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Differentials (The common presentations), spot diagnoses and the CBD station Ronan Fitzgerald – Ronan.Fitzgerald3@wales.nhs.uk Jocelyn Mak - maksh@cardiff.ac.uk CHEST PAIN CARDIO RESP GI MSK OTHER ACS Pneumothorax Reflux Costochondritis Panic attack Pericardium Pneumonia Peptic ulcer disease Muscle strain anaemia Myocardium PE Gastritis Conduction Asthma system exacerbation VesselsThe key with chest pain Acute: will normally be straightforward Chronic: may require more investigation and questioning • When presenting differentials don’t just state the main differential and leave it at that. Expand your answer • Furthermore, just because a patient doesn’t have a productive cough doesn’t rule out pneumonia. If a patient does not have haemoptysis this doesn’t mean the cause of chest pain isn’t a PE. If a patient presents with chest pain it can always be anything. Angina social history is very important e.g. exercise tolerance, diet, smoking e.t.c.ACS Diabetics: can often have an atypical presentation of an MI i.e. a silent MITroponin elevates 4-6hours after the event and remains elevated for 10 days Shortness of breath Hypoxaemia Hypercapnia Acidaemia Impaired O2 Other deliver system Pulmonary COPD exacerbation Ketoacidosis Heart failure CAD oedema Pneumonia Asthma Lactic acidosis Obstructive Anxiety exacerbation shock (massive PE/Tamponade/ tension pneum) PE Pain Pneumothorax Interstitial lung diseaseAsthma exacerbation (paeds)Abdo painDon’t just think abdo=GIRuptured AAA KEY FEATURES • BG:HTN • Back pain • Reduced GCS/collapse • IF RUPTURED: Hypotension/collapse/ peritonitis Acute pancreatitis Full history is important, and this could be what they assess you onHeadache physiological Intracranial Extracranial Tension headache GCA Trigeminal neuralgia Cluster headache Meningitis Sinusitis Migraine Intracranial bleed AACG Medication induced SAH CO poisoning Venous sinus thrombosis Raised ICP Aura: spots, wavy lines, or flashing lights. Your hands, arms, or face may tingle or Physiological feel numb Tension Cluster Migraine Trigeminal headache headache neuralgia Band like pain Around the eye Unilateral Stabbing pains Stress 30mins-3hours Pulsating Trigeminal nerve distribution Later in the day Lacrimation Aura Triggers (E.g. shaving) Flushing photophobia Sx's of cause (e.g. MS, aneurysm) SAH Blood in the sylvian fissure Blood in the basal cisternsVenous sinus thrombosis **Hypercoagulable stateRaised ICP • Worse in the morning, on bending or coughing • Vomiting • Visual disturbance • May have neuro symptoms or seizures CAUSES 1. Tumour 2. Intracranial bleed 3. IIH 4. HydrocephalusGCA **High dose corticosteroids is the treatment of choice. Very good way to diagnose GCA is response to steroid treatment • Unilateral throbbing pain • Scalp tenderness • Jaw claudication Inflammation and thickening of the temporal artery can cause ischaemia and result in vision loss. Temporal artery is the most common artery affected but other arteries can be affected Collapse/Fall Cardiovascular Neurological Other Arrhythmias (cardiac Seizure Drug OD syncope) Postural hypotension TIA/Stroke Alcohol intox Vertebrobasilar Vasovagal Mechanical fall insufficiency Aortic stenosis Raised ICP Shock caused by external diagnosis Carotid sinus Intracranial bleeds hypersensitivityHow to come up with a CBD? Jocelyn Mak - maksh@cardiff.ac.ukHow does this station work? • Most people PASS this station • You will be given your exact CBD submitted on LC, so I will not recommend 100% route- learning your whole case, but made sure you can discuss your case in a confident and smooth manner • The examiner ”shall” ask you the questions listed on LC, BUT THIS IS NOT 100% • Talk about the case for 7 minutes then question time – suggest you talk for 6-7 minutes • I finished the whole station in 13 minutes-ish…Where people struggles? ● Speak less than 6 minutes ● Did not have anything on social aspect ○ Something that affects one’s quality of life ○ e.g. no capacity to take care of themselves -> care home but patient doesn’t want to be there ○ Fracture -> can no longer run > stressed ● Did not prepare for “weird questions” *Taken from 2023 CBD template Questions? With respect to [the investigation selected], why was that particular test undertaken?’ ‘Regarding the patient’s management [e.g. the choice of a particular drug (being started or stopped) or procedure] what do you think are the risks and benefits of this approach to the patient’s management?’ ‘Are you aware of any guidelines that support this approach/ management?’ ‘What are the key impacts of [this management plan] from the perspective of your patient?’ *Taken from 2023 CBD template Questions ‘Finally, in regard to [ethical, EDI or social science issue] what issues arose and how were they addressed?’ ‘Are there any ethical frameworks, guidelines or principles that you encountered during the care of this patient?’ ‘And finally, what was it about this patient that made an impact on you?’Presentation Hx > Hx of PC > PMHx, PSHx > Drug Hx and allergies > FHx > SHx Initial differentials > Investigations taken place and results > final differentials Management plan Personally I will not talk about any aspect of my ethical discussion in my 7 minutes because then you would felt like you are repeating yourself, however you can hint it. e.g. the patient is a keen runner and not being able to run has a negative impact on her quality of life which we will discuss later in a more in depth.Do you say everything you write down or do you include info that isn’t there? ● Yes, I will say everything I write down because you should only include the most important info on your sheet of paper ● I will elaborate more when I am speaking as it feels more natural and it uses more time as you will get nervous and tend to speak more quickly ● Sheet of paper should aim to allow your examiner to have a brief idea of what your case about ● Don’t glue your eyes to the paper, YOU NEED EYE CONTACT Topics…? 💡always look for a social aspect in the case eg package of care – FAILED if not done so 💡run through your case with a doctor and the questions as well (on LC already) Peds Ortho Endo Cardio pyloric stenosis •NOF/hip dislocation DKA MI intussusception •Osteoarthritis asthma, CF Addisonian crisis Heart failure Neuro Thyrotoxicosis obs and gynae MS Cushing’s Resp PE pre-eclampsia, Stroke/TIA GI Pneumothorax placental abruption, MND Pancreatitis Pulmonary fibrosis placental previa Epilepsy bowel obstruction Lung cancer Endometrial cancer Headache Endometriosis Dementia Acute cholecystitis COPD Menorrhagia Parkinson’s Biliary sepsisGuidelines ● NICE guidelines ● Microguide ● Trust guidelines ● Any royal colleges ● Recommendations from trust’s microbiology ● Research papers (any)Your prep work…. • Make sure you know the condition chosen inside out – including investigation and management • When you practice with friends, ask your friends to test you on questions you don’t think is going to come up • E.g. Investigation – Hip X-ray for suspected NOF#, but instead ask why is a FBC taken • Management – Why is IM nerve block used as a pain relief not morphine? • Try to guess and predict what they are going to ask?Out of the blue…. Example questions 1. What were the complications of the condition? 2. Do you agree/disagree with the management plan? What aspect would you have changed? 3. What areas of the management could be improved?Top Tip Practice with a doctor and ask them to check your ‘answers’!