Differential Diagnosis List
Clinical Neurology, Year 3
Musculoskeletal Medicine (MSM), Year 3
Clinical Medicine I, Year 4
DDx Tool ➔ VINDICATES
Flashcard for each condition
• What is it?
o Definition as if you were explaining it to Granny
• Who gets it?
o Major epidemiology
o E.g. only geriatrics, paediatrics, age groups etc.
▪ NOT 2:1 males to females
o Would also include major risk factors.
• Hallmark symptoms
o What really has to be there for you to consider this condition present
• Hallmark signs
o Physical exam first
o Then any investigations like imaging/labs
o Know the abnormal
,DDx Process
1. Case history (DOC) = 90%
• Primary complaint ➔ Biomechanical pain, Neurological pain, Stiffness, Instability,
Weakness/Fatigue, Dizziness, Immunocompromise, Headache, Inflammation, Organ
referral, Systemic problem
• WHO is the Px (epidemiology)
W Where is the pain
W When did it start
W When does it occur / How often
W What do you think caused it
Q Quality - how does it feel + type of feeling
Q Quantity - how severe is it (scale 1-10 + PSB + @worst)
H How long does it last?
A Aggravates - what makes it worse
A Alleviates - what makes it better
A Associates - other symptoms
P Progression - is it getting worse
R Repetitive - have you had this before
I Insomnia – does it wake you at night or prevents you from sleeping
C Changes to bowl & bladder
H Handicap - does it prevent you from doing something
Been to GP? Diagnosis?
Past medical Hx / illnesses / trauma
Family Hx
Medications taken
Occupation
2. DDx list RELEVANT 5-7 ➔ inclusion/exclusion criteria + VINDICATES
• VINDICATES = include multiple categories to confirm your WD
• Inclusion = 3-4 hallmarks & epidemiology that match
• Exclusion = 3-4 missing hallmarks & confounders (Sx present that don’t make sense)
o What you expect vs not expect to see
3. Physical exam = 10% ➔ support/exclude differentials
• Base the testing on the presenting signs
• Be methodical
a) Observation
b) Palpation
c) ROM ➔ active, passive, resisted
d) Screens, Ortho
e) Neuro
f) Systemic (Vitals, Cardiovascular, Respiratory, Abdominal)
• Include negative testing ➔ i.e. proof it is not biomechanical to support vascular
4. Create working Dx ➔ leads to prognosis, could be combination of conditions
• Keep 1-2 alternative DDx if outcome is not as expected
, 1 – Shoulder
Vascular Avascular Necrosis (AVN)
Intoxication (w/ Steroid)
What Blood supply to the humeral head is disrupted, leading to joint deterioration
Who Age 30-60
RF: repetitive steroid injections
Symptoms Deep achy shoulder pain, progressive
Worse with activity, interferes with sleep
Signs OP – atrophy, tenderness
ROM – all limited, stiffness, weakness
Infective/Inflammatory Septic / Infectious Arthritis
What Painful infection of the shoulder joint
Who Infants & young children, older adults
RF: IV drug users, RA, DM, immunosuppression
Symptoms Sharp or severe joint pain & swelling combined with fever and malaise
Signs Fever
OP – swelling, tenderness, warmth, redness, malaise
ROM – limited in all planes
Infective/Inflammatory Subacromial Bursitis
What Inflammation of the subacromial bursa which results in an increase in synovial fluid
production
Who RF: overuse injury to supraspinatus (overhead movements)
Symptoms Gradual onset deep superior shoulder pain
Unable to lay on affected side
Signs OP – severe localised bursa tenderness, swelling
ROM – painful, abduction & flexion limited
Infective/Inflammatory Scapulothoracic Bursitis
What Inflammation of the scapulothoracic bursitis which results in painful snapping of the
scapula
Who RF: overuse injury (athletes, manual work)
Symptoms Pain during overhead activities, crepitus with shoulder movement
Signs OP – crepitus, tenderness, audible snap, winging scapula
ROM – normal with audible snapping/crepitus
Infective/Inflammatory Biceps Tendonitis
What Inflammation of the long head of the biceps tendon
Who Age >40
RF: repetitive overhead activities, throwing sports (baseball), lifting
Symptoms Achy anterior shoulder pain
Aggravated by lifting or overhead activities
Signs OP – bicipital groove tenderness, Popeye sign (with complete rupture)
ROM – painful/weak resisted flexion
Ortho – Speed’s, Yergason’s, Neer's
, Infective/Inflammatory Adhesive Capsulitis / Frozen Shoulder
What Inflammation of the shoulder capsule significantly restricting ROM
Who Females age >40
Symptoms Slow onset to severe shoulder pain in 3 progression phases, may take 2 years:
1. Freezing – gradually more & more severe pain, reducing ROM
2. Frozen – pain may reduce, stiffness remains
3. Thawing – ROM slowly improves
Unable to sleep on affected side
Signs OP – guarding shoulder, tenderness
ROM – reduced in every A/PROM (= Dx)
Ortho – Apley Scratch, Painful Arc, SITS (hugely restricted or impossible)
Infective/Inflammatory Polymyalgia Rheumatica (PMR)
What Inflammatory condition that causes muscle pain & stiffness, esp. shoulders/hips
Who Females age 65+
Symptoms Proximal muscle pain of the shoulder +/- Hip girdles
Morning stiffness >1hr
Can be unilateral but becomes bilateral after a few weeks
Signs Vitals – low-grade fever
OP – tenderness, atrophy
ROM – limited
Neoplastic/Neurological Pancoast Tumour
What Lung cancer at the top of the lung compressing the brachial plexus
Who RF: age, smoking, carcinogens, genetics
Symptoms Severe persistent shoulder pain radiating down the arm
Potentially chest pain
May start as TOS Sx ➔ diffuse achy with ulnar neuro progressing into wider neuro pain
Signs OP – atrophy, lumps, masses
ROM – may be limited, arm weakness
Imaging = Dx
Neoplastic/Neurological Cervical Disc Herniation (C5)
What Age-related disc degeneration causes it to bulge/break hereby compressing/irritating 1
or more nerve roots
Who Men age 25-50
RF: repetitive injury (Valsalva, trauma, lifting), flexion/rotation injury, LBP Hx
Symptoms Unilateral deep aching/burning pain in (central spinal neck/)arm ➔ follows dermatome
Weakness in hand/arm
Consistent severe pain (7-8), no alleviation at rest
Signs OP - head/neck tilt away from injury, Bakody's sign, paraspinal tenderness, spasm
Bakody's sign: symptoms reduced with the painful arm placed on top of head
ROM – reduced overall & painful flexion, IL lateral flexion and rotation
Ortho - Valsalva, compression, distraction, shoulder depression, brachial plexus stretch
Clinical Neurology, Year 3
Musculoskeletal Medicine (MSM), Year 3
Clinical Medicine I, Year 4
DDx Tool ➔ VINDICATES
Flashcard for each condition
• What is it?
o Definition as if you were explaining it to Granny
• Who gets it?
o Major epidemiology
o E.g. only geriatrics, paediatrics, age groups etc.
▪ NOT 2:1 males to females
o Would also include major risk factors.
• Hallmark symptoms
o What really has to be there for you to consider this condition present
• Hallmark signs
o Physical exam first
o Then any investigations like imaging/labs
o Know the abnormal
,DDx Process
1. Case history (DOC) = 90%
• Primary complaint ➔ Biomechanical pain, Neurological pain, Stiffness, Instability,
Weakness/Fatigue, Dizziness, Immunocompromise, Headache, Inflammation, Organ
referral, Systemic problem
• WHO is the Px (epidemiology)
W Where is the pain
W When did it start
W When does it occur / How often
W What do you think caused it
Q Quality - how does it feel + type of feeling
Q Quantity - how severe is it (scale 1-10 + PSB + @worst)
H How long does it last?
A Aggravates - what makes it worse
A Alleviates - what makes it better
A Associates - other symptoms
P Progression - is it getting worse
R Repetitive - have you had this before
I Insomnia – does it wake you at night or prevents you from sleeping
C Changes to bowl & bladder
H Handicap - does it prevent you from doing something
Been to GP? Diagnosis?
Past medical Hx / illnesses / trauma
Family Hx
Medications taken
Occupation
2. DDx list RELEVANT 5-7 ➔ inclusion/exclusion criteria + VINDICATES
• VINDICATES = include multiple categories to confirm your WD
• Inclusion = 3-4 hallmarks & epidemiology that match
• Exclusion = 3-4 missing hallmarks & confounders (Sx present that don’t make sense)
o What you expect vs not expect to see
3. Physical exam = 10% ➔ support/exclude differentials
• Base the testing on the presenting signs
• Be methodical
a) Observation
b) Palpation
c) ROM ➔ active, passive, resisted
d) Screens, Ortho
e) Neuro
f) Systemic (Vitals, Cardiovascular, Respiratory, Abdominal)
• Include negative testing ➔ i.e. proof it is not biomechanical to support vascular
4. Create working Dx ➔ leads to prognosis, could be combination of conditions
• Keep 1-2 alternative DDx if outcome is not as expected
, 1 – Shoulder
Vascular Avascular Necrosis (AVN)
Intoxication (w/ Steroid)
What Blood supply to the humeral head is disrupted, leading to joint deterioration
Who Age 30-60
RF: repetitive steroid injections
Symptoms Deep achy shoulder pain, progressive
Worse with activity, interferes with sleep
Signs OP – atrophy, tenderness
ROM – all limited, stiffness, weakness
Infective/Inflammatory Septic / Infectious Arthritis
What Painful infection of the shoulder joint
Who Infants & young children, older adults
RF: IV drug users, RA, DM, immunosuppression
Symptoms Sharp or severe joint pain & swelling combined with fever and malaise
Signs Fever
OP – swelling, tenderness, warmth, redness, malaise
ROM – limited in all planes
Infective/Inflammatory Subacromial Bursitis
What Inflammation of the subacromial bursa which results in an increase in synovial fluid
production
Who RF: overuse injury to supraspinatus (overhead movements)
Symptoms Gradual onset deep superior shoulder pain
Unable to lay on affected side
Signs OP – severe localised bursa tenderness, swelling
ROM – painful, abduction & flexion limited
Infective/Inflammatory Scapulothoracic Bursitis
What Inflammation of the scapulothoracic bursitis which results in painful snapping of the
scapula
Who RF: overuse injury (athletes, manual work)
Symptoms Pain during overhead activities, crepitus with shoulder movement
Signs OP – crepitus, tenderness, audible snap, winging scapula
ROM – normal with audible snapping/crepitus
Infective/Inflammatory Biceps Tendonitis
What Inflammation of the long head of the biceps tendon
Who Age >40
RF: repetitive overhead activities, throwing sports (baseball), lifting
Symptoms Achy anterior shoulder pain
Aggravated by lifting or overhead activities
Signs OP – bicipital groove tenderness, Popeye sign (with complete rupture)
ROM – painful/weak resisted flexion
Ortho – Speed’s, Yergason’s, Neer's
, Infective/Inflammatory Adhesive Capsulitis / Frozen Shoulder
What Inflammation of the shoulder capsule significantly restricting ROM
Who Females age >40
Symptoms Slow onset to severe shoulder pain in 3 progression phases, may take 2 years:
1. Freezing – gradually more & more severe pain, reducing ROM
2. Frozen – pain may reduce, stiffness remains
3. Thawing – ROM slowly improves
Unable to sleep on affected side
Signs OP – guarding shoulder, tenderness
ROM – reduced in every A/PROM (= Dx)
Ortho – Apley Scratch, Painful Arc, SITS (hugely restricted or impossible)
Infective/Inflammatory Polymyalgia Rheumatica (PMR)
What Inflammatory condition that causes muscle pain & stiffness, esp. shoulders/hips
Who Females age 65+
Symptoms Proximal muscle pain of the shoulder +/- Hip girdles
Morning stiffness >1hr
Can be unilateral but becomes bilateral after a few weeks
Signs Vitals – low-grade fever
OP – tenderness, atrophy
ROM – limited
Neoplastic/Neurological Pancoast Tumour
What Lung cancer at the top of the lung compressing the brachial plexus
Who RF: age, smoking, carcinogens, genetics
Symptoms Severe persistent shoulder pain radiating down the arm
Potentially chest pain
May start as TOS Sx ➔ diffuse achy with ulnar neuro progressing into wider neuro pain
Signs OP – atrophy, lumps, masses
ROM – may be limited, arm weakness
Imaging = Dx
Neoplastic/Neurological Cervical Disc Herniation (C5)
What Age-related disc degeneration causes it to bulge/break hereby compressing/irritating 1
or more nerve roots
Who Men age 25-50
RF: repetitive injury (Valsalva, trauma, lifting), flexion/rotation injury, LBP Hx
Symptoms Unilateral deep aching/burning pain in (central spinal neck/)arm ➔ follows dermatome
Weakness in hand/arm
Consistent severe pain (7-8), no alleviation at rest
Signs OP - head/neck tilt away from injury, Bakody's sign, paraspinal tenderness, spasm
Bakody's sign: symptoms reduced with the painful arm placed on top of head
ROM – reduced overall & painful flexion, IL lateral flexion and rotation
Ortho - Valsalva, compression, distraction, shoulder depression, brachial plexus stretch
