Lump in groin

1. Patient Identification

• Name, Age, Gender, Occupation, Address

Chief Complaint

• Primary Symptom: Lump in the groin.

• Duration: How long has the lump been present?
• Size: Describe the size of the lump (pea-sized, walnut-sized, etc.).
• Pain: Is the lump painful? Does it vary with movement or pressure?
• Progression: Has the lump changed in size or characteristics over time?
• Associated Symptoms: Any associated symptoms like fever, weight loss, night sweats?

2. History of Present Illness

• Onset: Was the onset sudden or gradual?

• Precipitating Factors: Any events or activities that preceded the appearance of the
lump?
• Changes Over Time: Any recent changes in size, color, or consistency of the lump?
• Symptoms of Compression: Does the lump cause any symptoms such as pain or
discomfort when walking, coughing, or straining?

3. Past Medical History

• Previous Lumps: History of similar lumps or masses in any other part of the body?
• Chronic Conditions: Any chronic illnesses or conditions (e.g., cancer, autoimmune
diseases)?
• Surgeries: Previous surgeries, especially in the abdominal or pelvic area?

4. Medication History

• Current Medications: List all current medications.

• Previous Treatments: Any treatments tried for the lump (e.g., antibiotics, pain
relievers)?

5. Family History

• Genetic Predispositions: Family history of cancers or benign tumors?

• Other Relevant Conditions: Any family members with similar lumps or masses?

6. Social History

• Occupation: Current and past occupations, especially those involving exposure to

toxins or chemicals.
• Lifestyle: Smoking history, alcohol consumption, recreational drug use.
• Sexual History: Risk factors for sexually transmitted infections (if relevant).
7. Review of Systems

• General: Fever, weight loss, night sweats.

• Skin: Rashes, changes in skin color over the lump.
• Respiratory: Cough, shortness of breath.
• Gastrointestinal: Changes in bowel habits, abdominal pain.
• Urinary: Changes in urinary habits, pain with urination.
• Neurological: Numbness or weakness in the lower extremities.
• Musculoskeletal: Joint pain or stiffness.

8. System-Specific Examination

Inspection:

• Location: Identify the exact location of the lump in relation to landmarks such as the
inguinal ligament, femoral vessels, and adjacent structures.
• Size and Shape: Note the dimensions (length, width) and shape (round, oval, irregular)
of the lump.
• Color and Surface: Assess for any skin changes overlying the lump (redness,
discoloration) and note the texture of the skin covering the lump.
• Symmetry: Compare with the contralateral side for symmetry.

3. Palpation:

• Surface Palpation:
o Gentle Palpation: Start with light palpation to assess tenderness and superficial
characteristics (smooth, irregular).
o Deep Palpation: Apply deeper pressure to assess the depth and consistency of
the lump (soft, firm, hard).
o Mobility: Determine if the lump is fixed to underlying structures or if it moves
with palpation.
o Borders: Feel for well-defined vs. poorly defined margins of the lump.
• Pulsations: Check for pulsations which could indicate a vascular origin (e.g., femoral
artery aneurysm).

4. Lymph Node Examination:

• Palpate the regional lymph nodes:

o Inguinal Nodes: Along the inguinal ligament and around the femoral vessels.
o Femoral Nodes: In the femoral triangle (below the inguinal ligament and lateral
to the femoral artery).
• Note any enlargement, tenderness, or fixation of lymph nodes which may suggest
infection or metastasis.

5. Hernia Examination:

• Assess for the presence of a hernia, especially if the lump is reducible or changes with
position (cough impulse) or Valsalva maneuver.
• Differentiate between inguinal hernias (direct vs. indirect) and femoral hernias.
6. Abdominal Examination:

• Palpate the abdomen to check for any intra-abdominal masses or organomegaly that
may be associated with the groin lump.
• Assess for signs of peritoneal irritation (tenderness, guarding) which could suggest a
surgical abdomen.

7. Genital Examination (if indicated):

• Examine the genitalia and perineal area for any lesions, ulcers, or signs of
inflammation.
• Look for evidence of sexually transmitted infections or other genital pathology.

9. Investigations)
• Imaging Studies:

• Ultrasound: Useful for identifying characteristics such as size, location, and contents
of the lump.
• CT Scan or MRI: Sometimes necessary for further evaluation of deeper structures or
suspected malignancies.

• Laboratory Tests:

• Blood Tests: Complete blood count (CBC), inflammatory markers (ESR, CRP), and
specific tests based on clinical suspicion (e.g., tumor markers).
• Biopsy: Consider fine-needle aspiration cytology (FNAC) or core biopsy for suspicious
lumps or those not clearly defined by imaging.

• Special Tests:

• Hernia Examination: Assess for reducibility and presence of bowel sounds to

differentiate hernias.
• Lymph Node Biopsy: For enlarged lymph nodes to exclude malignancy or infection.
Differential diagnosis
Condition Key Features Exclusion Criteria
Inguinal Hernia Bulge that may appear with Absence of reducibility, negative
coughing or straining, cough impulse, normal bowel
reducible, may be painful, sounds, lack of bowel obstruction
bowel sounds may be heard. symptoms.
Femoral Hernia Lower groin lump, more Absence of femoral hernia signs
common in women, often (absence of lump, negative impulse
non-reducible, may cause on cough), normal bowel function.
symptoms of intestinal
obstruction.
Lymphadenopathy Enlarged lymph nodes Negative lymph node biopsy
palpable in inguinal region, showing no evidence of
associated with infection or malignancy, resolution with
malignancy. treatment of underlying infection.
Abscess Localized collection of pus, Absence of fluctuance on
(Furuncle/Carbuncle) may be tender, red, warm to palpation, resolution with antibiotic
touch, history of skin treatment, absence of systemic
infection. signs of infection.
Lipoma Soft, mobile, painless lump, Typical fatty consistency on
slow-growing, typically palpation, lack of growth or change
benign. in size over time, no associated
symptoms.
Sebaceous Cyst Firm, mobile lump under the Punctum visible on inspection,
skin, may be tender, often content expressible through the
associated with a punctum punctum, lack of signs of infection.
(central pore).
Varicocele Dilated veins in the scrotum Absence of visible varicose veins
(more common on the left or dilated vessels, no change with
side), may extend into the Valsalva maneuver, lack of scrotal
inguinal canal. swelling.
Inguinal Enlarged, tender lymph nodes Improvement with antibiotics,
Lymphadenitis due to infection (e.g., negative lymph node biopsy for
sexually transmitted malignancy, absence of systemic
infections). symptoms.
Inguinal Liposarcoma Rare malignant tumor arising Histopathological examination
from fat cells, may present as showing malignant cells, growth
a painless, slowly enlarging despite conservative management,
mass. systemic symptoms.
 Neck swelling
History of Present Illness (HPI)

1. Onset:
o When did the swelling first appear?
o Was the onset sudden or gradual?
2. Duration:
o How long has the swelling been present?
o Has it been constant or intermittent?
3. Location:
o Where exactly is the swelling located? (Anterior, lateral, posterior neck)
4. Size and Progression:
o Has the size of the swelling changed over time? (Increasing, decreasing, or stable)
5. Associated Symptoms:
o Pain: Is the swelling painful? If so, describe the nature and severity of the pain.
o Redness or warmth: Any signs of inflammation?
o Fever, night sweats, weight loss: Any systemic symptoms suggesting infection or
malignancy?
o Dysphagia or odynophagia: Difficulty or pain with swallowing?
o Hoarseness: Any changes in the voice?
o Respiratory symptoms: Shortness of breath, stridor, or wheezing?
6. Character of Swelling:
o Hard or soft?
o Mobile or fixed?
7. Other Symptoms:
o Any history of recent infections (e.g., upper respiratory tract infections, dental
infections)?
o Recent travel history or exposure to tuberculosis?
o Any history of trauma to the neck?
o Changes in appetite or bowel habits?
o Recent dental procedures or infections?

Past Medical History

1. Previous Neck Swellings:

o Any prior episodes of neck swelling?
o Previous diagnoses or treatments?
2. Chronic Illnesses:
o History of autoimmune diseases, thyroid disorders, malignancies, or infectious diseases?
3. Surgical History:
o Any previous neck surgeries or radiation therapy?
4. Medications:
o Current medications, including over-the-counter drugs and supplements.
o History of immunosuppressive therapy?

Family History
1. Thyroid Disorders:
o Family history of thyroid diseases (e.g., goiter, thyroid cancer)?
2. Genetic Conditions:
o Any known genetic conditions in the family that might present with neck swelling?

Social History

1. Occupation:
o Any occupational exposures to chemicals, radiation, or infections?
2. Lifestyle:
o Smoking, alcohol use, recreational drug use?

Review of Systems (ROS)

General:

• Fever, chills, night sweats, weight loss, fatigue

HEENT (Head, Eyes, Ears, Nose, Throat):

• Visual changes, headaches, nasal congestion, sore throat, ear pain

Respiratory:

• Cough, shortness of breath, wheezing

Cardiovascular:

• Chest pain, palpitations, edema

Gastrointestinal:

• Nausea, vomiting, abdominal pain, changes in bowel habits

Endocrine:

• Heat or cold intolerance, changes in weight, excessive sweating, hair loss

Hematologic/Lymphatic:

• Easy bruising, bleeding, history of anemia, other lymph node swellings

Physical Examination

1. General Appearance:
o Vital signs: Fever, tachycardia, hypertension
o Overall health status
2. Neck Examination:
o Inspection: Swelling, asymmetry, skin changes
o Palpation: Size, consistency, mobility, tenderness, warmth
o Lymph nodes: Location, size, consistency, tenderness, fixation
 o Thyroid gland: Size, nodularity, tenderness, consistency, presence of bruit
3. HEENT Examination:
o Oral cavity: Dental issues, mucosal lesions
o Ears: Signs of infection
o Nasopharynx: Nasal congestion, postnasal drip
o Eyes: Conjunctival pallor, exophthalmos
4. Respiratory Examination:
o Auscultation for breath sounds, stridor, wheezes
5. Cardiovascular Examination:
o Heart sounds, murmurs, peripheral pulses
6. Abdominal Examination:
o Hepatosplenomegaly, masses
7. Neurological Examination:
o Cranial nerves, motor and sensory function

Investigations
1. Blood Tests:

• CBC: To check for infection or hematological malignancy.

• ESR, CRP: Inflammatory markers for infection or autoimmune diseases.
• Thyroid Function Tests (TSH, T3, T4): To assess thyroid disorders.
• Autoantibodies (ANA, anti-dsDNA, SSA/SSB): For autoimmune diseases.
• Serological Tests (EBV, CMV, HIV, TB): To identify specific infections.

1. Imaging:

• Ultrasound: First-line imaging for evaluating neck masses.

• CT Scan: Detailed evaluation of neck structures and for suspected neoplasms or congenital
lesions.
• MRI: For detailed soft tissue assessment, particularly in suspected malignancies.
• Doppler Ultrasound: To assess vascular anomalies.
• Chest X-ray: For suspected tuberculosis or mediastinal involvement.

2. Biopsy:

• Fine Needle Aspiration (FNA): For cytological evaluation of the swelling.

• Excisional Biopsy: For histopathological diagnosis if FNA is inconclusive.
 Differential Diagnoses
Diagnosis Clinical Features Investigations for Exclusion
Infections Fever, redness, tenderness, CBC (elevated WBC), CRP, ESR,
(Bacterial/Viral) recent infection blood cultures, throat swab,
serology for EBV/CMV, chest X-
ray for TB
Tuberculosis (TB) Chronic cough, weight loss, PPD test, IGRA, chest X-ray,
night sweats, travel history sputum culture, biopsy of lymph
node (Ziehl-Neelsen stain, PCR)
Thyroid Disorders Goiter, hyperthyroid or TSH, Free T3, Free T4, anti-TPO
hypothyroid symptoms antibodies, ultrasound, fine needle
aspiration biopsy (FNA)
Reactive Recent infection, tender lymph Clinical history, physical exam,
Lymphadenopathy nodes, mobile CBC (usually normal), imaging if
needed (ultrasound)
Lymphoma Painless, firm lymph nodes, B CBC (possible cytopenias), LDH,
symptoms (fever, night sweats, excisional biopsy, CT scan, PET
weight loss) scan
Metastatic Cancer Hard, fixed lymph nodes, Imaging (CT, MRI, PET scan),
primary cancer symptoms FNA or excisional biopsy, primary
cancer workup (mammogram,
colonoscopy, etc.)
Congenital Soft, cystic, present since Ultrasound, CT scan, MRI, FNA if
Lesions childhood necessary
Thyroglossal Duct Midline neck mass, moves with Ultrasound, CT scan, MRI, FNA
Cyst swallowing or tongue protrusion
Branchial Cleft Lateral neck mass, no movement Ultrasound, CT scan, MRI, FNA
Cyst with swallowing
Autoimmune Multisystem involvement, non- ANA, ACE levels, chest X-ray,
Diseases (e.g., tender lymphadenopathy biopsy (non-caseating granulomas
Sarcoidosis, in sarcoidosis), specific
Lupus) autoantibodies
Vascular Pulsatile mass, bruit on Doppler ultrasound, CT
Anomalies auscultation angiography, MRI angiography
Trauma Recent neck injury, tender Clinical history, physical exam,
(Hematoma) swelling ultrasound, CT scan
Neoplasms Painless mass, possible Ultrasound, CT scan, MRI, FNA or
(Primary Thyroid, dysphagia or hoarseness core biopsy
Salivary Gland)

Midline Neck Lumps:

1. Thyroglossal Duct Cyst:
o Key Features: Midline, moves with swallowing or tongue protrusion, may be tender,
fluctuant.
o Exclusion Criteria: Imaging (ultrasound) to confirm cystic nature, presence of thyroid
tissue on imaging supports diagnosis.
2. Thyroid Nodule:
o Key Features: Midline or slightly off midline, firm or cystic, may be associated with
thyroid dysfunction.
o Exclusion Criteria: Thyroid function tests (TSH, T4), ultrasound to evaluate
characteristics (solid vs. cystic), and fine-needle aspiration biopsy if suspicious.
3. Thyroid Cancer (Papillary or Follicular):
o Key Features: Firm, painless nodule in thyroid gland, may have cervical
lymphadenopathy.
o Exclusion Criteria: Histopathological examination following biopsy, imaging (CT scan,
MRI) for staging.
4. Dermoid Cyst:
o Key Features: Midline, soft to firm, mobile, may contain sebaceous material or hair.
o Exclusion Criteria: Imaging (CT scan, MRI) to assess contents and relation to
surrounding structures, histopathological examination if necessary.
5. Branchial Cleft Cyst (Second Branchial Cleft):
o Key Features: Lateral to midline, anterior to sternocleidomastoid muscle, may enlarge
with upper respiratory tract infections.
o Exclusion Criteria: Imaging (ultrasound, CT scan) to delineate cystic nature and relation
to adjacent structures, surgical exploration may be diagnostic.

Vertical Neck Lumps:

1. Lymphadenopathy:
o Key Features: Enlarged lymph nodes, often due to infection (reactive) or malignancy
(lymphoma, metastasis).
o Exclusion Criteria: Clinical assessment of size, consistency, mobility, and associated
symptoms; biopsy (fine-needle aspiration or excisional) for definitive diagnosis.
2. Carotid Body Tumor:
o Key Features: Along the carotid artery, pulsatile, may cause hoarseness or dysphagia if
large.
o Exclusion Criteria: Imaging (CT scan, MRI, angiography) to evaluate vascular
involvement, biopsy for definitive diagnosis.
3. Thyroid Goiter:
o Key Features: Enlargement of the thyroid gland, may cause neck swelling or compression
symptoms.
o Exclusion Criteria: Thyroid function tests (TSH, T4), ultrasound to assess size and
characteristics, fine-needle aspiration biopsy if suspicious for malignancy.
4. Parathyroid Adenoma:
o Key Features: Vertical alignment with thyroid gland, may cause hyperparathyroidism.
o Exclusion Criteria: Serum calcium and parathyroid hormone (PTH) levels, imaging
(ultrasound, sestamibi scan), surgical exploration for definitive diagnosis.
5. Cervical Vertebrae Osteophytes:
o Key Features: Bony outgrowths along cervical vertebrae, may cause local discomfort or
dysphagia.
o Exclusion Criteria: Imaging (X-ray, CT scan) to visualize bony changes and rule out
other pathology causing neck prominence.
 Abscess
1. Analysis of Complaint:

• Onset:
o When did you first notice the abscess?
o Was the onset sudden or gradual?
• Location:
o Where is the abscess located?
o Have you had abscesses in this location before?
• Duration:
o How long have you had the abscess?
• Character:
o Describe the appearance of the abscess (size, color, any discharge).
o Is the abscess painful?
• Radiation:
o Does the pain or swelling spread to nearby areas?
• Intensity:
o How severe is the pain on a scale of 1 to 10?
• Timing:
o Is the pain constant or intermittent?
o Have you noticed any changes in the size or severity over time?
• Exacerbating/Relieving Factors:
o What makes the abscess worse?
o What, if anything, makes it better?
• Associated Symptoms:
o Do you have fever or chills?
o Have you experienced any malaise or fatigue?
o Is there any redness or warmth around the abscess?
o Any drainage of pus or other fluid from the abscess?

2. Associated Symptoms:

• Systemic Symptoms:
o Fever, chills, night sweats
o Malaise or general feeling of unwellness
• Local Symptoms:
o Redness, warmth, swelling around the abscess
o Pain and tenderness at the site
o Discharge of pus or other fluids
• Other Symptoms:
o Swollen lymph nodes near the site of the abscess
o Any limitation in movement or function due to the abscess

3. Questions to Exclude Differential Diagnosis:

• Infected Cyst:
o Have you had any lumps or cysts in this area before?
o Have you noticed any previous similar episodes?
• Cellulitis:
o Is there extensive redness or spreading infection around the abscess?
o Do you have any chronic conditions such as diabetes or a compromised immune system?
• Folliculitis:
o Is the abscess associated with hair follicles?
o Have you had any recent shaving or trauma to the area?
 • Furuncle/Carbuncle:
o Are there multiple abscesses clustered together?
o Have you noticed any recurrence of similar boils?
• Hydradenitis Suppurativa:
o Do you have multiple, recurrent abscesses in areas like armpits or groin?
o Do you have a family history of similar skin conditions?
• Necrotizing Fasciitis:
o Is the pain disproportionate to the size of the abscess?
o Do you have severe systemic symptoms, such as high fever or rapidly spreading redness?

4. Review of Systems:

• General:
o Fever, weight loss, night sweats, fatigue
• Skin:
o Redness, warmth, swelling, tenderness, pus discharge, any other skin lesions or rashes
• Musculoskeletal:
o Pain, swelling, or limitation in movement near the abscess
• Lymphatic:
o Swollen lymph nodes near the affected area
• Cardiovascular:
o Any signs of systemic infection (e.g., endocarditis symptoms like heart murmur)
• Respiratory:
o Any difficulty breathing, cough, or other respiratory symptoms if abscess is near chest or
respiratory tract
• Gastrointestinal:
o Any abdominal pain, nausea, vomiting, especially if abscess is in the abdominal area
• Neurological:
o Any weakness, numbness, or other neurological symptoms, especially if abscess is near spine
or brain

Investigations
1. Laboratory Tests:

• Complete Blood Count (CBC):

o WBC Count: Elevated white blood cell count can indicate infection.
o Differential: Neutrophilia may suggest bacterial infection, while eosinophilia could indicate
a parasitic infection or allergic reaction.
• C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR):
o Elevated levels suggest inflammation or infection.
• Blood Cultures:
o To identify any bacteremia, especially if the patient has systemic symptoms like fever or
chills.
• Gram Stain and Culture of Abscess Fluid:
o Obtain a sample of pus or discharge from the abscess for Gram staining and culture.
o This helps identify the causative organism and its antibiotic sensitivity.
• Basic Metabolic Panel (BMP):
o To assess renal function, especially if systemic infection or sepsis is suspected.
• Liver Function Tests (LFTs):
o To evaluate liver function in cases of systemic involvement or suspected hepatic abscess.

2. Imaging Studies:

• Ultrasound:
 o Helps assess the extent of the abscess and differentiate it from other soft tissue masses.
o Can guide aspiration or drainage procedures.
• Computed Tomography (CT) Scan:
o Useful for evaluating deep-seated abscesses (e.g., intra-abdominal, pelvic, or retroperitoneal
abscesses).
o Provides detailed imaging to assess the size, location, and involvement of adjacent structures.
• Magnetic Resonance Imaging (MRI):
o Useful for complex cases or when abscesses are located near critical structures (e.g., spinal
abscess).
o Provides high-resolution images to assess the extent of soft tissue involvement.

3. Specific Tests Based on Location and Clinical Suspicion:

• Chest X-ray:
o If there is a suspicion of thoracic involvement or pleural effusion.
• Echocardiogram:
o If infective endocarditis is suspected, especially in patients with underlying heart conditions
or persistent bacteremia.
• Aspiration and Biopsy:
o In cases where the diagnosis is uncertain, fine-needle aspiration or biopsy of the abscess may
be performed for histopathological examination.
• Specific Cultures and Sensitivity:
o Fungal culture if fungal infection is suspected (e.g., in immunocompromised patients).
o AFB (Acid-Fast Bacilli) stain and culture if tuberculosis is suspected.

4. Other Investigations:

• Serologic Tests:
o For specific infections based on clinical suspicion (e.g., HIV, hepatitis, syphilis).
• Autoimmune Workup:
o If an autoimmune condition is suspected as the underlying cause (e.g., rheumatoid arthritis).

investigation Purpose
Complete Blood Count (CBC) Assess for leukocytosis indicating infection.
C-Reactive Protein (CRP), ESR Indicate inflammation or infection.
Blood Cultures Detect bacteremia or sepsis.
Gram Stain and Culture of Abscess Identify causative organism and antibiotic sensitivity.
Basic Metabolic Panel (BMP) Evaluate renal function.
Liver Function Tests (LFTs) Assess liver function in systemic involvement.
Ultrasound Visualize abscess and guide drainage.
CT Scan Detailed imaging for deep-seated abscesses.
MRI High-resolution imaging for complex cases.
Chest X-ray Evaluate thoracic involvement or pleural effusion.
Echocardiogram Assess for infective endocarditis.
Aspiration and Biopsy Histopathological examination for uncertain cases.
Fungal Culture Identify fungal infections in immunocompromised patients.
AFB Stain and Culture Detect tuberculosis if suspected.
Serologic Tests Diagnose specific infections (e.g., HIV, hepatitis).
Autoimmune Workup Identify autoimmune conditions as underlying causes.
 Differential diagnosis

Type of Abscess Differential Diagnoses

Skin and Soft Tissue
Cellulitis, infected cyst, furuncle (boil), carbuncle, erysipelas
Abscess
Appendicitis with abscess, diverticulitis, pelvic inflammatory disease
Intra-abdominal Abscess
(PID), liver abscess, spleen abscess
Peritonsillar Abscess Tonsillitis, retropharyngeal abscess, parapharyngeal abscess
Dental Abscess Dental caries, periodontal abscess, Ludwig's angina
Brain Abscess Meningitis, encephalitis, cerebral infarction, brain tumor
Spinal Abscess Discitis, epidural abscess, vertebral osteomyelitis
Lung Abscess Pneumonia, empyema, lung cancer
Hepatic Abscess Pyogenic liver abscess, amebic liver abscess
Renal Abscess Pyelonephritis, renal cyst, renal tumor
Psoas Abscess Tuberculosis, Crohn's disease, appendicitis
Rectal Abscess Anal fistula, perianal cellulitis, Crohn's disease
Perianal Abscess Anal fistula, hemorrhoid, hidradenitis suppurativa
Joint Abscess Septic arthritis, gouty arthritis, rheumatoid arthritis

Examination

1.Inspection: Appearance:
▪ Observe the abscess for size, shape, color, and presence of any discharge.
▪ Look for signs of erythema (redness), swelling, and warmth around the area.
▪ Note any fluctuation, which may indicate a collection of pus.
• Location:
▪ Determine the exact anatomical location of the abscess.
▪ Check for symmetry and compare with the contralateral side.
• Number:
▪ Assess if there are multiple abscesses or a single lesion.
▪ Look for satellite lesions or spread.
• Surrounding Area: Examine the skin around the abscess for signs of cellulitis or spreading infection.
Look for streaking or lymphangitis, indicating the spread of infection through lymphatic channels
2. Palpation: Tenderness: Gently palpate the abscess to assess tenderness and pain. Note the degree of
tenderness and whether it is localized or extends beyond the abscess.
• Fluctuation: Use gentle pressure to assess for fluctuation, indicating the presence of pus. Check if the
abscess feels soft and compressible or hard and firm.
• Induration: Palpate around the abscess to check for induration (hardness), which can indicate the extent of
the infection or inflammation. Assess if the induration is well-defined or diffuse.
• Temperature: Feel the area to determine if it is warmer than the surrounding skin, indicating active
inflammation.
• Lymph Nodes: Note the size, consistency, and tenderness of any palpable lymph nodes
▪ Palpate regional lymph nodes (e.g., cervical, axillary, inguinal) to check for lymphadenopathy.

3.Examination of Discharge: If there is discharge, observe its color, consistency, and odor. Note if the
discharge is purulent (pus), serous (clear fluid), or sanguineous (bloody).

Culture and Sensitivity: If appropriate, obtain a sample of the discharge for culture and sensitivity to
identify the causative organism and guide antibiotic therapy.
 Breast lump
1. Chief Complaint

• Primary Symptom: Presence of a breast lump.

• Duration: When was the lump first noticed?
• Location: Which breast (left, right, both)? Specific quadrant or area?
• Character: How would you describe the lump (size, consistency, mobility)?
• Pain: Is there any associated pain or tenderness?
• Changes Over Time: Has the lump grown in size or changed in any way since first
noticed?

2. History of Present Illness

• Onset: Did the lump appear suddenly or gradually?

• Progression: Has there been any recent rapid growth or changes?
• Associated Symptoms:
o Skin changes (redness, dimpling, puckering)?
o Nipple discharge (color, consistency)?
o Any axillary lymph node enlargement or tenderness?
• Menstrual History: Menopausal status, last menstrual period.

3. Past Medical History

• Breast Conditions: Any history of previous breast lumps, cysts, or fibroadenomas?

• Breast Cancer History: Personal or family history of breast cancer or other cancers?
• Hormonal Factors: Use of hormonal replacement therapy, oral contraceptives?

4. Medication History

• Current Medications: Including hormone therapy or supplements.

• Allergies: Any known drug allergies.

5. Family History

• Breast Cancer: Family history of breast or ovarian cancer (especially in first-degree

relatives)?
• Other Relevant Conditions: Any other familial conditions of significance?

6. Social History

• Occupation: Exposure to potential carcinogens (e.g., chemicals, radiation)?

• Lifestyle: Smoking history, alcohol consumption, physical activity level.

7. Review of Systems

• General: Weight loss, fatigue, fever.

• Skin: Rashes, itching.
• Endocrine: Changes in appetite, heat or cold intolerance.
• Respiratory: Cough, dyspnea, chest pain.
• Gastrointestinal: Changes in bowel habits, abdominal pain.
• Genitourinary: Changes in urinary habits, dysuria.

8. System-Specific Examination

General Examination:

• Patient's Appearance: Note general appearance, signs of distress, or any obvious

abnormalities.
• Vital Signs: Temperature, pulse, blood pressure, respiratory rate.

2. Breast Inspection:

• Positioning: Ask the patient to sit comfortably with arms relaxed at the sides.
• Visual Inspection:
o Symmetry: Compare both breasts for symmetry in size, shape, and position.
o Skin Changes: Look for dimpling, puckering, erythema, or peau d'orange (orange-
peel appearance).
o Nipple Changes: Check for retraction, scaling, ulceration, or discharge.
o Asymmetry: Note any obvious differences in contour or appearance between the
breasts.
• Axillary Examination:
o Palpate the axillary lymph nodes for enlargement, tenderness, or firmness.

3. Breast Palpation:

• Technique: Use the pads of your fingers (not fingertips) to palpate the breast tissue.
• Pattern: Perform palpation in a systematic pattern (e.g., circular, vertical strip).
• Pressure: Use light, medium, and deep pressure to assess different layers of breast tissue.
• Areas to Cover:
o Entire breast including the nipple-areolar complex.
o Upper outer quadrant (most common location for breast cancers).
o Upper inner quadrant, lower inner quadrant, lower outer quadrant.
• Characteristics to Assess:
o Size and Shape: Note the size, shape, and delineation of the lump.
o Consistency: Determine if the lump is soft, firm, hard, or fluctuant.
o Mobility: Assess whether the lump moves independently from surrounding tissue
(mobile) or is fixed.
o Tenderness: Ask the patient if palpation causes pain or tenderness.
o Borders: Note if the edges of the lump are well-defined or irregular.

4. Nipple Examination:

• Gently compress the nipple to check for discharge (color, consistency).

• Inspect for any changes in the nipple, such as retraction or scaling.

Investigations
• Imaging Studies:

• Mammography: Standard for evaluating breast masses, can detect calcifications and
suspicious features.
• Ultrasound: Differentiates between solid and cystic masses, helps determine if a mass is
suspicious.
• MRI: Used for further characterization of suspicious lesions or to evaluate extent of
disease.

• Biopsy and Pathological Evaluation:

• Core Needle Biopsy: Provides tissue for histopathological examination to differentiate

between benign and malignant lesions.
• Fine-needle Aspiration (FNA): Used for fluid-filled cysts or suspicious masses to obtain
cells for cytological evaluation.
• Histopathology: Examination of tissue for specific features (e.g., stromal overgrowth in
phyllodes tumor, presence of malignant cells).

• Laboratory Tests:

• Cultures: If infection (mastitis, abscess) is suspected, cultures from breast tissue or

aspirate to identify causative organism.

BIRADS
BI- Description Management Recommendations
RADS
Category
0 Incomplete assessment: Additional imaging or Further imaging or evaluation as
evaluation is needed to determine the breast indicated.
abnormality's significance.
1 Negative: No suspicious findings. Routine screening mammography
recommended according to age-specific
guidelines.
2 Benign: Findings are definitely benign (e.g., cysts, Routine screening mammography
calcifications, lipomas). recommended according to age-specific
guidelines.
3 Probably benign: Findings have a high likelihood Short-term follow-up mammography or
(>90%) of being benign, but short-term follow-up ultrasound to monitor stability.
(typically 6 months) is recommended.
4 Suspicious: Findings are suspicious for malignancy Biopsy recommended for definitive
(e.g., architectural distortion, suspicious diagnosis.
calcifications, mass with irregular margins).
- 4A - Low suspicion for malignancy (2-10% Consider biopsy or short-term follow-up
likelihood). depending on clinical factors.
- 4B - Moderate suspicion for malignancy (10-50% Biopsy recommended.
likelihood).
- 4C - Moderate to high suspicion for malignancy (50- Biopsy recommended.
95% likelihood).
5 Highly suggestive of malignancy: Findings are Biopsy strongly recommended.
highly suspicious for malignancy (>95%
likelihood).
6 Known biopsy-proven malignancy: Findings are Management based on known
already known to be malignant based on prior malignancy status and treatment
biopsy. planning.
 Differential Diagnoses
Condition Key Features Exclusion Criteria
Fibrocystic Multiple bilateral lumps, cyclic pain Unilateral solitary lump, fixed or
Changes related to menstrual cycle, smooth and irregular margins, absence of
mobile on palpation, fluctuating in size, hormonal correlation,
often associated with hormonal changes. persistence throughout the cycle.
Fibroadenoma Single, well-defined, firm, rubbery Rapid growth, significant size
lump, mobile, typically painless, most (>3 cm), irregular margins,
common in young women. imaging (ultrasound,
mammography) showing
suspicious features.
Breast Localized area of swelling, redness, Absence of systemic symptoms,
Abscess warmth, tenderness, fluctuant mass, negative cultures from
often associated with fever and systemic aspiration, lack of response to
symptoms. antibiotics.
Breast Cancer Single, firm, irregularly shaped lump, Negative imaging findings
may be fixed to surrounding tissue, skin (mammography, ultrasound,
or nipple changes (dimpling, retraction), MRI) suggestive of benign
associated axillary lymphadenopathy, lesion, absence of malignant
non-cyclic pain. cells on biopsy.
Fat Necrosis History of trauma or surgery to the Negative imaging findings
breast, firm lump with irregular borders, (absence of suspicious features
may be tender, skin retraction or nipple on mammography, ultrasound),
retraction possible. lack of characteristic
histopathological findings.
Mastitis Unilateral breast pain, redness, warmth, Negative bacterial cultures from
swelling, fever, usually occurs during milk or breast tissue, absence of
lactation or breastfeeding. response to antibiotics.
Phyllodes Rapidly growing lump, large size (>3 Absence of stromal overgrowth
Tumor cm), leaf-like projections on imaging, on histopathology, lack of leaf-
stromal overgrowth on histopathology, like projections on imaging,
potential for local recurrence after benign imaging characteristics.
excision.
Inflammatory Rapid onset of red, swollen, warm breast Negative biopsy findings
Breast Cancer with peau d'orange appearance, often (absence of malignant cells),
mistaken for mastitis, absence of fever lack of response to initial
or response to antibiotics, associated treatment for mastitis.
with skin changes (dimpling,
thickening).
Metastatic History of previous cancer, painless, Negative imaging findings
Breast Cancer firm, irregularly shaped lump, fixed to (absence of suspicious lesions in
surrounding tissue, skin or nipple other organs), absence of
changes, systemic symptoms depending malignant cells on biopsy.
on metastatic spread.
 Enlarged liver
Analysis of Complaint

1. Presenting Symptoms:
o Duration and onset of liver enlargement.
o Associated symptoms: pain (character, location, radiation), jaundice, weight loss, fever, fatigue,
pruritus, dark urine, pale stools, anorexia, abdominal distension, bleeding tendencies, and changes in
bowel habits.
2. Characterize the Pain:
o Onset: Sudden or gradual.
o Duration: Continuous or intermittent.
o Nature: Sharp, dull, throbbing.
o Location: Right upper quadrant, epigastrium.
o Radiation: To the back, shoulder, or other areas.
o Aggravating/Relieving Factors: Movement, eating, medication.
3. Associated Symptoms:
o Jaundice: Yellowing of the skin or eyes.
o Fever: Presence of chills or rigors.
o Weight Loss: Unintentional or significant weight loss.
o Fatigue: Severity and impact on daily activities.
o Pruritus: Itching, especially at night.
o Dark Urine/Pale Stools: Changes in urine and stool color.
o Gastrointestinal Symptoms: Nausea, vomiting, diarrhea, constipation.
o Abdominal Distension: Presence of ascites.
o Bleeding Tendencies: Easy bruising, nosebleeds, gum bleeding.
o Changes in Appetite: Anorexia or increased appetite.
4. Past Medical History:
o Previous liver disease: Hepatitis, cirrhosis, liver cancer.
o History of alcohol use: Quantity, duration, and type of alcohol.
o History of blood transfusions: Risk of viral hepatitis.
o History of chronic diseases: Diabetes, hypertension, hyperlipidemia.
o History of liver injury: Trauma, surgery.
o Previous infections: Hepatitis B, C, or other infections.
5. Medication History:
o Current and past medications: Over-the-counter, prescribed, herbal, and supplements.
o Medications known to affect the liver: Acetaminophen, statins, antiepileptics, antibiotics.
6. Social and Occupational History:
o Alcohol consumption: Frequency, quantity, duration.
o Drug use: Intravenous drug use, shared needles.
o Sexual history: Risk of sexually transmitted infections.
o Occupation: Exposure to hepatotoxins, travel history.
o Dietary habits: High-fat diet, consumption of raw shellfish.
7. Family History:
o History of liver disease: In family members.
o Genetic conditions: Hemochromatosis, Wilson's disease.
Excluding Differential Diagnoses

1. Infectious Causes:
o Hepatitis (A, B, C, D, E): Ask about risk factors, travel history, sexual history, and symptoms of
jaundice and fatigue.
o Liver Abscess: Ask about fever, chills, history of intra-abdominal infections.
2. Malignancies:
o Hepatocellular Carcinoma: Ask about history of cirrhosis, hepatitis, weight loss, and anorexia.
o Metastatic Liver Disease: Ask about history of primary malignancies elsewhere in the body.
3. Metabolic Disorders:
o Non-alcoholic Fatty Liver Disease (NAFLD): Ask about obesity, diabetes, hyperlipidemia.
o Hemochromatosis: Ask about family history, skin pigmentation, diabetes.
o Wilson's Disease: Ask about family history, neurological symptoms, Kayser-Fleischer rings.
4. Cardiac Causes:
o Congestive Heart Failure: Ask about history of heart disease, shortness of breath, leg swelling.
o Constrictive Pericarditis: Ask about history of tuberculosis, pericarditis, and dyspnea.
5. Vascular Causes:
o Budd-Chiari Syndrome: Ask about abdominal pain, ascites, history of clotting disorders.
o Portal Vein Thrombosis: Ask about abdominal pain, ascites, history of thrombophilia.
6. Autoimmune and Inflammatory Disorders:
o Autoimmune Hepatitis: Ask about autoimmune diseases, fatigue, arthralgia.
o Primary Biliary Cholangitis (PBC): Ask about pruritus, fatigue, jaundice.
o Primary Sclerosing Cholangitis (PSC): Ask about history of inflammatory bowel disease,
jaundice, pruritus.
7. Toxic Causes:
o Alcoholic Liver Disease: Ask about alcohol consumption history.
o Drug-Induced Liver Injury: Ask about recent medications and supplements.

Review of Affected Systems

1. Gastrointestinal System:
o Nausea, vomiting, diarrhea, constipation.
o Changes in stool color and consistency.
o Abdominal pain, distension, and changes in appetite.
2. Cardiovascular System:
o Symptoms of heart failure: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea.
o Edema, chest pain, palpitations.
3. Hematological System:
o Easy bruising, bleeding tendencies.
o Anemia symptoms: Fatigue, pallor, shortness of breath.
4. Endocrine System:
o Diabetes symptoms: Polyuria, polydipsia, weight loss.
o Thyroid dysfunction: Fatigue, weight changes, temperature intolerance.
5. Neurological System:
o Symptoms of hepatic encephalopathy: Confusion, asterixis, somnolence.
o Symptoms of Wilson's disease: Tremor, dystonia, psychiatric symptoms.
6. Dermatological System:
o Jaundice, spider angiomas, palmar erythema.
o Pruritus, skin pigmentation changes.
7. Renal System:
o Symptoms of renal impairment: Oliguria, hematuria, edema.
8. Musculoskeletal System: Arthralgia, myalgia. and Osteoporosis symptoms: Bone pain, fractures.
Key Questions to Exclude Differential Diagnoses

1. Infections:
o Any recent travel history?
o History of unprotected sex or multiple sexual partners?
o History of intravenous drug use?
2. Malignancies:
o Any history of cancer in the family?
o Unexplained weight loss?
o Loss of appetite?
3. Metabolic Disorders:
o History of diabetes, hypertension, hyperlipidemia?
o History of iron overload or bronze skin pigmentation?
4. Cardiac Causes:
o History of heart disease or symptoms of heart failure?
o Any swelling in the legs or difficulty breathing?
5. Autoimmune Disorders:
o Any history of autoimmune diseases?
o Joint pain or skin rashes?
6. Toxic Causes:
o Alcohol intake details?
o Any recent new medications or herbal supplements?

Investigations for Case of Enlarged Liver (Hepatomegaly)

1. Complete Blood Count (CBC):

o Assess for anemia, leukocytosis, thrombocytopenia, or thrombocytosis.
2. Liver Function Tests (LFTs):
o Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST): Elevated in
hepatocellular injury.
o Alkaline Phosphatase (ALP): Elevated in cholestasis or infiltrative liver disease.
o Gamma-Glutamyl Transferase (GGT): Helps differentiate the cause of elevated ALP.
o Bilirubin (Total and Direct): Elevated in hepatic dysfunction or biliary obstruction.
o Albumin: Low levels suggest chronic liver disease.
o Prothrombin Time (PT)/International Normalized Ratio (INR): Prolonged in severe liver
dysfunction.
3. Renal Function Tests:
o Blood urea nitrogen (BUN) and creatinine to assess renal involvement.
4. Electrolytes:
o Assess for metabolic disturbances.
5. Viral Hepatitis Panel:
o Hepatitis A IgM, Hepatitis B surface antigen (HBsAg), Hepatitis C antibody (anti-HCV), and
Hepatitis E IgM.
6. Autoimmune Markers:
o Anti-Nuclear Antibody (ANA), Anti-Smooth Muscle Antibody (ASMA), Anti-Mitochondrial
Antibody (AMA): For autoimmune hepatitis or primary biliary cholangitis.
o Immunoglobulin levels (IgG, IgM, IgA): Elevated IgG suggests autoimmune hepatitis.
7. Iron Studies:
o Serum Iron, Ferritin, Total Iron-Binding Capacity (TIBC), Transferrin Saturation: To assess
for hemochromatosis.
 8. Wilson's Disease Tests:
o Ceruloplasmin: Low in Wilson's disease.
o 24-Hour Urine Copper: Elevated in Wilson's disease.
9. Alpha-1 Antitrypsin Level:
o To assess for alpha-1 antitrypsin deficiency.
10. Lipid Profile:

• To assess for non-alcoholic fatty liver disease (NAFLD).

11. Serum Amylase and Lipase:

• Elevated in pancreatitis, which can cause referred hepatomegaly.

12. Tumor Markers:

• Alpha-Fetoprotein (AFP): Elevated in hepatocellular carcinoma.

• Carcinoembryonic Antigen (CEA) and CA 19-9: For metastatic cancer to the liver.

Imaging Studies

1. Ultrasound Abdomen:
o First-line imaging to assess liver size, texture, and any focal lesions.
o Assess for biliary obstruction, ascites, and splenomegaly.
2. Computed Tomography (CT) Abdomen:
o Detailed assessment of liver anatomy and pathology.
o Helpful in detecting tumors, abscesses, or metastatic disease.
3. Magnetic Resonance Imaging (MRI) Abdomen:
o Superior soft tissue contrast for detailed assessment of liver lesions.
o Magnetic Resonance Cholangiopancreatography (MRCP): For bile duct evaluation.
4. Elastography (FibroScan):
o Non-invasive assessment of liver fibrosis.

Specialized Tests

1. Liver Biopsy:
o Indicated if the diagnosis remains unclear after non-invasive tests.
o Provides histological diagnosis.
2. Endoscopic Retrograde Cholangiopancreatography (ERCP):
o For suspected biliary obstruction or cholangitis.
3. Genetic Testing:
o For hereditary conditions like hemochromatosis or Wilson's disease.
4. Hepatic Doppler Ultrasound:
o To assess hepatic blood flow, useful in Budd-Chiari syndrome.

Additional Tests Based on Clinical Suspicion

1. Ascitic Fluid Analysis:

o If ascites is present, perform paracentesis and analyze fluid for infection, malignancy, or other
causes.
2. Blood Cultures: If there is a suspicion of infection or sepsis.
Differential diagnosis

. Infectious Causes:

• Viral Hepatitis (A, B, C, D, E):

o Differentiation:
▪ History of exposure, travel, sexual history.
▪ Acute hepatitis typically shows markedly elevated ALT/AST levels.
▪ Specific serological markers for each virus (e.g., HBsAg, Anti-HCV).
• Liver Abscess:
o Differentiation:
▪ Fever, right upper quadrant pain, leukocytosis.
▪ Imaging (Ultrasound, CT) shows a fluid-filled cavity.
▪ Aspiration of pus confirms diagnosis.
• Parasitic Infections (e.g., Schistosomiasis, Echinococcosis):
o Differentiation:
▪ History of exposure to endemic areas.
▪ Imaging may show cystic lesions (e.g., hydatid cyst).
▪ Serology or stool examination for parasites.

2. Metabolic Causes:

• Non-Alcoholic Fatty Liver Disease (NAFLD):

o Differentiation:
▪ Associated with obesity, diabetes, dyslipidemia.
▪ Mildly elevated ALT/AST.
▪ Imaging (Ultrasound, MRI) shows fatty infiltration.
• Alcoholic Liver Disease:
o Differentiation:
▪ History of chronic alcohol use.
▪ Elevated GGT and AST > ALT.
▪ Imaging and clinical signs of liver disease.
• Hemochromatosis:
o Differentiation:
▪ Family history, symptoms of iron overload.
▪ Elevated serum ferritin and transferrin saturation.
▪ Genetic testing for HFE mutations.
• Wilson's Disease:
o Differentiation:
▪ Younger patients, neurological symptoms.
▪ Low serum ceruloplasmin, elevated 24-hour urine copper.
▪ Liver biopsy shows copper deposition.
3. Vascular Causes:

• Congestive Hepatopathy (Right Heart Failure):

o Differentiation:
▪ Symptoms of heart failure (e.g., edema, dyspnea).
▪ Elevated jugular venous pressure, ascites.
▪ Echocardiogram shows reduced cardiac function.
• Budd-Chiari Syndrome:
o Differentiation:
▪ Sudden onset of abdominal pain, ascites.
▪ Hepatic venous outflow obstruction on Doppler ultrasound.
▪ CT/MRI shows thrombosis of hepatic veins.

4. Neoplastic Causes:

• Primary Liver Cancer (Hepatocellular Carcinoma):

o Differentiation:
▪ History of chronic liver disease (e.g., hepatitis B/C, cirrhosis).
▪ Elevated AFP levels.
▪ Imaging (Ultrasound, CT, MRI) shows focal liver lesion.
• Metastatic Liver Disease:
o Differentiation:
▪ Known primary malignancy elsewhere.
▪ Multiple lesions on imaging.
▪ Elevated CEA, CA 19-9 for specific cancers.

5. Autoimmune Causes:

• Autoimmune Hepatitis:
o Differentiation:
▪ Predominantly affects young women.
▪ Elevated IgG, positive ANA, ASMA.
▪ Liver biopsy shows interface hepatitis.
• Primary Biliary Cholangitis (PBC):
o Differentiation:
▪ Middle-aged women, pruritus, fatigue.
▪ Elevated ALP and GGT.
▪ Positive anti-mitochondrial antibody (AMA).
• Primary Sclerosing Cholangitis (PSC):
o Differentiation:
▪ Associated with inflammatory bowel disease.
▪ Elevated ALP.
▪ MRCP/ERCP shows bile duct strictures and beading.
 Generalized edema
Patient Identification

• Name, Age, Gender, Occupation, Address

Presenting Complaint

• Chief complaint: "Generalized swelling" or "edema"

History of Presenting Complaint

• Onset: When did the swelling start? Was it sudden or gradual?

• Duration: How long has the swelling been present?
• Location: Is the swelling generalized or more pronounced in certain areas (e.g., legs,
face)?
• Progression: Has the swelling increased, decreased, or remained the same over time?
• Associated Symptoms:
o Shortness of breath
o Fatigue
o Weight gain
o Abdominal distension
o Decreased urine output
• Aggravating/Relieving Factors: What makes the swelling worse or better? (e.g., time of
day, activity, lying down)
• Previous Episodes: Has the patient experienced similar episodes in the past? If so, how
were they managed?

Past Medical History

• History of cardiovascular disease (e.g., heart failure, hypertension)

• History of liver disease (e.g., cirrhosis)
• History of kidney disease (e.g., nephrotic syndrome, chronic kidney disease)
• History of thyroid disease (e.g., hypothyroidism)
• History of venous insufficiency or deep vein thrombosis (DVT)
• Diabetes mellitus
• History of malignancy

Medication History

• Current medications (including over-the-counter drugs and supplements)

• Recent changes in medication
• Use of medications known to cause edema (e.g., NSAIDs, steroids, calcium channel
blockers)

Allergies

• Any known drug allergies or reactions

 Family History

• Family history of cardiovascular, renal, or hepatic diseases

• Any hereditary conditions (e.g., hereditary angioedema)

Social History

• Smoking history
• Alcohol consumption
• Illicit drug use
• Diet and fluid intake
• Occupational history (exposure to toxins, sedentary lifestyle)

Review of Systems

Cardiovascular System

• Chest pain
• Palpitations
• Dyspnea on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Syncope

Respiratory System

• Cough
• Sputum production
• Hemoptysis
• Wheezing

Gastrointestinal System

• Abdominal pain
• Nausea/vomiting
• Changes in bowel habits
• Jaundice

Genitourinary System

• Changes in urine output (frequency, volume)

• Hematuria
• Dysuria
• Nocturia

Endocrine System

• Symptoms of hypothyroidism or hyperthyroidism (e.g., weight changes, temperature

intolerance)
• Diabetes symptoms (e.g., polyuria, polydipsia)
 Hematological System

• Bruising or bleeding tendencies

• Fatigue
• Anemia symptoms (e.g., pallor, shortness of breath)

Musculoskeletal System

• Joint pain or swelling

• Muscle weakness
• History of trauma

Neurological System

• Headache
• Visual disturbances
• Weakness or numbness
• Seizures

Physical Examination

• General Appearance: Look for signs of distress, weight gain, or cachexia.

• Vital Signs: Blood pressure, heart rate, respiratory rate, temperature.

• Cardiovascular Examination: Check for jugular venous distention, heart sounds,
peripheral pulses, capillary refill.
• Respiratory Examination: Assess for crackles, wheezes, or decreased breath sounds.
• Abdominal Examination: Check for hepatomegaly, ascites, tenderness.
• Peripheral Examination: Look for pitting edema, skin changes, varicosities.

• Basic Laboratory Tests:

• CBC: To check for anemia, infection, or inflammation.

• Basic Metabolic Panel: To evaluate kidney function (creatinine, BUN), electrolytes.
• Liver Function Tests: To assess hepatic function.
• Urinalysis: To detect proteinuria or hematuria.

• Specific Tests Based on Clinical Suspicion:

• BNP: To assess for heart failure.

• Echocardiography: To evaluate cardiac function and structure.
• TSH and Free T4: To assess thyroid function.
• 24-hour Urinary Protein: To quantify proteinuria in suspected nephrotic syndrome.
• Serum Albumin and Total Protein: To assess for hypoalbuminemia.
• Chest X-ray and Ultrasound: To evaluate for signs of heart failure, liver disease, or
kidney disease.

• Advanced Investigations:

• CT/MRI: To further evaluate abdominal organs or cardiac structures.

• Kidney Biopsy: If nephrotic syndrome or glomerulonephritis is suspected.
• Serological Tests: For specific infections or autoimmune conditions.

Category Potential Cause Key Clinical Features Investigations

Cardiovascul Congestive Heart Dyspnea, orthopnea, JVD, BNP, echocardiography,
ar Failure (CHF) S3 gallop chest X-ray
Pericardial Disease Chest pain, pulsus Echocardiography,
paradoxus, muffled heart ECG, chest X-ray
sounds
Renal Nephrotic Proteinuria, Urinalysis, serum
Syndrome hypoalbuminemia, albumin, kidney biopsy
hyperlipidemia, edema
Acute Kidney Oliguria/anuria, elevated Serum creatinine, blood
Injury (AKI) serum creatinine urea nitrogen (BUN),
electrolytes, ultrasound
Chronic Kidney Fatigue, uremic symptoms, Serum creatinine, BUN,
Disease (CKD) hypertension GFR, ultrasound, biopsy
Hepatic Liver Cirrhosis Jaundice, ascites, spider Liver function tests
angiomas, palmar erythema (LFTs), ultrasound,
CT/MRI, biopsy
Endocrine Hypothyroidism Fatigue, weight gain, cold TSH, free T4, anti-
intolerance, dry skin thyroid antibodies
Cushing's Central obesity, moon facies, 24-hour urinary free
Syndrome striae, hypertension cortisol, dexamethasone
suppression test
Nutritional Severe Protein- Weight loss, muscle wasting, Serum albumin, total
Calorie fatigue protein, dietary
Malnutrition assessment
Beriberi (Thiamine Cardiovascular symptoms, Thiamine levels, clinical
Deficiency) neurologic symptoms response to thiamine
Infectious Severe Infections Fever, hypotension, Blood cultures, complete
(Sepsis) tachycardia, organ blood count (CBC),
dysfunction inflammatory markers
Parasitic Infections Lymphatic obstruction, Blood smear, serology,
(e.g., Filariasis) tropical exposure PCR for specific
parasites
Drug- Medications (e.g., Recent medication history, Medication review,
induced NSAIDs, steroids, specific drug side effects clinical correlation
calcium channel
blockers)
Other Idiopathic Edema Diagnosis of exclusion, Clinical diagnosis, rule
often in premenopausal out other causes
women
Allergic Reactions Urticaria, recent allergen Clinical history, specific
(e.g., exposure IgE levels, tryptase
Angioedema)
 Joint Pain & Swelling
1. Patient Identification

• Name, Age, Gender, Occupation, Address

2. Chief Complaint

• Primary Symptom: Joint pain and swelling.

• Duration: How long have the symptoms been present?
• Location: Which joints are affected?
• Severity: On a scale of 1 to 10, how severe is the pain?
• Character: Is the pain sharp, dull, throbbing, or burning?
• Onset: Was the onset sudden or gradual?
• Progression: Has the pain been getting better, worse, or staying the same?
• Pattern: Is the pain constant or intermittent? Any diurnal variation?
• Swelling: Is the swelling constant or does it fluctuate?

2. History of Present Illness

• Precipitating Factors: Any events that triggered the pain (trauma, infection, overuse)?
• Alleviating Factors: What makes the pain better (rest, medication, heat/cold
application)?
• Aggravating Factors: What makes the pain worse (movement, specific activities)?
• Associated Symptoms:
o Morning stiffness? If yes, how long does it last?
o Redness or warmth over the joints?
o Systemic symptoms like fever, fatigue, weight loss?
• Impact on Daily Activities: Any difficulty with walking, dressing, or other daily tasks?

3. Past Medical History

• Previous Joint Issues: Any prior episodes of joint pain or swelling?

• Chronic Conditions: History of chronic diseases (diabetes, hypertension, autoimmune
diseases)?
• Infections: Recent infections (gastrointestinal, genitourinary, respiratory)?
• Surgeries: Any surgeries involving joints?

4. Medication History

• Current Medications: Any medications currently being taken (including over-the-

counter and herbal supplements)?
• Previous Treatments: Treatments tried for the current symptoms (NSAIDs, steroids,
disease-modifying antirheumatic drugs)?
• Allergies: Any known drug allergies?

5. Family History

• Genetic Predispositions: Family history of arthritis or autoimmune diseases?

 • Other Relevant Conditions: Any family members with similar symptoms or chronic
conditions?

6. Social History

• Occupation: Current and past occupations (to assess for occupational hazards)?
• Lifestyle: Physical activity level, hobbies, smoking, alcohol consumption, recreational
drug use?
• Living Conditions: Home environment, support systems?

7. Review of Systems

• General: Fever, chills, weight loss, fatigue, malaise?

• Skin: Rashes, nodules, psoriasis, erythema migrans (Lyme disease)?
• Eyes: Redness, pain, vision changes (uveitis, conjunctivitis)?
• Mouth: Ulcers, dryness?
• Cardiovascular: Chest pain, palpitations, Raynaud’s phenomenon?
• Respiratory: Cough, shortness of breath, pleuritic pain?
• Gastrointestinal: Abdominal pain, diarrhea, blood in stool?
• Genitourinary: Dysuria, frequency, urethral discharge?
• Neurological: Numbness, tingling, muscle weakness?
• Musculoskeletal: Muscle pain, stiffness, joint deformities, limited range of motion?

8. System-Specific Examination

• Musculoskeletal System: Detailed examination of the affected and unaffected joints:

o Inspection: Redness, swelling, deformity.
o Palpation: Tenderness, warmth, effusion.
o Range of Motion: Active and passive.
o Strength Testing: Muscle power around the joints.
• Skin: Look for rashes, nodules, tophi.
• Eyes: Check for redness, discharge, visual acuity.
• Cardiovascular System: Heart sounds, murmurs, peripheral pulses.
• Respiratory System: Lung sounds, pleural rubs.
• Abdomen: Tenderness, organomegaly.
• Neurological System: Reflexes, sensation, motor function.

9. Investigations (if necessary)

• Laboratory Tests:

• Complete blood count (CBC) to check for infection or anemia.

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for inflammation.
• Rheumatoid factor (RF) and anti-CCP antibodies for RA.
• Antinuclear antibody (ANA) and anti-dsDNA for SLE.
• Uric acid levels for gout.
• HLA-B27 typing for ankylosing spondylitis and reactive arthritis.
• Lyme serology for Lyme disease.
• Viral serologies (parvovirus B19, hepatitis B and C, etc.) for viral arthritis.
• Joint Aspiration and Synovial Fluid Analysis:

• Microscopy for crystals (urate, calcium pyrophosphate).

• Gram stain and culture for septic arthritis.
• Cell count and differential to assess for inflammatory vs. non-inflammatory conditions.

• Imaging Studies:

• X-rays for osteoarthritis (osteophytes, joint space narrowing), chondrocalcinosis

(pseudogout).
• MRI or ultrasound for soft tissue involvement and to detect early joint damage.
• Sacroiliac joint imaging (X-ray, MRI) for ankylosing spondylitis.

• Special Tests:

• Skin biopsy if dermatologic manifestations are present (psoriasis, SLE rash).

• Nail examination and biopsy for psoriatic arthritis.
• Consider infectious disease consultation for atypical infections.
 Differential diagnosis of joint pain and swelling

Condition Key Features Exclusion Criteria

Rheumatoid Symmetrical joint involvement, morning Absence of RF and anti-CCP,
Arthritis (RA) stiffness > 1 hour, small joints of lack of typical radiographic
hands/feet affected, rheumatoid nodules, changes, no morning stiffness
positive rheumatoid factor (RF) and anti- improvement with activity.
CCP antibodies.
Osteoarthritis Asymmetrical joint involvement, weight- Symmetrical involvement,
(OA) bearing joints (knees, hips), brief morning inflammatory markers (ESR,
stiffness (<30 minutes), crepitus, CRP) elevated, lack of
osteophytes on X-ray. osteophytes on X-ray.
Gout Sudden onset, severe pain, often first MTP Normal uric acid levels, joint
joint (podagra), hyperuricemia, tophi in aspiration showing absence of
chronic cases. monosodium urate crystals.
Pseudogout Acute attacks, larger joints (knees, wrists), Joint aspiration showing
calcium pyrophosphate deposition disease absence of calcium
(CPPD), chondrocalcinosis on X-ray. pyrophosphate crystals, lack of
chondrocalcinosis on X-ray.
Septic Single hot, swollen, painful joint, fever, Negative joint aspiration
Arthritis elevated WBC count, positive joint culture, absence of systemic
aspiration culture. signs of infection, normal
WBC count.
Psoriatic Associated with psoriasis, asymmetric Absence of skin/nail changes,
Arthritis oligoarthritis, dactylitis (sausage digits), positive RF, symmetrical joint
nail pitting, negative RF. involvement typical of RA.
Systemic Multisystem involvement, malar rash, Negative ANA and anti-
Lupus photosensitivity, ANA positive, anti- dsDNA antibodies, lack of
Erythematosus dsDNA antibodies, non-erosive arthritis. systemic features, erosive
(SLE) changes on X-ray.
Reactive Post-infectious, often after GU or GI No history of preceding
Arthritis infection, asymmetric large joint arthritis, infection, absence of HLA-
enthesitis, conjunctivitis, urethritis. B27, negative culture for
infectious agents.
Ankylosing Young males, inflammatory back pain, Lack of spinal involvement,
Spondylitis enthesitis, sacroiliitis on imaging, HLA- negative HLA-B27, absence of
B27 positive, reduced spinal mobility. sacroiliitis on imaging.
Lyme Disease Erythema migrans rash, history of tick bite, Negative Lyme serology, no
migratory polyarthritis, positive Lyme history of tick exposure,
serology (ELISA, Western blot). absence of erythema migrans.
Viral Arthritis Acute onset, symmetrical polyarthritis, Prolonged course, negative
associated with viral prodrome (fever, serology for common viral
rash), self-limiting. causes, absence of viral
prodrome.
 Abnormal unsteady gait
Analysis of Complaint

1. Chief Complaint:
o What is the main issue or symptom? (e.g., difficulty walking, imbalance)
o When did it start? Was the onset sudden or gradual?
2. History of Present Illness:
o Describe the onset, duration, and progression of the symptom.
o Any precipitating factors or events? (e.g., trauma, infection, stress)
o Exact nature of the gait abnormality (e.g., shuffling, wide-based, staggering).
o Severity and impact on daily activities.
o Any associated pain? (e.g., leg pain, back pain)
3. Past Episodes:
o Any previous similar episodes?
o How were they resolved? (e.g., spontaneously, with treatment)

Associated Symptoms

1. General Symptoms:
o Fever, weight loss, fatigue, night sweats.
2. Neurological Symptoms:
o Dizziness, vertigo, seizures, altered consciousness, memory loss.
o Other sensory deficits (e.g., tingling, numbness).
o Motor deficits (e.g., weakness, difficulty with coordination).
o Visual disturbances (e.g., blurred vision, double vision).
o Hearing loss or tinnitus.
o Speech difficulties (e.g., slurred speech).
o Incontinence (bowel or bladder).

Excluding Differential Diagnoses

1. Cerebellar Ataxia:
o Key Features: Wide-based, unsteady gait, difficulty with coordination, intention
tremor, dysmetria.
o Inclusion Criteria: History of alcohol abuse, family history of ataxia, recent
viral illness.
o Exclusion Criteria: Normal cerebellar function tests, normal MRI of the brain.
2. Vestibular Disorders:
o Key Features: Vertigo, dizziness, nausea, vomiting, nystagmus.
o Inclusion Criteria: Positive Dix-Hallpike maneuver, abnormal vestibular testing.
o Exclusion Criteria: Absence of vertigo or dizziness, normal vestibular testing.
3. Parkinson's Disease:
o Key Features: Shuffling gait, bradykinesia, rigidity, resting tremor, postural
instability.
o Inclusion Criteria: Progressive symptoms, positive response to dopaminergic
therapy.
 o Exclusion Criteria: Rapid progression, absence of classic motor symptoms, lack
of response to dopaminergic therapy.
4. Stroke:
o Key Features: Sudden onset, hemiparesis, facial droop, speech difficulties.
o Inclusion Criteria: Acute onset, risk factors (hypertension, diabetes), positive
neuroimaging (CT/MRI).
o Exclusion Criteria: Gradual onset, normal imaging, absence of vascular risk
factors.
5. Peripheral Neuropathy:
o Key Features: Stocking-glove pattern sensory loss, weakness, reduced reflexes.
o Inclusion Criteria: History of diabetes, alcohol use, positive nerve conduction
studies (NCS).
o Exclusion Criteria: Normal NCS, absence of risk factors, central nervous
system signs.
6. Spinal Cord Lesions:
o Key Features: Sensory level, motor weakness, bowel/bladder dysfunction.
o Inclusion Criteria: Positive MRI findings, acute or subacute onset.
o Exclusion Criteria: Normal MRI, lack of sensory level or motor weakness.
7. Normal Pressure Hydrocephalus (NPH):
o Key Features: Triad of gait disturbance, urinary incontinence, cognitive
impairment.
o Inclusion Criteria: Enlarged ventricles on MRI, improvement with lumbar
puncture.
o Exclusion Criteria: Normal ventricular size, absence of triad symptoms.
8. Multiple Sclerosis (MS):
o Key Features: Relapsing-remitting course, optic neuritis, sensory disturbances,
motor weakness.
o Inclusion Criteria: MRI showing demyelinating lesions, positive oligoclonal
bands in CSF.
o Exclusion Criteria: Normal MRI, absence of oligoclonal bands, no relapsing-
remitting pattern.
9. Myelopathy:
o Key Features: Gait disturbance, spasticity, sensory deficits, bladder dysfunction.
o Inclusion Criteria: Positive MRI findings, acute or subacute onset.
o Exclusion Criteria: Normal MRI, no sensory level, no upper motor neuron
signs.

Review of Affected System

1. Neurological System:
o Detailed neurological examination including cranial nerves, motor function,
sensory function, reflexes, coordination, and gait.
o Cognitive assessment (orientation, memory, attention, language).

Review of Other Systems

1. Cardiovascular System:
o History of hypertension, diabetes, heart disease, arrhythmias.
o Examination for heart murmurs, carotid bruits, peripheral pulses.
2. Respiratory System:
 o History of respiratory infections, chronic cough, smoking.
o Examination for respiratory rate, breath sounds, oxygen saturation.
3. Gastrointestinal System:
o History of liver disease, gastrointestinal bleeding, alcohol use.
o Examination for abdominal tenderness, hepatomegaly, ascites.
4. Genitourinary System:
o History of renal disease, urinary tract infections.
o Examination for bladder distention, prostate enlargement.
5. Musculoskeletal System:
o History of joint pain, muscle weakness, back pain.
o Examination for joint swelling, muscle strength, spinal tenderness.
6. Endocrine System:
o History of thyroid disease, diabetes, adrenal insufficiency.
o Examination for thyroid enlargement, skin changes, weight changes.

Physical Examination:

o General physical examination: vital signs, signs of systemic illness.

o Neurological examination: cranial nerves, motor function, sensory function,
reflexes, coordination, and balance.
o Gait assessment: observe different gait patterns (e.g., walking, turning, tandem
gait).
o Musculoskeletal examination: joint range of motion, muscle strength, signs of
arthritis.

Investigations
Laboratory Tests

1. Basic Blood Tests:

o Complete blood count (CBC): to check for anemia or infection.
o Blood glucose: to identify diabetes or hypoglycemia.
o Electrolytes: to check for imbalances affecting muscle function.
o Liver function tests (LFTs): to assess for hepatic encephalopathy or chronic
alcohol use.
o Renal function tests: to identify uremia.
o Thyroid function tests: to exclude hypothyroidism or hyperthyroidism.
o Vitamin B12 and folate levels: to identify deficiencies causing neuropathy or
myelopathy.
2. Specialized Blood Tests:
o Autoimmune markers: ANA, anti-dsDNA, rheumatoid factor (RF), anti-CCP for
autoimmune diseases.
o Paraneoplastic panel: if a paraneoplastic syndrome is suspected.
o Genetic testing: for inherited disorders like muscular dystrophy.

Imaging Studies

1. Brain Imaging:
o MRI of the brain: to identify stroke, multiple sclerosis, cerebellar atrophy, or
other structural abnormalities.
o CT scan of the brain: useful in acute settings to rule out hemorrhage or stroke.
2. Spinal Imaging:
o MRI of the spine: to detect spinal cord lesions, myelopathy, or disc herniations.
 3. Vascular Imaging:
o Carotid Doppler ultrasound: to assess for carotid artery stenosis.
o MR angiography (MRA) or CT angiography (CTA): to visualize intracranial and
extracranial vessels.

Neurophysiological Tests

1. Electromyography (EMG) and Nerve Conduction Studies (NCS):

o To evaluate for peripheral neuropathy, myopathy, or neuromuscular junction
disorders.
2. Electroencephalography (EEG):
o If seizures or epilepsy are suspected as a cause of gait disturbances.

Cerebrospinal Fluid (CSF) Analysis

• Lumbar Puncture: To analyze CSF for infections, multiple sclerosis (oligoclonal

bands), or other inflammatory or neoplastic conditions.

Vestibular Function Tests

1. Dix-Hallpike Maneuver:
o To diagnose benign paroxysmal positional vertigo (BPPV).
2. Electronystagmography (ENG) or Videonystagmography (VNG):
o To evaluate for vestibular disorders.
3. Rotary Chair Test:
o To assess vestibular function in more detail.

Cardiovascular Assessment

1. Electrocardiogram (ECG):
o To check for cardiac arrhythmias that may cause syncope and subsequent
unsteady gait.
2. Echocardiography:
o To assess cardiac function, if cardiovascular disease is suspected.

Additional Tests Based on Clinical Suspicion

1. Neuropsychological Testing:
o To evaluate for cognitive impairments if conditions like normal pressure
hydrocephalus (NPH) or dementia are suspected.
2. Muscle Biopsy:
o If myopathy or muscular dystrophy is suspected and genetic testing is
inconclusive.
3. Bone Scintigraphy:
o To identify conditions like Paget's disease or metastatic bone disease.

Types of Abnormal Unsteady Gait

1. Ataxic Gait
 o Description: Unsteady, wide-based gait with irregular, jerky, and exaggerated
movements.
o Associated Conditions: Cerebellar ataxia, multiple sclerosis, alcohol
intoxication, vitamin B12 deficiency.
o Key Features: Difficulty with balance, staggering, swaying, inability to walk in a
straight line.
2. Parkinsonian Gait
o Description: Slow, shuffling gait with small steps, stooped posture, reduced arm
swing, and difficulty initiating movement.
o Associated Conditions: Parkinson's disease, parkinsonism due to medications or
other neurological conditions.
o Key Features: Bradykinesia, rigidity, resting tremor, postural instability.
3. Spastic Gait
o Description: Stiff, scissor-like movements with legs crossing each other, often
seen in patients with increased muscle tone.
o Associated Conditions: Upper motor neuron lesions, cerebral palsy, multiple
sclerosis, stroke.
o Key Features: Hypertonia, hyperreflexia, clonus, muscle spasms.
4. Waddling Gait
o Description: Waddling motion with a sway of the hips, often due to weakness in
the pelvic girdle muscles.
o Associated Conditions: Muscular dystrophy, myopathies, hip dislocation,
bilateral hip arthritis.
o Key Features: Difficulty climbing stairs or rising from a seated position,
lordosis.
5. Steppage Gait
o Description: High-stepping gait where the patient lifts their legs excessively high
to prevent toes from dragging.
o Associated Conditions: Peripheral neuropathy, peroneal nerve palsy, lumbar
radiculopathy.
o Key Features: Foot drop, weakness in ankle dorsiflexion, slapping of the foot on
the ground.
6. Antalgic Gait
o Description: Limping to avoid pain, characterized by a shorter stance phase on
the affected side.
o Associated Conditions: Pain due to arthritis, trauma, fractures, or other
musculoskeletal conditions.
o Key Features: Pain on weight-bearing, reduced time on the affected limb,
compensatory movements.
7. Trendelenburg Gait
o Description: Pelvic drop on the contralateral side during the stance phase on the
affected side.
o Associated Conditions: Hip abductor weakness, gluteus medius/minimus
weakness, hip joint pathology.
o Key Features: Lateral trunk bending towards the affected side to compensate for
hip abductor weakness.
8. Vestibular Gait
 o Description: Unsteady, veering to one side, often accompanied by vertigo and
balance issues.
o Associated Conditions: Vestibular disorders such as benign paroxysmal
positional vertigo (BPPV), Meniere's disease, vestibular neuritis.
o Key Features: Vertigo, dizziness, nystagmus, imbalance.
9. Sensory Ataxia Gait
o Description: High-stepping, stomping gait to increase sensory input from the
feet, often with eyes looking down.
o Associated Conditions: Peripheral neuropathy, dorsal column lesions (e.g., tabes
dorsalis), vitamin B12 deficiency.
o Key Features: Loss of proprioception, positive Romberg sign (worsening with
eyes closed), numbness or tingling in the legs.
10. Choreiform Gait
o Description: Irregular, dance-like movements with unpredictable changes in
speed and direction.
o Associated Conditions: Huntington's disease, Sydenham's chorea, certain
medications (e.g., antipsychotics).
o Key Features: Involuntary, jerky movements of the limbs and trunk, difficulty
maintaining a consistent gait pattern.

Summery:

Type of Gait Key Features Associated Conditions

Ataxic Gait Unsteady, wide-based, irregular, Cerebellar ataxia, MS, alcohol
jerky movements intoxication, vitamin B12 deficiency
Parkinsonian Slow, shuffling, small steps, Parkinson's disease, parkinsonism
Gait stooped posture, reduced arm
swing
Spastic Gait Stiff, scissor-like movements, legs UMN lesions, cerebral palsy, MS,
crossing each other stroke
Waddling Gait Waddling motion, sway of hips Muscular dystrophy, myopathies, hip
dislocation, bilateral hip arthritis
Steppage Gait High-stepping, excessive leg lift to Peripheral neuropathy, peroneal
prevent toe dragging nerve palsy, lumbar radiculopathy
Antalgic Gait Limping to avoid pain, shorter Arthritis, trauma, fractures,
stance phase on affected side musculoskeletal pain
Trendelenburg Pelvic drop on contralateral side, Hip abductor weakness, gluteus
Gait lateral trunk bending medius/minimus weakness, hip joint
pathology
Vestibular Gait Unsteady, veering to one side, Vestibular disorders (BPPV,
often with vertigo and balance Meniere's disease, vestibular neuritis)
issues
Sensory Ataxia High-stepping, stomping, worsens Peripheral neuropathy, dorsal column
Gait with eyes closed lesions, vitamin B12 deficiency
Choreiform Irregular, dance-like movements, Huntington's disease, Sydenham's
Gait unpredictable speed and direction chorea, certain medications
changes (antipsychotics)
Differential Diagnosis of Abnormal Unsteady Gait
Condition Key Features Inclusion Criteria
Cerebellar Ataxia Unsteady, wide-based gait, History of alcohol use, family
dysmetria, intention tremor history, recent viral illness
Parkinson's Shuffling gait, bradykinesia, Progressive symptoms, positive
Disease rigidity, resting tremor response to dopaminergic therapy
Stroke Sudden onset, hemiparesis, facial Acute onset, risk factors (HTN,
droop, speech difficulties diabetes), positive neuroimaging
(CT/MRI)
Peripheral High-stepping gait, foot drop, History of diabetes, alcohol use,
Neuropathy sensory loss positive nerve conduction studies
(NCS)
Vestibular Vertigo, dizziness, veering to one Positive Dix-Hallpike maneuver,
Disorders side, nystagmus abnormal vestibular testing
Multiple Sclerosis Relapsing-remitting course, sensory MRI showing demyelinating
(MS) disturbances, motor weakness lesions, positive oligoclonal bands
in CSF
Normal Pressure Gait disturbance, urinary Enlarged ventricles on MRI,
Hydrocephalus incontinence, cognitive impairment improvement with lumbar
(NPH) puncture
Spinal Cord Sensory level, motor weakness, Positive MRI findings, acute or
Lesions bowel/bladder dysfunction subacute onset
Myelopathy Gait disturbance, spasticity, sensory Positive MRI findings, acute or
deficits subacute onset
Muscular Waddling gait, pelvic girdle muscle Family history, genetic testing
Dystrophy weakness
Hip Joint Painful, limited range of motion, Hip pain, positive imaging (X-ray,
Pathology Trendelenburg gait MRI)
BPPV (Benign Vertigo triggered by head Positive Dix-Hallpike test,
Paroxysmal movements, nystagmus resolution with Epley maneuver
Positional
Vertigo)
 Dizziness
Analysis of Complaint

1. Onset:
o When did the dizziness start?
o Was it sudden or gradual?
2. Duration:
o How long does each episode of dizziness last?
o Is it constant or intermittent?
3. Frequency:
o How often do the episodes occur?
4. Triggers:
o Is there anything that seems to trigger the dizziness (e.g., position changes, stress,
certain activities)?
5. Character:
o Can you describe the dizziness? (e.g., spinning sensation, lightheadedness,
feeling faint, imbalance)

Associated Symptoms

1. Hearing Changes:
o Any hearing loss, tinnitus (ringing in the ears), or ear fullness?
2. Visual Symptoms:
o Any blurred vision, double vision, or visual disturbances?
3. Neurological Symptoms:
o Any headaches, numbness, weakness, slurred speech, or difficulty swallowing?
4. Cardiovascular Symptoms:
o Any palpitations, chest pain, shortness of breath, or syncope (fainting)?
5. Gastrointestinal Symptoms:
o Any nausea, vomiting, or abdominal pain?
6. Other Symptoms:
o Any recent infections, especially respiratory or ear infections?
o Any recent trauma or head injury?
o Any signs of anxiety or hyperventilation?

Excluding Differential Diagnosis

1. Benign Paroxysmal Positional Vertigo (BPPV):

o Does the dizziness occur with specific head movements?
o Dix-Hallpike maneuver during the physical exam to elicit symptoms.
2. Meniere’s Disease:
o Is there a triad of episodic vertigo, hearing loss, and tinnitus?
o Audiometry to assess hearing loss.
3. Vestibular Neuritis/Labyrinthitis:
o Was there a recent viral illness?
o Unilateral hearing loss (Labyrinthitis) or no hearing loss (Vestibular Neuritis).
4. Migrainous Vertigo:
 o Any history of migraines?
o Headache, photophobia, and phonophobia associated with dizziness.
5. Orthostatic Hypotension:
o Does the dizziness occur upon standing up?
o Measure blood pressure lying down and standing up.
6. Cardiovascular Causes:
o Any history of arrhythmias or heart disease?
o ECG, Holter monitor, and echocardiogram.
7. Cerebrovascular Causes:
o Any risk factors for stroke (e.g., hypertension, diabetes, smoking)?
o MRI or CT scan of the brain.
8. Psychogenic Dizziness:
o Any history of anxiety or panic attacks?
o Psychiatric evaluation.

Review of Systems

1. Neurological System:
o Cranial nerve examination.
o Motor and sensory examination.
o Coordination tests (e.g., finger-to-nose test, heel-to-shin test).
o Gait assessment.
2. Cardiovascular System:
o Blood pressure and pulse.
o Heart auscultation.
o Peripheral pulses.
3. ENT (Ear, Nose, Throat):
o Otoscopic examination.
o Rinne and Weber tests for hearing.
o Dix-Hallpike maneuver.
4. General Examination:
o Assess for signs of dehydration or anemia.
o General physical examination for systemic signs (e.g., skin rashes,
lymphadenopathy).

Investigations
Basic Investigations

1. Blood Tests:
o Complete Blood Count (CBC): To check for anemia or infection.
o Electrolyte Panel: To detect imbalances such as hyponatremia or hyperkalemia.
o Glucose Levels: To identify hypoglycemia or diabetes.
o Thyroid Function Tests: To rule out hyperthyroidism or hypothyroidism.
o Liver Function Tests (LFTs): To detect liver disease.
o Kidney Function Tests: To identify renal issues.
2. Vital Signs:
 o Blood Pressure Measurement: To check for orthostatic hypotension by
measuring blood pressure lying down and standing up.
o Pulse Rate and Rhythm: To detect arrhythmias.

Specialized Investigations

1. Imaging Studies:
o MRI or CT Scan of the Brain: To rule out central causes such as stroke, tumors,
or multiple sclerosis.
o Carotid Doppler Ultrasound: To assess for carotid artery stenosis or other
vascular issues.
2. Cardiovascular Tests:
o Electrocardiogram (ECG): To detect arrhythmias or myocardial infarction.
o Holter Monitor: For continuous ECG monitoring to identify intermittent
arrhythmias.
o Echocardiogram: To assess cardiac structure and function.
o Tilt Table Test: To evaluate for orthostatic hypotension or vasovagal syncope.
3. Hearing and Vestibular Tests:
o Audiometry: To assess hearing loss, which can help diagnose Meniere's disease
or labyrinthitis.
o Electronystagmography (ENG) or Videonystagmography (VNG): To
evaluate the function of the inner ear and diagnose vestibular disorders.
o Dix-Hallpike Maneuver: To diagnose BPPV by eliciting characteristic vertigo
and nystagmus.
o Head Impulse Test: To assess vestibulo-ocular reflex (VOR) function, useful for
detecting vestibular hypofunction.
4. Neurological Tests:
o Evoked Potentials: To assess the function of sensory and motor pathways,
especially if multiple sclerosis is suspected.
o Lumbar Puncture: To analyze cerebrospinal fluid if an infectious or
inflammatory cause is suspected.
5. Balance and Gait Tests:
o Romberg Test: To assess proprioception and balance.
o Gait Analysis: To observe any abnormalities in walking that may indicate a
neurological or vestibular cause.
o Posturography: To quantify balance and postural control.

Other Considerations

• Psychiatric Evaluation: To assess for anxiety, depression, or other psychiatric causes

of dizziness.
• Medication Review: To identify any drugs that may cause dizziness as a side effect.
Summary Table for investigations required
Investigation Purpose Conditions Targeted
Complete Blood Count Detect anemia or infection Anemia, infection
(CBC)
Electrolyte Panel Identify electrolyte imbalances Hyponatremia, hyperkalemia
Glucose Levels Check for hypoglycemia or Hypoglycemia, diabetes
diabetes
Thyroid Function Tests Rule out thyroid disorders Hyperthyroidism,
hypothyroidism
Liver Function Tests Detect liver disease Liver disease
(LFTs)
Kidney Function Tests Identify renal issues Renal disease
Blood Pressure Check for orthostatic hypotension Orthostatic hypotension
Measurement
Pulse Rate and Rhythm Detect arrhythmias Arrhythmias
MRI or CT Scan of the Rule out central causes Stroke, tumors, multiple
Brain sclerosis
Carotid Doppler Assess for vascular issues Carotid artery stenosis
Ultrasound
Electrocardiogram Detect arrhythmias or myocardial Arrhythmias, myocardial
(ECG) infarction infarction
Holter Monitor Continuous ECG monitoring for Arrhythmias
intermittent arrhythmias
Echocardiogram Assess cardiac structure and Cardiac conditions
function
Tilt Table Test Evaluate for orthostatic Orthostatic hypotension,
hypotension or vasovagal syncope vasovagal syncope
Audiometry Assess hearing loss Meniere's disease,
labyrinthitis
ENG or VNG Evaluate inner ear function Vestibular disorders
Dix-Hallpike Maneuver Diagnose BPPV BPPV
Head Impulse Test Assess vestibulo-ocular reflex Vestibular hypofunction
function
Evoked Potentials Assess sensory and motor Multiple sclerosis
pathways
Lumbar Puncture Analyze cerebrospinal fluid Infectious or inflammatory
causes
Romberg Test Assess proprioception and balance Neurological or vestibular
causes
Gait Analysis Observe walking abnormalities Neurological or vestibular
causes
Posturography Quantify balance and postural Vestibular disorders
control
Psychiatric Evaluation Assess for psychiatric causes Anxiety, depression
Medication Review Identify drugs causing dizziness Medication side effects
Differential Diagnosis of Dizziness
Condition Features Inclusion Exclusion
Benign Paroxysmal Sudden, brief episodes of Positive Dix- Normal
Positional Vertigo vertigo triggered by head Hallpike ENG/VNG,
(BPPV) movements maneuver, brief absence of
episodes of vertigo with
vertigo, no hearing positional
loss changes
Meniere’s Disease Episodic vertigo, hearing Audiometry Persistent hearing
loss, tinnitus, and aural showing loss without
fullness fluctuating low- fluctuation,
frequency hearing negative
loss, clinical triad ENG/VNG
of symptoms
Vestibular Acute onset of severe History of recent Absence of
Neuritis/Labyrinthitis vertigo, often following a viral infection, preceding
viral infection; may have unilateral caloric infection,
hearing loss (labyrinthitis weakness on bilateral caloric
only) ENG/VNG weakness
Migrainous Vertigo Vertigo associated with History of No history of
migraine headaches, migraine, vertigo migraine,
photophobia, phonophobia episodes absence of
coinciding with headache,
migraine, response photophobia, or
to migraine phonophobia
treatment
Orthostatic Dizziness upon standing, Orthostatic blood Normal
Hypotension associated with a drop in pressure orthostatic blood
blood pressure measurement pressure
showing a measurement
significant drop,
history of
symptoms upon
standing
Cardiac Arrhythmias Palpitations, syncope, Abnormal ECG, Normal ECG and
episodic dizziness Holter monitor Holter monitor,
showing absence of
arrhythmias, palpitations
symptoms related
to arrhythmias
Transient Ischemic Sudden onset of MRI/CT scan Normal imaging
Attack (TIA)/Stroke neurological deficits, showing ischemic studies, absence
including vertigo, often changes, presence of risk factors
with risk factors for stroke of focal and focal
neurological neurological
deficits deficits
Anemia Fatigue, pallor, shortness of Low hemoglobin Normal CBC
breath, and dizziness and hematocrit on
CBC, history of
chronic blood loss
or dietary
deficiency
Hypoglycemia Sweating, tremors, Low blood glucose Normal glucose
palpitations, confusion, level during levels during
dizziness symptomatic episodes, absence
episodes, history of of hypoglycemia
diabetes or symptoms
medication use
Anxiety/Panic Episodes of intense fear, Psychiatric Absence of
Attacks palpitations, sweating, evaluation, history anxiety
dizziness of anxiety or panic symptoms,
attacks, response to normal
anxiolytics psychiatric
evaluation
Multiple Sclerosis Episodic neurological MRI showing Normal MRI,
deficits, including vertigo, demyelinating absence of other
often in young adults lesions, history of neurological
multiple symptoms
neurological
episodes
Medication Side Dizziness associated with Temporal Persistent
Effects the use of certain relationship symptoms after
medications between discontinuing the
medication use and suspected
symptom onset, medication
resolution upon
stopping
medication
 Focal neurological deficit

Analysis of Complaint

1. Chief Complaint:
o What is the main issue or symptom? (e.g., weakness, numbness, vision changes)
o When did it start? Was the onset sudden or gradual?
2. History of Present Illness:
o Describe the onset, duration, and progression of the symptom.
o Any precipitating factors or events? (e.g., trauma, infection, stress)
o Exact location of the deficit (e.g., left arm, right leg, facial muscle).
o Severity and impact on daily activities.
o Any associated pain? (e.g., headache, neck pain, back pain)
3. Past Episodes:
o Any previous similar episodes?
o How were they resolved? (e.g., spontaneously, with treatment)

Associated Symptoms

1. General Symptoms:
o Fever, weight loss, fatigue, night sweats.
2. Neurological Symptoms:
o Headache, dizziness, seizures, altered consciousness, memory loss.
o Other sensory deficits (e.g., tingling, numbness).
o Motor deficits (e.g., weakness, difficulty walking, coordination issues).
o Speech difficulties (e.g., aphasia, dysarthria).
o Visual disturbances (e.g., blurred vision, double vision, visual field loss).
o Hearing loss or tinnitus.
o Swallowing or chewing difficulties.

Excluding Differential Diagnosis

1. Vascular Causes:
o Transient ischemic attack (TIA) or stroke: Sudden onset, risk factors
(hypertension, diabetes, smoking), presence of atrial fibrillation.
o Intracranial hemorrhage: Sudden severe headache, vomiting, hypertension.
2. Infectious Causes:
o Meningitis/encephalitis: Fever, neck stiffness, altered mental status.
o Brain abscess: Fever, focal neurological signs, immunocompromised state.
3. Inflammatory/Demyelinating Causes:
o Multiple sclerosis: Relapsing-remitting course, young adults, optic neuritis.
o Guillain-Barré syndrome: Ascending paralysis, recent infection.
4. Neoplastic Causes:
o Brain tumor: Gradual onset, headaches, seizures, cognitive changes.
o Spinal cord tumor: Back pain, radicular pain, progressive weakness.
5. Traumatic Causes:
 o History of head or neck trauma, acute onset after injury, presence of contusions
or lacerations.
6. Metabolic/Toxic Causes:
o Hypoglycemia: Sudden onset, history of diabetes.
o Electrolyte imbalances: Gradual onset, history of renal disease or endocrine
disorders.
o Drug/toxin exposure: History of substance abuse, medication history.
7. Degenerative Causes:
o Amyotrophic lateral sclerosis (ALS): Progressive weakness, muscle atrophy,
fasciculations.
o Parkinson’s disease: Bradykinesia, rigidity, tremor.

Review of Affected System

1. Neurological System:
o Detailed neurological examination including cranial nerves, motor function,
sensory function, reflexes, coordination, and gait.
o Cognitive assessment (orientation, memory, attention, language).

Review of Other Systems

1. Cardiovascular System:
o History of hypertension, diabetes, heart disease, arrhythmias.
o Examination for heart murmurs, carotid bruits, peripheral pulses.
2. Respiratory System:
o History of respiratory infections, chronic cough, smoking.
o Examination for respiratory rate, breath sounds, oxygen saturation.
3. Gastrointestinal System:
o History of liver disease, gastrointestinal bleeding, alcohol use.
o Examination for abdominal tenderness, hepatomegaly, ascites.
4. Genitourinary System:
o History of renal disease, urinary tract infections.
o Examination for bladder distention, prostate enlargement.
5. Musculoskeletal System:
o History of joint pain, muscle weakness, back pain.
o Examination for joint swelling, muscle strength, spinal tenderness.
6. Endocrine System:
o History of thyroid disease, diabetes, adrenal insufficiency.
o Examination for thyroid enlargement, skin changes, weight changes.

Types of Focal Neurological Deficits

1. Motor Deficits:
o Hemiparesis/Hemiplegia: Weakness or paralysis on one side of the body,
commonly due to a stroke affecting the motor cortex or corticospinal tract.
o Monoparesis/Monoplegia: Weakness or paralysis in a single limb, often due to
localized lesions in the brain or spinal cord.
o Paraparesis/Paraplegia: Weakness or paralysis of both legs, commonly seen in
spinal cord lesions.
 o Quadriparesis/Quadriplegia: Weakness or paralysis of all four limbs, typically
due to cervical spinal cord injuries or diffuse brain damage.
2. Sensory Deficits:
o Hemianesthesia: Loss of sensation on one side of the body, often associated with
strokes affecting the sensory cortex or thalamus.
o Monoanesthesia: Loss of sensation in a single limb, typically due to peripheral
nerve or spinal root lesions.
o Stocking-glove pattern: Sensory loss in a distal distribution, commonly seen in
peripheral neuropathies.
3. Visual Deficits:
o Homonymous Hemianopia: Loss of the same half of the visual field in both
eyes, usually due to lesions in the optic tract or occipital lobe.
o Quadrantanopia: Loss of a quarter of the visual field, often caused by lesions in
the temporal or parietal lobes.
o Monocular Vision Loss: Loss of vision in one eye, which may be due to optic
nerve lesions.
4. Language Deficits (Aphasia):
o Broca’s Aphasia (Expressive): Difficulty in speech production, but
comprehension is relatively preserved, typically due to lesions in the frontal lobe
(Broca’s area).
o Wernicke’s Aphasia (Receptive): Difficulty in understanding spoken or written
language, with fluent but nonsensical speech, usually due to lesions in the
temporal lobe (Wernicke’s area).
o Global Aphasia: Severe impairment in both comprehension and production of
language, often due to large lesions affecting both Broca’s and Wernicke’s areas.
5. Cranial Nerve Deficits:
o Facial Nerve Palsy (VII): Weakness of facial muscles, drooping of one side of
the face, inability to close the eye, and loss of taste on the anterior two-thirds of
the tongue.
o Oculomotor Nerve Palsy (III): Ptosis, dilated pupil, and eye deviating "down
and out."
o Trigeminal Neuralgia (V): Severe, shooting pain in the distribution of the
trigeminal nerve.
6. Cerebellar Deficits:
o Ataxia: Uncoordinated movements, difficulty with balance, and a wide-based
gait.
o Dysmetria: Inability to judge distances or scale of movement, leading to
overshooting or undershooting targets.
o Intention Tremor: Tremor that occurs during purposeful movement.
7. Higher Cortical Function Deficits:
o Neglect: Inattention to one side of the body or space, often seen in right parietal
lobe lesions.
o Apraxia: Inability to perform purposeful movements despite having the desire
and physical capability to do so.
o Agnosia: Inability to recognize objects, faces, or sounds, despite intact sensory
function
 Condition Key Features Inclusion Criteria Exclusion
Criteria
Ischemic Stroke Sudden onset, Acute onset, risk Gradual onset,
weakness/numbness, factors (HTN, normal imaging
aphasia, visual diabetes, smoking), (CT/MRI), no
disturbances, facial droop imaging (CT/MRI vascular risk
showing infarct) factors
Hemorrhagic Sudden severe headache, Acute onset, No headache or
Stroke vomiting, altered hypertension, imaging vomiting, normal
consciousness, focal (CT showing imaging (CT/MRI)
deficits hemorrhage)
Brain Tumor Gradual onset, headache, Progressive Acute onset,
seizures, focal deficits, symptoms, imaging normal imaging
personality changes (MRI showing mass) (MRI/CT), no
progressive
symptoms
Multiple Sclerosis Relapsing-remitting MRI showing Normal MRI,
(MS) course, young adults, demyelinating lesions, absence of
optic neuritis, sensory positive oligoclonal oligoclonal bands,
disturbances, motor bands in CSF lack of relapsing-
weakness remitting pattern
Infections (e.g., Fever, altered mental Positive Normal
Abscess, status, headache, focal cultures/serology, cultures/serology,
Encephalitis) deficits, immune imaging (MRI no fever, normal
compromise showing abscess or imaging
encephalitis), fever
Subdural/Epidural History of trauma, History of head No history of
Hematoma headache, altered trauma, imaging (CT trauma, normal
consciousness, focal showing hematoma) imaging
deficits
Transient Sudden onset, transient Symptoms resolve Persistent
Ischemic Attack focal deficits, high risk of within 24 hours, risk symptoms, normal
(TIA) stroke factors (HTN, vascular imaging
diabetes), normal (CTA/MRA)
imaging
Migraine with Recurrent headaches, History of migraine, Persistent focal
Aura visual aura, transient typical aura deficits, abnormal
neurological deficits symptoms, normal imaging, no history
neurological exam of migraine
Peripheral Nerve Unilateral facial Facial nerve palsy, Bilateral
Lesions (e.g., Bell's weakness, inability to exclusion of central symptoms, other
Palsy) close eye, sudden onset causes via imaging cranial nerve
(CT/MRI) involvement,
abnormal imaging
Epilepsy (Postictal Seizures, postictal History of seizures, No history of
State) confusion, transient focal EEG showing seizures, normal
deficits epileptiform activity EEG, persistent
deficits
Amyotrophic Progressive muscle EMG showing Sensory deficits,
Lateral Sclerosis weakness, atrophy, denervation, clinical no EMG evidence
(ALS) fasciculations, mixed signs, normal sensory of denervation,
upper and lower motor exam rapid progression
neuron signs
Guillain-Barré Ascending paralysis, History of recent Upper motor
Syndrome (GBS) areflexia, recent infection, infection, neuron signs, no
autonomic dysfunction albuminocytologic recent infection,
dissociation in CSF normal CSF
analysis
Vascular Headache, seizures, Imaging Normal imaging,
Malformations progressive focal deficits (MRI/CT/MRA absence of
(e.g., AVM) showing vascular vascular anomaly
anomaly)
Metabolic/Toxic Altered mental status, History of toxin No history of toxin
Encephalopathy asterixis, multifocal exposure, abnormal exposure, normal
deficits, history of toxin metabolic panel, metabolic panel
exposure improvement with
removal of toxin

How to Include or Exclude These Causes:

1. History and Physical Examination:
o History: Detailed history of onset, duration, and progression of symptoms.
Consider risk factors (hypertension, diabetes, trauma, infections, substance
abuse).
o Examination: Comprehensive neurological exam, including cranial nerves,
motor function, sensory function, reflexes, coordination, and mental status.
2. Imaging Studies:
o CT Scan/MRI: For structural abnormalities (stroke, hemorrhage, tumor,
abscess).
o Angiography (CTA/MRA): For vascular abnormalities (aneurysms, AVMs).
o EEG: For epileptiform activity in suspected seizure disorders.
3. Laboratory Tests:
o Complete Blood Count (CBC), Electrolytes, Glucose: To rule out metabolic
causes.
o Inflammatory Markers (ESR, CRP): For inflammatory or infectious causes.
o CSF Analysis: For infections (meningitis, encephalitis), multiple sclerosis
(oligoclonal bands).
4. Special Tests:
o EMG/NCS: For peripheral nerve or muscle disorders (ALS, GBS).
o Serology/Cultures: For specific infections.
o Autoantibody Panels: For autoimmune conditions (e.g., MS).
 Generalized weakness
Chief Complaint:

• Begin by asking the patient to describe their main concern related to weakness. Example: "Could you please
tell me more about the weakness you've been experiencing?"

Onset and Duration:

• Determine when the weakness started and how long it has been present. Example: "When did you first
notice the weakness? Has it been constant, or does it come and go?"

Character of Weakness:

• Explore the nature of the weakness (e.g., fatigue, difficulty moving limbs, overall body weakness).
Example: "Can you describe what the weakness feels like? Does it affect your entire body or specific
areas?"

Associated Symptoms:

• Inquire about any other symptoms occurring alongside weakness that might suggest specific differential
diagnoses:
o Neurological: Ask about changes in sensation, vision, speech, or coordination.
o Musculoskeletal: Inquire about joint pain, stiffness, or muscle cramps.
o Cardiovascular: Ask about chest pain, palpitations, or shortness of breath.
o Gastrointestinal: Explore changes in appetite, nausea, vomiting, or bowel habits.
o Endocrine: Assess for heat or cold intolerance, excessive sweating, or changes in weight.
o Psychological: Inquire about mood changes, anxiety, or sleep disturbances.

Aggravating or Relieving Factors:

• Explore factors that make the weakness worse or better, including activities, rest, or specific positions.
Example: "Do certain activities or times of day make the weakness more noticeable? Does rest improve it?"

Systemic Review:

• Conduct a systematic review covering other bodily systems to identify potential associated symptoms or
systemic diseases:
o Respiratory: Inquire about cough, sputum production, or difficulty breathing.
o Renal: Ask about changes in urine color, frequency, or pain during urination.
o Dermatological: Explore any skin changes, rashes, or lesions.
o Hematological: Inquire about easy bruising, bleeding tendencies, or lymph node swelling.
o Psychiatric: Assess for symptoms of depression, anxiety, or cognitive changes.

Past Medical History:

• Document any pre-existing medical conditions, surgeries, or chronic illnesses that may contribute to
weakness. Example: "Do you have any medical conditions such as diabetes, heart disease, or thyroid
problems?"
Medications and Allergies:

• Record current medications, including dosage and frequency, and any known drug allergies. Example: "Are
you taking any medications or supplements regularly? Have you ever had any allergic reactions to
medications?"

Social and Family History:

• Explore social habits (e.g., smoking, alcohol use) and family history of relevant conditions such as
neuromuscular disorders or autoimmune diseases. Example: "Do you have a family history of any medical
conditions that may cause weakness?"

Investigations
1. Complete Blood Count (CBC):
o To assess for anemia, infection, or signs of systemic illness.
2. Electrolyte Panel:
o Measures serum electrolytes (sodium, potassium, chloride, bicarbonate) to evaluate metabolic
disturbances.
3. Thyroid Function Tests:
o Measures thyroid hormone levels (TSH, T4) to assess for thyroid dysfunction.
4. Renal Function Tests:
o Includes serum creatinine and blood urea nitrogen (BUN) to evaluate renal function.
5. Liver Function Tests (LFTs):
o Measures liver enzymes (AST, ALT, ALP, bilirubin) to assess hepatic function.
6. Serum Calcium and Magnesium Levels:
o To evaluate for electrolyte abnormalities contributing to weakness.
7. Creatine Kinase (CK):
o Measures CK levels to assess for muscle damage or myopathy.
8. C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR):
o Non-specific markers of inflammation that may suggest underlying systemic illness.
9. Urinalysis:
o To evaluate for urinary tract infection or signs of renal dysfunction.
10. Vitamin B12 and Folate Levels:
o To assess for nutritional deficiencies that can cause weakness.
11. Serum Protein Electrophoresis:
o To evaluate for plasma cell dyscrasias such as multiple myeloma.
12. Autoimmune and Rheumatologic Tests:
o Depending on clinical suspicion, tests such as ANA (anti-nuclear antibody), RF (rheumatoid factor),
and specific antibodies (e.g., anti-dsDNA) may be indicated.
13. Electromyography (EMG) and Nerve Conduction Studies (NCS):
o For evaluating neuromuscular disorders and peripheral neuropathies.
14. Imaging Studies:
o Depending on clinical findings, imaging such as MRI (magnetic resonance imaging) of the brain or
spine, CT (computed tomography) scan of the chest or abdomen, or ultrasound may be ordered.
15. Specialized Consultations:
o Referral to specialists such as neurologists, rheumatologists, or endocrinologists may be necessary
based on initial investigations and clinical suspicion.
Differential diagnosis

1. Metabolic and Nutritional Causes:

o Electrolyte Imbalances: Hypokalemia (muscle cramps, arrhythmias), hyperkalemia (muscle
weakness, cardiac arrhythmias).
o Endocrine Disorders: Hypothyroidism (weight gain, cold intolerance), hyperthyroidism (weight
loss, heat intolerance), adrenal insufficiency (fatigue, hyperpigmentation).
o Nutritional Deficiencies: Vitamin B12 deficiency (paresthesias, glossitis), folate deficiency
(megaloblastic anemia), iron deficiency anemia (pallor, fatigue).
2. Neuromuscular Disorders:
o Peripheral Neuropathies: Diabetic neuropathy (symmetrical distal sensory loss), Guillain-Barré
syndrome (ascending weakness, areflexia), Charcot-Marie-Tooth disease (foot deformities, gait
abnormalities).
o Myopathies: Polymyositis (proximal muscle weakness, elevated muscle enzymes), dermatomyositis
(heliotrope rash, Gottron's papules), muscular dystrophies (progressive muscle weakness, genetic
testing).
o Neuromuscular Junction Disorders: Myasthenia gravis (fatigable weakness, ptosis), Lambert-
Eaton syndrome (proximal muscle weakness, autonomic symptoms).
3. Infectious Causes:
o Viral Infections: Influenza (fever, respiratory symptoms), Epstein-Barr virus (sore throat,
lymphadenopathy), HIV/AIDS (weight loss, opportunistic infections).
o Bacterial Infections: Sepsis (fever, hypotension), Lyme disease (erythema migrans rash, arthritis),
endocarditis (fever, new murmur).
4. Cardiovascular Causes:
o Heart Failure: Fatigue, dyspnea on exertion, lower extremity edema.
o Arrhythmias: Palpitations, syncope, irregular heartbeats.
5. Autoimmune and Rheumatologic Disorders:
o Systemic Lupus Erythematosus (SLE): Joint pain, skin rashes, renal involvement.
o Rheumatoid Arthritis (RA): Joint swelling, morning stiffness, rheumatoid nodules.
6. Hematologic Disorders:
o Anemia: Iron deficiency anemia (microcytic hypochromic), anemia of chronic disease (normocytic
normochromic), hemolytic anemias (jaundice, elevated bilirubin).
o Leukemias and Lymphomas: Lymphadenopathy, splenomegaly, cytopenias.
7. Psychiatric and Psychological Causes:
o Depression: Low mood, anhedonia, changes in appetite.
o Anxiety Disorders: Nervousness, restlessness, difficulty concentrating.
8. Medication-Related Causes:
o Side Effects: Beta-blockers (bradycardia, fatigue), chemotherapy agents (fatigue, cytopenias),
antiepileptic drugs (drowsiness, dizziness).
9. Toxicological Causes:
o Toxin Exposure: Heavy metals (lead, mercury), pesticides, carbon monoxide poisoning (headache,
dizziness).

Differentiation Points

• Temporal Pattern: Acute versus chronic onset.

• Systemic Symptoms: Presence of fever, weight loss, or other constitutional symptoms.
• Neurological Findings: Presence of sensory deficits, reflex abnormalities, or cranial nerve involvement.
• Muscle Biopsy or EMG Findings: Specific to myopathies and neuropathies.
• Response to Treatment: Improvement with specific therapy (e.g., steroids for autoimmune disorders).
 Leg and foot ulcer
Analysis of Complaint

1. Nature of the Ulcer:

o Onset and Duration: When did the ulcer first appear? How has it progressed
over time?
o Location: Exact location of the ulcer on the leg or foot.
o Size and Depth: Changes in the size or depth of the ulcer.
o Appearance: Description of the ulcer (e.g., color, exudate, necrosis, granulation
tissue).
2. Provoking and Relieving Factors:
o Aggravating Factors: Activities or conditions that worsen the ulcer or delay
healing (e.g., standing for long periods, trauma).
o Relieving Factors: Actions or treatments that improve the ulcer or promote
healing.
3. Associated Symptoms:
o Pain: Presence, severity, and nature of pain (e.g., constant, intermittent, burning,
throbbing).
o Swelling: Any associated swelling of the leg or foot.
o Signs of Infection: Redness, warmth, increased exudate, foul odor.
o Systemic Symptoms: Fever, chills, malaise.
4. Previous Treatment:
o Interventions: Previous treatments attempted (e.g., dressings, antibiotics,
debridement).
o Response to Treatment: Effectiveness and any adverse reactions.

Excluding Differential Diagnosis

1. Venous Ulcer:
o History of Venous Disease: Varicose veins, deep vein thrombosis.
o Symptoms: Aching, heaviness, swelling relieved by elevation, worsened by
prolonged standing.
o Clinical Features: Medial malleolus location, irregular shape, hemosiderin
staining, lipodermatosclerosis.
2. Arterial Ulcer:
o History of Arterial Disease: Peripheral arterial disease, smoking, diabetes.
o Symptoms: Claudication, rest pain.
o Clinical Features: Lateral malleolus or pressure points, punched-out appearance,
pale base, absent pulses, cold extremities.
3. Diabetic Ulcer:
o History of Diabetes: Duration and control of diabetes.
o Symptoms: Neuropathy (tingling, numbness), poor glycemic control.
o Clinical Features: Plantar surface or pressure points, callus formation, insensate
ulcer, foot deformities.
4. Pressure Ulcer:
o History of Immobility: Bedridden, wheelchair-bound.
o Symptoms: Areas exposed to prolonged pressure.
 o Clinical Features: Over bony prominences, varying stages of tissue damage.
5. Infectious Ulcer:
o History of Trauma or Infection: Recent injuries, insect bites,
immunocompromised state.
o Symptoms: Rapid onset, systemic signs of infection.
o Clinical Features: Erythema, pus, abscess formation, necrotic tissue.

Review of Affected System and Other Systems

1. Cardiovascular System:
o Peripheral Pulses: Assess for presence, symmetry, and strength of pulses.
o Capillary Refill Time: Delayed refill indicating poor perfusion.
o Ankle-Brachial Index (ABI): Assessment of arterial insufficiency.
2. Venous System:
o Varicosities: Presence of varicose veins, signs of chronic venous insufficiency.
o Edema: Extent and distribution of swelling.
3. Neurological System:
o Sensation: Assess for peripheral neuropathy using monofilament testing.
o Motor Function: Muscle strength and tone.
4. Dermatological Examination:
o Skin Changes: Erythema, scaling, signs of infection, previous scars.
o Temperature: Warmth indicating infection or coldness suggesting arterial
insufficiency.

Summary Table

Aspect Questions to Ask

Analysis of Onset, duration, location, size, depth, appearance, provoking/relieving
Complaint factors, pain, swelling, signs of infection
Associated Presence of systemic symptoms (fever, chills), previous treatments,
Symptoms response to treatment
Excluding History of venous disease, arterial disease, diabetes, immobility,
Differential trauma, infection
Diagnosis
Review of Systems Cardiovascular (pulses, capillary refill, ABI), venous (varicosities,
edema), neurological (sensation, motor function), dermatological (skin
changes, temperature)

Investigations
1Laboratory Investigations

1. Complete Blood Count (CBC):

o Purpose: Detects signs of infection (e.g., elevated white blood cell count),
anemia, or other hematological abnormalities.
o Indication: Helps in identifying systemic infections or conditions that may
impede wound healing.
2. Blood Glucose and HbA1c:
 o Purpose: Screens for diabetes mellitus and evaluates long-term glycemic control.
o Indication: Essential in patients with suspected or known diabetes to assess the
risk of diabetic ulcers.
3. Renal Function Tests:
o Purpose: Evaluates kidney function, which can impact overall health and wound
healing.
o Indication: Important in patients with systemic diseases affecting the kidneys.
4. Inflammatory Markers (ESR, CRP):
o Purpose: Detects systemic inflammation or infection.
o Indication: Useful in identifying inflammatory conditions or secondary
infections.
5. Nutritional Markers:
o Albumin and Prealbumin Levels:
▪ Purpose: Assess nutritional status.
▪ Indication: Important in patients with chronic ulcers and poor healing.
6. Wound Culture:
o Purpose: Identifies bacterial pathogens and determines antibiotic sensitivity.
o Indication: Recommended if there are signs of infection (e.g., increased exudate,
foul odor, erythema).

2. Imaging Studies

1. Doppler Ultrasound:
o Purpose: Evaluates venous and arterial blood flow in the legs.
o Indication: Useful for assessing venous insufficiency and arterial perfusion.
2. Ankle-Brachial Index (ABI):
o Purpose: Assesses the ratio of the blood pressure in the lower legs to the blood
pressure in the arms to evaluate peripheral arterial disease.
o Indication: Indicated in patients with suspected arterial insufficiency.
3. X-Ray:
o Purpose: Detects bone involvement or osteomyelitis.
o Indication: Recommended if there is a suspicion of underlying bone infection or
trauma.
4. MRI (Magnetic Resonance Imaging):
o Purpose: Provides detailed images of soft tissues, bones, and joints.
o Indication: Useful for detecting osteomyelitis, deep tissue infections, or
assessing complex ulcers.
5. CT Angiography:
o Purpose: Visualizes blood vessels and evaluates blood flow.
o Indication: Considered in patients with significant arterial disease or planning
for revascularization procedures.

3. Specialized Tests

1. Venography:
o Purpose: Provides detailed images of the venous system.
o Indication: Used to diagnose deep vein thrombosis or other venous
abnormalities when Doppler ultrasound is inconclusive.
2. Bone Scan:
 o Purpose: Detects areas of increased bone metabolism indicative of infection or
inflammation.
o Indication: Useful for diagnosing osteomyelitis when X-ray and MRI results are
inconclusive.

Summary Table

Investigation Purpose Indication

Complete Blood Detects signs of infection, Identifying systemic infections or
Count (CBC) anemia, or hematological conditions that may impede wound
abnormalities. healing.
Blood Glucose and Screens for diabetes and Assessing the risk of diabetic ulcers.
HbA1c evaluates long-term glycemic
control.
Renal Function Evaluates kidney function. Important in patients with systemic
Tests diseases affecting the kidneys.
Inflammatory Detects systemic Identifying inflammatory conditions
Markers (ESR, inflammation or infection. or secondary infections.
CRP)
Nutritional Markers Assess nutritional status. Important in patients with chronic
(Albumin, ulcers and poor healing.
Prealbumin)
Wound Culture Identifies bacterial pathogens Recommended if there are signs of
and determines antibiotic infection.
sensitivity.
Doppler Ultrasound Evaluates venous and arterial Assessing venous insufficiency and
blood flow in the legs. arterial perfusion.
Ankle-Brachial Assesses peripheral arterial Indicated in patients with suspected
Index (ABI) disease. arterial insufficiency.
X-Ray Detects bone involvement or Recommended if there is a suspicion
osteomyelitis. of underlying bone infection or
trauma.
MRI (Magnetic Provides detailed images of Detecting osteomyelitis, deep tissue
Resonance Imaging) soft tissues, bones, and joints. infections, or assessing complex
ulcers.
CT Angiography Visualizes blood vessels and Considered in patients with
evaluates blood flow. significant arterial disease or
planning for revascularization
procedures.
Venography Provides detailed images of Diagnosing deep vein thrombosis or
the venous system. other venous abnormalities when
Doppler ultrasound is inconclusive.
Bone Scan Detects areas of increased Useful for diagnosing osteomyelitis
bone metabolism indicative of when X-ray and MRI results are
infection or inflammation. inconclusive.
Differential Diagnosis of leg and foot ulcer
condition Description Inclusion Criteria Exclusion Criteria
Venous Ulcer Ulcers due to chronic - History of venous disease - Normal venous Doppler
venous insufficiency, (varicose veins, DVT) <br> - ultrasound <br> -
usually found on the Aching, heaviness relieved Absence of venous
medial malleolus. by elevation <br> - Edema, disease history
hemosiderin staining,
lipodermatosclerosis
Arterial Ulcer Ulcers due to peripheral - History of peripheral - Normal Ankle-Brachial
arterial disease, arterial disease, smoking, Index (ABI) <br> -
commonly located on diabetes <br> - Claudication, Absence of arterial
pressure points. rest pain <br> - Punched-out disease history <br> -
appearance, cold extremities, Normal Doppler
diminished pulses ultrasound
Diabetic Ulcer Ulcers due to - History of diabetes mellitus - Normal blood glucose
neuropathy and poor <br> - Peripheral neuropathy and HbA1c levels <br> -
blood flow in diabetic (loss of sensation) <br> - Absence of peripheral
patients, usually on Callus formation, foot neuropathy
pressure points. deformities
Pressure Ulcer Ulcers due to prolonged - History of immobility, - Absence of prolonged
pressure, often seen in bedridden status <br> - Over pressure or immobility
immobile patients over bony prominences <br> - <br> - Normal skin over
bony prominences. Varying stages of tissue bony prominences
damage
Infectious Ulcers caused by - Signs of infection - Absence of systemic
Ulcer bacterial, fungal, or (erythema, pus, foul odor) signs of infection <br> -
viral infections, rapid <br> - Rapid onset <br> - Negative wound culture
onset, often with Positive wound culture
systemic symptoms.
Malignant Ulcers caused by - Irregular borders, non- - Normal biopsy <br> -
Ulcer primary or metastatic healing, bleeding <br> - Absence of history of
cancer, often with History of skin cancer or malignancy
irregular borders and other malignancies <br> -
bleeding. Biopsy confirming
malignancy
Vasculitic Ulcers caused by - History of systemic - Absence of systemic
Ulcer inflammation of blood vasculitis <br> - Painful vasculitis <br> - Normal
vessels, often ulcers <br> - Biopsy biopsy
associated with showing vasculitis
systemic vasculitis.
Pyoderma Ulcers associated with - History of autoimmune - Absence of underlying
Gangrenosum autoimmune conditions, disease (e.g., IBD, autoimmune condition
characterized by rheumatoid arthritis) <br> - <br> - Biopsy excluding
painful, rapidly Rapid progression, pyoderma gangrenosum
progressing ulcers. undermined edges
 Osteoporosis
Analysis of Complaint

1. Presenting Symptoms:
o Primary Complaint: Ask about the main reason for the visit. Common
presentations include fractures (especially vertebral, hip, or wrist), back pain, and
height loss.
o Onset and Duration: When did the symptoms start? Are they acute or chronic?
o Character of Pain: If pain is present, ask about its nature (e.g., sharp, dull),
location, and radiation.
o Severity and Impact: How severe is the pain or other symptoms? How do they
affect daily activities?
2. Fracture History:
o Previous Fractures: Ask about any previous fractures, their locations, and
circumstances (e.g., minimal trauma or spontaneous).
o Healing and Complications: How well did they heal? Any complications or
prolonged recovery?

Associated Symptoms

1. Musculoskeletal:
o Back Pain: Character, duration, and aggravating/relieving factors.
o Height Loss: Noticeable decrease in height over time.
o Posture Changes: Development of kyphosis (stooped posture).
2. Systemic Symptoms:
o Weight Loss: Unintentional weight loss.
o Weakness or Fatigue: Generalized weakness or feeling tired easily.
3. Secondary Causes:
o Endocrine Symptoms: Symptoms suggestive of hyperthyroidism, Cushing’s
syndrome, hyperparathyroidism.
o Gastrointestinal Symptoms: Malabsorption syndromes (e.g., celiac disease),
chronic liver disease.

Risk Factors and History

1. Demographics:
o Age and Gender: Older age and female gender are major risk factors.
o Menopausal Status: Age at menopause and any hormone replacement therapy.
2. Family History:
o Genetic Predisposition: Family history of osteoporosis or fractures.
3. Lifestyle Factors:
o Diet: Calcium and vitamin D intake.
o Physical Activity: Level of physical activity and exercise.
o Smoking and Alcohol: History of smoking and alcohol consumption.
4. Medical History:
o Chronic Conditions: History of rheumatoid arthritis, chronic kidney disease,
gastrointestinal disorders.
 o Medications: Long-term use of glucocorticoids, anticonvulsants, or other drugs
affecting bone metabolism.
5. Reproductive History:
o Parity and Lactation: Number of pregnancies and duration of breastfeeding.

Differential Diagnosis and Exclusion

1. Other Metabolic Bone Diseases:

o Osteomalacia: Check for symptoms like bone pain and muscle weakness, assess
vitamin D levels.
o Paget’s Disease: Look for localized bone pain, deformities, and elevated alkaline
phosphatase.
2. Malignancies:
o Multiple Myeloma: Symptoms like bone pain, anemia, hypercalcemia; order
serum protein electrophoresis and urine Bence Jones protein.
o Bone Metastases: History of primary cancer, localized bone pain, imaging
studies showing lytic lesions.
3. Endocrine Disorders:
o Hyperparathyroidism: Symptoms like kidney stones, abdominal pain, high
calcium levels.
o Cushing’s Syndrome: Symptoms like weight gain, purple striae, muscle
weakness, elevated cortisol levels.

Review of Systems

1. Musculoskeletal System:
o Assess for pain, deformities, range of motion, muscle strength.
o Evaluate gait and balance.
2. Endocrine System:
o Symptoms of thyroid, adrenal, and parathyroid dysfunction.
o Menstrual history and signs of androgen excess or deficiency.
3. Gastrointestinal System:
o Symptoms of malabsorption (e.g., chronic diarrhea, steatorrhea).
o History of gastrointestinal surgeries or chronic liver disease.
4. Renal System:
o History of kidney stones or chronic kidney disease.
o Symptoms like polyuria, hematuria.
5. Neurological System:
o Any signs of neuropathy or muscle weakness.
o Cognitive function, especially in elderly patients.
Summary Table

Aspect Questions to Ask

Analysis of Primary complaint, onset and duration, character of pain, severity,
Complaint impact on daily activities, fracture history
Associated Symptoms Back pain, height loss, posture changes, weight loss, weakness,
endocrine or gastrointestinal symptoms
Risk Factors and Age, gender, menopausal status, family history, diet, physical
History activity, smoking, alcohol, chronic conditions, medications
Differential Diagnosis Symptoms and signs of osteomalacia, Paget’s disease, multiple
and Exclusion myeloma, bone metastases, hyperparathyroidism, Cushing’s
syndrome
Review of Systems Musculoskeletal, endocrine, gastrointestinal, renal, neurological
symptoms

Investigations
Bone Mineral Density (BMD) Testing

1. Dual-energy X-ray Absorptiometry (DXA) Scan:

o Purpose: Measures BMD at the hip and spine, providing a T-score compared to
young healthy adults (standard deviation from the mean).
o Indication: Used to diagnose osteoporosis (T-score ≤ -2.5) or osteopenia (T-
score between -1 and -2.5).
2. Vertebral Fracture Assessment (VFA):
o Purpose: Identifies vertebral fractures using specialized imaging during DXA
scan.
o Indication: Helps in evaluating fracture risk and planning treatment.

2. Laboratory Investigations

1. Serum Calcium and Phosphorus:

o Purpose: To assess calcium and phosphorus levels, which are essential for bone
health.
o Indication: Abnormal levels can indicate metabolic bone diseases or secondary
causes of osteoporosis.
2. Serum 25-Hydroxy Vitamin D (25(OH)D):
o Purpose: Evaluates vitamin D status, essential for calcium absorption and bone
mineralization.
o Indication: Low levels can contribute to osteoporosis or secondary causes like
malabsorption.
3. Complete Blood Count (CBC):
o Purpose: Rules out anemia or chronic inflammation, which can affect bone
health.
o Indication: Anemia may suggest underlying chronic disease affecting bone
metabolism.
4. Renal Function Tests:
 o Purpose: Evaluates kidney function, important for vitamin D metabolism and
calcium homeostasis.
o Indication: Kidney disease can lead to metabolic bone disorders.
5. Thyroid Function Tests (TFTs):
o Purpose: Assesses thyroid hormone levels (TSH, T4), which influence bone
metabolism.
o Indication: Hyperthyroidism or hypothyroidism can affect bone density.
6. Bone Turnover Markers:
o Purpose: Measures markers of bone formation (e.g., osteocalcin) and resorption
(e.g., CTX, NTX).
o Indication: Provides insight into bone metabolism and response to treatment.

3. Imaging Studies

1. X-rays:
o Purpose: To assess for fractures, especially vertebral fractures not visible on
DXA VFA.
o Indication: Detects current or previous fractures, assessing severity and healing.

4. Additional Investigations Based on Clinical Context

1. Genetic Testing:
o Purpose: Identifies genetic mutations predisposing to osteoporosis (e.g., in cases
of early-onset or familial osteoporosis).
2. Hormonal Assessments:
o Purpose: Investigates for hormonal abnormalities (e.g., estrogen, testosterone)
influencing bone health.
3. Secondary Causes Screening:
o Purpose: Tests for conditions like malabsorption syndromes, chronic liver
disease, or hyperparathyroidism contributing to bone loss.

Summary Table

Investigation Purpose
DXA Scan (Hip and Spine) Assess bone mineral density (BMD)
Vertebral Fracture Assessment (VFA) Identify vertebral fractures
Serum Calcium and Phosphorus Assess mineral status
Serum 25(OH)D (Vitamin D) Evaluate vitamin D status
Complete Blood Count (CBC) Rule out anemia or chronic inflammation
Renal Function Tests Evaluate kidney function
Thyroid Function Tests (TFTs) Assess thyroid hormone levels
Bone Turnover Markers Measure bone metabolism markers
X-rays Detect fractures
Genetic Testing (if indicated) Identify genetic predisposition
Hormonal Assessments (if indicated) Investigate hormonal influences on bone health
Secondary Causes Screening (if Test for underlying conditions contributing to
indicated) bone loss
Differential Diagnosis of Osteoporosis
Condition Description Inclusion Criteria Exclusion Criteria
Primary Osteoporosis Age-related bone loss not - Age > 50 years - Absence of
associated with other secondary causes
identifiable causes.
Secondary Bone loss due to - Presence of - Absence of primary
Osteoporosis underlying medical secondary cause (e.g., osteoporosis, adequate
conditions or glucocorticoid use, vitamin D and calcium
medications. hyperthyroidism) intake
Osteomalacia Softening of bones due to - Low serum - Normal bone mineral
impaired mineralization, 25(OH)D levels density (BMD),
typically from vitamin D absence of
deficiency or mineralization defects
malabsorption. on bone biopsy
Paget's Disease Abnormal bone - Elevated alkaline - Absence of typical
remodeling leading to phosphatase levels, radiographic or
weakened and deformed characteristic histological features of
bones. radiographic findings Paget's disease
Multiple Myeloma Cancer of plasma cells in - Presence of - Absence of typical
bone marrow leading to monoclonal protein in findings on bone
bone destruction and serum or urine, bone marrow biopsy,
weakened bones. marrow biopsy absence of lytic bone
findings lesions
Hyperparathyroidism Overactive parathyroid - Elevated serum - Normal serum
glands leading to calcium levels, calcium and
increased calcium release elevated parathyroid parathyroid hormone
from bones. hormone levels levels
Cushing's Syndrome Excess cortisol - History of chronic - Normal cortisol
production leading to glucocorticoid use, levels, absence of
bone loss and typical clinical adrenal or pituitary
osteoporosis. features abnormalities
Malabsorption Conditions impairing - History of celiac - Normal absorption of
Syndromes nutrient absorption, disease, inflammatory nutrients, absence of
affecting bone bowel disease, or gastrointestinal
mineralization. other malabsorption symptoms
syndromes
Chronic Liver Liver dysfunction - History of chronic - Normal liver function
Disease affecting vitamin D liver disease, tests, absence of
metabolism and bone abnormal liver chronic liver disease
health. function tests complications
Chronic Kidney Impaired kidney function - Elevated serum - Normal kidney
Disease leading to disturbances in creatinine levels, function, absence of
calcium and phosphorus abnormal kidney uremia or electrolyte
metabolism. function tests imbalances
Anorexia Nervosa Eating disorder causing - History of severe - Normal nutritional
severe malnutrition and weight loss, status, absence of
hormonal disturbances. nutritional eating disorder
deficiencies behaviors
 proximal and distal muscle weakness
Analysis of the Complaint

1. Onset and Duration:

o When did the weakness start?
o Was the onset sudden or gradual?
o How has the weakness progressed over time?
2. Location and Distribution:
o Are both proximal (near the trunk) and distal (away from the trunk) muscles affected?
o Are the weaknesses symmetrical or asymmetrical?
o Which specific muscle groups are involved?
3. Severity:
o How severe is the weakness?
o Does it fluctuate during the day or with activity?
4. Associated Symptoms:
o Is there muscle pain or tenderness?
o Any sensory changes like numbness or tingling?
o Any autonomic symptoms such as changes in sweating, bowel, or bladder function?
5. Functional Impact:
o How does the weakness affect daily activities (e.g., walking, climbing stairs, lifting objects,
buttoning clothes)?
o Has the patient had any falls or difficulty with coordination?

Excluding Differential Diagnoses (DD)

1. Neurological Causes:
o Peripheral Neuropathy: Any history of diabetes, alcohol use, or exposure to toxins?
o Motor Neuron Disease: Any signs of fasciculations, muscle atrophy, or bulbar symptoms (e.g.,
difficulty speaking, swallowing)?
o Myasthenia Gravis: Any fluctuation in muscle weakness, ptosis, or diplopia?
o Multiple Sclerosis: Any history of relapses and remissions, visual disturbances, or sensory
symptoms?
2. Muscular Causes:
o Polymyositis/Dermatomyositis: Any skin changes, rash, or history of autoimmune disease?
o Muscular Dystrophy: Any family history of similar symptoms, or history of progressive weakness
from childhood?
3. Endocrine/Metabolic Causes:
o Hypothyroidism: Any weight gain, cold intolerance, constipation, or dry skin?
o Hyperthyroidism: Any weight loss, heat intolerance, tremors, or palpitations?
o Electrolyte Imbalances: Any history of renal disease, diuretic use, or symptoms of hypokalemia or
hyperkalemia?
4. Infectious Causes:
o Guillain-Barré Syndrome: Any recent infections, vaccinations, or progressive ascending
weakness?

Review of Affected System and Other Systems

1. Neurological System:
o Detailed motor examination: strength testing of all major muscle groups.
o Reflexes: are they diminished, absent, or hyperactive?
o Sensory examination: light touch, pinprick, proprioception, and vibration.
o Coordination and gait assessment.
 2. Musculoskeletal System:
o Muscle bulk: look for atrophy or hypertrophy.
o Muscle tone: assess for rigidity or spasticity.
o Presence of fasciculations or involuntary movements.
3. Cardiovascular System:
o Blood pressure and heart rate.
o Signs of heart failure or peripheral vascular disease.
4. Respiratory System:
o Respiratory rate and effort.
o Any signs of respiratory muscle weakness.
5. Endocrine System:
o Thyroid examination for goiter or nodules.
o Signs of adrenal insufficiency or Cushing’s syndrome.

History Taking

1. Past Medical History:

o Any chronic illnesses (e.g., diabetes, hypertension, thyroid disease)?
o Any history of neurological or muscular disorders?
2. Family History:
o Any family members with similar symptoms or diagnosed conditions?
3. Medication History:
o Any current or recent medications, including over-the-counter and herbal supplements?
4. Social History:
o Occupation, alcohol, and tobacco use.
o Any exposure to toxins or chemicals?
5. Review of Systems:
o Comprehensive review to identify any additional symptoms that may be related or point to other
diagnoses.

Investigations
• . Blood Tests

• Complete Blood Count (CBC): To detect anemia, infection, or other hematological disorders.
• Electrolytes: Including sodium, potassium, calcium, and magnesium levels to identify electrolyte
imbalances.
• Renal Function Tests: Blood urea nitrogen (BUN) and creatinine to assess kidney function.
• Liver Function Tests (LFTs): To rule out liver disease.
• Thyroid Function Tests: To diagnose hypothyroidism or hyperthyroidism.
• Creatine Kinase (CK): Elevated levels can indicate muscle damage.
• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): To detect inflammation.
• Autoantibodies: ANA, anti-dsDNA, and others for autoimmune diseases.
• Glucose Tolerance Test or HbA1c: To assess for diabetes mellitus.

2. Urine Tests

• Urinalysis: To detect myoglobinuria (indicative of rhabdomyolysis) or proteinuria.

• 24-Hour Urine Collection: For creatinine clearance and protein levels.
3. Electrophysiological Studies

• Nerve Conduction Studies (NCS): To assess the electrical conduction of peripheral nerves.
• Electromyography (EMG): To evaluate the electrical activity of muscles and identify neuromuscular
disorders.

4. Imaging Studies

• Magnetic Resonance Imaging (MRI):

o Brain and Spinal Cord: To detect lesions or structural abnormalities.
o Muscle MRI: To assess for myositis or other muscle pathologies.
• Computed Tomography (CT):
o Brain and Spine: When MRI is not available or contraindicated.

5. Biopsy

• Muscle Biopsy: For histological examination to diagnose myopathies, inflammatory muscle diseases, or
other muscular disorders.
• Nerve Biopsy: In cases where peripheral nerve pathology is suspected.

6. Specialized Tests

• Genetic Testing: For inherited muscle diseases like muscular dystrophies.

• Lumbar Puncture:
o Cerebrospinal Fluid (CSF) Analysis: To diagnose conditions like Guillain-Barré syndrome,
multiple sclerosis, or other central nervous system disorders.
• Antibody Testing:
o Anti-Acetylcholine Receptor Antibodies: For myasthenia gravis.
o Anti-MuSK Antibodies: For seronegative myasthenia gravis.

7. Functional Tests

• Pulmonary Function Tests (PFTs): To assess respiratory muscle involvement, particularly in diseases like
myasthenia gravis or motor neuron disease.
• Cardiac Evaluation:
o ECG: To detect cardiac involvement in systemic diseases like myopathies.
o Echocardiography: For structural heart abnormalities or cardiomyopathy.

8. Other Investigations

• Endocrine Evaluation:
o ACTH Stimulation Test: For adrenal insufficiency.
o Parathyroid Hormone (PTH) Levels: For hyperparathyroidism.
• Nutritional Assessment:
o Vitamin B12 and Folate Levels: To rule out deficiencies that can cause neuropathy or myopathy.
o Vitamin D Levels: For musculoskeletal health.
Differential diagnosis

1.Neuromuscular Disorders

• Myopathies:
o Duchenne and Becker Muscular Dystrophies: X-linked recessive disorders causing progressive
muscle weakness.
o Polymyositis and Dermatomyositis: Inflammatory myopathies presenting with symmetric proximal
muscle weakness.
o Inclusion Body Myositis: An inflammatory myopathy, typically affecting older adults, with both
proximal and distal muscle involvement.
• Motor Neuron Diseases:
o Amyotrophic Lateral Sclerosis (ALS): Characterized by progressive muscle weakness, spasticity,
and atrophy.
• Peripheral Neuropathies:
o Guillain-Barré Syndrome (GBS): Acute inflammatory demyelinating polyneuropathy leading to
ascending muscle weakness.

2. Metabolic and Endocrine Disorders

• Electrolyte Imbalances:
o Hypokalemia: Muscle weakness due to low potassium levels.
o Hyperkalemia: Muscle weakness due to high potassium levels.
• Endocrinopathies:
o Hypothyroidism: Can cause generalized muscle weakness and myopathy.
o Hyperthyroidism: Can lead to thyrotoxic periodic paralysis.
o Cushing's Syndrome: Muscle weakness due to prolonged exposure to high cortisol levels.

3. Autoimmune and Connective Tissue Diseases

• Systemic Lupus Erythematosus (SLE): Can involve muscle weakness due to myositis.
• Rheumatoid Arthritis (RA): May cause muscle weakness secondary to inflammatory myositis or drug
therapy.
• Myasthenia Gravis: An autoimmune disorder affecting the neuromuscular junction, causing fluctuating
muscle weakness.

4. Toxic and Drug-Induced Causes

• Drug-Induced Myopathies:
o Statins: Can cause muscle pain and weakness.
o Corticosteroids: Long-term use can lead to steroid myopathy.
• Toxins:
o Alcohol: Chronic use can cause alcoholic myopathy.
o Heavy Metals: Lead and other heavy metals can cause neuropathy and myopathy.

5. Genetic and Hereditary Conditions

• Mitochondrial Myopathies: Genetic disorders affecting the mitochondria, leading to muscle weakness and
other systemic symptoms.
• Metabolic Myopathies: Glycogen storage diseases and lipid metabolism disorders causing muscle
weakness.
Neurological Examination
1. Mental Status
o Assess level of consciousness, orientation, memory, and cognitive functions.
2. Cranial Nerves
o Examine all 12 cranial nerves to identify any deficits that could indicate central nervous system
involvement.
3. Motor System
o Muscle Bulk: Observe for atrophy or hypertrophy.
o Muscle Tone: Assess for spasticity or flaccidity by passively moving the limbs.
o Muscle Strength: Use the Medical Research Council (MRC) scale to grade muscle strength from 0
to 5.
▪ Proximal Muscles:
▪ Shoulder abduction (deltoid)
▪ Hip flexion (iliopsoas)
▪ Distal Muscles:
▪ Wrist extension (extensor carpi radialis)
▪ Ankle dorsiflexion (tibialis anterior)
o Coordination: Test finger-to-nose and heel-to-shin maneuvers for cerebellar function.
o Reflexes: Test deep tendon reflexes (biceps, triceps, knee, ankle) and note any abnormalities like
hyperreflexia or hyporeflexia.
o Gait: Observe the patient's gait for abnormalities like foot drop, waddling gait, or spastic gait.
4. Sensory System
o Assess for sensory loss in modalities such as light touch, pain, temperature, vibration, and
proprioception.
o Check for sensory level to identify spinal cord involvement.
5. Special Tests
o Gower’s Sign: Ask the patient to rise from a sitting or lying position; a positive sign (using hands to
push off legs) suggests proximal muscle weakness.
o Romberg Test: Test for proprioceptive deficits by asking the patient to stand with feet together and
eyes closed.
 Sciatica
Analysis of Complaint

1. Chief Complaint
o What is the primary reason for your visit today?
2. History of Present Illness
o Onset: When did the pain start? Was it sudden or gradual?
o Duration: How long have you been experiencing this pain?
o Location: Where exactly is the pain located? Does it radiate to other areas (e.g., down the leg)?
o Character: Can you describe the nature of the pain (e.g., sharp, dull, burning)?
o Severity: On a scale of 1 to 10, how severe is the pain?
o Aggravating Factors: What activities or positions make the pain worse?
o Relieving Factors: What helps to alleviate the pain (e.g., rest, medications)?
o Associated Symptoms: Have you experienced any numbness, tingling, weakness, or changes in
bowel or bladder function?
3. Past Medical History
o Have you had any previous episodes of similar pain?
o Do you have any chronic medical conditions (e.g., diabetes, hypertension)?
o Have you had any surgeries, especially involving the spine?
4. Medications
o Are you currently taking any medications? If so, what are they?
5. Allergies
o Do you have any known allergies to medications or other substances?
6. Family History
o Is there a family history of back problems, arthritis, or neurological conditions?
7. Social History
o What is your occupation? Does it involve heavy lifting or prolonged sitting?
o Do you smoke or use alcohol? If so, how much?

Exclusion of Differential Diagnoses (DD)

1. Musculoskeletal Causes
o Herniated Disc: Any history of heavy lifting or trauma? Is the pain exacerbated by coughing,
sneezing, or straining?
o Lumbar Spinal Stenosis: Does the pain improve when sitting or bending forward?
o Piriformis Syndrome: Is the pain located in the buttock and worsens with sitting?
2. Neurological Causes
o Cauda Equina Syndrome: Any difficulty with bowel or bladder control, or saddle anesthesia?
o Peripheral Neuropathy: Do you have any conditions like diabetes that could cause nerve damage?
3. Inflammatory Causes
o Ankylosing Spondylitis: Do you have morning stiffness that improves with exercise?
o Rheumatoid Arthritis: Any history of joint pain, swelling, or stiffness?
4. Vascular Causes
o Deep Vein Thrombosis (DVT): Any swelling, redness, or warmth in the leg?
5. Infectious Causes
o Spinal Infection (e.g., osteomyelitis, discitis): Any history of fever, night sweats, or recent
infections?
6. Other Causes
o Tumors: Any unexplained weight loss, night pain, or history of cancer?
o Abdominal Aortic Aneurysm: Any pulsatile abdominal mass, history of hypertension, or
atherosclerosis?
Review of Systems

1. General
o Have you experienced any weight loss, fever, or general malaise?
2. Neurological
o Any headaches, dizziness, or seizures?
o Any sensory changes (numbness, tingling)?
3. Cardiovascular
o Any chest pain, palpitations, or shortness of breath?
4. Respiratory
o Any cough, wheezing, or difficulty breathing?
5. Gastrointestinal
o Any abdominal pain, changes in bowel habits, or gastrointestinal bleeding?
6. Genitourinary
o Any changes in urination, urinary retention, or incontinence?
7. Musculoskeletal
o Any joint pain, swelling, or stiffness?
o Any other muscle weakness?
8. Endocrine
o Any symptoms of thyroid dysfunction (e.g., weight changes, temperature intolerance)?

Investigations

• . • Imaging Studies:

• MRI (Magnetic Resonance Imaging): This is the gold standard for evaluating the spine and nerve roots,
helping to identify herniated discs, spinal stenosis, tumors, or infections.
• CT (Computed Tomography) Scan: Useful for assessing bony structures and sometimes used when MRI
is contraindicated or unavailable.
• X-rays: Often the initial imaging modality to assess for fractures, degenerative changes, or structural
abnormalities.

• Electrodiagnostic Tests:

• Nerve Conduction Studies (NCS) and Electromyography (EMG): These tests help assess nerve function
and identify nerve compression or damage, ruling out peripheral neuropathy or other neuromuscular
disorders.

• Laboratory Tests:

• Complete Blood Count (CBC) and Erythrocyte Sedimentation Rate (ESR): These tests can help rule
out infectious or inflammatory causes.
• C-reactive Protein (CRP): Elevated levels may indicate inflammation but are nonspecific.

• Provocative Tests:

• Straight Leg Raise Test: A common physical examination maneuver to reproduce pain and assess nerve
root irritation.
• Lasegue Test: Another maneuver to provoke pain and evaluate sciatic nerve involvement.
• Other Considerations:

• Bone Scintigraphy (Bone Scan): Occasionally used to detect bone abnormalities, such as fractures or
tumors.
• Ultrasound: Limited utility in spinal evaluation but may assist in specific soft tissue assessments or guided
procedures.
• Lumbar Spine Flexion and Extension Studies: Sometimes used to assess spinal instability.
• Provocative Tests: Special maneuvers performed during physical examination to reproduce or exacerbate
symptoms, aiding in diagnosis.

Differential diagnosis
 Tingling and Numbness
Analysis of Complaint

1. Nature of Symptoms:
o Description of Tingling and Numbness: Ask the patient to describe the
sensation (e.g., pins and needles, burning, electric shock-like).
o Distribution: Determine where the symptoms occur (e.g., specific area, whole
limb, bilateral or unilateral).
o Onset and Duration: When did the symptoms start? Are they continuous or
intermittent? How long do they last?
2. Provoking and Relieving Factors:
o Aggravating Factors: Activities or positions that worsen the symptoms.
o Relieving Factors: Actions or positions that alleviate the symptoms.
3. Associated Symptoms:
o Pain: Any concurrent pain associated with tingling and numbness.
o Weakness: Muscle weakness in the affected area.
o Bowel or Bladder Changes: Any urinary or fecal incontinence or retention.
o Balance Problems: Issues with coordination or balance.
4. Progression of Symptoms:
o Temporal Course: Has there been any change in the frequency or intensity of
symptoms over time?
o Pattern of Spread: Has the tingling or numbness spread to other parts of the
body?

Excluding Differential Diagnosis

1. Neurological Conditions:
o Peripheral Neuropathy: Diabetes, alcoholism, nutritional deficiencies.
o Radicular Pain: Herniated disc, spinal stenosis.
o Central Nervous System Disorders: Multiple sclerosis, stroke, spinal cord
injury.
o Peripheral Nerve Entrapment: Carpal tunnel syndrome, ulnar nerve
entrapment.
o Vascular Causes: Peripheral arterial disease, Raynaud's phenomenon.
2. Metabolic and Systemic Conditions:
o Diabetes Mellitus: Assess for diabetes-related neuropathy.
o Nutritional Deficiencies: Vitamin B12 deficiency, folate deficiency.
o Autoimmune Disorders: Rheumatoid arthritis, systemic lupus erythematosus.
3. Medication History:
o Recent Changes: Any new medications that could cause neuropathy or affect
nerve function.

Review of Affected System and Other Systems

1. Neurological Examination:
o Motor Function: Assess muscle strength and tone.
o Sensory Function: Test for light touch, pain, temperature sensation.
 o Reflexes: Check deep tendon reflexes (e.g., biceps, triceps, patellar).
o Coordination: Perform tests like finger-to-nose, heel-to-shin.
2. Musculoskeletal Examination:
o Joint Mobility: Assess range of motion and signs of arthritis or joint pathology.
o Muscle Atrophy: Look for signs of muscle wasting or weakness.
3. Cardiovascular Examination:
o Peripheral Circulation: Evaluate peripheral pulses, signs of ischemia.
4. Dermatological Examination:
o Skin Changes: Look for skin color changes, ulcers, or lesions that could indicate
vascular or neurological involvement.

Summary Table

Aspect Questions to Ask

Analysis of Description of tingling and numbness, distribution, onset, duration,
Complaint aggravating and relieving factors
Associated Presence of pain, weakness, bowel or bladder changes, balance
Symptoms problems
Excluding History of diabetes, alcohol use, nutritional status, autoimmune
Differential disorders, medication history
Diagnosis
Review of Systems Neurological examination (motor, sensory, reflexes, coordination),
musculoskeletal examination, cardiovascular assessment,
dermatological examination

Investigations
1. Neurological Investigations

1. Electromyography (EMG) and Nerve Conduction Studies (NCS):

o Purpose: Evaluates nerve function and identifies nerve damage or compression.
o Indication: Useful in diagnosing peripheral neuropathies, radiculopathies, or
nerve entrapment syndromes (e.g., carpal tunnel syndrome).
2. Imaging Studies:
o MRI (Magnetic Resonance Imaging) of the Spine and Brain:
▪ Purpose: Detects structural abnormalities (e.g., herniated discs, spinal cord
lesions, brain tumors).
▪ Indication: Recommended if symptoms suggest central nervous system
involvement or significant radiculopathy.
3. Nerve Biopsy:
o Purpose: Rarely indicated; assesses for specific neuropathies (e.g., vasculitic
neuropathy).
o Indication: When other tests are inconclusive, and a specific neuropathy is
suspected.

2. Laboratory Investigations

1. Complete Blood Count (CBC):

 o Purpose: Rules out anemia and infections that could affect nerve function.
o Indication: Helpful in systemic conditions causing neuropathy.
2. Blood Glucose and HbA1c:
o Purpose: Screens for diabetes mellitus-related neuropathy.
o Indication: Essential in patients with risk factors for diabetes or symptoms
suggestive of diabetic neuropathy.
3. Vitamin B12 and Folate Levels:
o Purpose: Evaluates for deficiencies associated with neuropathy.
o Indication: Necessary if there is suspicion of nutritional deficiencies or
malabsorption syndromes.
4. Thyroid Function Tests (TFTs):
o Purpose: Assesses thyroid hormone levels, which can affect nerve function.
o Indication: Important if symptoms suggest thyroid dysfunction.
5. Renal Function Tests:
o Purpose: Evaluates kidney function, which can affect electrolyte balance and
nerve function.
o Indication: Consider in systemic diseases affecting the kidneys or causing
uremic neuropathy.
6. Inflammatory Markers (e.g., ESR, CRP):
o Purpose: Assesses for systemic inflammation or autoimmune conditions.
o Indication: Indicated if clinical suspicion of vasculitis or autoimmune
neuropathy.

3. Specialized Tests

1. Lumbar Puncture (Spinal Tap):

o Purpose: Analyzes cerebrospinal fluid (CSF) for signs of infection,
inflammation, or malignancy affecting the nervous system.
o Indication: Consider in suspected central nervous system disorders or
inflammatory neuropathies.
2. Genetic Testing:
o Purpose: Identifies genetic mutations associated with hereditary neuropathies
(e.g., Charcot-Marie-Tooth disease).
o Indication: When there is a strong family history or clinical suspicion of a
genetic disorder.

4. Other Investigations Based on Clinical Context

1. Cardiovascular Assessment:
o Peripheral Vascular Studies: Doppler ultrasound to evaluate peripheral arterial
disease in cases of vascular-related neuropathy.
Differential Diagnosis of Tingling and Numbness
Condition Description Inclusion Criteria Exclusion Criteria
Peripheral Damage to peripheral - Distal symmetric pattern - Absence of primary
Neuropathy nerves, often causing of sensory loss and causes such as
tingling, numbness, or diminished or absent diabetes, alcohol use,
pain. tendon reflexes or toxins
Diabetic Nerve damage due to - History of diabetes - Normal blood
Neuropathy diabetes mellitus, mellitus glucose levels,
affecting peripheral absence of diabetic
nerves. complications
Carpal Tunnel Compression of the - Positive Tinel's sign, - Absence of median
Syndrome median nerve at the wrist, Phalen's test nerve compression
leading to hand tingling symptoms, normal
and numbness. nerve conduction
studies
Radicular Pain Compression or - Dermatomal distribution - Absence of spinal
(Radiculopathy) inflammation of spinal of symptoms, positive pathology, normal
nerve roots, causing straight leg raise test imaging of spine
radiating symptoms.
Multiple Sclerosis Autoimmune disease - Presence of white matter - Absence of
(MS) affecting the central lesions on MRI, history of characteristic MRI
nervous system, leading relapses and remissions findings, lack of other
to demyelination. typical MS symptoms
Guillain-Barré Autoimmune disorder - Rapid onset of - Absence of
Syndrome (GBS) affecting peripheral symmetric motor ascending paralysis,
nerves, causing ascending weakness, normal CSF findings
paralysis. albuminocytologic
dissociation in CSF
Stroke Interruption of blood flow - Focal neurological - Absence of ischemic
(Cerebrovascular to the brain, resulting in deficits corresponding to or hemorrhagic stroke
Accident) sudden neurological affected brain region on imaging, lack of
deficits. vascular risk factors
Hypocalcemia Low levels of calcium in - Low serum calcium - Normal serum
the blood, affecting nerve levels, symptoms improve calcium levels,
function. with calcium absence of other
supplementation metabolic
abnormalities
Vitamin B12 Deficiency in vitamin - Low serum vitamin B12 - Normal vitamin B12
Deficiency B12 leading to levels, megaloblastic levels, absence of
neurological symptoms. anemia pernicious anemia
Lyme Disease Infection caused by - History of tick bite or - Absence of
Borrelia burgdorferi, exposure to endemic characteristic rash,
leading to neurological areas, positive serological negative serological
complications. tests tests
Peripheral Narrowing of arteries - Diminished peripheral - Normal peripheral
Arterial Disease leading to reduced blood pulses, ABI < 0.9 pulses, absence of
(PAD) flow, causing ischemic vascular risk factors
neuropathy.
 Abnormal posture
Analysis of Complaint

1. Nature of the Abnormal Posture:

o Onset and Duration: When did the abnormal posture first appear? How has it
progressed over time?
o Description: Specific details about the posture (e.g., stooping, leaning, rigid).
o Frequency and Timing: Is the posture constant or intermittent? Does it worsen
at certain times of the day or with specific activities?
2. Provoking and Relieving Factors:
o Aggravating Factors: Activities or conditions that worsen the posture (e.g.,
standing, walking, fatigue).
o Relieving Factors: Actions or treatments that improve the posture (e.g., rest,
specific exercises).
3. Associated Symptoms:
o Pain: Presence, severity, and nature of pain (e.g., back pain, joint pain, muscle
pain).
o Weakness: Any associated weakness or loss of strength.
o Stiffness: Presence of stiffness in joints or muscles.
o Neurological Symptoms: Tingling, numbness, or changes in sensation.
4. Impact on Daily Life:
o Activities of Daily Living: How the posture affects the patient’s ability to
perform daily tasks.
o Mobility: Impact on walking, balance, and general mobility.
o Occupational and Social Impact: How it affects work, hobbies, and social
interactions.

Excluding Differential Diagnosis

1. Musculoskeletal Causes:
o Scoliosis: Ask about a history of spine curvature, family history, and symptoms.
o Kyphosis: Look for a history of forward rounding of the back, pain, and
stiffness.
o Spinal Stenosis: Inquire about pain radiating to legs, numbness, and weakness.
2. Neurological Causes:
o Parkinson’s Disease: Ask about tremors, rigidity, bradykinesia, and family
history.
o Cerebral Palsy: Ask about developmental history, muscle tone abnormalities,
and coordination issues.
o Stroke: Inquire about sudden onset of symptoms, weakness, and facial drooping.
3. Metabolic and Endocrine Causes:
o Osteoporosis: Ask about history of fractures, bone pain, and risk factors like
menopause.
o Hyperparathyroidism: Look for symptoms like bone pain, kidney stones, and
fatigue.
o Rickets/Osteomalacia: Ask about dietary history, sunlight exposure, and bone
pain.
 4. Psychiatric Causes:
o Conversion Disorder: Inquire about stress, psychological trauma, and history of
psychiatric conditions.
o Depression: Look for symptoms of low mood, lack of interest, and fatigue.

Review of Affected System and Other Systems

1. Musculoskeletal System:
o Inspection: Look for deformities, muscle atrophy, and alignment.
o Palpation: Assess for tenderness, muscle spasms, and swelling.
o Range of Motion: Evaluate the movement of joints and spine.
2. Neurological System:
o Cranial Nerves: Test for abnormalities in vision, facial movements, and speech.
o Motor Function: Assess muscle strength, tone, and coordination.
o Sensation: Evaluate for changes in sensation, particularly in limbs.
o Reflexes: Check for normal and pathological reflexes.
3. Endocrine System:
o Thyroid Examination: Look for signs of thyroid enlargement or nodules.
o Bone Health: Assess for signs of osteoporosis or metabolic bone disease.
o Calcium Levels: Consider symptoms related to hypercalcemia or hypocalcemia.
4. Psychiatric Evaluation:
o Mental Status: Assess mood, affect, and thought processes.
o History of Stress or Trauma: Inquire about recent or past psychological
stressors.

Summary Table

Aspect Questions to Ask

Analysis of Onset, duration, description, frequency, timing, provoking/relieving
Complaint factors, pain, weakness, stiffness, neurological symptoms, impact on daily
life
Associated Presence of systemic symptoms (fever, weight loss, fatigue), previous
Symptoms treatments, response to treatment
Excluding History of musculoskeletal disorders, neurological conditions,
Differential metabolic/endocrine diseases, psychiatric conditions
Diagnosis
Review of Musculoskeletal (inspection, palpation, range of motion), neurological
Systems (cranial nerves, motor function, sensation, reflexes), endocrine (thyroid,
bone health), psychiatric (mental status, history of stress or trauma)
Common types of abnormal posture
Type of Description Common Causes
Abnormal
Posture
Kyphosis Excessive outward curvature of Osteoporosis, spinal fractures, poor
the thoracic spine. posture, Scheuermann's disease.
Lordosis Excessive inward curvature of Obesity, pregnancy, weak abdominal
the lumbar spine. muscles, spondylolisthesis.
Scoliosis Lateral curvature of the spine. Idiopathic, congenital spine
deformities, neuromuscular
conditions.
Flat Back Decreased curvature of the Degenerative disc disease, ankylosing
Syndrome lumbar spine. spondylitis, post-surgical changes.
Forward Head Head positioned forward relative Poor posture, prolonged
Posture to the shoulders. computer/phone use, muscle
imbalances.
Dowager's Hump Pronounced curvature at the base Osteoporosis, advanced age, postural
of the neck. habits.
Functional Leg Apparent difference in leg Muscle contractures, scoliosis, hip
Length length. problems.
Discrepancy
Pelvic Tilt Anterior or posterior tilt of the Weak core muscles, tight hip
pelvis. flexors/hamstrings, postural habits.
Pigeon Toes (In- Feet turn inward while walking Femoral anteversion, tibial torsion,
toeing) or standing. metatarsus adductus.
Bow Legs (Genu Legs curve outward at the knees. Physiological in infants, rickets,
Varum) Blount’s disease.
Knock Knees Knees angle in and touch each Normal developmental stage in
(Genu Valgum) other when legs are straightened. children, rickets, obesity.

Investigations
Imaging Studies:

• X-rays:
o Spine X-ray: To assess spinal alignment, curvature (e.g., scoliosis, kyphosis,
lordosis), and vertebral anomalies.
o Pelvis and Hip X-ray: To evaluate pelvic tilt, leg length discrepancies, and hip
joint abnormalities.
• MRI (Magnetic Resonance Imaging):
o Provides detailed images of soft tissues, spinal cord, and nerve roots.
o Useful for detecting disc herniations, spinal stenosis, and other neurological
causes.
• CT Scan (Computed Tomography):
o Offers detailed cross-sectional images of bones and soft tissues.
o Useful for complex bone fractures, bone structure abnormalities, and detailed
assessment of bony structures.
 • Bone Density Scan (DEXA):
o To assess bone density and diagnose osteoporosis or osteopenia.

2. Laboratory Tests:

• Complete Blood Count (CBC):

o To check for signs of infection or anemia.
• Electrolyte Panel:
o To detect electrolyte imbalances that could affect muscle function.
• Calcium, Phosphate, and Vitamin D Levels:
o To assess bone health and detect metabolic bone diseases like rickets or
osteomalacia.
• Thyroid Function Tests:
o To rule out thyroid disorders affecting muscle and bone metabolism.
• Parathyroid Hormone (PTH) Levels:
o To evaluate for hyperparathyroidism, which can affect bone density.
• Inflammatory Markers:
o Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) to detect
inflammation or infection.

3. Neurological Tests:

• Nerve Conduction Studies (NCS) and Electromyography (EMG):

o To assess the function of nerves and muscles.
o Useful for diagnosing conditions like peripheral neuropathy or myopathies.
• Evoked Potentials:
o To evaluate the function of sensory and motor pathways.
o Useful in conditions like multiple sclerosis.

4. Specialized Tests:

• Genetic Testing:
o For diagnosing hereditary conditions like muscular dystrophies or congenital
scoliosis.
• Biopsy:
o Muscle or nerve biopsy to diagnose specific myopathies or neuropathies.
• Gait Analysis:
o To objectively evaluate the mechanics of walking and identify abnormalities.
• Posture Analysis:
o Using tools like plumb lines, digital analysis, or specialized software to assess
posture alignment.
Differential Diagnosis of abnormal posture
Condition Key Features Investigations
Kyphosis Hunched back, back pain, stiffness Spine X-ray, MRI, Bone
Density Scan (DEXA)
Lordosis Swayback, lower back pain, Spine X-ray, MRI, Physical
exaggerated lumbar curve Examination
Scoliosis Lateral spinal curvature, asymmetry Spine X-ray, MRI, Physical
in shoulder/hip height Examination
Flat Back Syndrome Decreased lumbar curve, difficulty Spine X-ray, MRI, Physical
standing upright Examination
Forward Head Head forward relative to shoulders, Physical Examination, Posture
Posture neck pain, shoulder pain Analysis
Dowager's Hump Pronounced curvature at the base of Spine X-ray, Bone Density
the neck Scan (DEXA)
Functional Leg Apparent leg length difference, Pelvis X-ray, Leg Length
Length Discrepancy pelvic tilt Measurement, Physical
Examination
Pelvic Tilt Anterior/posterior pelvic tilt, lower Pelvis X-ray, Physical
back pain Examination, Gait Analysis
Pigeon Toes (In- Feet turn inward while walking Physical Examination, Gait
toeing) Analysis
Bow Legs (Genu Outward curvature of legs at the Leg X-ray, Physical
Varum) knees Examination, Vitamin D
Levels
Knock Knees (Genu Knees angle in and touch each Leg X-ray, Physical
Valgum) other Examination, Vitamin D
Levels
Parkinson’s Disease Tremors, rigidity, bradykinesia, Neurological Examination,
postural instability MRI, PET Scan
Cerebral Palsy Muscle tone abnormalities, MRI, Genetic Testing,
developmental delays Neurological Examination
Osteoporosis Fragility fractures, bone pain, Bone Density Scan (DEXA),
dowager's hump Calcium and Vitamin D
Levels, X-ray
Hyperparathyroidism Bone pain, kidney stones, fatigue PTH Levels, Calcium Levels,
Bone Density Scan (DEXA),
X-ray
Rickets/Osteomalacia Bone pain, muscle weakness, Vitamin D Levels, Calcium
skeletal deformities and Phosphate Levels, X-ray
Conversion Disorder Inconsistent neurological Psychiatric Evaluation,
symptoms, no organic cause Neurological Examination,
MRI
Depression Low mood, lack of interest, fatigue, Psychiatric Evaluation,
poor posture Depression Screening Tools
 Stridor
1. Analysis of Complaint:

• Onset: When did the stridor first appear? Was it sudden or gradual?
• Duration: How long has the stridor been present? Has it been constant or intermittent?
• Characteristics: Can you describe the sound of the stridor? (e.g., high-pitched, inspiratory,
expiratory, biphasic)
• Severity: How severe is the stridor? Does it interfere with breathing or activities?
• Triggers: Are there specific triggers or exacerbating factors (e.g., position, activity, emotions)?
• Progression: Has the stridor worsened, improved, or remained the same over time?

2. Associated Symptoms:

• Respiratory Symptoms: Cough, shortness of breath, wheezing, hoarseness.

• Swallowing Difficulty: Dysphagia (difficulty swallowing), choking episodes.
• Voice Changes: Hoarseness or changes in voice quality.
• Pain: Is there any associated pain in the throat or chest?
• Systemic Symptoms: Fever, weight loss, night sweats (if suggestive of systemic illness).

3. Excluding Differential Diagnosis:

Given the nature of stridor, it's important to focus on excluding life-threatening causes first:

Upper Airway Obstruction:

• Foreign Body Aspiration: Inquire about sudden onset of symptoms after choking or playing with
small objects. Ask about choking episodes or witnessed aspiration events.
• Infections:
o Epiglottitis: Ask about rapid onset of severe sore throat, drooling, dysphagia, and high fever.
o Croup (Laryngotracheobronchitis): Inquire about a barking cough, inspiratory stridor, and recent
upper respiratory symptoms.
• Trauma: Assess for recent trauma to the head, neck, or chest that could lead to airway compromise.
• Tumors: Consider the possibility of benign or malignant tumors causing airway obstruction.
o Key Questions: Is there a history of voice changes, throat pain, or difficulty breathing that has been
progressive?

Lower Airway Obstruction:

• Asthma Exacerbation: Ask about a history of asthma and recent triggers or exacerbating factors.
o Key Questions: Is there a history of asthma? Have there been recent triggers such as allergens, cold
air, or exercise?
• Bronchiolitis: Evaluate for recent viral illness, especially in infants and young children.
o Key Questions: Is the patient an infant or young child? Is there a history of recent viral illness, such
as respiratory syncytial virus (RSV)?
• Vocal Cord Dysfunction (VCD): Inquire about episodes of inspiratory stridor triggered by stress or
exercise.
o Key Questions: Does the stridor occur during times of stress or exercise? Is there a history of anxiety
or panic attacks?

4. Review of Affected Systems:

• Respiratory System: History of asthma, chronic obstructive pulmonary disease (COPD), or previous
respiratory infections.
• Cardiovascular System: History of heart disease or congestive heart failure.
 • Neurological System: History of neurological disorders affecting swallowing or vocal cord function.
• Gastrointestinal System: History of gastroesophageal reflux disease (GERD) or esophageal
disorders.
• Immunological System: History of allergies or autoimmune conditions.

5. Other Relevant Factors:

• Medications: Current medications, including inhalers or treatments for allergies.

• Environmental Exposure: Occupational hazards or exposure to irritants.
• Social History: Smoking history, alcohol consumption, or recent travel history (relevant for
infections).
• Family History: Any relevant family history of respiratory or autoimmune diseases.

Investigations
1. Immediate Assessment:

• Airway Evaluation: Assess the patient's airway patency, breathing, and circulation (ABCs) as initial
steps to ensure immediate stabilization if necessary.

2. Diagnostic Imaging:

• X-ray (Neck and Chest): Useful for evaluating for foreign bodies, soft tissue swelling, or structural
abnormalities in the airway.
• CT Scan of Neck and Chest: Provides detailed imaging for evaluating structural abnormalities,
masses, or trauma affecting the upper airway.

3. Endoscopy:

• Flexible Laryngoscopy: Allows direct visualization of the larynx and upper airway to identify
anatomical abnormalities, foreign bodies, or lesions.
• Bronchoscopy: If lower airway involvement is suspected or if upper airway evaluation is
inconclusive, bronchoscopy can visualize and potentially retrieve foreign bodies, assess for tumors,
or evaluate for subglottic stenosis.

4. Laboratory Tests:

• Complete Blood Count (CBC): To assess for signs of infection or inflammation.

• Cultures: If infection is suspected (e.g., epiglottitis), obtain cultures of blood or throat swabs for
microbiological analysis.

5. Pulmonary Function Tests (PFTs):

• Spirometry: Evaluates lung function, helpful in assessing for underlying asthma or chronic
obstructive pulmonary disease (COPD).

6. Additional Tests:

• Serum IgE Levels: If allergic causes are suspected (e.g., angioedema or allergic reactions).
• Thyroid Function Tests: Evaluate thyroid function in cases where thyroid enlargement (goiter) may
be causing airway compression.
7. Biopsy or Fine-Needle Aspiration (FNA):

• Biopsy: If a mass or lesion is suspected, biopsy may be performed during endoscopy or under
imaging guidance.
• FNA: Particularly useful for evaluating lymph nodes or suspicious masses near the airway.

8. Dynamic Tests:

• Exercise Testing: For suspected exercise-induced vocal cord dysfunction (VCD), dynamic
assessment during exercise may reproduce symptoms.

Differential diagnosis

1. Upper Airway Causes:

• Epiglottitis:
o Etiology: Typically bacterial (e.g., Haemophilus influenzae type B).
o Clinical Features: Rapid onset of high fever, severe sore throat, drooling, dysphagia,
muffled voice, and inspiratory stridor.
o Investigations: Direct visualization (laryngoscopy) shows swollen, cherry-red epiglottis
("thumbprint sign").
o Management: Immediate airway management, antibiotics (e.g., ceftriaxone, ampicillin-
sulbactam).
• Croup (Laryngotracheobronchitis):
o Etiology: Viral (parainfluenza virus, often affecting children).
o Clinical Features: Barking cough, inspiratory stridor, hoarseness, fever, and symptoms
worsen at night.
o Investigations: Clinical diagnosis; imaging (X-ray) may show "steeple sign" due to
subglottic narrowing.
o Management: Supportive care (e.g., humidified air, steroids for severe cases).
• Foreign Body Aspiration:
o Etiology: Inhalation of solid or liquid foreign objects into the airway.
o Clinical Features: Sudden onset of coughing, choking, respiratory distress, unilateral
wheezing or decreased breath sounds, and stridor.
o Investigations: Chest X-ray (may show hyperinflation, atelectasis, or radio-opaque foreign
body); bronchoscopy for direct visualization and removal.
o Management: Emergency removal of the foreign body; supportive care as needed.
• Vocal Cord Dysfunction (VCD):
o Etiology: Paradoxical vocal cord motion due to abnormal vocal cord adduction during
inspiration.
o Clinical Features: Inspiratory stridor, episodic dyspnea often triggered by stress, exercise, or
emotional factors.
o Investigations: Direct laryngoscopy or video laryngoscopy during an episode to visualize
vocal cord movement.
o Management: Speech therapy for breathing techniques, psychological support; avoidance of
triggers.
• Laryngeal Tumors or Masses:
o Etiology: Benign or malignant growths in the larynx causing mechanical obstruction.
o Clinical Features: Progressive hoarseness, dysphagia, pain, and inspiratory stridor.
o Investigations: Laryngoscopy with biopsy or imaging (CT/MRI) to assess extent and nature
of the mass.
o Management: Surgical excision, radiation, or chemotherapy depending on pathology.
2. Lower Airway Causes:

• Asthma Exacerbation:
o Etiology: Airway hyperreactivity and inflammation leading to bronchospasm.
o Clinical Features: Wheezing, dyspnea, cough, and potentially inspiratory stridor during
severe attacks.
o Investigations: Spirometry showing reversible airflow obstruction; peak flow measurements.
o Management: Bronchodilators (e.g., albuterol), corticosteroids for inflammation.
• Bronchiolitis:
o Etiology: Viral infection (e.g., respiratory syncytial virus) affecting small airways.
o Clinical Features: Cough, wheezing, respiratory distress, and inspiratory stridor in infants
and young children.
o Investigations: Clinical diagnosis; chest X-ray may show hyperinflation and peribronchial
cuffing.
o Management: Supportive care, oxygen therapy, hydration; bronchodilators in severe cases.
• Subglottic Stenosis:
o Etiology: Narrowing of the subglottic region due to congenital anomalies, trauma, or
prolonged intubation.
o Clinical Features: Progressive stridor, dyspnea, and respiratory distress worsened with
agitation or exertion.
o Investigations: Laryngoscopy or imaging (CT/MRI) to visualize narrowing; may require
dynamic imaging during inspiration.
o Management: Surgical correction (e.g., dilation, tracheostomy) depending on severity and
cause.

3. Other Causes:

• Anaphylaxis:
o Etiology: Severe allergic reaction leading to airway edema and obstruction.
o Clinical Features: Rapid onset of stridor, urticaria, angioedema, hypotension, and respiratory
distress.
o Investigations: Clinical diagnosis supported by history of allergen exposure; serum tryptase
levels post-reaction.
o Management: Epinephrine (adrenaline) injection, airway management, antihistamines,
corticosteroids.
• Psychogenic Stridor:
o Etiology: Functional or psychological disorder causing abnormal vocal cord movements.
o Clinical Features: Variable presentation with episodic stridor, normal oxygenation, and no
structural abnormalities.
o Investigations: Diagnosis of exclusion; laryngoscopy to rule out anatomical abnormalities
during episodes.
o Management: Psychological evaluation and therapy, supportive care.
Category Condition Key Features/Clues

Upper Airway Rapid onset of high fever, severe sore throat, drooling, dysphagia,
Epiglottitis
Causes muffled voice, inspiratory stridor.

Barking cough, inspiratory stridor, hoarseness, fever, worsens at

Croup
night; "steeple sign" on X-ray.

Foreign Body Sudden onset cough/choking, respiratory distress, unilateral

Aspiration wheezing, decreased breath sounds, inspiratory stridor.

Vocal Cord Paradoxical vocal cord motion, triggered by stress/exercise,

Dysfunction (VCD) episodic inspiratory stridor.

Laryngeal Tumors or Progressive hoarseness, dysphagia, pain, inspiratory stridor;

Masses visualized on laryngoscopy or imaging.

Lower Airway Wheezing, dyspnea, cough, inspiratory stridor during severe

Asthma Exacerbation
Causes attacks; reversible airflow obstruction on spirometry.

Cough, wheezing, respiratory distress, inspiratory stridor in infants;

Bronchiolitis
hyperinflation on X-ray.

Progressive stridor, dyspnea, exacerbated by agitation/exertion;

Subglottic Stenosis
visualized on laryngoscopy or imaging.

Rapid onset of stridor, urticaria, angioedema, hypotension,

Other Causes Anaphylaxis
respiratory distress; history of allergen exposure.

Episodic stridor, normal oxygenation, no structural abnormalities;

Psychogenic Stridor
diagnosis of exclusion.
 Tinnitus
1. Analysis of Complaint:

• Onset: When did the tinnitus first start? Was it sudden or gradual?
• Duration and Progression: How has the tinnitus changed over time? Is it constant or intermittent?
• Description of the Sound: Can the patient describe the sound? (e.g., ringing, buzzing, hissing)
• Severity: How bothersome is the tinnitus to the patient? Does it affect daily activities or sleep?
• Aggravating or Relieving Factors: What makes the tinnitus worse or better? (e.g., noise exposure,
stress)
• Associated Symptoms: Any accompanying symptoms such as hearing loss, vertigo, ear pain, or
headaches?
• Impact on Quality of Life: How does tinnitus affect the patient’s emotional well-being and social
interactions?

2. Associated Symptoms:

• Hearing Loss: Is there any associated hearing impairment? If so, unilateral or bilateral?
• Vertigo or Dizziness: Does the patient experience spinning sensations or imbalance?
• Ear Symptoms: Any ear fullness, pressure, or pain associated with tinnitus?
• Headache or Facial Pain: Are there any headaches or facial pain that coincide with tinnitus
episodes?
• Psychological Symptoms: Does the patient report anxiety, depression, or difficulty concentrating
due to tinnitus?

3. Excluding Differential Diagnosis:

• Objective: To rule out other potential causes of tinnitus, including:

o Conductive Hearing Loss: Assess for middle ear pathologies like otitis media or
otosclerosis.
o Sensorineural Hearing Loss: Evaluate for presbycusis, noise-induced hearing loss, or
Meniere's disease.
o Neurological Causes: Consider conditions such as acoustic neuroma or multiple sclerosis
affecting the auditory pathways.
o Vascular Causes: Check for pulsatile tinnitus related to vascular abnormalities.
o Medication-Induced: Review current medications for ototoxic effects that could contribute
to tinnitus.
o Systemic Conditions: Explore systemic diseases like hypertension, diabetes, or thyroid
disorders.

4. Review of Affected Systems:

• Auditory System: Detailed history of any previous ear infections, trauma, or exposure to loud
noises.
• Neurological System: Assess for any neurological symptoms or disorders that could affect auditory
function.
• Cardiovascular System: Evaluate for hypertension or other vascular risk factors associated with
tinnitus.
• Psychological and Emotional Health: Discuss the impact of tinnitus on the patient’s mental well-
being and daily activities.
5. Other Systems:

• General Medical History: Review past medical history, surgeries, and chronic conditions.
• Medication History: List current medications, including over-the-counter drugs and supplements.
• Social History: Inquire about occupational noise exposure, recreational habits (e.g., concerts,
firearms), and smoking history.
• Family History: Any family members with hearing disorders or tinnitus?

Investigations
• Audiological Assessment:

• Pure Tone Audiometry (PTA): Evaluates hearing thresholds across different frequencies to detect
any associated hearing loss.
• Speech Audiometry: Assesses speech recognition ability, which can help determine the impact of
tinnitus on communication.
• Tympanometry: Measures the mobility of the eardrum and middle ear pressure, useful for detecting
middle ear pathologies.

• Imaging Studies:

• MRI (Magnetic Resonance Imaging): Recommended if there are signs or symptoms suggestive of
structural abnormalities such as acoustic neuroma, vascular malformations, or brain tumors.
• CT Scan (Computed Tomography): May be used to evaluate the temporal bones and detect bony
abnormalities or lesions.

• Vascular Studies:

• Doppler Ultrasound: Assess blood flow in the neck and head to investigate pulsatile tinnitus, which
could indicate vascular abnormalities like carotid artery stenosis.

• Laboratory Tests:

• Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP): Screen for systemic
conditions such as anemia, diabetes, thyroid dysfunction, and renal disorders that may contribute to
tinnitus.
• Lipid Profile: Evaluate for dyslipidemia, which can be associated with vascular tinnitus.

• Specialized Tests:

• Auditory Brainstem Response (ABR) or Brainstem Auditory Evoked Potentials (BAEP):

Assess the auditory nerve and brainstem function, particularly useful when neurologic causes are
suspected.
• Electrocochleography (ECochG): Measures electrical potentials generated in the inner ear, helpful
in diagnosing Meniere's disease or endolymphatic hydrops.
Differential diagnosis

Category Causes Clinical Features Diagnostic Clues

Subjective Noise-induced Hearing High-pitched ringing or History of noise exposure,
Tinnitus Loss buzzing sound audiometric findings
Presbycusis (Age-relatedBilateral, high-frequency Audiometry showing age-
Hearing Loss) tinnitus related hearing loss
Onset after starting Medication history,
Ototoxic Medications
medications audiometric evaluation
Episodic vertigo,
Audiometry, vestibular testing
Meniere's Disease fluctuating hearing loss,
(e.g., VNG)
tinnitus
Tinnitus associated with
Temporomandibular Joint Examination by dentist,
jaw movements or
Disorders imaging if indicated
clenching
Tinnitus exacerbated Psychological evaluation,
Stress and Anxiety
during stress stress assessment
Pulsatile nature Auscultation, vascular imaging
Objective
Vascular Causes synchronized with (e.g., Doppler ultrasound),
Tinnitus
heartbeat CT/MRI if indicated
Observation during
Clicking or fluttering
Middle Ear Myoclonus examination, audiometric
sound
testing
Clicking sound with Observation, ENT evaluation
Palatal Myoclonus
involuntary movements for confirmation
Clicking or thumping
Tensor Tympani Observation, audiological
sounds synchronous with
Syndrome assessment
jaw movements
Systemic and Unilateral sensorineural
Acoustic Neuroma MRI of the internal auditory
Neurological hearing loss, tinnitus,
(Vestibular Schwannoma) canal
Causes balance issues
Tinnitus along with other Neurological examination,
Multiple Sclerosis
neurological symptoms MRI of the brain and spine
Tinnitus associated with
Imaging studies of the cervical
Cervical Spine Disorders neck movements or
spine (e.g., MRI)
positions
Tinnitus associated with
Metabolic and
Thyroid Disorders other thyroid-related Thyroid function tests
Endocrine Causes
symptoms
Blood glucose monitoring,
Tinnitus along with other
Diabetes Mellitus evaluation of diabetic
diabetic complications
neuropathy
 Behavior problems
Analysis of Complaint:

• Chief Complaint: Begin by asking about the primary reason for seeking help regarding behavior problems.
• Onset: When did the behavior problems first start? Was there a specific event or trigger?
• Duration: How long have the behavior problems been occurring? Have they been constant or intermittent?
• Progression: Has there been any change in the behavior over time?
• Severity: How severe are the behavior problems? How do they impact daily life, relationships, and
functioning?
• Pattern: Are there any specific patterns to the behavior (e.g., time of day, specific situations)?
• Triggers: What seems to trigger or worsen the behavior problems?
• Relief Measures: What, if anything, provides relief or improves the behavior temporarily?

Excluding Differential Diagnoses (DD)

1. Autism Spectrum Disorder (ASD):

• Social Communication:
o Does the individual have difficulty with social interactions, such as making eye contact or
understanding non-verbal cues?
o How does the individual engage in social play or relationships compared to peers?
• Repetitive Behaviors:
o Are there repetitive movements or interests that are unusually intense or focused?
o Does the individual adhere strictly to routines or rituals?
• Sensory Sensitivities:
o Does the individual show heightened sensitivity or unusual responses to sensory stimuli (e.g., touch,
sound, light)?
o How does sensory input affect their behavior and comfort?

2. Attention-Deficit/Hyperactivity Disorder (ADHD):

• Inattention:
o Does the individual struggle to sustain attention on tasks or activities, such as schoolwork or play?
o Are they easily distracted by external stimuli?
• Hyperactivity-Impulsivity:
o Is there excessive fidgeting or restlessness?
o Does the individual frequently interrupt others or act impulsively without considering consequences?

3. Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD):

• Defiance and Rule-Breaking:

o Is there a pattern of arguing with authority figures or refusing to comply with rules or requests?
o Have there been instances of vindictiveness or spitefulness?
• Aggression and Antisocial Behavior:
o Does the individual exhibit physical aggression towards peers or caregivers?
o Are there behaviors indicating a lack of empathy or remorse?
4. Mood Disorders (Depression, Bipolar Disorder):

• Depressive Symptoms:
o Has there been a noticeable change in mood, such as sadness, irritability, or feelings of
hopelessness?
o Is there a loss of interest in previously enjoyed activities?
• Manic or Hypomanic Symptoms (in Bipolar Disorder):
o Has there been a period of unusually elevated mood or energy, accompanied by increased activity
levels?
o Are there periods of impulsivity or risky behavior?

5. Anxiety Disorders:

• Excessive Worry and Fear:

o Does the individual experience excessive worry about multiple aspects of life (e.g., school
performance, safety)?
o Are there specific fears or phobias that significantly interfere with daily functioning?

6. Other Medical and Psychiatric Conditions:

• Neurological Conditions: History of seizures, head trauma, neurological symptoms.

• Medical Conditions: Thyroid disorders, substance use, hepatic encephalopathy ,medication side effects.

3. Review of Affected System and Other Systems:

• Developmental History: Birth history, milestones, developmental delays.

• Family History: Any family history of similar conditions or psychiatric disorders.
• Educational History: School performance, interactions with peers and teachers.
• Social History: Family dynamics, stressors, support systems.
• Physical Examination: General physical examination to rule out any physical causes contributing to
behavior problems.

Investigations

1. Medical and Neurological Assessments:

• Physical Examination:
o Comprehensive physical examination to assess growth parameters, neurodevelopmental milestones,
dysmorphic features, and signs of neurological abnormalities.
• Laboratory Tests:
o Complete Blood Count (CBC): To screen for anemia or infections.
o Biochemical Profile (including liver and kidney function tests): To assess metabolic and organ
function.
o Thyroid Function Tests: To rule out thyroid disorders which can affect behavior.
o Toxicology Screen: Particularly in cases of suspected substance abuse.
• Neuroimaging:
o MRI (Magnetic Resonance Imaging) Brain: To evaluate for structural abnormalities or lesions.
o CT (Computed Tomography) Brain: Sometimes used if MRI is contraindicated or not available,
though less detailed.
2. Psychological and Psychiatric Assessments:

• Psychiatric Evaluation:
o Detailed assessment by a psychiatrist or psychologist to explore symptoms, behavioral patterns, and
emotional functioning.
• Neuropsychological Testing:
o Cognitive and behavioral assessments to evaluate intellectual functioning, attention, memory, and
executive functions.
• Behavioral Observations and Rating Scales:
o Behavioral assessments by caregivers, teachers, or other observers to gather information on
symptoms across different settings.

3. Developmental and Educational Assessments:

• Developmental History:
o Detailed history of developmental milestones and any regression or loss of skills.
• Educational Assessment:
o Evaluation of academic performance, learning disabilities, and any special educational needs.

4. Genetic and Metabolic Investigations (if indicated):

• Genetic Testing:
o Chromosomal microarray or specific genetic tests to identify genetic syndromes associated with
behavioral symptoms.
• Metabolic Screening:
o Screening for inborn errors of metabolism if clinical features suggest metabolic disorders.

5. Other Specialized Tests:

• Sleep Studies: If there are concerns about sleep disorders impacting behavior.
• Electroencephalogram (EEG): To evaluate for seizure disorders or abnormal brain electrical activity.
• Allergy Testing: In cases where allergies are suspected to contribute to behavioral symptoms.

Differential diagnosis

Differentiation Criteria:

• Age of Onset: Some disorders like ADHD typically manifest before adolescence.
• Pattern and Severity: Behavior disorders may differ in the persistence and severity of symptoms.
• Contextual Factors: Consideration of symptoms across different settings (e.g., home, school, community).
• Impact on Functioning: Assessing how symptoms affect daily life, relationships, and academic/work
performance.
• Exclusion of Other Conditions: Medical conditions, neurological disorders, or environmental factors
should be ruled out.
 Focal neurological deficit

Analysis of Complaint

1. Chief Complaint:
o What is the main issue or symptom? (e.g., weakness, numbness, vision changes)
o When did it start? Was the onset sudden or gradual?
2. History of Present Illness:
o Describe the onset, duration, and progression of the symptom.
o Any precipitating factors or events? (e.g., trauma, infection, stress)
o Exact location of the deficit (e.g., left arm, right leg, facial muscle).
o Severity and impact on daily activities.
o Any associated pain? (e.g., headache, neck pain, back pain)
3. Past Episodes:
o Any previous similar episodes?
o How were they resolved? (e.g., spontaneously, with treatment)

Associated Symptoms

1. General Symptoms:
o Fever, weight loss, fatigue, night sweats.
2. Neurological Symptoms:
o Headache, dizziness, seizures, altered consciousness, memory loss.
o Other sensory deficits (e.g., tingling, numbness).
o Motor deficits (e.g., weakness, difficulty walking, coordination issues).
o Speech difficulties (e.g., aphasia, dysarthria).
o Visual disturbances (e.g., blurred vision, double vision, visual field loss).
o Hearing loss or tinnitus.
o Swallowing or chewing difficulties.

Excluding Differential Diagnosis

1. Vascular Causes:
o Transient ischemic attack (TIA) or stroke: Sudden onset, risk factors
(hypertension, diabetes, smoking), presence of atrial fibrillation.
o Intracranial hemorrhage: Sudden severe headache, vomiting, hypertension.
2. Infectious Causes:
o Meningitis/encephalitis: Fever, neck stiffness, altered mental status.
o Brain abscess: Fever, focal neurological signs, immunocompromised state.
3. Inflammatory/Demyelinating Causes:
o Multiple sclerosis: Relapsing-remitting course, young adults, optic neuritis.
o Guillain-Barré syndrome: Ascending paralysis, recent infection.
4. Neoplastic Causes:
o Brain tumor: Gradual onset, headaches, seizures, cognitive changes.
o Spinal cord tumor: Back pain, radicular pain, progressive weakness.
5. Traumatic Causes:
 o History of head or neck trauma, acute onset after injury, presence of contusions
or lacerations.
6. Metabolic/Toxic Causes:
o Hypoglycemia: Sudden onset, history of diabetes.
o Electrolyte imbalances: Gradual onset, history of renal disease or endocrine
disorders.
o Drug/toxin exposure: History of substance abuse, medication history.
7. Degenerative Causes:
o Amyotrophic lateral sclerosis (ALS): Progressive weakness, muscle atrophy,
fasciculations.
o Parkinson’s disease: Bradykinesia, rigidity, tremor.

Review of Affected System

1. Neurological System:
o Detailed neurological examination including cranial nerves, motor function,
sensory function, reflexes, coordination, and gait.
o Cognitive assessment (orientation, memory, attention, language).

Review of Other Systems

1. Cardiovascular System:
o History of hypertension, diabetes, heart disease, arrhythmias.
o Examination for heart murmurs, carotid bruits, peripheral pulses.
2. Respiratory System:
o History of respiratory infections, chronic cough, smoking.
o Examination for respiratory rate, breath sounds, oxygen saturation.
3. Gastrointestinal System:
o History of liver disease, gastrointestinal bleeding, alcohol use.
o Examination for abdominal tenderness, hepatomegaly, ascites.
4. Genitourinary System:
o History of renal disease, urinary tract infections.
o Examination for bladder distention, prostate enlargement.
5. Musculoskeletal System:
o History of joint pain, muscle weakness, back pain.
o Examination for joint swelling, muscle strength, spinal tenderness.
6. Endocrine System:
o History of thyroid disease, diabetes, adrenal insufficiency.
o Examination for thyroid enlargement, skin changes, weight changes.

Types of Focal Neurological Deficits

1. Motor Deficits:
o Hemiparesis/Hemiplegia: Weakness or paralysis on one side of the body,
commonly due to a stroke affecting the motor cortex or corticospinal tract.
o Monoparesis/Monoplegia: Weakness or paralysis in a single limb, often due to
localized lesions in the brain or spinal cord.
o Paraparesis/Paraplegia: Weakness or paralysis of both legs, commonly seen in
spinal cord lesions.
 o Quadriparesis/Quadriplegia: Weakness or paralysis of all four limbs, typically
due to cervical spinal cord injuries or diffuse brain damage.
2. Sensory Deficits:
o Hemianesthesia: Loss of sensation on one side of the body, often associated with
strokes affecting the sensory cortex or thalamus.
o Monoanesthesia: Loss of sensation in a single limb, typically due to peripheral
nerve or spinal root lesions.
o Stocking-glove pattern: Sensory loss in a distal distribution, commonly seen in
peripheral neuropathies.
3. Visual Deficits:
o Homonymous Hemianopia: Loss of the same half of the visual field in both
eyes, usually due to lesions in the optic tract or occipital lobe.
o Quadrantanopia: Loss of a quarter of the visual field, often caused by lesions in
the temporal or parietal lobes.
o Monocular Vision Loss: Loss of vision in one eye, which may be due to optic
nerve lesions.
4. Language Deficits (Aphasia):
o Broca’s Aphasia (Expressive): Difficulty in speech production, but
comprehension is relatively preserved, typically due to lesions in the frontal lobe
(Broca’s area).
o Wernicke’s Aphasia (Receptive): Difficulty in understanding spoken or written
language, with fluent but nonsensical speech, usually due to lesions in the
temporal lobe (Wernicke’s area).
o Global Aphasia: Severe impairment in both comprehension and production of
language, often due to large lesions affecting both Broca’s and Wernicke’s areas.
5. Cranial Nerve Deficits:
o Facial Nerve Palsy (VII): Weakness of facial muscles, drooping of one side of
the face, inability to close the eye, and loss of taste on the anterior two-thirds of
the tongue.
o Oculomotor Nerve Palsy (III): Ptosis, dilated pupil, and eye deviating "down
and out."
o Trigeminal Neuralgia (V): Severe, shooting pain in the distribution of the
trigeminal nerve.
6. Cerebellar Deficits:
o Ataxia: Uncoordinated movements, difficulty with balance, and a wide-based
gait.
o Dysmetria: Inability to judge distances or scale of movement, leading to
overshooting or undershooting targets.
o Intention Tremor: Tremor that occurs during purposeful movement.
7. Higher Cortical Function Deficits:
o Neglect: Inattention to one side of the body or space, often seen in right parietal
lobe lesions.
o Apraxia: Inability to perform purposeful movements despite having the desire
and physical capability to do so.
o Agnosia: Inability to recognize objects, faces, or sounds, despite intact sensory
function
 Condition Key Features Inclusion Criteria Exclusion
Criteria
Ischemic Stroke Sudden onset, Acute onset, risk Gradual onset,
weakness/numbness, factors (HTN, normal imaging
aphasia, visual diabetes, smoking), (CT/MRI), no
disturbances, facial droop imaging (CT/MRI vascular risk
showing infarct) factors
Hemorrhagic Sudden severe headache, Acute onset, No headache or
Stroke vomiting, altered hypertension, imaging vomiting, normal
consciousness, focal (CT showing imaging (CT/MRI)
deficits hemorrhage)
Brain Tumor Gradual onset, headache, Progressive Acute onset,
seizures, focal deficits, symptoms, imaging normal imaging
personality changes (MRI showing mass) (MRI/CT), no
progressive
symptoms
Multiple Sclerosis Relapsing-remitting MRI showing Normal MRI,
(MS) course, young adults, demyelinating lesions, absence of
optic neuritis, sensory positive oligoclonal oligoclonal bands,
disturbances, motor bands in CSF lack of relapsing-
weakness remitting pattern
Infections (e.g., Fever, altered mental Positive Normal
Abscess, status, headache, focal cultures/serology, cultures/serology,
Encephalitis) deficits, immune imaging (MRI no fever, normal
compromise showing abscess or imaging
encephalitis), fever
Subdural/Epidural History of trauma, History of head No history of
Hematoma headache, altered trauma, imaging (CT trauma, normal
consciousness, focal showing hematoma) imaging
deficits
Transient Sudden onset, transient Symptoms resolve Persistent
Ischemic Attack focal deficits, high risk of within 24 hours, risk symptoms, normal
(TIA) stroke factors (HTN, vascular imaging
diabetes), normal (CTA/MRA)
imaging
Migraine with Recurrent headaches, History of migraine, Persistent focal
Aura visual aura, transient typical aura deficits, abnormal
neurological deficits symptoms, normal imaging, no history
neurological exam of migraine
Peripheral Nerve Unilateral facial Facial nerve palsy, Bilateral
Lesions (e.g., Bell's weakness, inability to exclusion of central symptoms, other
Palsy) close eye, sudden onset causes via imaging cranial nerve
(CT/MRI) involvement,
abnormal imaging
Epilepsy (Postictal Seizures, postictal History of seizures, No history of
State) confusion, transient focal EEG showing seizures, normal
deficits epileptiform activity EEG, persistent
deficits
Amyotrophic Progressive muscle EMG showing Sensory deficits,
Lateral Sclerosis weakness, atrophy, denervation, clinical no EMG evidence
(ALS) fasciculations, mixed signs, normal sensory of denervation,
upper and lower motor exam rapid progression
neuron signs
Guillain-Barré Ascending paralysis, History of recent Upper motor
Syndrome (GBS) areflexia, recent infection, infection, neuron signs, no
autonomic dysfunction albuminocytologic recent infection,
dissociation in CSF normal CSF
analysis
Vascular Headache, seizures, Imaging Normal imaging,
Malformations progressive focal deficits (MRI/CT/MRA absence of
(e.g., AVM) showing vascular vascular anomaly
anomaly)
Metabolic/Toxic Altered mental status, History of toxin No history of toxin
Encephalopathy asterixis, multifocal exposure, abnormal exposure, normal
deficits, history of toxin metabolic panel, metabolic panel
exposure improvement with
removal of toxin

How to Include or Exclude These Causes:

1. History and Physical Examination:
o History: Detailed history of onset, duration, and progression of symptoms.
Consider risk factors (hypertension, diabetes, trauma, infections, substance
abuse).
o Examination: Comprehensive neurological exam, including cranial nerves,
motor function, sensory function, reflexes, coordination, and mental status.
2. Imaging Studies:
o CT Scan/MRI: For structural abnormalities (stroke, hemorrhage, tumor,
abscess).
o Angiography (CTA/MRA): For vascular abnormalities (aneurysms, AVMs).
o EEG: For epileptiform activity in suspected seizure disorders.
3. Laboratory Tests:
o Complete Blood Count (CBC), Electrolytes, Glucose: To rule out metabolic
causes.
o Inflammatory Markers (ESR, CRP): For inflammatory or infectious causes.
o CSF Analysis: For infections (meningitis, encephalitis), multiple sclerosis
(oligoclonal bands).
4. Special Tests:
o EMG/NCS: For peripheral nerve or muscle disorders (ALS, GBS).
o Serology/Cultures: For specific infections.
o Autoantibody Panels: For autoimmune conditions (e.g., MS).
 Hearing loss
1. Analysis of Complaint:

• Onset: When did the hearing loss begin? Was it sudden or gradual?
• Duration: How long has the hearing loss been present? Has it been stable, improving, or worsening
over time?
• Progression: Has there been any change in hearing over time (e.g., fluctuating, progressive)?
• Quality: Is the hearing loss unilateral (one ear) or bilateral (both ears)?
• Characteristics: Is there any associated ringing in the ears (tinnitus) or feeling of fullness in the
ears?
• Severity: How severe is the hearing loss? Is it mild, moderate, severe, or profound?

2. Associated Symptoms:

• Tinnitus: Presence of ringing, buzzing, or other noises in the ears.

• Ear Pain or Discharge: Any history of ear pain, ear discharge, or infections.
• Vertigo or Balance Issues: Dizziness or imbalance, especially if associated with hearing loss (e.g.,
Ménière's disease).
• Speech Difficulty: Challenges in understanding speech, especially in noisy environments.
• Headache or Facial Pain: Any concurrent headaches or facial pain that might suggest associated
conditions like temporal arteritis.
• Systemic Symptoms: Fever, weight loss, fatigue, or symptoms suggestive of systemic diseases.

3. Excluding Differential Diagnosis:

To focus on excluding potential causes of hearing loss:

• Conductive Hearing Loss: Evaluate for causes such as otitis media, otosclerosis, or impacted
earwax.
• Sensorineural Hearing Loss: Consider conditions like presbycusis (age-related hearing loss), noise-
induced hearing loss, or autoimmune inner ear disease.
• Central Causes: Assess for neurological conditions affecting auditory pathways (e.g., acoustic
neuroma, multiple sclerosis).

4. Review of Affected Systems:

• Ear and Auditory System: History of previous ear infections, surgeries, or trauma.
• Neurological System: Any history of neurological disorders (e.g., stroke, meningitis) that could
affect hearing.
• Cardiovascular System: History of hypertension or cardiovascular diseases.
• Endocrine System: Diabetes mellitus, thyroid disorders, or autoimmune conditions (e.g.,
autoimmune inner ear disease).
• Medications: Current medications, including ototoxic medications (e.g., aminoglycoside antibiotics,
chemotherapy drugs).

5. Other Relevant Factors:

• Occupational History: Exposure to loud noise or ototoxic chemicals.

• Family History: Any family history of hearing loss or genetic conditions (e.g., genetic syndromes
associated with hearing loss).
• Lifestyle Habits: Smoking history, alcohol consumption, recreational drug use.
• Psychosocial Impact: How has the hearing loss affected daily activities, communication, and quality
of life?
Investigations
1. Physical Examination:

o Otoscopic examination: Look for earwax, tympanic membrane abnormalities, signs of

infection.
o Tuning fork tests (Rinne and Weber): Differentiate between conductive and sensorineural
hearing loss.

2. Audiological Tests:

• Pure Tone Audiometry:

o Measures hearing sensitivity across different frequencies.
o Differentiates between conductive and sensorineural hearing loss.
• Speech Audiometry:
o Assesses ability to hear and understand speech.
• Tympanometry:
o Evaluates middle ear function and mobility of the tympanic membrane.
o Identifies middle ear effusion, Eustachian tube dysfunction.
• Acoustic Reflex Testing:
o Measures the contraction of middle ear muscles in response to loud sounds.
o Assists in identifying retrocochlear pathology.

3. Radiological Investigations:

• CT Scan of Temporal Bone:

o Detailed images of the bony structures of the ear.
o Useful for detecting otosclerosis, cholesteatoma, congenital abnormalities, and temporal bone
fractures.
• MRI of the Internal Auditory Canal and Brain:
o Provides detailed images of the soft tissues, including the inner ear, cochlear nerve, and brain.
o Essential for diagnosing acoustic neuroma, multiple sclerosis, and other central causes of
hearing loss.

4. Laboratory Tests:

• Complete Blood Count (CBC):

o Detects signs of infection, anemia.
• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP):
o Evaluates for inflammatory or infectious processes.
• Autoimmune Panel:
o Tests for autoimmune inner ear disease (e.g., ANA, rheumatoid factor).
• Thyroid Function Tests:
o Assesses for hypothyroidism or hyperthyroidism.
• Serological Tests:
o Evaluates for infections (e.g., syphilis, cytomegalovirus, Lyme disease).

5. Specialized Tests:

• Otoacoustic Emissions (OAE):

o Measures the sounds produced by the inner ear (cochlea) in response to an auditory stimulus.
o Used to screen newborns and to assess cochlear function.
• Electrocochleography (ECoG):
o Evaluates the electrical potentials generated in the inner ear in response to sound stimulation.
o Useful for diagnosing Meniere’s disease.
 • Auditory Brainstem Response (ABR):
o Measures the electrical activity in the auditory nerve and brainstem in response to sound.
o Detects lesions of the auditory nerve, brainstem pathways, and inner ear.
• Vestibular Testing:
o Includes tests like Electronystagmography (ENG) or Videonystagmography (VNG) to assess
the balance system and vestibular function.

Differential diagnosis

1. Conductive Hearing Loss

• Otitis Media
o Etiology: Middle ear infection causing fluid buildup.
o Clinical Features: Ear pain, fever, hearing loss.
o Diagnostic Clues: Otoscopy, tympanometry.
• Otosclerosis
o Etiology: Abnormal bone growth in the middle ear.
o Clinical Features: Gradual hearing loss, better hearing in noisy environments.
o Diagnostic Clues: Audiometry, CT scan.
• Impacted Earwax
o Etiology: Accumulation of earwax blocking the ear canal.
o Clinical Features: Hearing loss, ear fullness, discomfort.
o Diagnostic Clues: Otoscopic examination.
• Chronic Otitis Media
o Etiology: Persistent middle ear infection.
o Clinical Features: Hearing loss, ear discharge, perforated tympanic membrane.
o Diagnostic Clues: Otoscopy, culture of ear discharge.

2. Sensorineural Hearing Loss

• Presbycusis
o Etiology: Age-related hearing loss.
o Clinical Features: Bilateral, high-frequency hearing loss.
o Diagnostic Clues: Audiometry.
• Noise-Induced Hearing Loss
o Etiology: Prolonged exposure to loud noises.
o Clinical Features: High-frequency hearing loss, tinnitus.
o Diagnostic Clues: Audiometry.
• Meniere’s Disease
o Etiology: Inner ear disorder affecting balance and hearing.
o Clinical Features: Episodic vertigo, fluctuating hearing loss, tinnitus.
o Diagnostic Clues: Audiometry, Electrocochleography (ECOG), Vestibular tests (VNG).
• Sudden Sensorineural Hearing Loss
o Etiology: Rapid onset of hearing loss.
o Clinical Features: Sudden hearing loss in one ear, tinnitus.
o Diagnostic Clues: Audiometry, MRI.
• Acoustic Neuroma
o Etiology: Benign tumor on the auditory nerve.
o Clinical Features: Unilateral hearing loss, tinnitus, imbalance.
o Diagnostic Clues: MRI.
3. Central Hearing Loss

• Stroke
o Etiology: Vascular event affecting auditory pathways.
o Clinical Features: Sudden hearing loss, other stroke symptoms.
o Diagnostic Clues: CT/MRI.

4. Other Causes

• Barotrauma
o Etiology: Pressure changes affecting the ear.
o Clinical Features: Hearing loss, ear pain.
o Diagnostic Clues: History of pressure changes, otoscopy.
• Diabetes Mellitus
o Etiology: Microvascular complications.
o Clinical Features: Progressive hearing loss.
o Diagnostic Clues: Blood glucose tests, audiogram.
• Thyroid Disorders
o Etiology: Hypo-/hyperthyroidism.
o Clinical Features: Progressive hearing loss.
o Diagnostic Clues: Thyroid function tests

Type of Hearing
Condition Clinical Features Diagnostic Clues
Loss
Conductive Hearing Ear pain, fever, hearing loss, fluid in Otoscopy,
Otitis Media
Loss the middle ear tympanometry
Gradual hearing loss, better in noisy
Otosclerosis Audiometry, CT scan
environments
Impacted Earwax Hearing loss, ear fullness, discomfort Otoscopic examination
Hearing loss, ear discharge,
Chronic Otitis Media Otoscopy, culture
perforated tympanic membrane
Sensorineural
Presbycusis Bilateral, high-frequency hearing loss Audiometry
Hearing Loss
Noise-Induced
High-frequency hearing loss, tinnitus Audiometry
Hearing Loss
Episodic vertigo, fluctuating hearing Audiometry, ECOG,
Meniere’s Disease
loss, tinnitus VNG
Sudden Sudden hearing loss in one ear,
Audiometry, MRI
Sensorineural HL tinnitus
Unilateral hearing loss, tinnitus,
Acoustic Neuroma MRI
imbalance
Central Hearing Sudden hearing loss, other stroke
Stroke CT/MRI
Loss symptoms
Other Causes Barotrauma Hearing loss, ear pain History, otoscopy
Blood glucose tests,
Diabetes Mellitus Progressive hearing loss
audiogram
Thyroid Disorders Progressive hearing loss Thyroid function tests
 Hoarseness
1. Analysis of Complaint:

• Onset: When did the hoarseness start? Was it sudden or gradual?

• Duration and Progression: How has the hoarseness changed over time? Is it constant or
intermittent?
• Quality of Voice Change: Can the patient describe the hoarseness? (e.g., rough, raspy, strained)
• Severity: How bothersome is the hoarseness to the patient? Does it affect speaking, singing, or daily
activities?
• Aggravating or Relieving Factors: What makes the hoarseness worse or better? (e.g., voice use,
environmental factors)
• Associated Symptoms: Any other symptoms such as throat pain, difficulty swallowing, cough, or
sensation of a lump in the throat?
• Impact on Daily Life: How does hoarseness affect the patient's occupation or social interactions?

2. Associated Symptoms:

• Throat Pain: Is there any pain or discomfort in the throat?

• Dysphagia: Any difficulty swallowing or sensation of food sticking in the throat?
• Cough: Is there a persistent cough or throat clearing?
• Laryngeal Sensation: Does the patient feel a lump or foreign body sensation in the throat?

3. Excluding Differential Diagnosis:

• Acute Laryngitis:

• When did the hoarseness start?

• Did it begin suddenly after a recent cold or upper respiratory infection?
• Have you experienced any fever or throat pain?
• Is there any recent history of voice overuse or shouting?

• Chronic Laryngitis:

• How long have you been experiencing hoarseness?

• Have you noticed any improvement or worsening over time?
• Do you have a history of smoking or exposure to irritants like dust, chemicals, or fumes?
• Do you experience heartburn or regurgitation (acid reflux)?

• Benign Vocal Cord Lesions (Nodules, Polyps, Cysts):

• Have you ever had voice strain or overuse (e.g., from singing, shouting)?
• Have you noticed any changes in your voice quality, such as roughness or breathiness?
• Do you frequently clear your throat or cough?
• Have you had a previous diagnosis of vocal cord nodules, polyps, or cysts?

• Laryngeal Cancer:

• Has your hoarseness persisted despite treatment for other conditions?

• Do you have a history of prolonged smoking or heavy alcohol consumption?
• Have you noticed any difficulty swallowing, ear pain, or a lump sensation in your throat?
• Have you experienced unintentional weight loss recently?
• Neurological Causes (Vocal Cord Paralysis, Spasmodic Dysphonia):

• Have you noticed any weakness or paralysis of your vocal cords?

• Do you experience periods of involuntary vocal cord spasms or voice breaks?
• Have you had any recent surgeries or trauma to the head or neck?
• Do you have a history of neurological conditions such as stroke or Parkinson's disease?

• Systemic Conditions (Thyroid Disorders, Autoimmune Diseases):

• Have you been diagnosed with any thyroid conditions?

• Are you currently taking medications for thyroid problems?
• Do you have a history of autoimmune diseases such as rheumatoid arthritis or lupus?
• Have you noticed any other symptoms related to autoimmune disorders, such as joint pain or skin
rash?

4. Review of Affected Systems:

• Respiratory System: Evaluate for associated respiratory symptoms or chronic conditions like
asthma.
• Gastrointestinal System: Assess for symptoms of gastroesophageal reflux disease (GERD) or
history of reflux.
• Endocrine System: Screen for thyroid dysfunction or other hormonal imbalances.
• Neurological System: Assess for any history of neurological disorders or surgeries that could affect
vocal cord function.

5. Other Systems:

• General Medical History: Review past medical conditions, surgeries, and allergies.
• Medication History: List current medications, including over-the-counter drugs and supplements.
• Social History: Inquire about smoking history, alcohol consumption, occupation (especially voice
use), and environmental exposures.
• Family History: Any family members with similar voice problems or history of laryngeal cancer?

Investigations
• Laryngoscopy:

• Direct Laryngoscopy: Visualization of the larynx using a flexible or rigid scope to assess for
structural abnormalities, lesions, or inflammation.
• Indirect Laryngoscopy: Examination of the larynx using mirrors or fiberoptic scopes.

• Biopsy:

• Vocal Cord Biopsy: If suspicious lesions are identified during laryngoscopy, a biopsy may be
performed to obtain tissue for pathological examination, particularly to rule out malignancy.

• Imaging Studies:

• Neck Ultrasound: To assess for thyroid nodules or other neck masses that could be compressing or
affecting the larynx.
• CT Scan or MRI: To evaluate the anatomy of the neck and detect structural abnormalities, tumors,
or metastases.
• PET-CT Scan: Particularly for assessing metabolic activity in suspected cases of laryngeal cancer or
metastases.
• Audiometry:

• Pure Tone Audiometry: To assess hearing thresholds, especially if sensorineural hearing loss is
suspected as a contributing factor to hoarseness.

• Laboratory Tests:

• Thyroid Function Tests: To evaluate thyroid function in cases where thyroid disorders are
suspected.
• Autoimmune Markers: If autoimmune diseases are considered, specific markers such as antinuclear
antibodies (ANA) may be tested.

• Swallowing Studies:

• Modified Barium Swallow (MBS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES):

To assess swallowing function and rule out dysphagia-related causes of hoarseness.

• pH Monitoring:

• Esophageal pH Monitoring: To evaluate for gastroesophageal reflux disease (GERD) as a potential

cause of chronic laryngitis and hoarseness.

• Neurological Evaluation:

• Electromyography (EMG) or Nerve Conduction Studies (NCS): If neurological causes such as

vocal cord paralysis are suspected, these tests may be considered to assess nerve function.

• Allergy Testing:

• Allergen Patch Testing or Skin Prick Tests: To evaluate for allergic rhinitis or other allergic
conditions that could contribute to chronic laryngitis and hoarseness

Differential diagnosis

• Acute Laryngitis:

• Causes: Viral or bacterial infections affecting the vocal cords.

• Clinical Features: Recent onset of hoarseness, often preceded by upper respiratory symptoms like
sore throat or cough.
• Diagnostic Clues: History of recent illness, improvement expected with resolution of infection.

• Chronic Laryngitis:

• Causes: Prolonged irritation due to smoking, vocal strain, reflux, or environmental irritants.
• Clinical Features: Persistent hoarseness lasting more than three weeks, throat discomfort, frequent
throat clearing.
• Diagnostic Clues: History of chronic exposure to irritants, worsened by voice use, response to
lifestyle modifications or medications.

• Benign Vocal Cord Lesions:

• Types:
o Vocal Cord Nodules: Due to vocal overuse, presenting as bilateral swellings on vocal cords.
o Polyps: Fluid-filled or swollen lesions on one or both vocal cords.
 o Cysts: Fluid-filled sacs on vocal cords, often asymptomatic until they grow or rupture.
• Clinical Features: Hoarseness related to voice use, varying in severity, may be accompanied by
voice fatigue or discomfort.
• Diagnostic Clues: Visualized during laryngoscopy, characteristic appearance on imaging (e.g.,
ultrasound, MRI).

• Laryngeal Cancer:

• Causes: Malignant growths in the larynx, often associated with smoking, alcohol use, or HPV
infection.
• Clinical Features: Persistent hoarseness, throat pain, difficulty swallowing, ear pain, neck mass.
• Diagnostic Clues: Suspicious lesions on laryngoscopy or imaging (CT, MRI), biopsy confirmation
required for diagnosis.

• Neurological Causes:

• Vocal Cord Paralysis: Due to injury or neurological conditions affecting the vocal nerves.
• Spasmodic Dysphonia: Involuntary spasms of the vocal cords affecting speech.
• Clinical Features: Variable hoarseness, breathiness, difficulty with voice modulation.
• Diagnostic Clues: History of neurological disease or trauma, abnormal EMG/NCS findings,
laryngoscopic assessment.

• Systemic Conditions:

• Thyroid Disorders: Hypo or hyperthyroidism affecting thyroid function and hormone levels.
• Autoimmune Diseases: Such as rheumatoid arthritis, affecting joint function and autoimmune
system.
• Clinical Features: Hoarseness, fatigue, throat pain, and diagnostic clues, affect, Histologic
Examination Biopsy

Differential
Causes and Features Diagnostic Clues
Diagnosis
Recent onset, upper respiratory
Acute Laryngitis Viral or bacterial infections affecting vocal cords. symptoms, resolves with
infection.
Persistent hoarseness >3 weeks,
Chronic Prolonged irritation from smoking, vocal strain, reflux,
throat discomfort, response to
Laryngitis or irritants.
lifestyle changes.
- Nodules: Vocal overuse, bilateral swellings. <br>- Visualized on laryngoscopy,
Benign Vocal
Polyps: Fluid-filled or swollen lesions. <br>- Cysts: characteristic appearance on
Cord Lesions
Fluid-filled sacs, asymptomatic until growth. imaging.
Persistent hoarseness, throat
Laryngeal Malignant growths, associated with smoking, alcohol,
pain, neck mass, biopsy
Cancer or HPV infection.
confirmation.
- Vocal Cord Paralysis: Injury or neurological History of neurological disease,
Neurological
conditions affecting vocal nerves. <br>- Spasmodic abnormal EMG/NCS,
Causes
Dysphonia: Involuntary spasms affecting speech. laryngoscopic findings.
- Thyroid Disorders: Hypo or hyperthyroidism
Associated symptoms, thyroid
Systemic affecting hormone levels. <br>- Autoimmune
function tests, autoimmune
Conditions Diseases: Rheumatoid arthritis, affecting autoimmune
markers.
system.
 Loss of vision
Analysis of the Complaint

1. Onset and Duration:

o When did the vision loss start?
o Was the onset sudden or gradual?
o Is the vision loss constant or intermittent?
2. Nature of Vision Loss:
o Is the vision loss partial or complete?
o Is it affecting one eye or both eyes?
o Is there any change in visual fields (e.g., peripheral vs. central vision)?
3. Associated Symptoms:
o Are there any visual disturbances (e.g., flashes of light, floaters, halos)?
o Any pain associated with vision loss?
o Any redness, discharge, or swelling of the eye?
4. Previous Episodes:
o Have there been any similar episodes in the past?
o If yes, how were they resolved?

Questions to Exclude Differential Diagnoses

1. Retinal Causes:
o Retinal Detachment: Any sudden flashes of light or floaters before vision loss? Any shadow or
curtain-like effect over the vision?
o Age-Related Macular Degeneration (AMD): Difficulty with central vision? Any straight lines
appearing wavy?
o Diabetic Retinopathy: History of diabetes? Any recent changes in blood glucose control?
2. Optic Nerve Causes:
o Optic Neuritis: Any pain with eye movement? Any history of multiple sclerosis?
o Glaucoma: Any history of increased intraocular pressure? Any halos around lights?
3. Vascular Causes:
o Central Retinal Artery Occlusion (CRAO): Sudden, painless loss of vision? Any cardiovascular
risk factors (hypertension, diabetes)?
o Central Retinal Vein Occlusion (CRVO): Any history of hypercoagulable state or vascular
diseases?
4. Neurological Causes:
o Stroke: Any other neurological deficits (weakness, speech difficulties)? Any history of transient
ischemic attacks (TIAs)?
o Migraine: Any preceding visual aura or headache? History of migraines?
5. Infectious/Inflammatory Causes:
o Uveitis: Any eye pain or photophobia? Any autoimmune diseases?
o Endophthalmitis: Any recent eye surgery or trauma?
6. Systemic Conditions:
o Hypertensive Retinopathy: History of uncontrolled hypertension? Any recent changes in blood
pressure?
o Temporal Arteritis: Any headache, jaw claudication, or scalp tenderness? Any elevated erythrocyte
sedimentation rate (ESR) or C-reactive protein (CRP)?
Review of Affected System and Other Systems

1. Ophthalmic System:
o History of eye diseases or surgeries?
o Use of glasses or contact lenses?
o Regular eye check-ups and any recent findings?
2. Neurological System:
o Any weakness, numbness, or tingling?
o Any changes in balance or coordination?
o Any recent headaches, dizziness, or changes in mental status?
3. Cardiovascular System:
o Any chest pain, palpitations, or shortness of breath?
o History of hypertension, diabetes, or hyperlipidemia?
4. Endocrine System:
o History of diabetes, thyroid disease, or adrenal disorders?
o Recent changes in weight, appetite, or energy levels?
5. General Review:
o Any recent infections or systemic illnesses?
o Any history of autoimmune or inflammatory conditions?
o Any use of medications, supplements, or recreational drugs?

Investigations
Initial Assessment

1. History and Physical Examination:

o Comprehensive patient history, including onset, duration, and progression of vision loss.
o Presence of pain associated symptoms (e.g., photophobia, floaters, flashes, headache).
o Past medical history (e.g., diabetes, hypertension, autoimmune diseases).
o Medications, trauma history, and family history of ocular diseases.
o Detailed eye examination including visual acuity, pupil reactions, and ocular movements.

Basic Investigations

1. Visual Acuity Test:

o Measure the clarity or sharpness of vision using a Snellen chart or equivalent.
2. Pupillary Light Reflex:
o Assess the reaction of pupils to light to identify afferent pupillary defect.
3. Intraocular Pressure (IOP):
o Measure the pressure inside the eye using tonometry to check for glaucoma.
4. Slit-Lamp Examination:
o Detailed examination of the anterior eye structures (cornea, lens, anterior chamber) to identify
inflammation, keratitis, or anterior uveitis.
5. Fundoscopy:
o Examine the retina, optic disc, and retinal vessels to detect signs of retinal detachment, diabetic
retinopathy, CRAO, CRVO, or optic neuropathy.
Advanced Investigations

1. Optical Coherence Tomography (OCT):

o Imaging to visualize the retina’s detailed structure, useful for diagnosing macular degeneration,
diabetic macular edema, and retinal detachment.
2. Fluorescein Angiography:
o Imaging test to assess retinal blood flow, useful for identifying retinal vein or artery occlusions and
diabetic retinopathy.
3. Ultrasound B-Scan:
o Imaging to visualize the posterior segment of the eye when the view is obscured, useful for detecting
vitreous hemorrhage or retinal detachment.
4. Visual Field Testing:
o Assess the peripheral vision, useful for diagnosing glaucoma and optic neuropathies.
5. Electroretinography (ERG):
o Measure the electrical response of the retina to light, useful for diagnosing retinal degenerative
diseases like retinitis pigmentosa.

Laboratory Tests

1. Blood Tests:
o Complete Blood Count (CBC): Check for infections or anemia.
o Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): Indicators of inflammation,
useful for conditions like giant cell arteritis.
o Blood glucose and HbA1c: Assess for diabetes mellitus.
o Autoimmune panel: ANA, ANCA, rheumatoid factor, and other specific tests based on clinical
suspicion (e.g., lupus, sarcoidosis).
o Infectious disease workup: Based on history and clinical findings (e.g., syphilis, Lyme disease,
tuberculosis).

Specialized Tests

1. Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) Scan of the Brain and Orbits:
o To assess the optic nerve and brain structures, useful for detecting optic neuritis, tumors, or other
central nervous system pathologies.
2. Carotid Doppler Ultrasound:
o To evaluate for carotid artery disease in cases where CRAO is suspected.

Differential diagnosis

1. Painful Loss of Vision:

o Acute Angle-Closure Glaucoma: Sudden increase in intraocular pressure causing severe pain,
redness, and vision loss.
o Optic Neuritis: Inflammation of the optic nerve, often associated with multiple sclerosis, causing
pain with eye movement.
o Uveitis: Inflammation of the uveal tract, presenting with pain, redness, and photophobia.
o Corneal Ulcer or Keratitis: Infection or inflammation of the cornea, causing severe pain and
decreased vision.
o Endophthalmitis: Inflammation of the interior of the eye, often post-surgical or post-traumatic,
causing severe pain and vision loss.
o Orbital Cellulitis: Infection of the tissues surrounding the eye, causing pain, swelling, and vision
impairment.
 2. Painless Loss of Vision:
o Retinal Detachment: Separation of the retina from the underlying tissue, presenting with flashes,
floaters, and a shadow or curtain over the visual field.
o Central Retinal Artery Occlusion (CRAO): Sudden, painless loss of vision due to obstruction of
the central retinal artery.
o Central Retinal Vein Occlusion (CRVO): Painless vision loss due to blockage of the central retinal
vein, often associated with retinal hemorrhages.
o Age-Related Macular Degeneration (AMD): Gradual, painless loss of central vision due to
degeneration of the macula.
o Diabetic Retinopathy: Vision loss due to retinal blood vessel damage caused by diabetes,
presenting with floaters and gradual vision loss.
o Cataract: Gradual, painless loss of vision due to opacification of the lens.
o Posterior Vitreous Detachment (PVD): Sudden onset of floaters and flashes, with possible retinal
detachment.
o Stroke: Sudden, painless loss of vision due to cerebral infarction affecting the visual pathways.

Classification Based on Sudden or Gradual Onset

1. Sudden Onset:
o Retinal Detachment
o CRAO and CRVO
o Optic Neuritis
o Acute Angle-Closure Glaucoma
o Endophthalmitis
o Stroke
2. Gradual Onset:
o Age-Related Macular Degeneration (AMD)
o Diabetic Retinopathy
o Cataract
o Primary Open-Angle Glaucoma
o Progressive Optic Neuropathies (e.g., compressive lesions)
o Posterior Vitreous Detachment (PVD)
o Chronic Uveitis

Onset Painful Conditions Painless Conditions

Sudden - Acute Angle-Closure Glaucoma - Retinal Detachment
- Optic Neuritis - CRAO
- Uveitis - CRVO
- Corneal Ulcer or Keratitis - Stroke
- Endophthalmitis
- Orbital Cellulitis
Gradual - Chronic Uveitis - Age-Related Macular Degeneration (AMD)
- Diabetic Retinopathy
- Cataract
- Primary Open-Angle Glaucoma
- Progressive Optic Neuropathies
- Posterior Vitreous Detachment (PVD)
Discussion

1. Acute Angle-Closure Glaucoma:

o Symptoms: Severe eye pain, headache, nausea, vomiting, halos around lights, and decreased vision.
o Signs: Red eye, mid-dilated pupil, corneal edema, and elevated intraocular pressure.
2. Optic Neuritis:
o Symptoms: Pain with eye movement, sudden vision loss, and often associated with multiple
sclerosis.
o Signs: Swollen optic disc (in some cases), afferent pupillary defect.
3. Uveitis:
o Symptoms: Eye pain, redness, photophobia, and decreased vision.
o Signs: Anterior chamber cells and flare, keratic precipitates.
4. Retinal Detachment:
o Symptoms: Sudden onset of floaters, flashes of light, and a shadow or curtain over part of the visual
field.
o Signs: Detached retina visible on fundoscopy, often with associated retinal tear.
5. CRAO:
o Symptoms: Sudden, painless loss of vision.
o Signs: Pale retina with a cherry-red spot at the macula.
6. CRVO:
o Symptoms: Sudden, painless loss of vision.
o Signs: Retinal hemorrhages, venous dilation, and cotton-wool spots.
7. Age-Related Macular Degeneration (AMD):
o Symptoms: Gradual loss of central vision, difficulty reading or recognizing faces.
o Signs: Drusen (yellow deposits) on the retina, pigmentary changes, neovascular membranes in wet
AMD.
8. Diabetic Retinopathy:
o Symptoms: Floaters, blurred vision, gradual vision loss.
o Signs: Microaneurysms, retinal hemorrhages, exudates, neovascularization.
9. Cataract:
o Symptoms: Gradual, painless loss of vision, glare, halos around lights.
o Signs: Lens opacity visible on slit-lamp examination.