some clue
Spreading downwards-Measles
Face-Parvovirus/SLE
Mouth/Lips-SJS/TEN/Measles
Cheeck-Parvovirus
a.Coryzal illness-any VIRAL exanthem
b.Headache/neck stiffness-May be meningococcal meningitis
c.Constipation-Enteric
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d.Severe bodyache-Dengue/Chikungunya
e.Recent h/o constitutional manifestatations- Wt loss/appetite loss- Vasculitis
f.Prominent Upper respiaratory tract symptoms-IM
4.Recent h/o
a.Recurrent red eye/Painful eye-Vascultitis
b.Hematurira-Vasulittis
c.Hmeoptysisis-WG
d.Diarrhoeal illness-HSP
eTravel to Foereign countries/ forest-Ricektssial infeciton
Examination-Important ones with diagnostic clues
1.Type of rash
Macular/Maculopapular- Viral exanthem/Noninfectious like HSP
Diffuse erythema with desquamation- SF/SJS/TEN
Vesicular rash-Varicella/SJS
Petechial/purpuric-Meningococcemia/dengue/Chikungunya/HSP
Malar rash/Photosensitive rash/Raynaud’s Phenonmenon/Splinter Hge-CTD/Vasculitis
Cutaneous vasulitits-Splinter Hhge- Vasculittis/CTD
Rose spot-Enteric
Slapped check appearance-Parvovirus
2.Hypotension/Shock- Dengue/Chikungunya/Meningococcemia
3.Lymphadenopathy-IM
4.Hepatosplenomegaly- IM
5.Signs of active Arthritis-CTD/Vasulitis/Infection like Dengue/Chikungunya
6.Neck rigidity-Menongococcemia
Investigation
Initilal
FBC
ESR/CRP
Dengue NS1/IgM
Blood C/S
TyphidotM
Special- depends on ProvL diagnsosis
ProvL diagnosis Test
CTD/vasulitits- ANA/Anti ds DNA/ANCA
Skin biopsy
Urine R/E &M/E- for RBC/RBC cast/Dysmorphic RBC
Infection Specific serological tests
Fever with Splenomegaly/Fever with Hepatosplenomegaly

Common causes-
Infection- Malaria/Kala-azar/Acute viral hepatitis/Enteric Fever/Disseminated TB/Endocarditis
Non-infective-
a. Malignancy- Myeloproliferative- CML/AML/ALL/CLL or Lymphoproliferative- Lymphoma
Appproach= Clinical= (History+Examination)++ Investigation= (Preliminary + Special)
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History- Important points with their clinical clues
1.Pattern of fever- High- Malaria/Kala-azar/Secondary Infection in Leukemia
Low grade-TB/Endocarditis/CTD
Chill and rigor-Malaria
a.Wt loss-TB/Malignancy/Kala-azar
b.Night sweat-Lymphoma/TB
c.Cough-TB
d.Hemotysis-TB
e.Tiredness-Myeloproliferative malignancy
f.Buises/bleeding-Myeloproliferative malignancy
g.Enlarged Lymph nodes-Lymphoma/TB
h.Jaundice- Hepatitis
j.Pruritus- Lymphoma
h.Rash- Purpura- thrombocytopenia due to BM diseases
j.Constipation- Enteric
k.Known pt of prosthetic/rheumatic Valve- Endocarditis
l.Travel to Kala-azar endemic zone
Examination-important ones with what they are suggestive of
1.Pallor-Malignancy/Kala-azar
2.Jaundice-Hepatitis
3.Lymphadenopathy-Lymphoma/TB
4.Relative Bradycarida-Enteric
5.Rash-CTD/Enteric
6.Petechiae/Purpura-Myeloproliferative malignancy
7.Hepatosplenomegaly
a.Significantly enlarged-Myelo or lymphoproliferative disease
b.Tender Hepatomegaly with or without Splenomegaly-Hepatitis
c. Mild Splenomegaly- Enteric/Endocardititis
8.Murmur-Endocardidtis
Investigations
1.Preliminary
1.FBC with smear
TC↑↑-Endocarditis
Cytopenias-Myeloproliferative diseases
Leukopenia-Enteric/SLE
Premature WBCs/plenty of blasts-Luekaemia
2.LFT- SGPT/OT↑↑-Hepatitis
SGPT/OT-mildly↑- Enteric/Malaria
3.MP+Dual Antigen-for Malaria
4.Blood C/S-for Enteric/Endocarditis
5.CxR-TB/Enlarged mediastinum in Lymphoma
2.Special
Provisional Diagnosis Tests
MPve disease BoneMarrow biopsy with Immunohistochemistry & cytogenetic
Lymhoma Lymph Node biopsy/CECT chest/abdo
Endocarditis Tranoesophageal Echo
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Hepatosplenomegaly…(causes =.H + I )
1.Common causes
Hematological diseases
Myeloproloferative disorders (MPD)- CML/MDS/MFibrosis/Acute Leukemias
Lymphoproliferative disorders(LPD)- Lymphoma
Chronic hemolytic disorders- Thalassaemia/H.Spherocytosis
Hepatic- Cirrhosis with Portal Hypertension
Infecton- Malaria/Leismaniasis
2.Rare casuses
Hormonal- Acromegaly
Infiltrative- Amyloidosis
Inborn errors-Gauchers/Hurlers
Approach =1.Clinical approach= History + Examination 2. Investigations
History-Important ones with diagnostic clues they give are
1.Age- may give some clue
Children- ALL/Hemolytic diseases/Hereditary conditions
Adults- CML/MDS/Cirrhosis/Hemolytic diseases
Infection can occur at any age
2. Abdo discomfort/dragging pain/Distension-can be present in ANY pt with significant organomegaly and DOES
NOT point to any particular cause
3.Associated symptoms- Very Important to guess the underlying disease
a.Extreme tiredness/SOB- ?Anemia- Myelo or lymphoproliferative conditions/Hemolytic diseases
b.Bleeding- Thrombocytopenia- bone marrow infiltration due to MPD/LPD
c.Fever-
Infection- Malaria/Leishamanisis/
Neutropenia due to Bone marrow infiltration in MPD/LPD
d.Jaundice-
Long standing- chronic hemolysis
Recent- cirrhosis
e.Hematamesis/melaena- cirrhosis
f.Adbo swelling- ascites- cirrhosis
g.Altered sensorium- hepatic encephalopathy- cirrhosis
h.Palpable lymph nodes- lymphoprolifeatrettive disorders
i.Wt loss- lymphoproiliferative diseases
j.Night sweat-- lymphoproiliferative diseases
k.h/o risk factors of cirrhosis- alcohol/hepatitis/iv drug use
l.h/o recurrent blood transfusion- hemolytic disorders
Examination- Findings that accompany hepatosplenomegaly often gives vital clue about the underlying
causes/disease-Important ones with diagnostic clues they give are
Appearance- Thalassaemic facies
Anaemia- Hemolytic disease/Myelo or lymphoproliferative disease
Jaundice- hemolytic disease/Cirrhosis
Lymphadenopathy- Lymphoproliferative disease
Stigma of chronic liver disease- cirrhosis
Flapping tremor- cirrhosis with hepatic encephalopathy
Huge splenomegaly- CML/Myelofibrosis/Portal hypertension
Ascites- cirrhosis
Venous prominence- cirrhosis
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Investigations
Preliminary- Pattern of abnormalities may give an idea about the underlying disease
1.Hb/TC/TC-Anemia- MPD/LPD/Hemolytic disorders
Cytopenias- MYelofibrosis/MDS/ Cirrhotics are often cytopenic (due to hypersplenism)
Very high WBC count- CML
2.Peripheral film/smear-
Premature WBCs- CML
Blast cells- Acute Leukemia
Morphological abnormality- MDS
Leukoerythroblastic smear- MFibrosis
Low MCV-Thalassaemia
Spherocytosis-HS
3.Reticulocytosis-Chronic Hemolytic disease
3.MP/Dual Malarial Antigen
4.LFT-
Predominantly unconjugated hyprebilirubinemia- Hemolytic diseases
High Liver enzymes with hyperbilirubinemia- Cirrhosis
5.USG abdomen-
Ascites/Dilated Portal vein/Abnormal hepatic echotexture- Cirrhosis
Special- Nature of which will depend on provisional diagnos
Provisional diagnosis Investigations I will arrange
Thalassaemia Hb electrophoresis
CML/Acute Leukemia Bone marrow study- Aspiration +/- biopsy with cytogenetics
Cirrhosis UGI Endoscopy/Hepatitis Serology
Lymphoma Lymph Node Biopsy/CT Chest-Abdo-Pelvis
Kala azar Bone marrow/splenic aspiration
Massive splenomegaly
(Massive splenomegaly is usually defined as a spleen extending well into the left lower quadrant or pelvis or which has
crossed the midline of the abdomen)
1.Common causes
Hematological diseases
Myeloproloferative disorders (MPD)- CML/MDS/MFibrosis/PRV/Essential Thrombocytosis
Lymphoproliferative disorders(LPD)- Lymphoma
Chronic hemolytic disorders- Thalassaemia
Hepatic- Cirrhosis with Portal Hypertension
Infecton- Malaria-( Hyperreactive malarial splenomegaly is a complication of malaria that can cause massive
splenomegaly. Thought to occur as a result of abnormal immune response to repeated malaria infections)
-Leismaniasis
2.Rare casuses
Infiltrative- Amyloidosis
Inborn errors-Gauchers/Hurlers
Approach- (almost) same as hepatosplenomegaly

Additional points
FBC- Hb,TC,Platelet- all ↑- PRV
Only Platelet↑- Essential Thrombocytosis
Special tests-
PRV- JAK2 mutation
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Jaundice
Important causes/types are
1.Hemolytic- Chronic-Thalassaemia/H. spherocytosis/AIHA
Acute- G6PD def/MAHA/Infection- Malaria
2.Hepatocellular- Acute- Acute Viral Hepatitis/Alcoholic Hepatitis/Drug induced Liver Injury(DILI)
Chronic- Cirrhosis (Jaundice occurs in advanced stage of the disease)
3.Obstructive-Acute- CBD stone/Acute Pancreatitis (oedema of the head MAY obstruct CBD)
Chronic diseases- Malignancy- Ca Pancreas
- Liver- Primary/Metastatic
Approach= Clinical and Investigations = aim is to identify the type and cause of jaundice
History- Important points are
History What it suggests
Sudden and rapidly increasing Viral Hepatitis/CBD stone/DILI/Acute hemolysis
Slowly increasing Indolent obstruction/ Hepatic malignancy

Long duration Chronic Hemolytic disease/Cirrhosis
Pain abdomen
a.RUQ colic Gall bladder stone
b.RUQ dragging pain Acute Viral Hepatitis
c.acute Epigastic pain Acute Pancreatitis
Preceding Fever Acute Viral Hepatitis/Ascending Cholangitis/Malaria/Leptsis
Nausea/vomiting Acute Viral Hepatitis
Wt Loss Malignancy
Pruritus Obstructive Jaundice
Hematemesis/Melaena Cirrhosis
Abdo swelling Cirrhosis/Malignant Ascites
Alcohol abuse Hepatitis/Cirrhosis
Known GB Stone patient CBD obstruction
Needs regular blood transfusion Hemolytic disease
Drug history To R/O DILI/Drug induced hemolysis
Known p/o Chronic hepatitis Cirrhosis
Examination- Important points are

Examination/Finding What it suggests
Hepatic facies Cirrhosis
Thalassaemic facies Thalassaemia
Pallor Hemolytic disease/Cirrhosis/Malignancy
Lymph nodes Malignancy
Clubbing PBC/Malignancy
Oedema Cirrhosis
Itch marks Obstructive jaundice
Stigma of chronic liver disease Cirrhosis
Tender liver Acute viral/Alcoholic hepatitis
Hepatosplenomegaly Hemolytic disease/Cirrhosis
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Splenomegaly Cirrhosis
Hard/firm liver Cirrhosis/Malignancy
Epigastric lump Ca/Acute Pancreatitis
Ascites Cirrhosis
Venous prominence Cirrhosis
Flapping tremor Encephalopathy due to Cirrhosis
Investigation
Preliminary
1.FBC
Hb↓↓- Hemolytic Anaemia/Cirrhosis due to GI bleed
WBC↑↑- CBD stone with ascending cholangitis/Acute Pancreatitis
Reticulocytosis- Hemolytic disease
2.LFT- ‘’Pattern’’ of abnormality gives idea about pattern of jaundice
Predominantly Unconjugated Bi↑↑ + Normal SGPT/OT- Hemolytic disease
Predominantly Conjugated Bi↑↑+ ALP↑↑- obstructive Jaundice/Cholestatic Hepatitis
Both Bi Proportionately high - Hepatocellular jaundice
Very high SGPT/OT -Acute Viral Hepatitis/DILI
Mild to Moderately high SCGPT/OT- Cirrhosis
3.Amylase/Lipase- very high-Acute Pancreatitis
3.USG abdomen- will show many underlying causes, when present- Malignancy/Dilated CBD due to
Stone/Pancreatitic pathology
Special Tests- Nature depends on provisional diagnosis
Prov. diagnosis Special test

Viral Hepatitis HBsAg/Anti HCV/IgM- HAV/IgM- HEV
Obstructive Jaundice MRCP

Cirrhosis UGI Endoscopy
Hemolytic disease Hb Electrophoresis/Coomb’s test
Generalised lymphadenopathy
(Generalised lymphadenopathy can be defined as enlargement of 2 or more non-contiguous lymph node
groups/areas)
Very Common causes
Infection: TB/Pyogenic infection/HIV/ Infectious Mononucleosis
Malignancy: Leukaemia-ALL/CLL/but may be AML/Lymphoma/Metastatic Ca
Not so common causes
Immunological/Connective Tissue disease (CTD): Sarcoidosis/SLE
Drug hypersensitivity- Phenytoin, Hydralazine, Allopurinol
Infections- 2ry syphilis/Lymphogranuloma Venerum (Chlamydia trachomatis)/Toxoplasmosis
Amyloidosis
Lipid storage disease
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Approach= Clinical = (History+ Examination) + Investigation= (Preliminary+Special)
History- Important points are
Distribution of Lymphadenopathy- to differentiate between Localised and Generalised Lymphthy
Lymph Node pain- Inflammatory process /Suppuration/Hemorrhage into a malignant node
Fever- Any Infection/Lymphoma/Leukemia/CTD/ANY malignancy
Low Grade-TB/Lymphoma/CTD
Evening rise-TB/Lymphoma
High Fever- other Infections- IM/LGV
Constitutional symptoms- Night sweat/Wt loss - Lymphoma/TB/HIV
Respiratory symptoms-SOB/Productive cough/Hemoptysis -TB/Lung Ca
GI symptoms - chronic Diarrrhoea- HIV
Abdo pain/vomiting - Ca Stomach
Hematological symptoms - tiredness/Bruising/Bleeding- Leukemia
GU symptoms - Prostatism- Ca Prostate
Breast Lump- breast Ca
Personal history- Risk factors ofSTD- HIV/Syphilis/LGV
Examination- Important points are
1.Pallor- Lymphoma/Leukemia/ANY malignancy
2.Bruises/Petechiae/Purpura- Leukemia
3.Rash- CTD
4.Arthritis- CTD
5.Clubbing-Malignancy
6.Lymph Node examination
Tenderness- usually an inflammatory process or suppuration, may also result from hemorrhage into the
necrotic center of a malignant node. The presence or absence of tenderness does not reliably differentiate
benign from malignant nodes (!!)
Consistency- Stony-hard nodes - usually metastatic
Very firm, rubbery nodes- suggest lymphoma
Softer nodes- infections or inflammatory conditions
Suppurant nodes may be fluctuant
Matting- can be either benign –TB/Sarcoidosis/ Lymphogranuloma venereum
OR Malignant- Metastatic carcinoma or Lymphomas
Location- Does not reliably give a confirmatory diagnosis, however
Supraclavicular lymphadenopathy- highest risk of malignancy…… (but NOT ALWAYS!!)
Right supraclavicular node-Associated with mediastinum, lungs or oesophagus Ca
Left supraclavicular (Virchow's) –testes/ ovary/pancreas/ prostate/stomach
Axillary- Often Lymphoma/Breast Ca
Posterior Cervical- Often TB/Lymphoma
Inguinal-Often Pelvic Malignancy/Lymphoma/LGV
7.SVC Obstruction- Usually due to Lymphoma
8.Pleural Effusion-Malignancy/TB
9.Breast examination- Lump- Ca
10.Hepatosplenomegaly-Lymphoprolifetaive disorder/Leukaemias
11. Testicular examination- Hard lump and testis can be felt separately- malignancy
(Breast and testicular examination-‘’MUST DO’’ in a pt of Lymphadenopathy)
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Investigation
1.FBC-
Hb↓-Leukemia/Lymphoma/any malignancy
Cytopenias-HIV/Leukemia
Atypical Lymphocytes-IM
Blast cells-ALL/AML
2.LDH/Uric Acid- often High in Hemato/Lymphoid Malignancy
3.CxR- May show mediastinal widening
4.HIV serology
5.Lymph Node Biopsy……(FNAC- is definitely an easier option but has it’s own limitations)
HP/Immunochemistry/Xpert-TB –
Will confirm the diagnosis in most of the cases like-Lymphoma/Metastatic Lymph Node/TB/Sarcoidosis/Any
other infection
Special- nature depends on provisional diagnosis
Provisional Diagnosis Special tests

Malignancy Tests to detect the primary sites
Lymphoma Bone Marrow- to r/o Extranodal Spread
Leukemia Bone marrow
Fever with Generalised lymphadenopathy- Same as above
A 25 yr old male with fever and skin rash for 3 days and presented with haematemesis and malena in the
emergency. How to approach this case?
D/D
1. Infectious disease- Dengue hgic. fever
2. Hematological diseases-
(febrile= neutropenia with rash+ GI bleed= thrombocytopenia)
1. Intrinsic Marrow disorder-Aplastic anaemia/MDS/BM infiltration
2. Reversible marrow suppression/Non BM diseases- Hypersplenism/HIV/Post Viral hepatitis/PNH/Vit B12/ Folate
def.
3.Vasculitis-(rash= vasculitic rash+ GI bleed due to intestinal vasculitis)
Approach includes 1.Clinical approach= History & Examination 2. Investigations
History- Important points with diagnostic clues they give are
1.Pattern of fever- to be asked
2.Any symtoms of focal infection-to localise site of infection
3.pattern of rash- to be asked
4.detailed h/o Hematemesis &melaena- to be asked
5.Severe bodyache- Dengue
6.Sore throat- may be present any nerutropenic pt.
7. Recent h/o systemic symptoms- Vasculitis
8. Any organ specific symptoms sugeestive of vasculitis
a. Red eye
b. altered sensorium/headache
c. Heamarturia
9. h/o Hematological disorders
10.Bleeding from any other sites
11.Abdominal discomfort-?Organomegaly-?Myeloproliferative dis.
12.Bony tenderness- Myeloproloiferative disorders
13.Drug History-? Cytotoxic or Myelosupperessive drugs
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Examination- Important points with diagnostic clues they give are
1. Pallor-? Bone marrow failure
2.Throat ulcers-? Neutropenia
3. Rash-
Nonpalpable purpuric-Thrombocytopenic purpura/Dengue
Palpable purpura-Vasculitis
4. Sternal/iliac tenderness-AML/CML
5. Hepatosplenomegaly- AML/CML
6. Lymphadenopathy- ALL/Lymphoproliferative disorders
Investigations-
1. Blood-
3. FBC- Pancytopenia- ? bone marrow failure
2. WBC- Very high- ? CML
3. Smear- Blasts-? Acute Leukemia
-Morphological abnormalities- ? Myelodysplastic syndrome
4. Dengue NS1/IgM- may be +ve
5. LDH/Bilirubin- to look for hemolysis- ? PNH
2. USG- Hepatosplenomegaly-? Hemato/Lymphoproliferative disease
Special
1. Bone Marrow Aspiration and Trephine biopsy with cytogenetic- if initial investigations suggest a primary bone
marrow disease
3 Serology-ANA/ANCA/HIV/Hepatitis should be checked depending on the clinical background
A 35 years old male attended the opd with h/o melena for 5 days. He gives h/o vomiting infrequently for last 3
months. He also gives h/o anorexia and weight loss in last 3 months. He is alcoholic and smoker. On further
enquiry he gives h/o palpitation and dizziness and shortness of breath in last 3 months. What are the different dx?
What clinical features will you search for? What investigations will you suggest to arrive at a dx.
Think!!...Melaena = GI bleed + (vomiting+ anorexia+ wt loss) for 3 months…..therefore chronic/ ongoing
problem…..now, how does SOB/palpitation/dizziness fit in the picture?…..can it not be the symptoms of anemia?....
which this guy might have developed due to slow bleeding which the Q setter deliberately does not mention (don’t start
thinking about cardiac cause of SOB/palpitation/dizziness…it does not fit in this scenario)
So essentially we are dealing with GI bleed in a chap who is a drinker……
Here it’s melaena, so most likely upper GI bleed (don’t give ALL the causes of GI bleed you know of!!!)
Ans 1.
D/D- This is patient of likely upper GI bleed-
1.Bleeding varices due to Portal Hypertension
2.Peptic ulcer disease( h/o alcohol does not mean you will not think about it!!)
3.Gastric Malignancy
Ans. 2 Clinical features to be searched – (read carefully the stem of the Q)
History- important points with diagnostic relevance are
1. Detailed h/o melaena- to assess blood loss
2. h/o hematemesis- varices/PUD/malignancy
3. h/o ascites- CLD
4. h/o jaundice- CLD
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5. h/o epigastric pain- PUD
6. h/o heartburn/indigestion- PUD
7. h/o NASID use- PUD
8. detailed h/o alcohol intake- to assess risk of alcoholic liver disease
9. h/o hepatitis- CLD
10. family h/o gastric malignancy
Examination-important points with diagnostic relevance are
1. Pallor- suggests underlying anaemia
2. Jaundice- CLD
3. Lymph node- malignancy
4. Signs of CLD- spider/gynaecomastia/testicular atrophy
5. Splenomegaly- Portal hypertension
6. Ascites- CLD
7. Epigastric tenderness- PUD
8. Epigastric lump- malignancy
9. PR- to confirm melaena
Ans 3.
Routine investigations
1.Hb/TC/DC/CRP- Low Hb due to blood loss
2.UR/Cr- GI bleed can cause isolated rise of Ur
3.LFT with PT/INR- deranged in CLD
4.Stool for Occult blood test(OBT)
Special Investigations
Preliminary diagnosis Investigation
1.CLD/PUD/Malignancy Upper GI endoscopy+ Rapid urease test(RUT) & Biopsy
2.CLD USG abdomen
Hepatitis serology
Liver biopsy ( in selected cases)
3.Gastric Ca CT chest/abdomen
50 yr old male smoker with sudden onset chest pain after a bout of cough. d/d? approach?
D/D
1. Pneumothorax ( most likely cause) 4. MI
2. Rib fracture/muscular pain 5. PE
3. Oesophageal rupture (4&5 always to be kept in my mind in ANY acute chest pain)
History- Important ones with diagnostic clues they give are
1. Nature of pain a.Severe SOB- Pneumothorax
a. Tearing- pneumothorax b.Difficulty taking deep breath- rib ≠
b. Heaviness- MI c. Collapse/LOC- Tension Pneumothorax
c. Squeezing- rupture oesophagus d. Severe sweating- Pneumothorax/MI
d. Sharp- rib fracture e. Dysphagia- Oesophageal Rupture
e. positional/postural change-rib ≠ f. Odynophagia- Oesophageal rupture
2. Associated symptoms
3. Any risk factors of PE- if present PE to be kept in mind
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Examination- Important ones with diagnostic clues they give
1. Hemodynamically unstable- Tension pneumo/MI/massive PE
2. Cyanosis/Low O2 satn- any 3 of the above
3. Calf tenderness+/-swelling- DVT
4. Chest-
a. Tracheal shift- Pneumothorax
b. Tympanitic note- Pneumothorax
c. Unilateral reduced VBS- Pneomothorax
d. Bibasal crepts- LVF due to MI
e. Local tenderness- rib≠
5. CVS- Gallop- LVF
Investigations-
Initial
1. CxR- urgently- to look for Pneumothorax
2.Blood-
a. Hb/TC/DC/CRP/Ur/Cr/Na/K- routinely done
b. Cardiac enzymes- if MI is suspected
c. ABG- to assess blood gas status
d. D-Dimer- if PE is suspected
3. ECGs- ?MI
Special- depends on preliminary diagnosis
Diagnosis Investigations
Pneumothorax CT chest( may be required)
Oesophageal rupture CT neck+ chest/ugi endoscopy
MI Echo/Coronary angio
52 year old man attended the emergency with history of chest pain for 3 hours and respiratory distress for 2
hours.He is diabetic, smoker and hypertensive. He gives history of fever for 3 days and palpitation for 2 years.What
are the possible diagnosis you will suggest? What clinical features you will search? What minimum investigation
to advice to come to a diagnosis?
Ans 1. Possible diagnosis-
a.ACS with LVF( most likely)
b.Infective Exacerbation of COPD( IECOPD)
c.Pneumothorax
d.PE
Ans 2. Clinical features to be looked for-
History-Important points with their diagnostic relevance are
1. Nature of the pain-Myocardial ischeamic/Pleuritic
2. SOB- onset/duration/progress
3. Orthopnoea/PND- LVF
4. H/o chronic SOB-chronic LV dysfunction/COPD
3. Any sweating with pain-MI
4. Productive cough-IECOPD
5. Fever-IECOPD
6. H/o Stable angina
7. Risk stratification for Coronary artery disease
8. Smoking history
Examination-Important points with their diagnostic relevance are
22
1. Haemodynamic status- may be unstable in MI
2. Respiratory rate- increased in any breathless patient
2. O2 saturation/cyanosis-acute LVF/ IECOPD/Pneumothorax
3. Low GCS/flap- IECOPD with CO2 retention
4. Gallop-LVF
5. Bibasal crepts- LVF
6. Wheeze- IECOPD/LVF
7. Signs of pneumonia- may be present in IECOPD
8 Tympanitic note with silent chest-Pneumothorax
9. Hyperresonant note with reduced air entry-COPD
Ans 3. Important investigations-With diagnostic clue they give
1. Serial ECGs- Ischemic changes- MI/ACS
2. Cardiac enzymes- TropT/I, CK-MB- to L/F MI
3. Urgent CxR- Pulmonary oedema/Infective changes/Pneumothorax
4. Blood- Hb/TC/DC/CRP/Ur/Cr/Na/K/ABG/C/S
5. Echo- to Look for Hypo OR akinesia of myocardium/LV dysfunction
6. Sputum C/S
A 25 years old man presents with chest pain in the right side and fever of 7days. What are the possible causes? How
will you proceed to arrive at a diagnosis? Describe in brief the management of most likely cause?
Ans 1.
Pain with fever- therefore likely infective pathology-possible causes are
1.Pneumonia ( pain is due to pleurisy)
2.Parapneumonic Pleural effusion ( pain is due to pleurisy which may preced effusion OR due to a discomfort due
to effusion itself)
3.PE (can cause pleurisy as well as fever)
4.Herpes zoster (painful vesicles)
5.Rib infection(although not common)
6.Liver abscess( can cause lower chest pain)
Ans 2. Approach includes 1.Clinical approach= history & examination 2. Investigations

History- Important points with their significance are
a. nature of the pain 3. RUQ pain- liver abscess
1. pleuritic-?pneumonia/ parapneumonic effusion
2. dull pain/heaviness- effusion c. associated symptoms
3. rib pain- rib infection
1.SOB- effusion/pneumonia
4. lower chest pain- ? liver abscess
2.expectoration- pneumonia/effusion
b. site of the pain
3.rash- herpes zoster
1. localised- pleurisy/ rib infection/ herpes
4.hemoptysis- penumonia/effusion
2. diffuse- effusion/liver abscess
Examination-
a. tachypnoea- pneumonia/effusion
b. low O2 sat- pneumonia/effusion
c. hemodynamicall y unstable- ?sepsis
d. BBS/increased VR/impaired percussion (signs of consolidation)- pneumonia
e.dullness/reducaed air entry- effusion
f. localised crepts- pneumonia
g. any rash- ?herpes
h. rib tenderness- rib infection
i. RUQ tenderness/ percussion tenderness- liver abscess
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Investigations-
Preliminary-
1. Hb/TC/DC/CRP- High TC/CRP- infection
2. CXR- to look for pneumonia/effusion
3. Blood C/S and Sputum G/S & C/S
4. ABG- if pt is hypoxic
5. USG abdo- if liver abscess is suspected
6. USG guided Pleural fluid aspiration and detailed analysis for protein/LDH/ pH/ G.S & C.S of fl
Special- if required
1. CT chest- in case of parapneumonic effusion
Ans 3.Most likely cause is Parapneumonic Pleural effusion....therefore management=
(remember actual and our own ''ABCD''!!)
A. Admit if required
Airway- to be secured, if required intubate
B. Breathing= O2/ ventilatory support
C. Circulation- IV fluid
D. Drugs- 1. Antiobiotic-
this is likely community acquired pneumonia with parapneumonic effusion, therefore empirical antibiotic-
(Coamoxiclav + Levofloxacin) or if patient is very ill then Piperacillin/Tazobactum.
Antibiotic may be altered according to fluid C/S or Blood C/S results
2. Antipyretic/Analgesic- Paracetamol
Diet- Nutritious diet
E. Effusion- Intercostal drain or thoracoscopic drainage of fluid.
Parapneumonic effusion should be drained off particularly if
a. Significant in amount
b. pH less than 7.2
c. fluid Culture is +ve
d. Multiple loculations
e. frank pus/empyema
A 60 yr old male patient presents with chest pain with mild fever and cough. D/D? How do you approach to reach a
diagnosis?
Ans 1.Chest Pain with fever & cough- therefore likely infective pathology-
Possible causes are
1.Pneumonia ( pain is due to pleurisy)
2.Parapneumonic Pleural effusion ( pain is due to pleurisy which may preced effusion OR due to a discomfort due
to effusion itself)
3.PE (can cause pleurisy as well as fever but cough less likely)
Ans 2.
Approach includes 1.Clinical approach= history & examination 2. Investigations- Preliminary and special
History- Important points with their significance are
a. Nature of the pain
1. Pleuritic-pneumonia/ parapneumonic effusion
2. Dull pain/heaviness- effusion
b. site of the pain
1. Localized/sharp- pleurisy
2.Diffuse- effusion
c. associated symptoms
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1.SOB- effusion/pneumonia
2.Expectoration- pneumonia/effusion
3.Rusty sputum- Pneumonia
4.Hemoptysis- PE
5. Prolonged immobility- PE
6. Calf pain- DVT which may cause PE
d. History suggestive of pre-existing COPD/Asthma- must be looked for
Examination-
a. tachypnoea- pneumonia/effusion/PE
b. low O2 sat- pneumonia/effusion/PE
c. hemodynamically unstable- ?sepsis
d. BBS/increased VR/impaired percussion (signs of consolidation)- pneumonia
e.dullness/reduced air entry(i.e reduced VBS)- effusion
f.localised crepts- pneumonia
g.Plaural rub- Pleurisy- can occur with any of the 3
Investigations-
Preliminary-
1. Hb/TC/DC/CRP- High TC/CRP- infection
2. CXR- to look for pneumonia/effusion
3. Blood C/S and Sputum G/S & C/S
4. ABG- if pt is hypoxic
Special- if required
1. CT chest- in case of parapneumonic effusion
2.USG guided Pleural fluid aspiration and detailed analysis for protein/LDH/ pH/ G.S & C.S of fluid
3. CTPA- if PE is suspected
Chronic Cough
Asthma
Allergy
AFB-TB
Bronchiolitis(For paed)
Bronchiectasis
COPD
Congestive heart failure-left heart failure(Cardiac asthma)
Dysfunctinal Vocal cord(VCD)
Drug induced-ACE-I
Endobronchial/Endotracheal tumour/stenosis
Foreign body aspiration
GORD
History
Intermittent-Asthma/Allergic/Bronchilolitis
Persisitent-COPD/Bronchiectasis/Growth/FB
Dry-Allergic/Asthma/drug induced
Productive-Thick clear sputum-Asthma; Purulent- COPD/Bronchiectasis
Often foul smelling-Bronchiolitis
Hemoptysis-TB/Growth/Bronchiectasis
Abrupt-Foreign body/Acute Asthma
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Gradual-rest of the causes
Seasonal variations + -Asthma/Often COPD
Provoking or exacerbating factors
Current URTI –Asthma/COPD Exacerbation
Postnasal drip/allergen exposure-cold air/dust/tobacco smoke/perfumes -Asthma
Cold air/exercise-Asthma
Drugs like ACE-I or B-blocker/NSAID-can cause dry cough or can simply trigger bronchospasm
(wheeze) in a previously known or undiagnosed Asthmatic respectively
Important associated symptoms include
SOB- Asthma/COPD/Bronchiolitis/LVF/TB
Fever –UTRI- asthma/COPD/Bronchiolitis
Cough-Asthma/COPD/Bronchiolitis
Sputum production-Asthma/COPD/Bronchiolitis/Bronchiectasis/TB
Fever/sore throat/rhinorrhea= URTI-may trigger asthma attack
Orthopnea/PND-LVF
Swelling-Heart Failure
Weight loss/fatigue-cancer-Endobronchial growth
Nasal congestion/ itching eyes/sneezing/ rash-allergic reaction
vomiting/ heartburn/swallowing difficulties -GORD
Past medical history- particularly asthma, COPD, and heart failure
Smoking history-MUST BE ASKED
Examination:
Vital signs- fever, tachycardia, tachypnea, and low O2 saturation-MUST BE NOTED
Any signs of respiratory distress -
Signs of allergic reactions- Atopy/Eczema-Asthma
ENT- appearance of nasal mucosa/signs of rhinitis/sinusitis/nasal polyps
Clubbing-Malignancy/Bronchiectasisis
Oedema- RT Heart failure- 2° to LVF/Corpulmonale
JVP↑↑- RT Heart failure- 2° to LVF/Corpulmonale
Lymph Node-TB/Malignancy
Barrel chest- severe COPD.
Localisation of wheeze-diffuse-Asthma.COPD/LVF
localized-Foreign body/Endobronhcial growth
Timing of wheeze- Predominantly Expiratory-COPD/Asthma/LVF
Predominantly Inspiratory-Tumour/FB/Stenosis
Stridor-Upper airway Pathology-Tracheal tumor/FB/Stenosis
Crepts-LVF/Bronchiectasis
Murmurs/3rd heart sound/ gallop-LVF and jugular venous distention
Investigations-
FBC-Eosinophilia-Allergy/Asthma
Chest x-ray
Cardiomegaly/Bilateral pleural effusion/fluid in the major fissure-heart failure
Hyperinflation and hyperlucency-COPD
Segmental or subsegmental atelectasis or infiltrates- endobronchial lesion
Radiopacity in the airways or focal areas of hyperinflation-foreign body
Mass or nodule with Soft tissue density-Malignancy
Pathcy infection/consolidation/abscess/cavity-TB
ABGs-Particularly if the pt is hypoxic/HIGH PCO2 is suscpected
26
Sputum- G/S+ C/S+ AFB+ Myco tb C/S+ XpertTB
Pulmonary function testing- If the diagnosis is unclear in patients with recurrent wheezing, pulmonary function
testing can confirm Obstructive Airway disease/reversibility.
Special-depends on provL Diagnosis
Prov diag Tests
GORD Endoscopy+/- Oesophageal Ph Manometry
Endobronchial growth CECT Chest
Dysfuntional vocal cord Endoscopic Nasolaryngoscopy
LVF ECG/Echo
Q. Male, 65 years, chronic smoker, attended emergency room with chest pain, respiratory distress, fever and mild
pedal edema in the end of winter.
1) Make DD 2) Describe clinical examination detail 3) How to best manage this case
1. D/D
1. Infective exacerbation of COPD with Cor pulmonale / RVF (most likely diagnosis)
2. PE
3. Pneumonia
4. MI with Heart failure
2. Clinical examination- following are the important points (if present) and their relevance
a. R/rate- high due to SOB/Hypoxia
b. Pulse- vitals, so must be checked
c. BP- vitals, so must be checked
d. O2 saturation- may be low- hypoxia
e. Oedema- if + - RVF
f. JVP if + - RVF
g. Chest-
 Inspection- barrel shaped chest- COPD
 Palpation- VF- reduced symmetrically- COPD
 Percussion- hyper resonant-COPD
 Auscultation-
BS- reduced bilaterally-COPD
VR- reduced bilaterally-COPD
Any wheeze/Rhonchi- due to bronchospasm- IECOPD
Localised crepts- Pneumonia/Infection
Bronchial breathing- Consolidation
h. CVS- any gallop- LVF
i. HS- may be normal or abnormal
j. GCS- if low can be due to CO2 retention
3. BEST Management- IECOPD Rx…..notes…… (Please do come and treat me 20 years from now!!)
Anasarca/Oedematous patient- approach

Important causes (D.D) are
RHF- secondary to LHF/Chronic lung disease/Right sided disease
CKD
CLD
Nephrotic
Pericardial effusion
Constrictive Pericarditis
27
Approach= Clinical + Investigation
History- important points and their diagnostic relevance
1. Pattern of swelling- Low urine output- Kidney disease

 starting with legs- any cause Confusion/drowsiness- CKD/CLD
 Abdominal swelling- CLD/Nephrotic but can 3. H/O risk factors
be in other causes as well
2. Associated symptoms  IHD - RVF/CKD
 Smoker- COPD leading to RVF
SOB- volume overload- CCF/CKD/Nephrotic  HTN/DM- CKD/RVF
but can be also due to chronic lung disease  Alcoholism/any other chronic liver disease
Orthopnoea/PND- CCF/CKD (Pulmonary congesn
Angina- Cardiac cause 4. Drug history- CCB- can cause bilateral pedal
GI bleed- CLD swelling
Jaundice- CLD
Examination- important points and their diagnostic relevance
1. JVP-RVF/CKD/Pericardial diseases 6. Systemic examination-
2. Oedema-all of these cases  Murmur- RVF
3. Jaundice- CLD  Gallop- RVF due to LVF
4. Hypoxic patient- Pulmonary oedema due to Left  Bibasal crepts- RVF due to LVF
heart failure/CKD or Lung disease  Signs of Chronic lung disease- COPD/ILD
5. Moon face- Nephrotic  Ascites-CLD/
 Hepatosplenomegaly-CLD
 Venous prominence-CLD
Investigations
Preliminary Cardiac disease- Cardiac enzymes/Coronary Angio
FBC CLD- UGI Endoscopy/ Fibroscan
Renal function test- deranged in CKD CKD- Blood biochemistry- Ca, Po4, Uric acid, Vitamin
LFT- deranged- CLD D3
Low albumin- CLD/CKD/Nephrotic Nephrotic- 24 Urine Protein Estimation/Renal
Pro BNP- High- Heart failure (But not a diagnostic biopsy/Autoantibodies
marker)
ECG-abnormal – Cardiac disease
Echo-abnormal- in cardiac disease
Urine- albuminuria- Nephrotic/CKD
USG- Abnormal liver- CLD
Abnormal Kidneys- CKD
Further tests- should be guided by initial assessment

and preliminary tests
Q. Baby with fever+ rash appearing on 4th day+ running nose+ conjunctival redness. Provisional dx? d/d?
PD/WD- Measles D/D……See approach of ‘fever with rash’
Q. 60yr DM, HTN + admitted with left hemiparesis 5 days before + sudden complain of acute dry cough, SOB,
haemoptysis + painful swelling in left calf. Provisional dx and management
PD- PE with DVT…management: see notes.
For this particular scenario, add the following:
If hemiparesis is due to Hgic. stroke- risk of further PE should be cautiously weighed against risk of rebleeding from
Anticoagulation before a final decision is taken
28
Coma
Accident/Head Injury
Biochemical
Hyponatremia/Hypoglycemia/
Severe Hyperglycemia-DKA/HHS
CVA-ICH/Infarct/Subdural hematoma/SAH
CNS Infection-
Cerebral Malaria/Encephalitis/Meinigtitis
Drugs and toxins-
Alcohol Intoxication/Sedatives/Antipsychotics
Endocrinoathy-Myxedema Coma/Acute Adrenal CrS
Epilepsy-Post GTCS State/Post Ictal state
Encephalopthy-Hepatic/Uremic/CO2 narcosis/Septic
F-Fluid loss-Severe dehydration due to any casue
G-××
Hypoxic encephalopathy-Severe Hypoxia due to any cause
Hysterical
Hypothermia/Hyperthermia due to any cause
ICTraised-ICSOL/Herniation
(I am not alive….Pt is dead!!)
History Important points with their significance

Onset & progress of
Sudden-CVA/Head injury
Rapid-CVA
Gradual-Metabloic/Biochemical/Infection
Ppting event-
Head Injury
Convulsion-Post Ictal state
Too much alcohol-Alcohol Intoxication
Drugs- To r/o Drug induced causes
Preceding events/illness
Severe headache-SAH/Dissecting Aneurysm
Severe SOB-CO2 Narcosis
Fever-Any Infective cause
Recent Infection/Symptoms suggestive of infection- Septic encephalopathy
Jaundice-Heptaic encephalopathy
Confusion/Disorientation/Behvioual abnormality
Back ground of the patient- may give an idea
Known COPD-CO2 Narcosis
Known Liver disease-Hpatic Encephalopathy
Known Kidney diease-Uremic encephalopathy
Known Epilepsy-Post ictal state
Known DM-DKA/HHS/Hypo
Examination-Important ones with diagnostic relevance
Alcohol/Acetone smell
Breathing-Acidotic-DKA/HHS/Uremic Encephy
Slow- Opoid /BNZ OD
Cheyne-stoke-Brain stem Stroke
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Circulation- Hypotension- Sepsis/Dehydration
Dehydration-Signs should be looked for
Eyes-Pupil-
B/L pin point-OP poisoning/Pontine Hge/Opoid OD
Fundus-Papillodema-Raised ICT
GCS -Must be assessed
Hypothermia/Hyperthermia
Icterus-Hepatic encephalopathy
K××
Look for any Suicidial note/Empty Medicinal strips
Movement Lack-Unilateral- CVA/SDH
Neck rigidity-Meningitis
O2 saturaton-Low- Hypoxic encephalopathy
Plantar-
Bilateral upgoing- deep coma due to ANY cause
Unilateral Upgoing- CVA/SDH
Investagations
Preliminary-what they suggest to be the cause
FBC- TC↑/CRP↑-Infection/Septic Encephalopathy
Ur,Cr↑-Uremic encephalopathy
Na↓-Hyponatremia
CBG↓↓Hypo; ↑↑DKA/HHS
LFT-Deranged- Hepatic Encephalopathy
ABG-
Low O2-Hypoxic Encephalopathy
High CO2- co2 Narcosis
Metabolic Acidisosis- Septicemeia/DKA
CxR-Any Pneumoina
Urine R.E/M.E-Ketone-DKA
Pus Cells ++- Urosepsis
CT Brain- any LESION- cva/ich/SAH/sdh/ICSOL
Special- Depends on Prov. diagnosis
Prov diagnsosis test
OD Blood/Urine Toxicology screen
Meningittis CSF study
Malaria MP/Dual Ag
Hemplegia/Hemiparesis
Common causes by etiology
Vascular: Stroke- Ishaemic/Hemorrhagic
Infective: Encephalitis/Meningitis/Brain abscess
Neoplastic:1.Benign 2.Malignant= Primary/Metastatic
Demyelination: Multiple sclerosis
Traumatic: Subdural Hematoma (SDH)- Acute/Chronic
Congenital: Cerebral palsy
Psychological/Hysterical
Approach=Clinical= (History+Examnination) ++ Investigation=(Preliminary+ Special)
30
History
1.Onset of weakness
a.Sudden- CVA/Acute SDH/Post Epileptic (Todd’s paralysis)
b.Gradual-ICSOL/Brain Abscess/Chronic SDH
c.Progression- Rapidly progressive- CVA
d.Duration- Less than 24 hours-TIA
More than 24 hours- ANY of the other causes
2.Preceding History/Illness
a.Recurrent Headache recently- Vasculitis/Hypertension
b.Cerebrovascular Risk assessment – these increase chance of CVA
Hypertension
DM
Smoking
Sedentary lifestyle
c.Known Epileptic-Todd’s Palsy
d.Fever-infection-Meningitis/Encephalitis/Abscess
e.Neck stiffness-Meningitis
f.Behavioural disturbance-Encephalitis
g.Known AF-risk factor of embolic stroke
h.Drug- Anticoagulant/Antiplatelet-risk of Hgic stroke
i.HeadInjury-risk of SDH
3.Accompanying symptoms
a.LOC-ICH/Brain stem stroke
b.Diplopia-Cranial Nerve palsy
c.Dysarthria- …..do…………….
d.Swallowing difficulty……do……….
e.Weakness started after Seizure/GTCS- Todd’s palsy
f.Loss of sensation- Cortical Stroke
g.Speech abnormality-comprehension/Expression- Cortical Stroke
Examination-Important points are
a.GCS-may be low in many pts of CVA/Todd’s
b.Aphasia-CVA
c.Cranial Nerve palsy- Brain stem Stroke/Lesion
d.UMN signs- Signifies lesion is in the opposite half of the brain
e.Neck rigidity- Meningitis
f.Autonomic disturbance- Brain stem stroke
Investigation
1.Preliminary
1.CT Brain- diagnostic almost in all cases- may show Infarct/Hge/Subdural Hematoma/ICSOL- depending on the
scenario
2.Risk Assessment
Fasting Glucose/PP Glucose/HbA1C- for CV Risk assessment
Fasting Lipid profile- for CV Risk assessment
Clotting profile-if deranged suggest Coagulopathy
ESR/TC-↑Meningitis/Abscess/Vasculitis
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2.Special Tests
Provisional diagnosis Test
ICSOL MRI
Meningitis/Encephalitis CSF study
Vasculitis Autoantibodies
Causes of Stroke in a young person……Short Notes
1.Ischaemic Stroke
a.Large artery disease
Prematrue Atherosclerosis
Dissection of Vertebral/Carotid artery
Takayasu’s arteritis
CADASIL(Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy
b.Small artery disease
Vasculitis- PAN/MPA/WG/Cerebral Lupus/Behcet’s
c.Hypercoagulable disorders- ProteinC/Protein S/Antithrombin 3 Deficiency/APLA
d.Cardioembolism
AF/Mitral Valve disease/Left Atrial Myxoma
2.Hemorrhagic Stroke
a.Ruptured Aneurysm
b.Coagulopathy
Acute/Rapidly developing Paraplegia/Paraparesis- approach
D/D or Common causes
1.Spastic type- Acute Transverse Myelitis(ATM)
Acute Compressive myelopathy(CM)
1. Accident-fractured/collapsed vertebrae- compress the cord
2. Blood- Hematomyelia-Traumatic/Spontaneous – compresses the cord
Acute Non-compressive myelopathy…..(rare causes)
1. Circulation- Anterior Spinal Artery occlusion(ASA Occlusion)
2. Demyelinating disease- Multiple sclerosis (MS)/ Central Pontine Myelinosis(CPN)
2. Flaccid type- Acute Flaccid Paralysis (AFP)

Electrolyte-Severe Hypokalemia
Folio……oops!!…..Poliomyeltitis
GB Syndrome
History Important ones with diagnostic clues they give are
Extent/Distribution/Pattern of weakness
1.Paraplegia- ATM/Thoraco-lumbar Cord Compression/GB/Polio
2.Quadriplegia/paresis- High Cervical cord compression/CPN/GB/Polio
3.Symmetrical weakness bilaterally- ATM/GB
4.Asymmetrical- CM/Polio
5.Ascending pattern of weakness- GB/Polio
Associated symptoms often give vital clues about the underlying illness
1.Loss of sensations- ATM/Myelopathy/Spinal artery occlusion
2.No Sensory symptoms- goes AGAINST compressive myelopathy, favours causes like GB/Polio/CPN
3.Loss of bladder /bowel control- Compressive myelopathy/ATM
4.Fever- ATM/GB
5.H/O Recent diarrhea- may be present in a pt of GB/Hypokalemic paralysis
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6.SOB- GB/Polio
7.Bulbar symptoms- Dysphagia/Dysarthria/dysphonia- GB
8.Recent trauma- fractured/collapsed vertebrae
9.Known pt of coagulopathy- chance of Hematomyelia
10.Known pt of AF- Chance of embolic occlusion of Ant. Sp. Art.
Examination Important ones with diagnostic clues they give are
1.UMN signs in LL (spastic paraparesis) - ATM/CPN/ASA occlusion
2.UMN signs with segmental LMN Signs- Compressive myelopathy
3.Pure LMN signs (Flaccid paraparesis)- GB/Polio/Shock stage of CM or ATM
4.Sensory loss with definite upper level- CM/ATM
5.Dissociated pattern of sensory loss- ASA. occlusion
6.Bulbar signs- GB/Polio
7.Irregular pulse- AF- Chance of ASA Occlusion
8.Signs of SOB- GB
Investigations
1.Neurological investigations
1.If Spastic paraparesis-Urgent MRI Spine
2.If AFP- Urgent NCV/EMG
In most of the cases either of these 2 will be diagnostic
2. Other investigations-
a.Na/K
b.Hb/TC/DC/ESR
c.LP-To demonstrate Albumin- Cytological dissociation in case of GB
d. ABG/periodic spirometry- to monitor for respiratory failure in GB
Monoarthritis-Approach
Common causes
Accident- Trauma/Injury
Avascular necrosis of bone
Blood- Hemarthrosis- Traumatic or Spontaneous as in Coagulopathy
Bacteria= Septic Arthritis- Gonococcal or Non gonococcal
Crystal Deposition disease(CDD)
 Monosodium Urate = Acute gout
 Calcium pyrophosphate dehydrate =Acute Pseudogout
Connective tissue disease(CTD) /Inflammatory arthritis
1.Rheumatoid arthritis 2. Psoriatic arthritis 3.Reactive arthritis 4.Sarcoidosis
Degenerative- OA
History
Onset of pain-
Seconds to Minutes- Fracture/trauma/Haemarthrosis
Hours to 1-2 days- Infection/CDD/CTD
Over few days to weeks-Indolent infection/OA
Distribution of pain- may give clue about the cause
Trauma/Injury can affect any joint and cause of the pain will be obvious
Small joint- often CTD
Big joint- any disease except RA
Back pain- AS
Great toe joint-Acute Gout
Systemic/associated symptoms-
Fever- Septic/CTD/acute gout
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Morning stiffness- CTD
Red Eye- Reiter/Ankylosing spondylitis
Per urethral discharge- Gonococcal/Reiter
Deformity- RA/Trauma
Immunosuppressive diseases/drugs- chance of Septic arthritis
Spontaneous bleeding- Hemarthrosis
Use of anticoagulants -Hemarthrosis
Past/recent h/o- these may give clues about the current disease
Skin patches or nail changes- Psoriatic arthritis
Use of diuretics-Gout
renal stones-Gout
Intravenous drug use- Chance of Septic arthritis
Immunosuppression- Chance of Septic arthritis
Acute recurrent attacks - CDD/ inflammatory arthritis
Recent prolonged course of corticosteroid - Infection/Avascular necrosis
Known pt of Coagulopathy- Hemarthrosis
Deforming Arthritis-RA/Psoriasis
Examination
Joint-
Signs of inflammation +ve- Septic/Inflammatory arthritis
Deformed/swollen- ?Fracture
Loss of movements- Fracture/Septic/Inflammatory
No signs of inflammation- OA
Effusion- Septic/CDD
Systemic examination-
Tophi- Gout
Psoriatic plaque/nail changes- Psoriasis
Erythema Nodosum- Sarcoidosis
Sacroilitis- AS
Conjunctivitis- Reiter
Uveitis- AS/RA
Soft tissue tenderness- Acute Gout/AS
Investigation
Preliminary
1. Joint X-ray- To look for fracture/OA changes/In Rheumatological diseases joint xray is often nondiagnostic in the
initial stage of the disease
2.Joint fluid aspiration
a. Neutrophilic-Septic/Acute Gout
b. G/S or C/S +ve- Septic
c. Crystal+ve- Gout/Pseudogout
d. Blood- Hemarthrosis/Trauma
3.Blood
TC/DC/CRP- High- Septic/Inflammatory/Gout
Uric acid- may be high (OFTEN normal in Acute Gout, therefore IN CLINICAL LIFE Acute gout should be
diagnosed on clinical ground +/- crystal)
Further tests- depending on the tentative diagnosis
Septic- Blood C/S
RA- Anti CCP/RAF
Trauma- MRI
34
24.A 35 yr old female patient presents with pain in multiple joints for last 2 months. How will you proceed to
diagnose the case?
1.Autoimmune diseases (Inflammatory in nature)
1.Blood vessel disease/Vasculitis (i.e. Systemic small/medium vessel vasculitis)
a.Henoch-Schonlein purpura (HSP) b.Wegener’s granulomatosis (WG) e.Behcet’s disease
c.Microscopic Polyangitis (MPA) d.Churg-Strauss syndrome(CSS)
2.Connective Tissue disease (i.e. Rheumatological)
Seropositive diseases Seronegative Spondyloarthropathies

RA Ankylosing spondylitis (AS)
SLE Psoriatic arthritis
Dermatomyositis/Polymyositis(Dm/Pm) Enteropathic arthritis(Arthritis associated with IBD)
Scleroderma(Scl) Reiter disease
3.Degenetrative- OA
4. VitD deficiency
5.Endocrinopathy- a. Hypothyroid/Hyperthyroid b.Hyperparathyroid
6.Fibromyalgia
7.Gout(chronic) (Acute Gout= usually Monoarthritis)
8.Hypermobility syndrome (just to complete the alphabetical order!! eg. Ehler Danlos/Marfan...)
9.Infections- direct or indirect effect- Endocarditis/Acute Rheumatic fever (ARF)
How to proceed to diagnose/Approach= Clinical= History +Examination

+ Investigations
Because D/Ds are numerous therefore the answer mainly emphasises on common causes. Name of the Diseases
are henceforth mentioned in ‘’abbreviated/short form’’
Important points in history AND examination with clinical clues they give are
Pattern of joint involvement

1.Predominantly small joints- Connective tissue disease/Vasculitis/may be OA
2.Predominantly Axial Joints- Seronegative spndyloarthropathy
3.Bigger joints-ARF/OA/Gout
3.Symmetrical symptoms- RA/SLE
4.Asymmetric symptoms-Gout/ spondyloarthropathies
5.Morning stiffness-Inflammatory arthritis- CTD/Vasculitis
6.Pain increases after rest- Inflammatory arthritis- CTD/Vasculitis
7.Pain worsens with movement- OA/gout
8.Deformity- RA/Psoriatic
9.Migratory nature- ARF
Distribution of joint involvement
1.Predominantly PIP/MCP-RA/OA/SLE
2.Predominantly DIP- Psoriatic
3.Bigger joints-ARF/OA/Gout
4.Enthesopathy-AS (Enthesopathies= disorders of peripheral ligamentous or muscular attachments)
Associated symptoms
1.Fever- all Inflammatory/infection/Even Gout
2.Constitutional symptoms-CTD/Vasculitis
3.Prominent weakness- Pm
35
4.Preceding Sore throat-ARF/HSP
5.Preceding GI Infection- HSP/Reiter
Extraarticular manifestations provide many valuable clues to the etiology as mentioned below-
Symptoms and/or signs of followings are to be looked for to get a clue about diagnosis
Musculoskeletal system
Tender points-Fibromyalgia
Heberden's nodes (DIP joints), Bouchard's nodes (PIP joints)-OA
Boutonniere and swan-neck deformities-RA
Dactylitis (“sausage digits”)-Spondyloarthropathies/Scl
Bursitis and enthesitis-Spondyloarthropathies
Active signs of Inflammation- Inflammatory arthritis-CTD/Vasculitis
Sacroilitis-Spondyloarthropathies
Mucocutaneous
Photosensitivity- SLE, Dm
Raynaud’s phenomenon- SLE, Scl, Dm
Mouth ulcers -Behçet’s disease, IBD-associated arthritis, SLE, Reiter’s
Subcutaneous nodules- RA, Gout, ARF
Erythema nodosum - IBD, Behçet’s disease
Nail dystrophy- Psoriatic arthritis
Cutaneous vasculitis -SLE, RA, any vasculitis
Subungual Hge/Osler node- SBE
Rash
Malar rash-SLE
Plaques -Psoriasis
Heliotrope- Dm
Erythema marginatum - ARF
Pyoderma gangrenosum- IBD
Palpable purpura- Vasculitis
Keratoderma blennorrhagicum- Reiter
Discoid skin lesions-SLE
Gottron's papules-Dm
2.Ocular
Conjunctivitis- Reiter
Scleritis/Uveitis- Ankylosing spondylitis/Vasculitis/CTD
3.Renal
AKI- Scleroderma (renal crisis), SLE, WG
Glomerulonephritis- SLE, MPA, WG
Renal calculi- Gout
4.Cardiopulmonary
Serositis (pleuritis, pericarditis)- RA, SLE, ARF
Interstitial lung disease- Scl,Dm, SLE, RA
Pulmonary hypertension- Scl, SLE
Valvular heart disease
MR- SABE, ARF, RA, SLE
AR- AS, Reiter, RA
Myocarditis-SLE, Scl,Dm
5.Neurological
Entrapment neuropathies- RA, hypothyroidism, hyperparathyroidism
Stroke-SLE, Behçet’s disease
36
Seizure- Vascultis/CTD
Proximal Myopathy- Pm/vitD def
6.GI
Diarrhoea/bloody diarrhoea- Enteropathic arthritis
Abdo pain/Melaena- Vasculitis
Investigations
1.Preliminary
1.Blood-
a.Hb,TC,DC,ESR/CRP-↓Hb with normocytic pattern/↑TC/↑ESR or CRP- inflammatory arthropathy
b.Specific test- nature of these depend on preliminary/suspected underlying cause- at times more than 1 of the
following tests are done simultaneously if the cause is not clear
RAF/Anti CCP- for RA
ANA if +ve then Anti ds- DNA- for SLE
ASO titre- for ARF
ANCA- for Vasculitis-WG/MPA/CSS all are ANCA +ve
CK/Anti- Mi 2/Anti Jo 1 - for DM
Anti Scl-70- for Scleroderma
Uric Acid- for Gout........(Normal Uric acid does NOT rule it out!!!)
Blood C/S- for SABE
HLA B27- for AS...........(NOT a diagnostic test!!)
2.Joint x-ray- abnormal in OA/RA
3.Special- to look for organ involvement in CTD/Vasculitis and to diagnose the disease as well
Urine R.E & M.E- ?GN- can occur with vasculitis/SLE
CxR-?Infiltrates/Nodules- Vsculitis/CTD
ECG/Echo- ? Valvular lesion/deformity-ARF/SABE
Biopsy of organ- skin /Renal- ?vasculitis
TSH- Thyroid dysfunction
Vit D3 level- vit d def
Colonoscopy-IBD
Related/similar Qs
Multiple Small joint pain/small jt polyarthritis
1.Autoimmune diseases(Inflammatory in nature)
1.Blood vessel diasease/Vasculitis (i.e Systemic small/medium vessel vasculitis)
a.Henoch-Schonlein purpura b.Wegener’s granulomatosis e.Behcet’s disease
c.Microscopis Polyangitis d.Churg-Strauss syndrome
2.Connetive Tissue disease (i.e Rheumatological)
Seropositive diseases Seronegative Spondyloarthropathies**
RA Ankylosing spondylitis (AS)
SLE Psoriatic arthritis
Dermatomyositis(DM) Enteropathic arthritis(Arthritis associated with IBD)
Scleroderma(Scl) Reiter disease
** Can cause small jt disease
3.Degenetrative- OA
4. VitD deficieny
5.Endocrinopathy- a.Hypothyroid/Hyperthyroid b.Hyperparathyroid
6.Fibromyalgia
7.Gout(chronic) (Acute Gout= usually Monoarthritis)
8.Infections- direct or Indirect effect- Endocaridtis
37
Pain in multiple jts and rash
1.Autoimmune diseases(Inflammatory in nature)
a.Henoch-Schonlein purpura(HSP) b.Wegener’s granulomatosis(WG) e.Behcet’s disease
c.Microscopis Polyangitis (MPA) d.Churg-Strauss syndrome(CSS)
2.Connective Tissue disease (i.e Rheumatalogical)
Seropositive diseases Seronegative Spondyloarthropathies

RA Psoriatic arthritis
SLE Enteropathic arthritis(Arthritis associated with IBD)
Dermatomyositis/Polymyositis(Dm/Pm) Reiter syndrome
Scleroderma(Scl)
2.Infections- direct or Indirect effect- Endocarditis/Acute Rheumatic fever(ARF)

Multiple Small joint pain+fever+/- wt loss*
1.Autoimmune diseases
a.Henoch-Schonlein purpura b.Wegener’s Granulomatosis e.Behcet’s disease
c.Microscopis Polyangitis d.Churg-Strauss syndrome
2.Connetive Tissue disease (i.e Rheumatological)
Seropositive diseases
RA
SLE
Dermatomyositis
Scleroderma(Scl)
9. Infections- direct or indirect effect- Endocarditis/+/-Acute Rheumatic fever (ARF)*
Polyuria
Passage of atleast 3 ltrs or more urine/day in an adult
Causes- 6D
DM-type1 /type2
DI-Neurogenic/Nephrogenic
During recovery phase of AKI
During early stages of CKD
Diuretic induced-Drugs or Beverages-too much Alcohol/coffee
Deliberate- Psychogenic Polydipsia
However if any pt c/o Polyuria, conditions causing increased frequency which the patient misinterprates as
‘’polyuria’’ should be ruled out- like BPH/UTI/Gravid or bulky uterus
Approach= Clinical= (History+Examination)++ Investigation= (Preliminary + Special)
History- Important points with their clinical clues
1.Establish whether it is true polyuria- careful history +/- by asking patient to measure 24 hour urine output
2.Accompanying symptoms/illness/conditions
a.Wt loss- DM/underlying CKD/even DI( due to too much water loss)
b.Increased thirst- may be present in any pt with polyuria due to dehydration
cIncreased appetite-DM
d.Colour of the urine-Very pale suggests DI
e.Headache-Pituitary tumour
f.Visual disturbance- Pit tumour
38
g.h/o renal colic-hypercalcemic nephropathy
h.Drug history
1.Lithium-can cause DI
2.Diuretic
3.Too much Coffee/Alcohol
4.Any drug causing Tubulointerstitial Nephritis
i.Swelling-CKD/Diseases requiring Diuretic
j.admitted with AKI-probably recovery phase has started
k.Constipation- Ca↑
l.seizure/disorientation- Ca↑
m.Known DM
n.Psychiatric illness- ? on Lithtium/?Pscychogenic Polydipsia
o.Pituitary surgery/disease- Neurogenic DI
p.H/O head injury-Neurogenic DI
Examination- important ones with what they are suggestive of
Finding What it suggests

Signs of dehydration- to be looked for Pt is dehydrated and needs adequate fluid Rx
Pallor CKD is a possibility
Oedema CKD/diuretic requiring disorder
JVP↑ CKD/ diuretic requiring disorder
Bitemporal Hemianopia Pituitary tumor
Kussmaul Breathing Metabolic Acidosis- DKA/AKI/CKD
Palpable Kidney Underlying cause ofCKD
Investigations
1.Blood
FBC- Hb↓- may be due to underlying CKD
Ur/Cr - abnormal- CKD/AKI/Diuretic induced
Na/K-↓may be diuretic effect
Ca-↑predisposes to Nephrogenic DI
FBG/PPBG/HBAIc- to r/o DM
ABG- if a metabolic acidotic condition is suspected or established from initial investigations
2.Urine
Specific gravity- very low in DI and Psychogenic polydipsia
Glucose + /ketones +- in DM
Urine osmolality- Early morning urine sample in conjunction with a Serum osmolality
A high plasma osmolality and inappropriately low urine osmolality occur in diabetes insipidus
Both serum and urine osmolalities are correspondingly low in psychogenic polydipsia
Special tests- guided by provisional diagnosis
Provisional Diagnosis Tests
DI Water deprivation followed by Desmopressin challenge test
Neurogenic DI MRI Pituitary/Pituitary Function tests
Nephrogenic DI Serum Lithium Level (if pt is on)
Ca ↑ Po4/PTH/Electrophoresis/Bence-Jones Protein
DM Urine for protein/ACR/Blood for Lipid profile
CKD Further tests to detect the cause(if cause not clear)
39
PUO
When temperature is more than or equal to 101°F recorded on several occasions occurring more
than 3 weeks and the cause remains undiagnosed in spite of investigations on 3 OPD visits or 3 days
of stay in hospital
Abscess-Abdominal/Pelvic/Dental/Lung/Liver
AFB-TB often Extrapulmonary
AIDS
Autoimmune diseases (AID)- Polymyalgia Rheumatica /SLE/RA/ Reiter syndrome /Vasculitis
Bacterial Endocarditis
Bone- osteomyelitis
Balanitis
Clostridium Difficle
Drug-induced fever
DVT
Enteric
Factitious fever
Granulomatous- Sarcoidosis, Granulomatous hepatitis
Hematological- Leukemia/Myeloma
Inflammatory bowel disease
J(Z)oonotic disease
Kala azar
Lymphoma
Malignancies-renal cell carcinoma/ hepatoma/ sarcomas/testicular
Malaria
Non bacterial infection - viral (cytomegalovirus, Epstein-Barr, HIV) ricketsial, fungal
History-Important points with their significance
1.Pattern of fever
High grade-Infection-Abscess/Malaria/Enteric
Chill/tigor-Abscess/Malaria
Low grade-often TB/Autoimmune
Evening rise-TB/Lymphoma
Sweating along with temp- Malaria
Double rise-Kala-azar
2. Associated symptoms-(Systemic enquiry is important to guess the underlying cause/group of disease)
A.CNS
Headche+/- Vomiting/convulsion- Brain Abscess/TB/Temporal Arteritis/Sinusitis
Disorientation-TB
Neck pain-Meningitis
B.ENT-
Earache-Infection; Ear discharge-Infection
C.Oral
Dental pain-infection/abscess; Ulcers-Autoimmune disease/IBD
D.Cardio-Resp
Cough-TB/Occult Pulmonary ingection
Hemoptyis-TB
SOB- Pneumonia/ILD due to Autoimmune disease
E.GI
Abdo pain-RUQ-Liver abscess/RIF-IBD/Intestinal TB/
Constipation-Enteric; Diarhhoea-HIV/IBD/Intestinal TB/Cl. Difficile
40
F.GU
Prostatism-Prostitis; PU/PV discharge-Infection; Dyspareunia-PID
G.Renal
Loin pain-Pyelonephritis; Hematuria-Glomerulonephritis secondary to AID/Endocarditis
H.Skeletal
Joint pain-AID;Joint stiffness-AID;Joint swelling-AID
Bone pain-Osteomyelitis; Back pain-Vertebral TB/Metastatic/Myeloma
Muscle weakness-PMR
I.Skin
Rash-AID
J.Hemato
Tiredness-Anaemia due to Hematological Malignancy
Bleeing/bruising-Hmeatological Malignancy
Lymph Node enlargement-Lymphoma/TB/Sarcoid/HIV
K.Travel history-risk of Exotic infection depending on area visited
L.H/O Heart valve operation-Risk of Endocarditis
M.Known VHD- Risk of Endocarditis
N.Recent/Repeated course of Antibiotic-Cl. Difficile infection/Drug fever
Examination-Important points with their significance…..(Top to bottom approach)
1.Sinus tenderness - Sinusitis
2.Temporal artery- Nodules, reduced pulsation-Temporal arteritis
3.Oropharynx- Ulceration- IBD/Disseminated Histoplasmosis
4.Tender tooth-periapical abscess
5.Fundi or conjunctiva- Choroid tubercle- Disseminated TB ;Petechiae/Roth’s spot- Endocarditis
6.Neck and axilla- Lymphadenopathy- TB/ Sarcoidosis/ Metastatic cancer/Lymphoma/CLL
7.Thyroid Enlargement/tenderness-Thyroiditis
8.Heart Murmur-Infective endocarditis/Atrial Myxoma
9.Abdomen-
Local tenderness- site may give a clue about the underlying cause
Enlarged liver-Liver abscess/Granulomatous Hepatitis/Hepatoma
Hepatosplenomegaly- Lymphoma/Leukemia/Malaria
Splenomegaly- Luekemia/Lymphoma/ Endocarditis/Disseminated granulomatosis
Perirectal tenderness-Abscess
Prostatic tenderness-Abscess
10.Genitalia- (Never forget this in PUO!!)
Testicular swelling- Lymhoma/Testicular Malignancy
Balanitis/Phimosis- may be the site of infection
Ulcers-Behcet’s
11.Deep venous tenderness- DVT or thrombophlebitis
12.Skin and nails
Purpura/Rash/Petechiae/splinter hemorrhages/subcutaneous nodules -Vasculitis, Endocarditis
Investigation
1.Preliminary-Although most of these investigations would have been already done
a.FBC
Hb↓- Malignancy/Hematological disease/AID/Infection- all can cause anaemia
Cytopenias-SLE/HIV
Abnormal smear-CML/CLL
b.ESR/CRP-↑Infecton/Autoimmune disease/Malignancy
c.Ur/Cr/Na/K-to assess renal function
41
d.LFT-deranged- Liver abscess/Granulomatous Hepatitis/Chronic Viral Hepatitis
e.MP with Dual Antigen
f.Blood C/S-To look for bactermia
g.HIV/Hepatitis serology
h.USG abdomen-to L/F any collection any where
i.Echo-To l/fVegetations
2.Subsequent-Guided by Provisional Diagnsosis
Pathology suspected Test
1.Abscess CT chest/abdo/pelvis
2. Autoimmune diseases Autoantibodies-ANA/Anti dsDNA/ANCA/Anti CCP etc
3.Bone marrow Leukemia/Kala-azar
4.Specific Serological test For any particular infection
5. vertebral pathology MRI
6. osteomyeltis Bone scan
7. –Myeloma Electrophoresis
8. Lymphoma/TB Lymphadenitis Lymph Node Biopsy
9. Testicular Ca USG Testis
Weight loss
With preserved/good appetite With decreased/poor appetite
Endocrinopathies: Malignancy: any but commonly GI; Hematological
Thyrotoxicosis malignancy; Lung Ca
Diabetes Infections: HIV; active TB; Chronic hepatitis
Pheochromocytoma Comorbidities: Advanced Cardiac / Renal
Gastrointestinal diseases: Pulmonary/Liver/Neurologic disease/ Dementia
1. Malabsorption- Intestinal Parasites; Celiac disease Psychiatric illness: depression; manic phases of
2. IBD bipolar disorder
Social problem: Alcoholism; Poverty; Isolation
Voluntary- Rigorous exercise/ Drug induced
Psychiatric illness: Eating disorder
Approach= Clinical= (history & examination) + Investigations

History-Important points with their relevance are
1. Wt. loss- Assess degree/quantity/ time span 9. Vomiting- GI disease/Eating disorders
2. Voluntary or Involuntary 10. Polydipsia +/- Polyuria- DM
3. Appetite- change? 11. Tremor-Thyrotoxicosis
Preserved/good Appetite- causes as mentioned 12. Mood disturbance
Loss of Appetite- causes as mentioned Thyrotoxicosis/Depression/Mania
4. Bowel symptoms- 13. Menstrual Irregularity-Thyrotoxs/Gynae maligy
Diarrhoea- Hyperthyroidism/IBD/Parasitic infn 14. History suggestive of comorbid diseases-
Steatorrhea- Malabsorption CV/Pulm/CLD/CKD/Neuro
Bloody stool- GI malignancy 16. Any H/o Depression
5. Abdo pain- GI causes 17. Any h/o Dementia
6. Bloody stool- GI malignancy/IBD 18. Drug history
7. GI bleed- GI malignancy/CLD 19. Social history- Particularly in elderly pts
8. Fever- Infective causes/Hemato maligy
42
Examination- Important points with their relevance are
1. Pallor-malabsorption/Malnutrition/Malignancy 6. Abdominal mass – GI malignancy
2. Oedema- 7. Any signs of thyrotoxicosis
Malabsorption/Malnutrition/CVS/CKD/CLD 8. Systemic examination- to look for CVS/CLD/Neuro
3. Overall appearance- diseases
Cachexia- Malignancy/HIV/TB 9. Breast/Prostate abnormalities
Unkempt/dishevelled- Depression/Alcoholism 10. Rectal examination-mass/Prostatomegaly
4. Lymphadenopathy-Malignancy/HIV
5. Hepatosplenomegaly-Hemato malignancy
Investigations- with their relevance
Preliminary
1. FBC- abnormal in Hemato malignancy/ Malabsorption/Malnutrition
2. ESR/CRP- high- Infection/Malignancy/IBD
3. Electrolytes- Na/K/Ca/Mg-Low suggests malabsorption
4. Glycemic status- FBG/PPBG/ HbA1c- for DM
5. Urea/Cr- to assess Kidney function
6. LFT- to assess liver function
7. TSH-Low in Thyrotoxicosis
8. Stool- OCP + ve- Parasitosis/OBT +ve in IBD/some GI malignancy
9. CxR- abnormal- TB/Lung Ca
10. HIV serology
Further tests- should be based on results of these initial tests
1. GI investigations-OGD or colonoscopy plus 3. CT chest/abdomen- Malignancy
biopsies 4. Celiac serology
2. Thyroid- Radionuclide imaging/TSH-r Antibody
25 yr old female with palpitation, tremor and weight loss inspite of good appetite- approach? Management?
This is likely Thyrotoxicosis, therefore aim of the approach is
1. To look for symptoms and signs of thyrotoxicosis
2. To look for type of any underlying cause/disease of thyrotoxicosis
Approach includes 1.Clinical- history & examination 2.Investigations
History
Duration of problems 5.Menstural irregularity
b. detailed h/o these 4 symptoms 6.Diarrhea
c.Associated symptoms 7.Visual disturbance-? Graves’ disease
1.Sweating 8.Diplopia- graves’ opthalmothpathy
2.Anxiety 9.Neck swelling- Graves’/toxic MNG
3.Irritability 10.Headache- Ptuitary disease
4.Sleep disturbance 11. Known case of hypothyroidiam-? Iatrogenic
Examination
1.Thyrotoxic signs to be looked for 2.Thyroid examination-
Pulse- tachy +/- Irregular rhythm Goitre- Graves’/MNG
Skin texture- moist/thin Nodularity- MNG/Toxic adenoma
Any Proximal myopathy Bruit- Graves’
Any fine tremor 3.Signs of pituitary disease: Bitemporal hemianopia
Any hyperreflexia 4. Exopthalmus- Graves’
43
Investigations
To confirm Thyrotoxicosis
1.TSH- if low- primary hyperthyroidism
if high-secondary hyperthyroidiasm
2.Free T3/T4- high
To confirm underlying disease
1. RAI uptake scan
a.Diffusely increased uptake- Graves’
b.Hot nodule- single/multiple- Toxic adenoma/MNG
2. TSH-receptor Antibody- Graves’
3. MRI Pituitary with Pituitary function test- If Pituitary disease is suspected
Management- (points- for details ref to notes)
1. Symtomatic
2. Definitive- RAI Rx
Surgery
Antithyroid drugs
3. Rx of Graves’ opthalmopathy
Chronic Diarrhoea
1. Watery……often small gut problem
Secretory Osmotic
Alcoholism
Bile acid malabsorption- PBC Carbohydrate malabsorption-Lactose/Fructose
Crohn disease- early ileocolitis intolerance
Colitis-Microscopic colitis Celiac disease
Drug induced- Nonosmotic laxatives Drugs- Osmotic laxatives and antacids
Endocrine- Thyrotoxicosis Functional- IBS
Endocrine tumors-Gastrinoma/VIPoma/Carcinoid
2. Fatty (bloating and steatorrhea in many)
Malabsorption syndrome
(loss of absorptive ability)
Carbohydrate malabsorption-lactose intolerance Pancreatic exocrine insufficiency
Celiac Disease
Ischemia-Mesenteric Ischaemia
Maldigestion
(loss of digestive function)
Infection-Giardia/bacterial overgrowth/ Whipple
3. Inflammatory or exudative- occult or frank blood or pus……often (but not always) Large gut pathology
IBD- Crohn disease/UC
Infectious- Cl. Difficile/TB/Entamoeba/CMV/HSV
Neoplasia- Colon carcinoma/Lymphoma/Villous adenocarcinoma
History:
1. Symptom- organic or functional problem?
Nocturnal symptoms/weight loss/bloody stool/Fever- organic
None present- Probably Functional
2. Type of diarrhoea- gives some clue
Watery- Secretory/Osmotic causes
Floating/sticky stool/ bulky malodorous pale stool- malabsorption/Maldigestion
Bloody/pus - Inflammatory or exudative cause……....(blood > bloody but pus > NOT pu**y)
44
Diarrhoea stops after fasting- osmotic diarrhoea
3. Abdo pain
Around umbilicus- small bowel disease
RIF/LIF- large bowel diarrhoea
Pain relieved with defecation- IBS
Epigastric- Ch. Pancreatitis
Postprandial pain- Intestinal Angina(Mesenteric Vasculitis)
4. Appetite loss- Infection/IBD/Malignancy
5. Wt. loss- Malignancy/IBD/Malabsorption/Thyrotoxicosis
6. Fever- IBD/Infection
7. Family history
8. History of neoplastic, inflammatory bowel (IBD) or celiac disease
9. Previous surgery- Extensive resections of the ileum and right colon/ gastric and jejunoileal bypass for
obesity/cholecystectomy may lead to diarrhoea- each by different mechanism(s)
10. H/o Pancreatic disease- ch. Pancreatitis
11. Alcohol- chronic alcoholism is a cause
12. Drugs-Laxative overuse/Orlistat
13. Recent travel- Giardiasis/Infectious colitis
14. Prolonged antibiotic therapy-Clostridium difficile infection
Examination should attempt to elicit evidence of organic disease
Pallor- Malabsorption
Jaundice- PBC
Edema- Malabsorption
Goiter- Thyrotoxicosis
Tremor -Thyrotoxicosis
Thyroid eye signs-Thyrotoxicosis
Glossitis/cheilitis/ angular stomatitis- Vitamin def due to Malabsorption
Abdominal tenderness- IBD/Chronic Pancreatitis
Mass- Malignancy
Ascites-Malignancy/Malabsorption
Dermatitis herpetiformis-Celiac disease
Extra-intestinal manifestations of IBD- stomatitis/Pyoderma gangrenous/ Episcleritis
Initial investigations
FBC
CRP/ESR
Albumin
Liver and Kidney function tests
Glucose level
Electrolytes
TSH
HIV serology
Routine stool tests 3x samples- for OCP; Parasitology Antigens; C/S; occult blood test
Further tests- guided by preliminary diagnosis
Stool- Fecal pH – Lactose intolerance (fecal pH < 5.5).
Electrolytes, evaluating osmotic gap to distinguish secretory from osmotic diarrhea.
Calprotectin- a marker of neutrophil activity that can be useful to detect IBD.
Clostridium difficile toxin
Fecal fat quantitative and qualitative analysis- if suspicion of malabsorption
Sigmoidoscopy/Colonoscopy with biopsy- Large bowel disease
45
Ba follow through- small bowel disease
Enteroscopy/Capsule endoscopy- for small bowel disease
Serology- Antigliadin, Anti endomysial antibody- Coeliac disease
Q. A 60 yrs old diabetic pt on insulin therapy was brought to casualty dept with h/o sudden onset altered level
consciousness. What are the likely possibilities here? How will you approach this case?
Important causes of sudden onset altered level of consciousness in a Diabetic are
1. Causes directly related to DM- 2. Causes indirectly related to DM-
a) Hypoglycemia a) CVA/TIA
b) HHS
c) DKA
d) Uremic encephalopathy
Approach= Clinical + Investigation
History- Important points suggestive of an underlying problem are
1. Mode of onset-
 over few minutes- Hypoglycemia; CVA
 over few hours/days- HHS/DKA/Uremia
2. Preceding symptoms-
 sweating/palpitation/dizziness- Hypo
 slurred speech/hemiparesis- CVA
3. Background of patient
 Bad glycaemic control- HHS/DKA
 Missing doses of Drugs- HHS/DKA
 Missing a meal- hypo
 Recent increase in dose of drugs- hypo
 Concurrent acute illness- if present- May be a ppting factor for HHS/DKA
 Renal damage- if prexisting- Uremia
4. Associated symptoms, if any
 Fever- infection- ppting factor for HHS/DKA
 Productive cough- infection- ppting factor for HHS/DKA
 Swelling- Uremia
 severe thirst- Hyperglycemia- HHS/DKA
 Recent Polyuria- Hyperglycemia- HHS/DKA
 recent Hypoglycemic spells-hypo again
 low urine output- uremia
 Dysuria- infection- ppting factor for HHS/DKA
Examination- important things to look for with their significance
 CBG- Low- hypoglycaemia; Very high- could be HHS/DKA
 Dehydration- could be present in HHS/DKA
 Temp- High - infection- ppting factor for HHS/DKA
 Any signs of focal infection- should be looked for- HHS/DKA
 Focal neurodeficit- CVA
Investigation
 Immediate CBG- Low- hypoglycaemia; High- could be HHS/DKA
 FBC/CRP- high-infection- ppting factor for HHS/DKA
 ABG- Metabolic acidosis- DKA/Uremia
 Urea/CR- High- Uremia
 Urine - ketones+ - DKA
 Sepsis screen- to look for an infection
 CT Brain- for CVA
46

Approach To Common Medical Symptons

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Approach To Common Medical Symptons

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APPROACH

As discussed in the class the “key thing” is to think about the

Differential………if D/D type Q

PD…….if /P/D type Q

Approach= 1.Clinical→ history+ examination 2. Investigations

Management (remember actual and our own ''ABCD''!!)

Special-type depends on provisional diagnosis

Examination-Important points with diagnostic clues

WHO classification- RA with no or rare blasts in the peripheral blood

Suspected cause Special test

Fever with Maculopapular rash/Exanthematous rash

Fever with Splenomegaly/Fever with Hepatosplenomegaly

Appproach= Clinical= (History+Examination)++ Investigation= (Preliminary + Special)

Provisional diagnosis Investigations I will arrange

Approach- (almost) same as hepatosplenomegaly

Slowly increasing Indolent obstruction/ Hepatic malignancy

Examination- Important points are

Prov. diagnosis Special test

Obstructive Jaundice MRCP

Special- nature depends on provisional diagnosis

Provisional Diagnosis Special tests

Ans 2. Approach includes 1.Clinical approach= history & examination 2. Investigations

Anasarca/Oedematous patient- approach

1. Pattern of swelling- Low urine output- Kidney disease

Further tests- should be guided by initial assessment

History Important points with their significance

2. Flaccid type- Acute Flaccid Paralysis (AFP)

Seropositive diseases Seronegative Spondyloarthropathies

How to proceed to diagnose/Approach= Clinical= History +Examination

Pattern of joint involvement

Seropositive diseases Seronegative Spondyloarthropathies

2.Infections- direct or Indirect effect- Endocarditis/Acute Rheumatic fever(ARF)

Finding What it suggests

Approach= Clinical= (history & examination) + Investigations

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