94476b2a-84c7-41da-955a-3d030dc94d66.jpg
Can you give me the history points that are to be asked from the patient in all these, uh, topics so I get full marks?
Reading File
These are surgical/clinical OSCE topics. Given my budget constraints, I'll compile a comprehensive history-taking guide for all 15 topics from my clinical knowledge directly - this is well-established surgical clerking content that doesn't require deep textbook lookup.
Here is a complete, exam-focused history-taking guide for each topic. For each condition, I've structured the questions around Chief Complaint, History of Presenting Illness (HPI), and relevant systemic/social history - the framework examiners expect.
History-Taking Points for Full Marks
General Framework (ask for ALL topics)
- Name, age, sex, occupation, address
- Chief complaint in patient's own words
- Duration
- Mode of onset (sudden vs. gradual)
- Progression (static, worsening, improving)
- Previous similar episodes
- Past medical/surgical history
- Drug history and allergies
- Family history
- Social history (smoking, alcohol, diet)
- Menstrual/obstetric history (for female patients)
1. Laparoscopic Cholecystectomy (Symptomatic Gallstones / Cholecystitis)
Presenting complaint: Pain in the right hypochondrium / epigastrium
HPI:
- Site, onset, character (colicky vs. constant dull ache), radiation (to right shoulder tip / back - classic biliary colic)
- Severity (1-10)
- Duration and frequency of attacks
- Aggravating factors: fatty meal (key trigger), lying on left side
- Relieving factors: analgesics, vomiting
- Associated features:
- Nausea and vomiting
- Fever and chills (suggests cholecystitis or cholangitis)
- Jaundice (suggests CBD stone / cholangitis)
- Dark urine / pale stools (obstructive jaundice features)
- Pruritus
- Dyspepsia, bloating, flatulence
- Previous episodes - how managed?
- Any previous ERCP or imaging done?
Relevant history:
- Diet: high fat, low fibre
- Oral contraceptive pill use (female)
- Parity (more pregnancies = more risk)
- Rapid weight loss (bariatric surgery, prolonged fasting)
- Haemolytic anaemia (pigment stones)
- Family history of gallstones
- BMI / obesity
2. Acute Appendicitis
Presenting complaint: Right iliac fossa pain
HPI:
- Classic migration: started as central/periumbilical pain, shifted to right iliac fossa (McBurney's point) - ask specifically
- Onset: sudden vs. gradual
- Character: constant dull ache (peritoneal irritation)
- Severity and progression
- Aggravating factors: movement, coughing, walking
- Relieving factors: lying still, flexing right hip
- Associated features:
- Anorexia (often the first symptom - ask if they want to eat)
- Nausea and vomiting (usually after pain onset - important sequence)
- Low-grade fever
- Constipation or diarrhoea (pelvic appendix can cause loose stools)
- Dysuria / frequency (pelvic appendix near bladder)
- Last menstrual period (to rule out ectopic in females)
- Any previous similar episodes (recurrent appendicitis)
- Any prior treatment for this episode (antibiotics may mask)
Relevant history:
- Similar pain before?
- Family history of IBD (Crohn's can mimic)
- Recent travel / gastroenteritis (mesenteric lymphadenitis as differential)
3. Multinodular Goitre (MNG)
Presenting complaint: Swelling in the front of the neck
HPI:
- Duration of swelling (years vs. months)
- Rate of growth (slow = benign MNG; rapid = malignant change)
- Pain or tenderness in the swelling
- Change in size with swallowing
- Pressure symptoms (very important):
- Dysphagia (difficulty swallowing)
- Dyspnoea / stridor (tracheal compression)
- Hoarseness of voice (recurrent laryngeal nerve involvement - suggests malignancy)
- Congestion in face/neck on bending (SVC obstruction - Pemberton's sign)
- Disfigurement
- Thyroid status symptoms:
- Hyperthyroid: weight loss despite good appetite, palpitations, heat intolerance, excessive sweating, tremor, irritability, diarrhoea, irregular menstruation, eye changes (exophthalmos - more Graves')
- Hypothyroid: weight gain, cold intolerance, constipation, lethargy, dry skin, hair loss, bradycardia, menorrhagia, hoarse voice
- Euthyroid: no such symptoms
- Any previous thyroid problems or treatment
- Radioiodine therapy or neck irradiation in the past
- Medications: amiodarone, lithium (cause thyroid dysfunction)
- Iodine intake / dietary history (endemic goitre in iodine-deficient areas)
Family history: Thyroid cancer (MEN syndrome), thyroid disease
4. Cellulitis
Presenting complaint: Redness, swelling, warmth, pain in a body part
HPI:
- Site of involvement
- Duration and rate of spread (mark the edge and ask if spreading)
- Onset: was there a preceding wound, insect bite, skin crack, tinea pedis (athlete's foot - classic portal for leg cellulitis)?
- Character: diffuse redness vs. focal fluctuant swelling (suggests abscess)
- Fever, chills, rigors
- Systemic upset: malaise, nausea
- Any discharge / pus from wound
- Skin changes: blistering, necrosis, black discolouration (necrotising fasciitis - surgical emergency)
- Lymphangitis (red streaking) or lymphadenopathy (lymph node tenderness)
- History of trauma, cuts, IV drug use, animal bite
Relevant history:
- Diabetes (major predisposing factor - always ask)
- Peripheral vascular disease, venous insufficiency
- Immunosuppression (steroids, chemotherapy, HIV)
- Recurrent cellulitis in the same area
- Obesity
- Chronic oedema / lymphoedema
5. Inguinal Hernia
Presenting complaint: Swelling in the groin
HPI:
- Duration of swelling
- Onset: sudden (after straining) vs. gradual
- Location: right, left, bilateral
- Character:
- Reducibility - does it go back on lying down or with manual pressure? (key question)
- Does it come out on coughing / straining / standing?
- Size - constant or variable?
- Pain: mild discomfort vs. severe pain (irreducible / strangulated hernia - emergency)
- Any episode of sudden pain with irreducibility (incarceration / strangulation - ask specifically)
- Vomiting and inability to pass stool/flatus (obstruction)
- Precipitating factors: chronic cough, constipation, straining at micturition (raise intra-abdominal pressure)
Relevant history:
- Chronic cough (COPD, smoker)
- Constipation (straining)
- Urinary symptoms - hesitancy, poor stream, straining (BPH)
- Heavy manual labour / lifting
- Previous hernia repair (recurrent hernia)
- Previous abdominal surgery
- Family history of hernias
6. Diabetic Ulcers
Presenting complaint: Non-healing wound / ulcer on the foot/leg
HPI:
- Site and duration of ulcer
- Onset: was there precipitating trauma (even trivial - new shoes, walking barefoot)?
- Pain: painless ulcer = neuropathic (key); painful = ischaemic/venous; mixed
- Progress: healing, static, or worsening
- Discharge: serous, purulent, foul smell
- Any black or gangrenous tissue
- Fever, systemic sepsis
- Symptoms of neuropathy: numbness, tingling, burning, loss of sensation in feet
- Symptoms of PVD: claudication (leg pain on walking, relieved by rest), rest pain (severe ischaemia), cold feet
Relevant history:
- Diabetes: duration, type (Type 1 or 2), control (HbA1c), medications (insulin, oral agents)
- Previous foot ulcers or amputations
- Hypertension, hyperlipidaemia (cardiovascular risk)
- Smoking (major vascular risk)
- Visual impairment (unable to inspect own feet)
- Foot care practices (footwear, nail cutting)
- Nephropathy (renal function)
7. Ovarian Tumour
Presenting complaint: Lump in lower abdomen / pelvic discomfort
HPI:
- Duration of lump / symptoms
- Rate of growth
- Pain: character, radiation, cyclical vs. constant
- Abdominal distension (ascites suggests malignancy)
- Associated features:
- Nausea, vomiting, anorexia, weight loss (malignancy)
- Urinary symptoms: frequency, urgency (pressure)
- Bowel: constipation, altered bowel habit (pressure)
- Hormonal effects: virilisation (androgen-secreting), precocious puberty (granulosa cell), post-menopausal bleeding
- Acute presentation: sudden onset severe pain (torsion of ovarian cyst - emergency)
- Rupture: sudden pain with peritonism
Gynaecological history:
- Age at menarche, regularity of periods
- LMP (last menstrual period) - if post-menopausal, new mass = malignant until proven otherwise
- Parity and gravidity
- Oral contraceptive use (protective against ovarian cancer)
- Infertility / nulliparity (risk factor for ovarian cancer)
- Previous pelvic surgeries or ovarian cysts
Family history: Ovarian, breast, or colorectal cancer (BRCA1/BRCA2, Lynch syndrome)
8. Appendicular Mass
Presenting complaint: Lump in right iliac fossa following pain
HPI:
- History of acute right iliac fossa pain 3-5 days ago (perforated appendix with abscess/phlegmon)
- Did the pain partially resolve but the lump appeared?
- Current status of pain (should be decreasing in a resolving mass)
- Fever (ongoing infection)
- Nausea, vomiting, anorexia
- Bowel habits: constipation, inability to pass flatus (obstruction)
- Any antibiotic treatment received (may partially treat)
- Previous appendicitis episodes
Relevant history:
- Immunosuppression (may present atypically)
- Other causes of RIF mass: Crohn's (ask about chronic diarrhoea, blood in stool, weight loss), caecal carcinoma (ask about altered bowel habits, PR bleeding, weight loss, tenesmus - always differentiate)
- Pelvic inflammatory disease in females (right adnexal mass)
9. Injection Site Abscess
Presenting complaint: Painful swelling at site of previous injection
HPI:
- Site of swelling
- Duration: when was the injection given vs. when swelling appeared
- Character: painful, fluctuant, warm, red
- Discharge: spontaneous pus drainage
- Fever, systemic sepsis
- Type of injection received: intramuscular, intravenous, subcutaneous
- Drug injected (some medications are more irritant - quinine, diclofenac, paraldehyde - common in developing countries)
- Was sterile technique used?
- Number of injections at the same site
Relevant history:
- Intravenous drug use (IVDU) - very important to ask sensitively
- Diabetes (impaired immunity)
- Immunosuppression
- Poor nutritional status
- HIV/AIDS
- Previous abscesses in the same or different sites
- Recurrent infections (consider immunodeficiency)
10. Carcinoma of the Breast (CA Breast)
Presenting complaint: Lump in the breast
HPI:
- Duration of lump
- Rate of change in size
- Pain: most breast cancers are painless - note if painful (more likely benign)
- Skin changes: dimpling, peau d'orange, skin thickening, ulceration
- Nipple changes: retraction, discharge (colour - serous, bloody = worrying), eczema of nipple (Paget's disease)
- Axillary lump (nodal metastasis)
- Systemic symptoms suggesting metastasis:
- Bone pain (back, hip) - bone mets
- Breathlessness, cough - lung mets / pleural effusion
- Jaundice, right upper quadrant pain - liver mets
- Headache, seizures, neurological deficit - brain mets
- Weight loss, anorexia
Gynaecological/Hormonal history:
- Age at menarche (early menarche = risk)
- Age at menopause (late menopause = risk)
- Age at first pregnancy (late or nulliparous = risk)
- Breastfeeding (protective)
- OCP / HRT use (slight increased risk)
- LMP
Family history: Breast cancer, ovarian cancer (first-degree relatives; BRCA1/BRCA2), bilateral or early-onset
Past history: Previous breast lumps, biopsies, DCIS, breast cancer in other breast
11. Intestinal Obstruction
Presenting complaint: Distension, vomiting, colicky pain, inability to pass stools/flatus
HPI - the 4 cardinal features:
- Abdominal pain: colicky (comes and goes in waves), site (central/periumbilical = small bowel; lower abdomen = large bowel)
- Vomiting: onset relative to pain, character - bilious (proximal obstruction) vs. faeculent (distal obstruction)
- Distension: onset and degree
- Absolute constipation: inability to pass stools AND flatus (key - differentiates from relative constipation); ask specifically about the last time they passed flatus
- Absolute constipation is the hallmark - ask explicitly
- Ask if they passed any stool/flatus since onset (may have partial obstruction)
- Progression of symptoms
Aetiology clues (essential):
- Previous abdominal surgeries (adhesions - #1 cause in developed world)
- Known hernia (strangulated hernia - examine groin)
- Altered bowel habits before this episode (colorectal cancer)
- PR bleeding, mucus in stool, tenesmus (colorectal cancer)
- Weight loss (malignancy)
- Abdominal TB history (strictures)
- Inflammatory bowel disease history (Crohn's strictures)
- Ingestion of foreign body (in children)
- Volvulus risk: chronic constipation, high-fibre diet, psychiatric medications (sigmoid volvulus)
12. Intestinal Perforation
Presenting complaint: Sudden onset severe generalised abdominal pain
HPI:
- Sudden onset (classically) - ask exact time of onset ("Was it sudden like a knife or gradual?")
- Character: severe, constant, generalised (peritonitis) - "board-like rigidity" on exam
- Aggravated by movement, breathing, coughing
- Radiation: shoulder tip pain (diaphragmatic irritation from free gas)
- Vomiting
- Fever (may develop later)
- Cessation of bowel movements
Aetiology (ask about all common causes):
- Peptic ulcer disease: prior epigastric pain, heartburn, water brash, NSAID use, H. pylori treatment, alcohol, stress
- Typhoid fever: fever for weeks, rose spots, diarrhoea (perforated typhoid ulcer - common in developing world)
- Trauma: RTA, stab wound
- Colorectal cancer: prior bowel symptoms, PR bleeding
- Diverticular disease: left lower quadrant pain history, constipation, age >60
- IBD: known Crohn's/UC history
- Appendicitis: prior RIF pain, now generalised (perforated appendix)
Relevant history:
- NSAID / steroid use (peptic ulcer)
- Alcohol use
- Previous PUD or H. pylori
- Immunosuppression (atypical presentation)
13. Diabetic Foot
Presenting complaint: Pain, swelling, ulcer, gangrene of foot in a diabetic patient
HPI:
- Duration and onset of current foot problem
- Precipitating event: trivial injury, nail cut, corn removal, new shoes
- Current symptoms: pain (or painlessness - neuropathic), swelling, redness, discharge, smell
- Extent: single toe, multiple toes, forefoot, whole foot
- Black/gangrenous tissue (dry vs. wet gangrene)
- Fever, rigors (systemic sepsis)
- Classification: Wagner Grade (useful to discuss - Grade 0-5)
Neuropathy symptoms:
- Numbness, tingling, burning ("glove and stocking" distribution)
- Loss of protective sensation (painless injuries)
- Charcot's joint history
Ischaemia symptoms:
- Claudication: which distance, which muscle (calf = femoral disease), worsens with activity
- Rest pain (severe, nocturnal, relieved by hanging leg off bed)
- Cold feet
- Colour changes: pallor, cyanosis, rubor
Diabetes history:
- Type, duration, control, medications
- HbA1c, last eye/foot check
- Complications: nephropathy, retinopathy, neuropathy, previous amputations
- Other cardiovascular risk factors: hypertension, hyperlipidaemia, smoking
14. Right-Sided Paralysis (Stroke / Hemiplegia)
Presenting complaint: Sudden weakness / paralysis of right side of body
Note: Right-sided paralysis = Left hemisphere lesion (dominant hemisphere) - expect aphasia/dysphasia
HPI:
- Onset: sudden (ischaemic/haemorrhagic stroke) vs. gradual (tumour, subdural)
- Time of onset (very important - thrombolysis window is 4.5 hours for ischaemic stroke)
- "Last known well" time
- Progression: improving, static, or worsening
- Extent: face, arm, leg (UMN pattern), complete or partial hemiplegia
- Associated features:
- Speech: unable to speak (expressive/Broca's aphasia), unable to understand (receptive/Wernicke's), or both (global aphasia)
- Facial drooping (LMNL - whole face; UMNL - lower face only)
- Dysphagia (swallowing difficulty)
- Visual field defect (homonymous hemianopia)
- Headache: sudden severe headache ("worst headache of life") = subarachnoid haemorrhage
- Vomiting, loss of consciousness (raised ICP / haemorrhagic)
- Seizures at onset
- Sensory loss / hemisensory disturbance
- Bowel and bladder incontinence
Risk factor history (ESSENTIAL):
- Hypertension (most important risk factor)
- Diabetes mellitus
- Atrial fibrillation (cardioembolic stroke)
- Previous TIA (transient ischaemic attack - sudden reversible deficit lasting <24h)
- Previous stroke
- Hyperlipidaemia
- Smoking
- Obesity
- OCP use, pregnancy (in women)
- Cardiac: rheumatic heart disease, valve prosthesis, recent MI, endocarditis
- Carotid artery disease, peripheral vascular disease
- Sickle cell disease
- Drug use: cocaine, amphetamines
15. Periampullary Mass / Carcinoma
Presenting complaint: Jaundice, lump in epigastrium
Periampullary = tumour near ampulla of Vater (head of pancreas, distal CBD, duodenum, ampulla itself)
HPI:
- Progressive, painless jaundice (classic presentation - Courvoisier's law: painless jaundice + palpable gallbladder = malignancy until proven otherwise)
- Dark urine (bilirubinuria)
- Pale/clay-coloured stools (obstructive jaundice)
- Pruritus (bile salts in skin - ask about scratch marks)
- Epigastric / back pain: dull, boring, radiating to back (pancreatic involvement, coeliac plexus invasion)
- Anorexia and significant weight loss (malignant systemic effect)
- Nausea, vomiting
- New-onset diabetes (pancreatic endocrine destruction) - ask about polyuria, polydipsia, weight loss
- Steatorrhoea: pale, bulky, foul-smelling, floating stools (exocrine pancreatic insufficiency)
- Altered bowel habits
- Symptoms of metastasis: ascites (liver mets), breathlessness (pleural effusion)
- Trousseau's sign history: migratory thrombophlebitis (associated with pancreatic cancer)
Relevant history:
- Smoking (risk factor for pancreatic cancer)
- Chronic alcohol use (chronic pancreatitis leading to cancer)
- Chronic pancreatitis history
- Diabetes mellitus (long-standing DM is a risk factor AND a consequence)
- Family history of pancreatic cancer, BRCA2, Lynch syndrome
- Previous ERCP, biliary investigations
Quick Summary: Common Points to Include for ALL Topics
| Category | Always Ask |
|---|---|
| Pain (SOCRATES) | Site, Onset, Character, Radiation, Alleviating/Aggravating, Timing, Exacerbating, Severity |
| Associated symptoms | As listed per topic |
| Drug history | Especially NSAIDs, steroids, OCP, anticoagulants, insulin |
| Allergy history | Drugs, food, latex |
| Past medical history | Especially DM, HTN, IHD, previous surgeries |
| Family history | Cancer, cardiovascular, endocrine, hereditary |
| Social history | Smoking (pack-years), alcohol (units/week), occupation, travel, diet |
| In females | LMP, parity, gravidity, menstrual regularity, OCP/HRT use |
Good luck with your exam!
94476b2a-84c7-41da-955a-3d030dc94d66.jpg
Can you give me the differential diagnosis of all these topics?
Here is a complete differential diagnosis list for all 15 topics, organized the way examiners expect - by most likely to less likely, with key distinguishing features noted.
Differential Diagnoses
1. Lap Cholecystectomy (Symptomatic Gallstone Disease / Cholecystitis)
| Differential | Key Distinguishing Feature |
|---|---|
| Acute peptic ulcer / duodenal ulcer | Epigastric pain, relieved by food, no fever, endoscopy confirms |
| GERD / hiatal hernia | Burning retrosternal, worse lying down, no fever |
| Acute pancreatitis | Severe epigastric pain radiating to back, raised serum amylase/lipase |
| Right lower lobe pneumonia | Pleuritic chest pain, cough, fever, CXR confirms |
| Hepatitis (viral/alcoholic) | Diffuse liver tenderness, jaundice, LFT pattern different, no gallstones on USS |
| Renal colic (right) | Loin-to-groin colicky pain, haematuria, no fever unless infected |
| Fitz-Hugh-Curtis syndrome | RUQ pain in young women, history of PID/STI |
| Angina / MI | Right-side cardiac ischaemia can mimic biliary pain; ECG, troponin |
2. Acute Appendicitis
| Differential | Key Distinguishing Feature |
|---|---|
| Mesenteric lymphadenitis | Children, preceded by URTI, no guarding, USS shows enlarged lymph nodes |
| Ovarian cyst (torsion / rupture) | Females, sudden onset, no classic migration of pain, USS confirms |
| Ectopic pregnancy | Females of reproductive age, LMP, positive beta-hCG |
| Pelvic inflammatory disease (PID) | Females, bilateral tenderness, cervical excitation, vaginal discharge |
| Mesenteric ischaemia | Elderly, pain out of proportion to signs, atrial fibrillation |
| Crohn's disease | Chronic history, diarrhoea, weight loss, perianal disease |
| Caecal carcinoma | Elderly, PR bleeding, weight loss, palpable mass, colonoscopy |
| Ureteric colic (right) | Loin-to-groin pain, haematuria, no peritonism |
| Psoas abscess | Hip flexion pain, fever, may mimic RIF tenderness |
| Meckel's diverticulitis | Clinically indistinguishable pre-op; younger patients |
| Appendicular mass | Pain 3-5 days ago, now resolving, mass in RIF |
| Right-sided torted varicocoele / hydatid cyst | Males, specific USS findings |
3. Multinodular Goitre (MNG)
The question here is: what else presents as a neck swelling?
| Differential | Key Distinguishing Feature |
|---|---|
| Thyroid carcinoma | Hard, irregular, single dominant nodule, rapid growth, hoarseness, lymphadenopathy - must always rule out |
| Graves' disease (diffuse goitre) | Diffuse smooth swelling, hyperthyroidism, exophthalmos, bruit over gland |
| Thyroid adenoma (solitary) | Single smooth nodule, may be toxic (Plummer's), FNAC confirms |
| Hashimoto's thyroiditis | Rubbery firm diffuse goitre, hypothyroidism, anti-TPO antibodies |
| De Quervain's thyroiditis | Painful tender thyroid, viral prodrome, raised ESR, transient hyperthyroid then hypothyroid |
| Thyroglossal cyst | Midline, moves on swallowing AND protrusion of tongue, younger patients |
| Lymph node enlargement (cervical) | Does NOT move on swallowing - key differentiator; TB, lymphoma, metastasis |
| Branchial cyst | Lateral neck, anterior to SCM, young adults, does not move on swallowing |
| Carotid body tumour | Pulsatile, lateral neck, splays carotid bifurcation on angiography |
| Parathyroid adenoma | Usually not palpable but consider if hypercalcaemia found |
| Lipoma / sebaceous cyst | Superficial, no relation to swallowing |
4. Cellulitis
| Differential | Key Distinguishing Feature |
|---|---|
| Necrotising fasciitis | Rapidly spreading, disproportionate pain, skin necrosis, gas on imaging - surgical emergency, must not miss |
| Erysipelas | Superficial dermis only, sharply demarcated raised border, usually Strep pyogenes |
| Deep vein thrombosis (DVT) | Calf swelling and erythema, no fever usually, Doppler USS confirms |
| Abscess | Localised fluctuant swelling, needs incision and drainage |
| Eczema / contact dermatitis | Bilateral involvement, itching predominant, no systemic fever |
| Lipodermatosclerosis | Chronic venous insufficiency, hyperpigmentation, indurated skin, not acutely infected |
| Insect bite / allergic reaction | History of bite, urticaria, rapid onset, responds to antihistamines |
| Gout / septic arthritis | Periarticular, involves joint, joint aspiration distinguishes |
| Lymphoedema | Non-pitting, no fever, chronic, bilateral in primary form |
| Pyomyositis | Deep muscle infection, MRI shows muscle involvement, common in tropics |
5. Inguinal Hernia
The question here is: what else presents as a groin swelling?
| Differential | Key Distinguishing Feature |
|---|---|
| Femoral hernia | Below and lateral to pubic tubercle, more common in women, higher risk of strangulation |
| Hydrocele | Transilluminates, confined to scrotum, cannot get above it |
| Varicocoele | "Bag of worms" feel, left-sided usually, increases on standing, reduces on lying |
| Epididymo-orchitis | Testicular tenderness, fever, urinary symptoms, USS |
| Testicular torsion | Sudden severe testicular pain, elevated testis, Doppler - absent flow |
| Undescended testis | No testis in scrotum on that side, non-tender groin lump |
| Lipoma of cord | Soft, reducible feel but does NOT change with cough impulse |
| Saphena varix | Bluish, compressible, disappears on lying down, thrill on coughing, varicose veins in leg |
| Inguinal lymphadenopathy | Multiple, firm/rubbery nodes, look for source of infection/malignancy in lower limb, genitalia |
| Psoas abscess | Fluctuant, cold, below inguinal ligament, comes from lumbar spine (TB) |
| Femoral artery aneurysm | Pulsatile, expansile, Doppler confirms |
6. Diabetic Ulcers
Classify by type of ulcer:
| Differential | Key Distinguishing Feature |
|---|---|
| Neuropathic ulcer (diabetic) | Painless, pressure points (sole, heel), punched-out edges, warm foot, good pulses |
| Ischaemic ulcer (PVD) | Painful, distal (toes, tips), pale/cold foot, weak/absent pulses, ABI <0.9 |
| Mixed (neuroischaemic) ulcer | Features of both, most common in diabetic foot |
| Venous ulcer | Medial gaiter area (above medial malleolus), shallow, sloping edges, haemosiderin pigmentation, varicosities |
| Traumatic ulcer | Clear history of injury, healing normally if no infection |
| Marjolin's ulcer | SCC arising in chronic ulcer, raised everted edges, induration, regional LN |
| Pressure sore / decubitus ulcer | Over bony prominences in bedridden patients, sacrum, heel |
| Tropical ulcer | Rapidly spreading, foul smell, young adults in tropics |
| Syphilitic ulcer (gumma) | Punched out, painless, no discharge, serology |
| Vasculitic ulcer | Rheumatoid, SLE - irregular, multiple, on dorsum of foot |
| Pyoderma gangrenosum | Violaceous undermined edges, associated with IBD, RA |
7. Ovarian Tumour
| Differential | Key Distinguishing Feature |
|---|---|
| Functional ovarian cyst | Common in premenopausal women, usually resolves in 6 weeks |
| Endometrioma ("chocolate cyst") | Cyclical pain, dysmenorrhoea, dyspareunia, history of endometriosis |
| Ovarian carcinoma | Postmenopausal, solid/complex cyst, ascites, raised CA-125 |
| Dermoid cyst (teratoma) | Young women, may contain teeth/hair on imaging, risk of torsion |
| Fibroma | Solid, benign, associated with Meigs' syndrome (ascites + pleural effusion) |
| Tubo-ovarian abscess | Fever, PID history, tender, USS shows complex collection |
| Ectopic pregnancy | Adnexal mass, positive beta-hCG, haemoperitoneum |
| Uterine fibroid (pedunculated) | Arises from uterus, moves with uterus, may mimic ovarian mass |
| Appendiceal abscess | RIF, prior appendicitis history |
| Bowel mass (caecal/sigmoid CA) | Colonoscopy, CEA, CT scan |
| Urinary bladder distension | Arises from pelvis, dull to percussion, catheterisation empties it |
| Mesenteric cyst | Mobile, transilluminates, moves perpendicular to mesentery |
8. Appendicular Mass
A mass in the right iliac fossa has broad differentials:
| Differential | Key Distinguishing Feature |
|---|---|
| Appendicular mass (phlegmon) | History of acute appendicitis 3-5 days ago, resolving pain, tender RIF mass |
| Appendicular abscess | Appendicular mass + high fever + fluctuance = abscess (USS guided drainage) |
| Caecal carcinoma | Elderly, PR bleeding, weight loss, altered bowel habit, colonoscopy - must always rule out |
| Crohn's disease | Chronic diarrhoea, weight loss, perianal disease, skip lesions on imaging |
| Ileal TB | Endemic areas, fever, night sweats, weight loss, Mantoux/biopsy |
| Ovarian cyst / tumour | Females, USS confirms adnexal origin |
| Psoas abscess | Lumbar spine or hip TB, hip flexion pain, cold fluctuant swelling |
| Kidney (palpable) | Ballottable, moves with respiration, resonant on percussion (colon in front) |
| Hydatid cyst | Endemic area (sheep farmers), smooth, cystic, Casoni's test, serology |
| Lymphoma | Rubbery nodes, systemic B symptoms, CT lymphadenopathy |
| Actinomycosis | Rare, woody hard mass, sinuses, history of GI surgery or IUD use |
9. Injection Site Abscess
| Differential | Key Distinguishing Feature |
|---|---|
| Cellulitis | Diffuse, no fluctuance, no pus; may coexist |
| Haematoma | History of anticoagulant use, fluctuant but not warm/tender as abscess, aspiration yields blood |
| Seroma | Post-surgical/post-traumatic, clear fluid on aspiration |
| Granuloma | Hard, non-tender nodule, sterile; from oil-based injection (e.g. paraldehyde) |
| Pyomyositis | Deep seated, intramuscular abscess, MRI for depth |
| Necrotising fasciitis | Rapidly spreading, crepitus, systemic sepsis - emergency |
| Thrombophlebitis | Along vein track in IV drug users, cord-like tender vein |
| Infected sebaceous cyst | Pre-existing cyst in that area |
| Deep vein thrombosis | IV drug users; Doppler USS |
10. Carcinoma of the Breast (CA Breast)
| Differential | Key Distinguishing Feature |
|---|---|
| Fibroadenoma | Young women <30 yrs, smooth, firm, very mobile ("breast mouse"), non-tender, no skin changes |
| Fibrocystic disease (fibroadenosis) | Cyclical pain and nodularity, worse premenstrually, bilateral |
| Breast cyst | Well-defined, smooth, fluctuant, transilluminates, USS and aspiration confirms |
| Fat necrosis | History of trauma, irregular, firm, skin tethering mimics cancer; biopsy distinguishes |
| Breast abscess | Lactating women, hot, tender, fluctuant, fever |
| Phyllodes tumour | Large, rapidly growing, bosselated, can be benign or malignant, FNAC/biopsy |
| Lipoma | Soft, lobulated, non-tender, no skin changes |
| Gynaecomastia | Males, bilateral disc of tissue under nipple, hormonal causes |
| Paget's disease of nipple | Eczema-like change of nipple/areola, underlying DCIS or invasive cancer |
| Metastasis to breast | Lymphoma, melanoma, contralateral breast cancer |
| Mondor's disease | Thrombophlebitis of chest wall veins, cord-like, self-limiting |
11. Intestinal Obstruction
| Differential | Key Distinguishing Feature |
|---|---|
| Paralytic ileus | No colicky pain, absent bowel sounds, diffuse distension, post-surgery or peritonitis |
| Pseudo-obstruction (Ogilvie's) | Elderly, massive colonic dilation, no mechanical cause on imaging |
| Peritonitis | Board-like abdomen, no bowel sounds, guarding/rigidity, generalised |
| Volvulus (sigmoid/caecal) | Massive distension, AXR - "coffee bean sign" (sigmoid), CT confirms |
| Acute pancreatitis | Epigastric pain, raised amylase, ileus, no mechanical obstruction |
| Intussusception | Children, "red-currant jelly" stool, sausage-shaped mass, USS confirms |
| Mesenteric ischaemia | Elderly, pain out of proportion, no mechanical cause, urgent CT angiography |
| Gastroenteritis | Diarrhoea (not obstipation), no distension, settles with supportive care |
| Diabetic ketoacidosis | Abdominal pain and vomiting mimic obstruction; check blood glucose |
12. Intestinal Perforation
| Differential | Key Distinguishing Feature |
|---|---|
| Perforated peptic ulcer | Epigastric pain suddenly becoming generalised, PUD history, free gas under diaphragm on erect CXR |
| Perforated appendix | RIF pain spreading to generalise, young patient |
| Perforated typhoid ulcer | Endemic area, fever for 2-3 weeks, sudden abdominal pain |
| Perforated diverticulum | Elderly, left-sided pain, constipation history |
| Perforated bowel cancer | Altered bowel habits, weight loss, PR bleeding |
| Acute pancreatitis | Can mimic perforation; no free gas, raised amylase |
| Ruptured aortic aneurysm | Elderly male, pulsatile mass, haemodynamic shock, CT confirms |
| Ruptured ectopic pregnancy | Females, amenorrhoea, positive beta-hCG, haemoperitoneum |
| Mesenteric ischaemia | Ischaemic bowel may perforate; Doppler/CT angiography |
| Spontaneous bacterial peritonitis | Cirrhotic patient, ascites, fever, no free gas |
13. Diabetic Foot
(overlaps with diabetic ulcers but focuses on the foot as a whole)
| Differential | Key Distinguishing Feature |
|---|---|
| Ischaemic foot (PVD without DM) | Absent pulses, cold, ABI low, claudication, no neuropathy |
| Acute limb ischaemia | 6 Ps (Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold), acute onset |
| Gout / pseudogout | Acute joint inflammation, first MTP joint, raised uric acid, joint aspiration |
| Septic arthritis | Hot, swollen joint, fever, pus on aspiration |
| Osteomyelitis | Bone pain, fever, deep infection, MRI gold standard for diagnosis |
| Charcot's joint (neuropathic) | Painless, warm, swollen, deformed foot, X-ray shows joint destruction |
| Venous ulceration | Medial gaiter area, varicose veins, no neuropathy |
| Cellulitis | Diffuse erythema, no underlying ulcer, responds to antibiotics |
| Deep vein thrombosis | Calf swelling, Doppler USS, no arterial compromise |
14. Right-Sided Paralysis
| Differential | Key Distinguishing Feature |
|---|---|
| Ischaemic stroke (most common) | Sudden onset, no headache, CT - hypodense area after 24h, MRI diffusion early |
| Haemorrhagic stroke | Sudden onset, severe headache, vomiting, hypertensive, CT shows hyperdense area |
| Subarachnoid haemorrhage | "Thunderclap" worst-ever headache, neck stiffness, LP shows xanthochromia |
| Subdural haematoma | Elderly, on anticoagulants, minor trauma history, fluctuating consciousness, crescent on CT |
| Extradural haematoma | Trauma, "lucid interval," lenticular hyperdensity on CT |
| Hypertensive encephalopathy | Very high BP, confusion, seizures, PRES on MRI |
| Brain tumour | Gradual onset weakness, headache worse in morning, seizures, ring-enhancing lesion on CT/MRI |
| Brain abscess | Fever, raised ICP, ring-enhancing lesion, source of infection |
| Todd's palsy | Post-ictal transient hemiplegia after seizure, resolves in <24 hours |
| Multiple sclerosis | Young patient, relapsing-remitting, white matter plaques, other episodes |
| Hemiplegic migraine | Young, resolves completely, migraine history, MRI normal |
| Hypoglycaemia | Focal neurological deficit, check blood glucose immediately - treatable |
| Conversion disorder | Young patient, psychological stressor, inconsistent neurology, normal imaging |
15. Periampullary Mass
Differential for obstructive jaundice with a mass:
| Differential | Key Distinguishing Feature |
|---|---|
| Carcinoma of head of pancreas | Most common, painless jaundice, back pain, weight loss, very poor prognosis |
| Ampullary carcinoma | Intermittent (silver-coloured "silver stool"), better prognosis, ERCP and biopsy |
| Cholangiocarcinoma (distal CBD) | Progressive jaundice, thin patient, MRCP shows stricture |
| Duodenal carcinoma | Rare, may bleed PR, duodenoscopy confirms |
| Chronic pancreatitis | History of alcohol, recurrent pancreatitis, calcification on CT, can cause stricture |
| Choledocholithiasis (CBD stone) | Colicky pain, intermittent jaundice, Charcot's triad if cholangitis (pain + jaundice + fever), USS and MRCP |
| Mirizzi syndrome | Gallstone impacted in Hartmann's pouch compressing CBD, USS/MRCP |
| Primary sclerosing cholangitis (PSC) | Young males, associated with UC, beaded appearance on MRCP |
| Lymphoma (periportal) | B symptoms (fever, night sweats, weight loss), lymphadenopathy, staging CT |
| Metastatic lymph nodes at porta hepatis | Known primary cancer, diffuse disease, CT confirms |
| Hepatitis (acute) | Medical jaundice - no palpable gallbladder, LFTs hepatitic pattern, serology |
Quick Rule of Thumb for Exams
- Always include malignancy as a differential for any lump, ulcer, or obstructive picture
- Always include ectopic pregnancy in any female of reproductive age with abdominal pain
- Always include DVT with any leg swelling
- Always include necrotising fasciitis as a differential for spreading skin infection - it is the one you must not miss
- For jaundice: divide into prehepatic / hepatic / posthepatic before listing differentials
This is a shared conversation. Sign in to Orris to start your own chat.