Constant discomfort or pain (depends from location: RUQ, LUQ, RLQ, LLQ), malaise, fever.
Nausea, loss of appetite, weight loss.
CT follow by needle aspiration
Abdominal Aortic Aneurysm (AAA)
Asymptomatic. Generalized abdominal pain; Chest pain; Low back pain; Sudden onset, severe pain; typically slowly expand and sometimes rupture;
May cause a pulsing sensation in the abdomen and; when they rupture; cause deep; excruciating pain; low blood pressure; and death; Elderly population most affected; hypertensive
Palpable pulsatile mass is present or not.
With a stethoscope placed on the middle of the abdomen; doctors may hear a whooshing sound (bruit) caused by turbulence as blood rushes past the aneurysm.
Hypotension.
US of abdomen;
CT angiography of abdomen;
Abdominal x-ray detects an aneurysm that has calcium deposits in its wall.
Achalasia
Inability to swallow (dysphagia), which may feel like food or drink is stuck in your throat;
Regurgitating food or saliva;
Heartburn;
Belching;
Chest pain that comes and goes;
Coughing at night;
Weight loss;
Vomiting
Upper endoscopy
Acne vulgaris
Whiteheads (closed plugged pores);
Blackheads (open plugged pores);
Small red, tender bumps (papules);
Pimples (pustules), which are papules with pus at their tips;
Large, solid, painful lumps under the skin (nodules);
Painful, pus-filled lumps under the skin (cystic lesions)
Mild acne: fewer than 20 comedones, or fewer then 15 inflammatory lesions, or total lesion count fewer than 30;
Moderate acne: 20 – 100 comedones, or 15 – 50 inflammatory lesions, or total lesion count 30 – 125;
Severe acne: more than 5 nodules, or total inflammatory count greater than 50, or total lesion count greater than 125 (presence of active scarring);
R/O: perioral dermatitis;
R/O: acne rosacea;
Acromegaly
Increase head, ring size, shoe size;
Voice is deeper;
Increase body odor;
BIT: insulin like factor (IGF-1);
IGF or glucose load;
GH changes during day! – 75 g glucose, measure after 1 and 2 hours – conformation test;
If positive – MRI of pituitary adenoma;
Actinic keratoses
While most people see only a change to their skin, an AK can:
Itch;
Burn or sting
Feel tender or painful when touched;
Stick to your clothing, causing discomfort'
Bleed;
< 3mo, winter months, URI for 3-4 days; loose, hacking cough that becomes productive, afebrile; sputum may be clear, purulent, or occasionally contain blood; Fatigue; SOB
Coarse, fine crackles on auscultation, lungs clear on auscultation; low-to-moderate fever; pharyngitis; otitis; cervical lymphadenopathy;
Wheezing; Fever (r/o pneumonia and influenzas)
x-ray, CBC: to R/O pneumonia
Also R/O common cold and asthma;
oximetry (if with dyspnea)
Sputum culture – only in persistent cases;
Acute coronary syndrome
Heavy, dull, pressure/squeezing sensation
Substernal or epigastric pain with radiation to left shoulder
Nausea, vomiting
Diaphoresis, anxiety
Dizziness, lightheadedness, syncope
Pain may improve with nitroglycerin.
ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions, Q waves
Increased or normal troponin
TTE: hypokinesis, regional wall motion abnormalities
First – EKG
After normal EKG – stress test (look for ST depression)
Ideology unclear – stress test (80% of the max heart rate 220-years)
Enzymes – acute pain in an emergency department
Irreversible stress test confirms the presence of dead tissue
LDL <100 for ACD (LDL<70 for DM);
BP: 140/90 (130/80 for DM);
HDL >40 (but not low mortality);
TGR <150;
Acute epiglottitis
High fever, acute onset; Poor oral intake; Drooling (30%); SOB (37%);
Often unimmunized; Toxic-appearing; Respiratory distress; Stridor (12%);
Voice changing; Muffled crying (54%); Tripoding; Fever (42%);
Cervical adenopathy (41%)
Thump sign on x-Ray (but do not order the x-Ray!);
For older kids: laryngoscopy --> cherry-red swollen epiglottis;
Acute Hypercalcemia
Often asymptomatic;
Constipation;
Anorexia;
Nausea and vomiting;
Generalized abdominal pain;
Ileus;
Impairment of the renal concentrating mechanism leads to polyuria; nocturia; polydipsia;
Neuromuscular symptoms; including skeletal muscle weakness;
Chest x-ray; Electrolytes; BUN; creatinine; ionized calcium; phosphate; PTH; alkaline phosphatase; and serum protein immunoelectrophoresis
ECG: Short QT interval;
Acute Hypoxemic Respiratory Failure (AHRF, ARDS)
Dyspnea;
Restlessness;
Anxiety;
Confusion;
Alteration of consciousness;
Diaphoresis;
Сyanosis;
Tachypnea;
Tachycardia;
Acute Infectious Arthritis
Severe pain of the wrists, hands, and knees;
Warmth and erythema diffusely over the backs of the hands;
Rash may sometimes be present;
Arthrocentesis with synovial fluid examination and culture;
Blood culture;
CBC; ESR;
Molecular testing (polymerase chain reaction);
Sometimes x-ray or CT;
Acute leukemia
Fatigue; Infection; Bleeding
Best initial test: blood smear (blasts);
Most accurate test (flow cytometry);
Pancytopenia;
Acute Liver Failure
Bilirubin metabolism:
Jaundice;
Protein synthesize:
Coagulopathy;
Peripheral edema;
Ascites;
Detox:
Hepatic encephalopathy (confusion, delirium, death, asterixis);
Sex hormones metabolism;
Increased conversion of estrone to estradiol;
Testicular atrophy, gynecomastia, spider telangiectasias;
Palmar erythema;
Acute Medication Poisoning
Acute Mesenteric Ischemia (AMI)
Generalized pain; Severe abdominal pain; Sudden onset;
Pain that may be mild, moderate or severe;
An urgent need to have a bowel movement;
Frequent, forceful bowel movements;
Abdominal tenderness or distention;
Blood in your stool;
Mental confusion in older adults;
Beginning: abdomen remains soft, with little or no tenderness. Mild tachycardia. Mild pain;
Later (necrosis): abdominal tenderness, guarding, rigidity, and no bowel sounds. Pain out of proportion to exam.
Clinical examination;
Computed tomography (CT) angiography;
FOBT; Stool may be heme-positive;
Acute Pancreatitis
Sudden onset; Epigastric pain; Radiates to back;
Pain is steady and boring in quality;
NOT POSITION DEPENDENT;
History of cholelithiasis or excessive alcohol us;
Nausea; Vomiting; Diaphoresis;
Low grade fever; abdominal distension;
Fatigue;
Light headedness;
Weakness;
Fever;
Weight loss;
Anxiety;
Darkening palmar creases (chronic adrenal insufficiency - primary);
Addisonian crisis:
Sudden loss of strength;
Severe pain in the lower back, abdomen or legs;
Vomiting and diarrhea potentially causing dehydration;
Low blood pressure and loss of consciousness.
Panful abdominal mass;
Eyeballs that seem to protrude from the sockets (proptosis);
Dark circles, similar to bruises, around the eyes;
Back pain;
Fever; Malaise;
Unexplained weight loss;
Bone pain;
HTN;
Hepatomegaly;
Do not palpate! Can provoke rapture;
Urinary test:
↑VMA;
↑Homovanillic acid (HVA);
Tumor on CT scan;
AIDS
Weight loss (10% unintentionally); Nausea; Anorexia; Fever; Generalized lymphadenopathy
Inflamed boggy nasal mucosa;
Pale or violaceous turbinates;
Clinical diagnosis;
IgE level may be elevated;
Nasal smear with ↑eosinophils;
Skin test can be done;
Alopecia Areata
Hair loss
Nail changes;
CBC, Ferritine;
CRP;
Antinuclear antibody;
TSH;
Free and total testosterone;
FSH/LH;
Alzheimer disease
Difficulty to remembering recent events, progressive;
Difficulty to completed complex tasks , activities for daily leaving;
Disinhibition;
Personality changes;
Delusions;
Mini-Mental Status Examination (MMSE);
CT or MRI;
Comprehensive metabolic panel;
CBC;
UA;
B12;
TSH;
RPR (syphilis);
HIV;
Best test: brain biopsy (never!)
Amyotrophic lateral sclerosis (ALS)
Difficulty walking or doing normal daily activities;
Tripping and falling;
Weakness in your leg, feet or ankles;
Hand weakness or clumsiness;
Slurred speech or trouble swallowing;
Muscle cramps and twitching in your arms, shoulders and tongue;
Inappropriate crying, laughing or yawning;
Cognitive and behavioral changes;
Idiopathic;
Difficulty chewing and swallowing;
Decreased Gag reflex;
Slowed rapid alternating movement, gait disorder;
Dysarthria or dysphagia (bulbar dysfunction) 20%;
Asymmetric limb weakness (80%);
Sexual, bladder, rectal functions are intact ;
Exclusively a loss of upper and lower motor neuron;
NO sensory loss! Only moto neuron loss;
Sphincters are spared
MRI of the brain and, if no cranial nerve involvement, cervical spine;
Electromyography – best test;
Loss of neural innervation in multiple muscle group;
CPK level ↑;
Anal fissure
Cutting or tearing pain during defecation and gnawing
rectal exam
Anoscopy
Anaphylaxis
Tingling in the skin;
Pruritus;
Chest tightness;
Swallowing and breathing;
Angioedema (face, tongue, eyes, airway);
Syncope;
Tachycardia;
Wheezing;
Urticaria;
Hives, itching;
Airway constriction – upper airway stridor;
Swollen tongue;
Dyspnea;
Nausea/Vomiting/Diarrhea;
Dizziness or fainting;
Hypotension
Anemia (iron defficiency)
Extreme fatigue; Weakness;
Pale skin;
Chest pain, fast heartbeat or shortness of breath with exertion;
Headache, dizziness or lightheadedness;
Cold hands and feet;
Inflammation or soreness of your tongue;
Brittle nails;
Increased pulse rate, pale mucosa, smooth red tongue
CBC with indices, serum iron; ferritin, transferrin;
Best initial test: CBC with peripheral blood smear;
Hgb, Hct (Hgb = 3*Hct), B12;
Anemia of chronic disease
Feeling tired or weak.
Having pale skin.
Having shortness of breath.
Sweating.
Being dizzy or feeling faint.
Rapid heartbeat.
Having headaches.
Developmental delays, including no crawling or babbling at 6 to 12 months;
Intellectual disability;
No speech or minimal speech;
Difficulty walking, moving or balancing well;
Frequent smiling and laughter;
Happy, excitable personality;
Trouble going to sleep and staying asleep;
Seizures, usually beginning between 2 and 3 years of age;
Stiff or jerky movements;
Small head size, with flatness in the back of the head;
Tongue thrusting;
Hair, skin and eyes that are light in color;
Unusual behaviors, such as hand flapping and arms uplifted while walking;
Sleep problems;
Angioedema
Welts that form in minutes to hours.
Swelling and redness, especially around the eyes, cheeks or lips.
Pain or warmth in the affected areas.
Hereditary: no itching, purities;
Clinical evaluation.
Best initial test:
C2 and C4 in complimentary pathway -> decreased;
C1 esterase inhibitor -> decreased;
R/O: oral cancer, HSV-1;
Mouth swab to test for viruses like herpes or fungal infections;
Blood: CBC, iron panel; B12;
Ankylosing spondylitis
Backpain in low back;
Pain is worsening by rest and relive by activity;
Flattening of the normal lumbar curvature; Decreased chest expansion; Peripheral arthritis of knees, hips, shoulder (50%);
Cardiac: atrioventricular block in 3% to 5%: aortic insufficiency;
Chronic; inflammatory; large joints; symmetrical;
ESR elevated 85%;
CRP elevated;
xray: Bamboo spine – fusion of vertebral joints – late finding;
Best initial test: xRay of SI joint (narrowing on the joint);
Most accurate test – MRI (very early can detect abnormalities);
(-)ANA;
(-)RF;
Anorexia nervosa
Fear of being fat; low self-esteem; depression; isolation; over-achiever; hair loss; abdominal bloating
Amenorrhea; Excessive exercises; Caloric control; Fasting
Low body weight; short stature; yellow, dry skin; hypotension; systolic murmur; often mitral valve prolapse
Low BP; Lanugo hair
TSH nl; prolactin nl; LH low; FSH low; glucose nl; ECG; bradycardia; T wave inversion; ST depression
↓K; Edema
Anxiety
Reaction out of proportion to event;
Fatigue;
Concentration difficulty;
Sleep problems;
Muscle tension;
Restlessness;
SOB not improve with rest.
Sudden severe chest or upper back pain, often described as a tearing, ripping or shearing sensation, that radiates to the neck or down the back;
Sudden severe abdominal pain;
Syncope;
Shortness of breath (SOB);
Sudden difficulty speaking, loss of vision, weakness or paralysis of one side of your body, similar to those of a stroke;
Weak pulse in one arm or thigh compared with the other;
Leg pain; Difficulty walking; Leg paralysis;
x-ray – best initial test;
Most accurate: angiogram;
(+) D-dimer, but not diagnostic b/c not specific;
ECG: nonspecific ST-segment changes;
CT angiography of chest/abdomen/pelvic;
R/O stroke with stroke like symptoms
Aortic Regurgitation
Shortness of breath (SOB) with exercise;
Fatigue and weakness;
Lightheadedness or fainting;
Chest pain;
Heartbeat;
Palpitations;
Swollen ankles and feet;
Diastolic-decrescendo murmur;
Heart murmur;
Irregular pulse (arrhythmia);
S3;
Water hammer pulse (wide, bounding);
Quincke pulse (pulsation in nail bed);
Hill sign (BP in legs as much as 40 mmHg above arm BP);
Head bobbing -> de Musset sign;
handgrip ↑ afterload -> AR;
Valsalva and standing decreases vinous return -> softer murmur;
Handgrip increases afterload -> worse;
Echocardiogram;
ECG and chest a-ray: LVH;
Aortic stenosis
Chest pain worse with exertion, better with rest;
substernal and anginal in quality;
fatigue;
palpitation;
dizziness;
syncope;
Systolic murmur on base;
Radial pulse diminished; loud, harsh systolic crescendo-decrescendo mid-systole murmur at base, Radiated to carotids, heard best at second right ICS with patient leaned forward;
Thrill; S4 gallop;
Valsalva and standing ↓intensity of the murmur – less venus return - less murmur
Handgrip – softens murmur b/c decrease afterload
Echocardiogram ECG;
Chest xRay – left ventricular hypertrophy;
No stress test!
Aplastic Anemia
Significant fatigue or weakness;
Bruising or bleeding easily;
Shortness of breath (SOB);
Recurring infections and/or flu-like symptoms;
The appearance of small red dots on the skin that indicates bleeding under the skin;
Headache;
Fever;
CBC;
RC;
Bone marrow biopsy;
Appendicitis
RLQ; suprapubic pain; periumbilical pain; sometimes epigastric pain;
RUQ (subhepatic appendicitis);
Sudden onset of colicky pain that progresses to constant pain that progresses to constant pain;
Pain worsen with movement or coughing;
Vomiting after onset of pain sometimes;
Loss of appetite (not common in elderly);
Low-grade fever that may worsen as the illness progresses;
Constipation or diarrhea;
Abdominal bloating; Flatulence;
CBC with diff (nl of WBC can't R/O appendicitis);
US;
CT with contrast;
Laparoscopy;
Arrhythmia
Chest pain;
Shortness of breath;
Anxiety;
Fatigue;
Lightheadedness or dizziness;
Sweating;
Fainting (syncope) or near fainting.
A fluttering in your chest;
A racing heartbeat (tachycardia);
A slow heartbeat (bradycardia);
ECG; Holter monitor
Asherman Syndrome
Amenorrhea; History of uterine infection; tuberculosis; schistosomiasis; uterine iatrogenic scarring; curettage, irradiation; recurrent miscarriages and/or infertility.
Pelvic exam nl
Hysteroscopy adhesions
Aspergillosis
Aspiration Pneumonitis and Pneumonia
Chest pain;
Shortness of breath (SOB);
Wheezing;
Fatigue;
Blue discoloration of the skin;
Cough, possibly with green sputum, blood, or a foul odor;
Difficulty swallowing;
Bad breath;
Excessive sweating;
Chest x-ray
Asthma
Dry, hacking cough, Nocturnal cough (only one sign, typical for younger patients); Chest Tightness; Anxiety;
SOB; Increased sputum production; Fever (sometimes);
Symptoms worse at night;
Symptoms at work: check environment;
Exercises induced asthma;
Family history of atopy (dermatitis, rhinitis);
Acute onset SOB relives with rest or use of bronchodilators
End-expiratory wheeze, prolonged expiratory phase
Wheezing (DDx with CHF); Tachypnea; Tachycardia;
Expiratory phase of respiration increased:
I/E ratio decreases (normal 1:2)
Increased use of accessory respiratory muscles
Pulsus paradoxus
Cyanosis
Difficulty talking
Pulmonary function testing chest x-ray, oxygen saturation, bronchoprovocation, allergy testing
Reversible airway abstraction.
Use bronchodilator for diagnostic purpose.
Methacholine provocation – vasoconstrictor
R/O: CHF;
Acute setting:
Best initial test during exacerbation: Arterial blood gas (ABG)
Chest xray
Pulse oximeter
Chronic setting:
Most accurate test: peak expiratory flow(PEF) – chronic state decreased
Methacholine challenge (if PEF are normal)
Atelectasis
Dyspnea (SOB);
Decreased breast sound;
Immediate after surgery;
Lack of cough;
xRay: trachea deviation;
Atherosclerosis
May be asymptomatic;
Chest pain or pressure;
Sudden numbness or weakness in your arms or legs;
Difficulty speaking or slurred speech;
Temporary loss of vision in one eye;
Leg pain when walking;
High blood pressure;
Fasting lipid profile;
HbA1C;
Atopic Dermatitis (Eczema)
Atrial Septal Defect (ASD)
Autism
Lacks or relationships;
Poor eye contact, no social smile;
Absent or bizarre speech;
Repetitive behaviors:
Stacking;
Injurious behavior
Autoimmune atrophic gastritis
Abdominal pain;
Nausea and vomiting;
Loss of appetite;
Unexpected weight loss;
Anti-intrinsic factor (specific but not sensitive);
Antiparietal cell antibodies (sensitive, but not specific);
Fasting gastrin (support diagnosis);
Endoscopy: stomach ulcers.
Iron study: iron deficiency anemia (a low level of healthy red blood cells)
Autoimmune hemolytic anemia
Chills;
Palpitation;
Shortness of breath;
Weakness / fatigue;
Chest pain;
Dark urine;
Tachycardia;
A feeling of abdominal fullness related to an enlarged spleen;
Yellow skin or whites of the eyes (jaundice);
CBC;
Coomb’s is positive;
Spherocytic;
Autoimmune hepatitis
Fatigue;
Abdominal discomfort;
Abnormal blood vessels on the skin (spider angiomas);
Skin rashes;
Joint pains;
Loss of menstrual periods;
Yellowing of the skin and whites of the eyes (jaundice);
An enlarged liver;
Positive ANA;
Most specific:
Liver-KI microsomal-1 AB (LKM-1);
Anti-smooth muscle AB (ASMA);
Antinuclear AB (ANA);
Most accurate: LV biopsy;
Liver problems Type 1:
Anti-smooth muscle AB (ASMA) titer
Liver problems Type 2:
Anti-LKM AB
Anti-Liver cytosol AB
Hypothyroid: dry skin; fine fair; galactorrhea
Hyperthyroid: moist skin; hyperpigmentation over bones; thin fair; goiter
Hypothyroid: TSH high
Hyperthyroid: TSH low; T3 high; T4 high
Avascular necrosis
Minor early joint pain;
Joint pain gets worse as bone and joint start to collapse;
Limited range of motion because of pain;
Babesiosis
Deer tick transmission;
Hemolytic anemia
Mild-moderate:
- Common: chills, sweats, and myalgia
- Less common: anorexia, headache, nausea, and dry cough
- Least common: arthralgia, shortness of breath, sore throat, neck stiffness, emotional lability, abdominal pain, vomiting, diarrhea, dark urine, conjunctival injection, photophobia, hyperesthesia, and weight loss
Blood smear; PCR
Bacteremia
Sometimes only mild fever.
Later: tachypnea, shaking chills, persistent fever, altered sensorium, hypotension, and gastrointestinal symptoms (abdominal pain, nausea, vomiting, diarrhea) suggests sepsis or septic shock.
Vitals!
CBC; Blood culture;
Bacterial conjunctivitis
Gradual onset;
Unilateral follow by bilateral;
Redness in one or both eyes;
Slight sensitivity to bright light (photophobia);
Purulent discharge 24h/day;
Poorly transmission;
NORMAL vision;
NOT ITCHY;
Purulent discharge;
Visual acuity fine;
No adenopathy;
Red eye, discharge, photophobia, decreased visual acuity;
Most common in contact lens users;
Pathogens include Pseudomonas, Staphylococcus aureus, and Serratia; yellow-green discharge suggests Pseudomonas
Ophthalmology referral for slit lamp evaluation;
Corneal culture
Bacterial vaginosis
Thin, gray, white or green vaginal discharge;
Foul-smelling "fishy" vaginal odor;
Vaginal itching;
Burning during urination;
Not inflammatory;
Swelling behind your knee, and sometimes in your leg;
Knee pain;
Stiffness and inability to fully flex the knee;
Restricted ROM
x-Ray, US;
Observation: posterior knee pain;
Balanitis
Tight, shiny skin on the glans;
Redness around the glans;
Inflammation, soreness, itchiness, or irritation of the glans;
A thick, lumpy discharge under the foreskin;
An unpleasant smell;
Tight foreskin that cannot be pulled back;
Painful urination;
Swollen glands near the penis;
Sores on the glans;
Local erythema and edema; presence of smegma
None
Barotrauma
Severe pain; History of diving (24 h within presentation).
Conductive hearing loss; tinnitus.
With perilymph fistula: sensorineural hearing loss and/or vertigo;
Symptoms worsen during rapid increase in external air pressures during scuba diving or air travel.
Otoscopic examination:
bleeding behind TM: perforation of TM
Barrett's esophagus
Frequent heartburn and regurgitation of stomach contents;
Difficulty swallowing food;
Less commonly, chest pain;
Symptoms of acid reflux (50%)
Endoscopy with biopsy;
Bartholin's Gland Cyst
Basal cell carcinoma
Waxy lesion;
Shiny like a pearl;
Shave biopsy (exception)
Benign paroxysmal positional vertigo (BPPV)
Adults: associated with positional changes;
Recurrent episodes;
Vertigo lasts seconds to minutes;
Some relief if motionless;
Nystagmus;
Child: usually 2-3 y/o, sudden onset with crying by child;
Feeling or rotational movement;
Adult: Lateral or rotary nystagmus; no tinnitus or hearing loss
Child: vomiting, pallor, sweating, and nystagmus common; no loss of consciousness; neurological and audiological examination can be normal
Dix-Hallpike maneuver
Adult: Provoke nystagmus and vertigo by position that causes response; ENG;
Child: Can have hypoactive or absent response to caloric testing;
TSH;
CT or MRI to r/o brain tumor of schwannoma;
AB pain in RUQ that "comes and goes";
Postprandial or nocturnal pain;
Dark urine;
Pain may radiate to back, right scapula, right flank, or chest;
May have nausea and/or vomiting;
Pain begins 1-4 hours after eating or may awaken the patient during the night;
May be precipitated by fatty meals;
Epigastric tenderness;
Abdominal distension and rebound tenderness are not common.
AB US;
Lipase; Liver panel; CBC; UA;
Biotin Deficiency (Vitamin B7)
Bipolar disorder
Manic:
-elevated mood
-increased self-esteem
-distractibility
-pressured speech
-decreased need for sleep
-increase in goal directed activity
-racing thoughts
-excessive involvement in pleasurable activities
Mania for at least 1 week, it has affect your activities
Black hairy tongue syndrome
Bladder cancer
Painless blood in the urine;
Hematuria;
Frequent urination;
Back pain;
May have: Dysuria, change in frequency, nocturnal.
Late:
Suprapubic pain; palpable mass; ureteric obstruction;
UA: blood;
Urine for cytology: malignant cells (can be false negative);
Cystoscopy to directly visualize the tumor;
Upper tract imaging;
US, CT scan with contrast;
UA for RBC;
Blastomycosis
Blepharitis
Bilateral, gradual onset; no pain;
Infection of eyelids and lashes secondary to seborrhea (red swollen lid margins + dandruff on lashes);
Lids inflamed;
Visual acuity fine;
None
Bone fracture
History of trauma
x-ray
Botulism
Blurred or double vision; Drooping eyelids;
Difficulty focusing on nearby objects; Pupils that do not constrict normally when exposed to light;
Dry mouth; Slurred speech; Difficulty swallowing;
Nerve damage by the toxins affects muscle strength but not sensation. Also, the mind usually remains clear.
Electromyography
When possible, tests to detect toxins in food, blood, or stool
Bowen Disease
Brain abscess
Headache; Nausea, Vomiting;
Seizures; Fever and chills are mild, do not occur until late in the infection
MRI or CT with contrast
Brain cancer
New onset or change in pattern of headaches;
Headaches that gradually become more frequent and more severe over the span of weeks to months; Can wake patient up;
Vision problems: blurred vision, double vision or loss of peripheral vision;
Gradual loss of sensation or movement in an arm or a leg;
Dizziness;
Speech difficulties;
Confusion in everyday matters; Personality or behavior changes;
Seizures, especially in someone who doesn't have a history of seizures;
Hearing problems.
Focal neurologic deficits;
Altered mental status.
Nausea/Vomiting;
Papilledema
CT scan
Breast cancer
Mass solid and immobile;
Peau d’orange;
New nipple retraction;
Dimpling of the breast.
Axillary lymphadenopathy
Mammogram (screening test);
CA 15-3;
Biopsy: FNA, but better core biopsy;
Breast cysts
Soft or hard.
Round and smooth.
Painful, especially before your menstrual cycle.
Easily movable under the skin.
Frequent resp infections (usually gram(-))
bronchiectasis on image
Best initial test: chest xRay
Multiple cysts and bronchial crowing
Most accurate test: high resolution chest CT – abnormally dilated and thickened airways
Sputum culture (in addition)
Spirometry: abstractive airflow
Bronchiolitis (RSV)
onset over 48 h; fever, rhinorrhea, cough
Copious nasal secretion
Wet cough
Fever
Poor feeding
Wheezing or noisy breathing
wheezing, tachypnea, tachycardia, shallow breathing, respiratory distress, use of accessory muscle of respiration, nasal flaring, cyanosis
Tachypnea
Expiratory wheezing
Crackles
Hyper Resonance on percussion
WBC with dif. (5000-24000/mm3)
Chest xRay:
Air trapping
Patchy perihilar infiltrates
Bronchogenic carcinoma
Cough with hemoptysis; weigh loss; shortness of breath
Enlarged supraclavicular nodes; dull chest percussion over tumor; increased breath sounds distal to tumor
Chest radiograph; CT scan of chest
Bulimia
Being preoccupied with your body shape and weight; fear of gaining weight; eating abnormally large amounts of food; self-induced vomiting, use of laxatives or diuretics, excessive exercise, and/or fasting
Normal weight; swollen parotid glands; scars on the knuckles (from repeatedly inducing vomiting by using fingers to trigger gag reflex); dental erosion
Clinical criteria
Bullous Pemphigoid
Bursitis
Affected joint:
Feel achy or stiff;
Hurt more when you move it or press on it;
Look swollen and red.
US, MRI
Calcium pyrophosphate dihydrate deposition disease (CPPD or pseudogout)
Sudden, intense joint pain;
Swollen joint that's warm to the touch;
Red or purple skin around the joint;
Severe tenderness around the joint - even the slightest touch or pressure may bring extreme pain;
Synovial fluid analysis;
Identification of crystals microscopically;
Observe; palpate lymph nodes, consolidations, lesions
Physical exam may be normal
CBC with dif. to rule out anemia;
Leucocyte count;
CT scan;
Biopsy;
Cancer metastasis
Pain and fractures, when cancer has spread to the bone;
Not relived by rest, worse at night;
Headache, seizures, or dizziness, when cancer has spread to the brain;
Shortness of breath (SOB), when cancer has spread to the lung;
Jaundice or swelling in the belly, when cancer has spread to the liver.
↑ LDH, ↑ ALP,
Biopsy;
MRI (best for bone cancer);
Nuclear medicine bone scan, PET scan;
↑ Ca; ↑ P;
Candidiasis
Oral Thrush.
Candidiasis that develops in the mouth or throat is called “thrush.
Generalized abdominal pain;
Flushing (few minutes to a few hours or longer);
Palpitation;
Wheezing;
CV murmur (tricuspid regurgitation);
Diarrhea; Abdominal cramps;
Purplish areas of spiderlike veins may appear on your nose and upper lip;
Best initial: ↑5-HIAA (urine);
↑serotonin(serum);
Cardiomyopathy
SOB;
Chest pain worse with exertion;
Better with rest (for abstractive cardiomyopathy);
Hypertrophic: syncope, light headedness;
Edema;
JVD;
Rales;
Murmur NOT increasing with expiration (HOCM, MVP);
Dilated: S3 gallop, paroxysmal dyspnea;
Hypertrophic: S4 gallop; valsalva, standing suddenly;
Restrictive: Kussmaul sign (↑jugulovenous pressure on inhalation);
ECG – best initial, also most accurate;
Most accurate: echocardiography;
xray – no additional information;
Cardiovascular risk assessment (CVD risk)
May be asymptomatic
LDL; total cholesterol; HDL; triglycerides; Lp(a);
Fasting glucose; HbA1C;
Electrolytes (K, Ca, Mg);
CRP;
Cardio markers: troponin, CK-MB; LDH;
BNP (helps to R/O pneumonia, PE, CHF);
Carotid artery dissection
Headache.
Scalp or face pain.
Eye pain.
Neck pain.
One eye with a droopy lid and small pupil (partial Horner syndrome)
Weakness or numbness on one side of your body.
Having trouble understanding speech or speaking.
Pulsing sound in an ear.
Doppler U/S—carotid;
Angiography if necessary after 70% of occlusion;
MRI of the brain and neck;
Carpal tunnel syndrome
Hand and wrist pain;
Burning and tingling in digits 1-4 (thumb, index, middle, ring fingers);
Numbness in digits 1-4;
An electric-like shock through the wrist and hand;
Reduced hand dexterity;
Poor sleep quality due to hand tingling and/or numbness;
Weakness, particularly of the thumb;
(+) Phalen’s maneuver;
(+) Tinel’s sign;
Sensory symptoms before motor symptoms;
Nerve conduction studies;
Most accurate test: electromyography (EMG) and nerve conductive study;
Clouding in the lens of the eye;
Often bilaterally;
Painless progressive vision loss;
Patient used reading glasses before, but don’t need it anymore
Early cataract: ophthalmoscope;
Slit-lamp exam;
Cauda equina
Bowel and bladder incontinence;
Erectile dysfunction;
Urinary retention;
Change in bowel habits;
Saddle anesthesia;
Bilateral leg weakness;
Bilateral sciatica;
SLR (+), abnormal DTRs, motor weakness
Request imaging!
MRI (gold std and definitive diagnosis);
Celiac disease (Gluten intolerance)
Diarrhea: paleness; looseness; and bulkiness of stool within 3-6 mo of dietary onset;
Dermatitis herpetiformis 10%
Children: Bloating; Abnormal stool;
Look for time of bread products introduction.
Peak frequency 9-18 mo.
Adults: Diarrhea; Steatorrhea; Weigh loss;
Acid reflux;
Abdominal pain;
Joint pain;
Anal itching;
CBC, iron study
Anti-tissue transglutaminase AB – best initial 90% sensitive and 95% specific
Anti-endomysial AB - 90% sensitive and 95% specific
Radiography.
Most accurate: histology small bowel biopsy (flattening of villi), can help to r/o lymphoma
IgA antigliadin AB – not in use
Clinical perl: Also order TTG IgG, TTG IgA, not only IgA.
Cellulitis
Redness, pain, and tenderness over an area of skin;
Warm, red, swollen, tender skin; fever
Flat borders;
Blanching with simple pressure
Observation;
If fever: ↑WBC, ↑ESR, ↑CRP, blood culture;
Most accurate test: inject saline into skin, aspirate for culture
R/O: DVT -> Pulmonary Embolism - D-dimer;
Cerebral Palsy (CP) Syndromes
Developmental delays. The child is slow to reach milestones such as rolling over, sitting, crawling, and walking- the main clues;
Abnormal muscle tone. Body parts are floppy or too stiff.
Abnormal posture. The child might also use one side of the body more than the other when reaching, crawling, or moving.
Cervical cancer
Vaginal bleeding after intercourse, between periods or after menopause;
Watery, bloody vaginal discharge that may be heavy and have a foul odor;
Pelvic pain or pain during intercourse;
Asymptomatic
Postcoital bleeding
Watery discharge
Symptoms related to compression of lymphatics, veins, ureters
History of injury of trauma; pain with deep breaths; splinting of chest wall
Shallow respiration; chest wall pain on palpitation
Chest radiograph
Chlamydia
Painful urination;
Vaginal discharge in women;
Discharge from the penis in men;
Painful sexual intercourse in women;
Bleeding between periods and after sex in women;
Testicular pain in men;
Watery discharge
Leading cause of blindness of newborns;
Riders syndrome:
Reactive arthritis;
Uveitis;
Urethritis;
Swab;
DNA prob;
Serology (intracellular);
Chlamydia pneumonia
Slow onset of symptoms: Runny or stuffy nose, Fatigue (feeling tired), Low-grade fever, Hoarseness or loss of voice, Sore throat, Slowly worsening cough that can last for weeks or months,
Headache
Sinusitis,
Conjunctivitis
↑WBC;
↑ALP;
↑bilirubin;
↑AST↑ALT;
↑amylase;
US ok’ but HIDA scan is better;
Blood culture (if infection suspected);
Most accurate: Endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography (MRCP);
Cholecystitis / Cholelithiasis
Colicky pain (30 m – 6 h) after fatty meal or at night.
Pain goes around the side to the back RUQ or between scapulars. Worse after fatty meal;
The pain of acute cholecystitis is similar to biliary colic (pain caused by gallstones) but is more severe and lasts longer;
Nausea / vomiting;
History of dark urine of light stool;
Indigestion;
Flatulence;
Murphy sign (+) - sharp pain in cholecystitis;
Kehr’s sign (diaphragm irritation causing shoulder pain);
Gall bladder is palpable;
Tender RUQ;
FEVER in cholecystitis;
First test: US of GB: Gallstones; Classic acoustic shadowing is seen beneath the gallstones; Thicken GB wall;
↑ WBC (leucocytes) in cholecystitis;
↑ bilirubin; ↑ ALP;
Cholera
Diarrhea;
Nausea and vomiting;
Dehydration;
Stool culture and serogrouping/subtyping;
Cholesteatoma
A full feeling or pressure in the ear;
Hearing loss in the affected ear;
Dizziness;
Pain;
Numbness or muscle weakness on one side of the face;
Pain or numbness in the ear or around the ear.
Shiny white irregular mass on otoscope examination;
Foul-smelling discharge can be present;
Bone distraction can be visible;
Conductive hearing loss can be present
CT scan
Chromium Deficiency
Chromium Toxicity
Chronic Bronchitis
Productive cough, periodically;
Facial erythema;
Productive cough for >3 months/year for 2 consecutive years – clinical diagnosis;
Hemoglobin hematocrit may be elevated;
Chronic fatigue syndrome (CFS)
Fatigue lasting longer than 6 m; sudden onset of flulike symptoms that persist or recur
Normal; cervical and axillary lymphadenopathy
CBC; ESR
Chronic Hypercalcemia
Chronic mesenteric ischemia
Recurrent postprandial abdominal pain (often in the first hour and
diminishing 1-2 hours later);
Pain brought on by food;
Food fear;
Weight loss;
Doppler US (noninvasive) follow by CT angiography (more invasive, to confirm positive findings);
Chronic obstructive pulmonary disease (COPD)
Productive cough, periodical (smokers in their 40s and 50s); mild dyspnea, progressive, worse during respiratory infection (late 50s or 60s); history of COPD; history of cigarette smoking; yellow sputum;
Hacking, rasping cough; normal breath sounds or rhonchi that clear with coughing; resonant to dull chest, possible barrel chest, prolong expiration, possible wheezing; facial erythema
Chest x-ray, pulmonary function tests
Hemoglobin: hematocrit may be elevated
Productive cough for >3 months/year for 2 consecutive years – clinical diagnosis;
Chronic pancreatitis
Epigastric pain radiating to the back;
Pain gets worse when you eat or drink alcohol;
Diarrhea or oily stools;
Nausea and vomiting;
Severe pain that may be constant or that comes back;
Weight loss;
Amylase and lipase – mildly increase or normal;
Low fecal elastase – most specific and sensitive test;
CT scan with contract – 80-90% specific for calcification;
Vitamin D and A deficiency;
AB xRay (50-60% sensitive for calcification, very specific);
Secretin stimulation test – most accurate diagnostic test;
Nausea / Vomiting;
Loss of appetite;
Fatigue and weakness;
Sleep problems;
Changes in how much you urinate;
Decreased mental sharpness;
Muscle twitches and cramps;
Swelling of feet and ankles;
Persistent itching;
Swelling or heaviness, especially in the lower leg and ankle;
Pain;
Itchiness;
Varicose veins (twisted, enlarged veins close to the surface of the skin);
Skin that looks like leather;
Clinical evaluation;
Ultrasonography R/O DVT;
Circulatory Overload
Cirrhosis
Compensated: Weight loss; Fatigue; Loss of appetite; Nausea;
Decompensated: Yellow discoloration in the skin and eyes (jaundice); Easily bleeding or bruising; Swelling in your legs, feet or ankles (edema); Itchy skin;
Caput medusae;
Splenomegaly;
Gynecomastia;
Spider angiomata;
Ascites;
Palmar erythema;
Digital clubbing;
Asterixis;
Normal or low JVP
Splenomegaly
↑ALT and AST;
↓Albumin;
Anemia;
↓Platelets;
↑PT and PTT;
High estrogen;
High conjugated bilirubin;
Low Na;
High creatinine;
Gold standard: Liver biopsy;
US: small nodular liver;
Hepatitis B and C serologies;
Liver biopsy
Shallow anterior chamber;
Eye is red, pupil fixed and mid-dilated, no reaction to light;
Rock-hard eye
Tonometry
Cluster headache
Frequently, short duration; Severe unilateral orbital; Supraorbital; Temporal;
Conjunctival infection;
Tearing/congestion, +/- discharge;
Edema; 1-3 hours; Ptosis; Miosis.
Red, tearing eye with rhinorrhea
CT of the head first time
r/o close angle glaucoma
Coal Workers’ Pneumoconiosis (Anthracosis; Black Lung Disease; Coal Miner’s Pneumoconiosis)
Cough, with or without black sputum;
Shortness of breath;
Chest tightness;
History of exposure to coal dust;
Chest CT (asbestosis) or chest x-ray;
Plural biopsy – MANDATORY! For an insurance. Otherwise not necessary.
Coarctation of the Aorta
Coccidioidomycosis (Valley Fever)
Fatigue (tiredness);
Cough;
Fever;
Shortness of breath (SOB);
Headache;
Night sweats;
Muscle aches or joint pain;
Rash on upper body or legs;
Colorectal cancer
Change in bowel habits;
Ab pain; RLQ; LLQ;
Most - left side. May cause change of stool caliber;
Constipation; +/- Diarrhea;
Hematochezia;
Melena;
Weakness;
Fatigue;
Weigh loss;
Iron def anemia in elderly male or post-meno female – colorectal cancer until proved otherwise;
↑CEA – 70%;
Colonoscopy with biopsy (screening test);
FOBT (screening test);
Common cold
Nasal and throat irritation, sneezing, rhinorrhea non-productive cough;
Community-Acquired Pneumonia
RUQ; LUQ abdominal pain;
Cough that produces sputum;
Fever;
Severe infection:
SOB,
Vital signs(tachycardia, hypotension, tachypnea)
Or mental status changes;
Diarrhea sometimes (legionella );
Chest pain (often pleuritic);
Hypothermia;
Auscultation; percussion;
CBC with diff;
chest x-Ray;
sputum culture - not good;
Blood culture - better;
Best initial test: chest xRay –
- lobar consolidation (typical)
- Interstitial infiltrates (not typical)
Or CT or MRI
Etiology: sputum gram stain and sputum culture
Ddx with bronchitis:
SOB, high fever, abnormal x-ray
Dullness to percussion (with effusion)
Consolidation in lungs: bronchial sounds and egophony
Sputum color doesn’t help!
Atypical pneumonia:
Mycoplasma, Chlamydophila, Legionella, Coxiella,
Viruses
Blood culture is positive: S. pneumonia
Congestive heart failure (CHF)
SOB; Edema; Intolerance to exercise; Orthopnea; S3 gallop;
Nocturnal dyspnea; HJR; Frothy white sputum with flecks of blood
Hepatosplenomegaly; Cardiac enlargement; Anxiety
RCHF: JVD; Ascites; Peripheral edema
JVP, S3 gallop, Orthopnea, wet crackles (pulmonary edema), pitting edema, may be ascites, big LV, SP; Crackles;
CBC, creatine, electrolytes, urea, albumin, uric acid, ALT/AST, fasting; glucose, lipid panel, TSH, UA;
Specific to HF: BNP, iron panel, ferritin, transferrin, HIV test;
Best initial test: Transthoracic ECG , Echo(echocardiography) – can help to distinguish systolic from diastolic disfunction);
BNP > 500 – is CFH present? If patient has SOB;
Most accurate test: MUGA scan;
Chest x-ray (enlarged heart, effusion);
Hyperventilation causes low CO2 and hypoxia (respiratory alkalosis);
Test which can alter acute management:
ECG – check them! Pulmonary edema possible.
Contact Dermatitis
Morbilliform rash (muscles type rash) days after 2nd exposure to allergen:
Plants, Nickel, Soaps, Latex
Not inflammatory condition
Chronic productive cough
Anxiety
Acute: worsening dyspnea, increase in sputum purulence, increase in sputum volume
Recurrent resp. infections, dyspnea improving with rest, SOB, wheezing, rhonchi; Productive cough;
Morning headache;
Cor pulmonale
Initially symptoms only on exertion
Dyspnea; SOB; Productive cough; Wheezing; Rhonchi;
Morning headache;
Clubbing, barrel chest, tachypnea, distant breath sounds
“Barrel chest”; Time of exploration 2 bigger time of inspiration
Pursed-lip breathing;
Prolong expiratory duration;
Decreased heart sounds;
Decreased breath sounds;
Accessory muscle use;
Acute: fever, increased wheezing or cough, increased respiratory rate and heart rate.
JVD;
spirometry: airflow obstruction with emphysema
Best initial test: xRay: Increased AP diameter
Air trapping, flattened diaphragms
Most accurate test: PFT. ↓FEV1 and FVC
FEV1/FVC <70%
TLC increase
ABG:
↓O2;
↑CO2;
ECG; Echocardiography;
Albuterol doesn’t normalize spirometry result
COPD staging:
GOLD1-FEV1>80 (mild)
GOLD2-FEV1 50-80 (moderate)
GOLD3-FEV1 30-50(severe)
GOLD4-FEV1 <30(very severe)
Decrease of FEV1 and FVC with increase in TLC
Not respond to bronchodilator
Copper deficiency
Copper Toxicity
Corneal abrasion
Eye pain; A gritty feeling in the eye;
Tearing; Redness;
Sensitivity to the light;
Headache.
Fluorescein stain is usually linear if from trauma or foreign body, and round if from contact lens use
Coronavirus Disease 2019 (COVID-19, SARS-CoV-2)
Most common symptoms:
fever;
cough;
tiredness;
loss of taste or smell;
Less common symptoms:
sore throat;
headache;
aches and pains;
diarrhoea;
a rash on skin, or discolouration of fingers or toes;
red or irritated eyes;
Serious symptoms:
difficulty breathing or shortness of breath;
loss of speech or mobility, or confusion;
chest pain;
Costochondritis
Pain along sternal border, increases with deep breaths; history of exercise, URI, or physical activity
Pain with palpitation over costochondral joints; breath sounds nl
none
Creutzfeldt–Jakob disease (CJD)
Crigler-Najjar Syndrome
Crohn Disease (IBD)
LLQ; RLQ pain; Crampy abdominal pain; Chronic diarrhea (which sometimes is bloody when the large intestine is severely affected; helps to DDx with appendix)); Fever; Anorexia; Weight loss; Inflammation;
Oral lesions; Erythema nodosa on the anterior legs; RLQ ab mass; Abdominal tenderness; Chronic anorexia;
Fever; Perianal fissures and fistulas; Oral ulcers
Barium study; abdominal CT;
Calprotectin stool test (IBS>50, IBD>150) --> not diagnostic;
Colonoscopy with biopsy: Skip lesions; Transmural granulomas; Fistulas and granulomas; Masses and obstructions; Perianal dz; affects terminal ilium;
Endoscopy: Inflammation.
Croup (acute laryngotracheobronchitis)
URTI, Gradual onset, Nasal congestion
Cough: progress to barky, harsh, seal-like barking cough (worse in the morning)
In severe cases it progresses to SOB and inspiratory stridor (inspiratory sound in upper airway)
Coryza
12-72 hours of mild fever and coryza; hoarseness and barking cough; peak respiratory distress at 24-48 hours; resolution in 1 week
lateral x ray: Steeple sign
Toxic appearing, drooling (DDx epiglottis)
NO need to xRay!
Enzyme immunoassay for fecal antigen;
Molecular probes for parasite DNA;
Cryptosporidium species
Recurrent episodes; variable amounts watery; no blood in stool; amount can be massive; severe RUQ pain with biliary tract involvement
Weight loss;
Stool for O&P; antigen test; PCR testing
Cushing syndrome
Weigh gain especially on the trunk, face;
Moon face;
Hyperhidrosis (sweating);
Hirsutism;
Buffalo hump;
Striae, easy bruising, decrease wound healing, thinning of the skin;
Polyuria;
No menses, ED;
Acne;
Hyperglycemia;
Central obesity; high blood pressure; increased pigmentation of the skin; moon face; acne; striae of abdomen; buffalo hump
Gold standard: 24 urinary cortisol
1mg dexamethasone suppression test (can’t suppress cancer, but suppress ;
ANY Cushing’s syndrome or dz), late-night salivary cortisol;
PAC:PRA;
Low:low;
ACTH – always to find the source of ACTH;
Don’t start with CT scan! (MRI for pituitary);
8 mg suppression test – we can suppress only pituitary lesion;
Lab shows: high sugar and high lipids;
Low K;
Metabolic alkalosis;
Leukocytosis;
Cushing’s Syndrome in Children
Weight gain, specifically in the mid-torso;
Vertical growth slows or stops;
Thin arms and legs compared to the rest of the body;
Stretch marks on abdomen, arms, thighs and buttocks;
Round or moon-shaped face;
Excess facial hair (hirsutism) in girls;
Menstrual changes in girls;
Acne;
Fatigue;
Precocious (early) puberty;
Diabetes;
High blood pressure (hypertension);
High cholesterol;
UA:
WBC;
Bacteria in urine (important for pregnant female);
Pyuria: leucocytes esterase and nitrates;
Gr gram+: no nitrates (Staph.S, Strep B, enterococcus sp.);
Nitrates:
Positive: Enterobacteriaceae (E.Coli);
Negative: S saprophyticus, Pseudomonas, or enterococci.
Urinalysis (microscopic);
Numerous WBCs, variable RBCs;
Urine culture:
Colony-forming units>105;
Cytokine storm
Fevers and chills;
Fatigue;
Swelling of extremities;
Nausea and vomiting;
Muscle and joint aches;
Headache;
Rash;
Cough;
Shortness of breath;
Rapid breathing;
Seizures;
Tremor;
Difficulty coordinating movements;
Confusion and hallucinations;
Lethargy and poor responsiveness;
Detection of CMV antigen or DNA;
Urine culture in infants;
Dacryocystitis
Pain, redness, and swelling in the inner corner of the eye.
Watery eye.
Swelling in the corner of the eye next to the nose.
Eye redness.
Pus or mucus in the corner of the eye.
Fever.
Clinical evaluation;
Deep Vain Thrombosis (DVT)
Sudden SOB with clear lungs on exam and normal chest xRay;
Cough;
Hemoptysis;
If DVT is present – leg pain;
Pleuritic chest pain from lung infarction;
Feeling that something terrible happen to them - anxiety;
Fever;
Big clot - hypotension;
Altered mental status;
Tachypnea;
Tachycardia;
(+) Homans sign - short duration calf pain;
Best initial tests: Chest x-Ray, ECG, ABG;
D-dimer can help to r/o DVT and PE;
Duplex ultrasonography (US);
x-Ray may show atelectasis, pleural infusion or “Hampton’s hump”;
ECG: sinus tachycardia;
Most common abnormality: ST-T wave changes;
5% will show right axis deviation, RV hypertrophy or RBBB;
ABG: hypoxia and resp. alkalosis;
Most accurate test: angiography (0.5% mortality) almost never used;
Wells risk score :
Clinical signs and symptoms of DVT;
PE is #1 diagnosis OR equally likely;
Heart rate > 100;
Immobilization at least 3 days OR surgery in the previous 4 weeks;
Previous, objectively diagnosed PE or DVT;
Hemoptysis;
Malignancy w/ treatment within 6 months or palliativepneumo;
Dehydration
Extreme thirst;
Less frequent urination;
Dark-colored urine;
Fatigue;
Dizziness;
Confusion;
Skin turgor
CBC
Delayed puberty
No menses after 16 y/o; more than 5 years between breast growth and menses
Electrolytes; Urinalysis
Pulse ox;
Review of medications;
If nothing: CT of the brain;
Depression
Children: feeling sad, angry, irritable. Decrease in academic performance. Somatic complains.
Adult: loss of interest in usual activities. Feeling of worthlessness. Sleep problems.
Most accurate test: CDI: Give vasopressin (drug, ADH)
NDI: no effect
↑serum Na
↓urine osmolality
↓serum osmolality
Conformation of diagnosis: water deprivation test: if urine not concentrated even after water restriction -> DI
Give ADH -> corrected -> central DI, not -> nephrogenic DI
Hyper Ca or Hypo K inhibit ADH;
Hyper Na -> neurology:
Diabetes mellitus (DM) type 1
Autoimmune;
Abrupt onset;
Weigh loss;
Possible DKA
Ab tests: IAA, ICA, GAD, IA-2;
Glucosuria;
Serum and urine ketones.
2 times fasting glucose >125
Or one random >=200 with symptoms
MOST accurate: oral glucose tolerance test (2 H after sugar intake)
H1C >= 6.5% - one test is enough
2 times fasting glucose >125;
Or one random >=200 with symptoms;
MOST accurate: oral glucose tolerance test (2 H after sugar intake);
H1C >= 6.5% - one test is enough;
Diabetic enteropathy
Nocturnal diarrhea; postprandial vomiting; fatty stools from malabsorption
Findings associated with diabetes
Diagnosis of exclusion in diabetic people
Diabetic ketoacidosis (DKA)
Generalized abdominal pain in children;
Hyperventilation; Polydipsia; polyuria; weakness;
Altered mental status; Dry mucous membranes; decreased skin turgor; Fruity odor; Nausea and vomiting; but no diarrhea;
Kussmaul respirations
Measure of severity: serum bicarb;
↑K in blood, but ↓total body K (without insulin K can’t enter the cell), ↑K in urine;
↑serum for ketones;
↑Glucose (300-800);
High anion gap metabolic acidosis;
Diabetic Nephropathy
Worsening blood pressure control;
Swelling of feet, ankles, hands or eyes;
Increased need to urinate;
Reduced need for insulin or diabetes medicine;
Confusion or difficulty concentrating;
Shortness of breath (SOB);
Loss of appetite;
UA: protein in the urine;
Random urine albumin/creatinine ratio;
Urinalysis for signs of other renal disorders (eg, hematuria, red blood cell [RBC] casts);
Diabetic retinopathy
Spots or dark strings floating in your vision (floaters);
Blurred vision;
Fluctuating vision;
Dark or empty areas in your vision;
Vision loss;
Referral to ophthalmologist
Diphtheria
A thick grey-white coating at the back of your throat;
A high temperature (fever) of 38C or above;
Feeling sick;
Sore throat;
Headache;
Swollen glands in your neck;
Difficulty breathing and swallowing;
Never in healthy people;
Uncontrolled bleeding;
Hemoptysis;
Jaundice;
R/O: Severe liver dz;
D-dimer;
↑PT and PTT;
↓platelets count;
↑BT;
↓fibrinogen;
All factors are low;
Diverticulitis / Diverticulosis
Diverticulosis:
Asymptomatic until bleeding or infection;
Cramping;
Bloating;
Flatulence;
Irregular defecation;
Painless rectal bleeding;
Diverticulitis:
LLQ; pain and tenderness;
May cause severe pain;
Fever; Nausea; Vomiting;
Alternating diarrhea/constipation;
Tenderness on palpation; Palpable mass
Diverticulosis:
Colonoscopy;
Barium enema;
Diverticulitis:
Best initial: CT scan with contract of the AB -98% accuracy;
NO BARIUM STUDY;
Always R/O colon cancer: Colonoscope;
↑ WBC;
Dog, cat, human bite
History of bite;
Pain and swelling;
Penetrating trauma;
Down syndrome
A flattened face, especially the bridge of the nose;
Almond-shaped eyes that slant up;
A short neck;
Small ears;
A tongue that tends to stick out of the mouth;
Tiny white spots on the iris (colored part) of the eye;
Small hands and feet;
Duchenne Muscular Dystrophy and Becker Muscular Dystrophy
Frequent falls.
Difficulty rising from a lying or sitting position.
Trouble running and jumping.
Waddling gait.
Walking on the toes.
Large calf muscles.
Muscle pain and stiffness.
Learning disabilities.
Duodenal ulcers
Epigastric consistent pain;
Pain is absent when the patient awakens but appears in mid-morning and is relieved by food;
Better 30+ min after food intake, but recurs 2 to 3 hours after a meal;
Pain that awakens a patient at night is common and is highly suggestive of duodenal ulcer;
Epigastric tenderness on palpation;
Upper Endoscopy;
Biopsy for H.pylori
Dyslipidemia
Asymptomatic;
Total cholesterol;
LDL cholesterol;
HDL cholesterol;
Triglycerides;
Ectopic pregnancy
RLQ; LLQ pain; Sudden onset; Sexually active female of childbearing age; spotting and persistent cramping in lower quadrant that begins shortly after missed period;
Sign of hemorrhage; shock; and lower ab peritoneal irritation that can be lateralized; enlarged uterus; tender adnexal mass;
hCG;
US;
Laparoscopy;
Surgical emergency;
Electrolyte disorders
Irregular heartbeat; fast heart rate.
Fatigue.
Lethargy.
Convulsions or seizures.
Nausea/vomiting.
Diarrhea or constipation.
Abdominal cramping.
Muscle cramping.
Muscle weakness.
Irritability.
Confusion.
Headaches.
Numbness and tingling.
Electrolytes;
ECG (helps evaluate K and Ca);
Encephalitis
Malaise;
Headache
Neck pain;
Vomiting;
AMS (alternated mental status);
DDx with meningitis: No photophobia, no stiff neck;
Focal neurologic defects:
Hemiparesis;
Pathologic reflexes;
Nerve palsies;
DDx with meningitis: Confusion -> herpes;
Skin lesions in HSV;
DDx:
Meningitis (with stiff neck);
Brain abscess (with focal neurological findings);
PCR – most specific test;
Serology for IgM AB – reliable test for specific virus;
Viral CFS:
↑some WBC(lymphocytes);
↑CSF pressure;
Normal glucose;
Normal protein;
Radiology:
CT of the head;
MRI of the head;
Endocarditis
RUQ; LUQ pain; Subacute bacterial endocarditis presenting as LUQ abdominal pain; History of Strep viridian exposure; Joint pain; confusion; fever; chills;
Janeway Lesions (specific but only 10-15% of patients); Painful nodules under the skin - Oster nodes; Murmur
Heavy periods;
Bleeding between periods;
Postmenopausal bleeding;
(any bleeding over age 35 and post-meno)
Endometrial biopsy;
Dilation and curettage;
US – for r/o others causes of bleeding;
CA-125 – monitoring response to therapy
Endometrial polyps
Irregular periods, when you can’t predict their timing, length, or heaviness;
Heavy periods;
Bleeding or spotting between periods;
Vaginal bleeding after menopause;
Trouble getting pregnant;
RLQ; LLQ pain most severe during menses; Dysmenorrhea; Painful defecation during menses; NO BLEEDING;
Laparoscopy to check for endometrial tissue;
Sometimes a biopsy;
CA-125 elevated
Eosinophilic esophagitis (EoE)
Reflux that DOES NOT RESPOND TO MEDICATION (acid suppressors such as PPI);
Difficulty swallowing;
Food impactions (food gets stuck in the esophagus);
Nausea and Vomiting;
Abdominal or chest pain;
Difficulty sleeping due to chest or abdominal pain, reflux, and/or nausea;
r/o GERD;
Endoscopy with biopsy
Eosinophilic Granulomatosis with Polyangiitis (EGPA, Churg-Strauss syndrome)
Eosinophil-rich and granulomatous inflammation involving the respiratory tract; necrotizing vasculitis of small to medium vessels; associated with asthma
Epidermal nevi
Epididymitis
low-grade fever; chills;
pain in the pelvic area;
pressure in the testicles;
pain and tenderness in the testicles;
redness and warmth in the scrotum;
enlarged lymph nodes in the groin;
pain during sexual intercourse and ejaculation;
pain during urination or bowel movements;
urgent and frequent urination; abnormal penile discharge;
blood in the semen
Clinical evaluation;
Sometimes urethral swab and urine culture
Epistaxis
Erythema infectiosum
Erythema multiforme
Esophageal cancer
SCC (2/3 upper part of the esophageal) and Adenocarcinoma - Barret (1/3 of lower part);
Progressive dysphasia (solids -> solids and liquids).
Most accurate: endoscopy;
Biopsy to confirm cancer;
CT combined with PET-CT – for metastasis;
Esophageal Diverticula (Zenker’s diverticulum)
Difficulty swallowing;
Feeling like food is caught in the throat;
Regurgitating food when bending over, lying down, or standing up;
Pain when swallowing;
Chronic cough;
Bad breath;
Chest pain;
Neck pain;
Sudden onset;
Squeezing pain in the chest;
Dysphasia for solids and liquids: red wine or extremely hot or cold liquids;
The feeling that an object is stuck in your throat;
Regurgitation;
R/o angina, MI (ECG and stress test --> normal)
Endoscopy - normal
Esophagram – best initial (x-ray with barium shallow.
Manometry – most accurate, the only way to DDx
“cork screw pattern on barium swallow ”
Esophageal varices
Vomiting with blood;
Light headiness;
Caput medusa;
Palmar erythema;
Asterixis;
Low BP;
Bleeding: urgent upper endoscopy to control bleed by banding;
Check Hct;
Platelet count;
Coagulation tests (PT or INR);
Essential cryoglobulinemic vasculitis
Ewing sarcoma
Bone pain;
Tissue swelling;
Fever;
Fatigue;
Weight loss;
Fracture with minor trauma;
Palpable mass;
Athletic training in young age; long distance runner; ballerina; gymnast
BMI < 17; low body fat
TSH nl; prolactin nl
External otitis
Painful swollen ear, ear pain;
White discharge; pruritus;
Red and swollen ear canal;
Hearing loss (possible);
Severe presentation: periauricular erythema, lymphadenopathy, fever.
Painful when move patient's pinna/auricle or push firmly on the tragus.
For severe or recurrent cases: culture.
Facial Nerve Palsy (Bell's Palsy)
Rapid onset of mild weakness to total paralysis on one side of your face — occurring within hours to days;
Facial droop and difficulty making facial expressions, such as closing your eye or smiling;
Drooling;
Pain around the jaw or in or behind your ear on the affected side;
Increased sensitivity to sound on the affected side;
Headache;
A loss of taste;
Changes in the amount of tears and saliva you produce;
Face feels stiff or pulled to one side;
Entire side of face paralysis;
Hyperacusis CN7 supplies stapedius - a shock absorber;
Taste disturbance. CN7 supplies sensation of teste to anterior 2/3 of tongue (sweet);
Sensation is intact;
Patient can wrinkle forehead or can’t lift up on affected side;
DDx: stroke, Lyme (by history), OM (check ear);
Clinical evaluation;
CT or MRI;
Most accurate: electromyography and nerve conduction studies;
Frequent diarrhea, chronic;
Bad-smelling and loose stool;
Stools that are light in color or bulky;
Stools that are hard to flush away because they float or stick to the toilet bowl;
Weight loss;
Scaly skin rashes;
Fat in stool;
Fat necrosis of the breast
Round lump, usually painless, may feel tender or painful in the area surrounding the necrosis. Skin around the lump may look red and bruised.
Clinical exam followed by biopsy.
Fetal alcohol syndrome
Low body weight;
Poor coordination;
Hyperactive behavior;
Difficulty with attention;
Poor memory;
Difficulty in school (especially with math);
Learning disabilities;
Speech and language delays;
Fibroadenoma
Most common benign breast tumor;
Round with distinct, smooth borders;
Easily moved;
Firm or rubbery;
Painless.
US
Fine needle aspiration
May not need mammogram before 35 y/o
Fibrocystic breast
Multiple, bilateral masses;
Lumps or lumpy areas in the breast;
Breast pain or tenderness;
Breast swelling or heaviness;
The symptoms can change with your menstrual cycle and often become worse just before or during your period.
Nausea/Vomiting; Watery or bloody diarrhea; Abdominal pain; Abdominal cramps; Fever
Blood test; stool test
Foreign body aspiration
History of environmental hazard; choking episode
Gagging, coughing, wheezing, stridor
Asymmetrical physical findings of decreased breath sounds, wheezing
Chest xRay;
Bronchoscopy: can be a treatment;
Asymmetrical radiograph with forced expiratory view;
Most common location for aspirating object: right bronchi;
Foreign body in ear canal
History of external body pentation
Otoscopic examination
Foreign body in eye
Foreign body in nose
Foreign body in vaginal canal
Gyno exam
Fragile X syndrome
Trouble learning skills like sitting, crawling, or walking;
Problems with language and speech;
Hand-flapping and not making eye contact;
Temper tantrums;
Poor impulse control;
Anxiety;
Extreme sensitivity to light or sound;
Hyperactivity and trouble paying attention;
Functional constipation
RLQ; LLQ pain; Changes in diet (such as decreased fluid intake; low-fiber diet; and/or constipating foods); Drugs that slow the bowels; Disordered defecation; Laxative overuse;
Palpable mass;
Fungal Keratitis
G6PD deficiency
Sudden onset of hemolytic anemia;
Jaundice;
Fatigue
Best initial test: peripheral smear (Heinz bodies and bite cells)
Most accurate: G6PD level (low)
But after hemolysis is normal, wait for few weeks
Gallbladder cancer
Pain jaundice;
Palpable GB;
↑Bilirubin;
↑ALP;
US; MRI; CT;
Porcelain GB (calcification) – 10-30% may be a cancer
Gastric bypass
Gastric cancer
LUQ epigastric pain; not specific in the beginning;
Weight loss;
Anorexia;
Ascites (poor prognosis);
Melena;
Non-healing ulcer;
Late in the course; abnormalities include an epigastric mass;
Left supraclavicular node: Virchow's node;
Periumbilical node: Sister Mary Joseph's node;
Hepatomegaly; and an ovarian or rectal mass; Pulmonary; CNS; and bone lesions may occur;
Heme-positive stools;
↑CEA;
Endoscopy with biopsy;
CT for metastasis: peritoneum, ovary, liver, lung, brain;
Gastric ulcer
Dull; sore; gnawing LUQ, epigastric, chest pain is worsen with eating;
Symptoms often do not follow a consistent pattern (eg; eating sometimes exacerbates rather than relieves pain);
This is especially true for pyloric channel ulcers; which are often associated with symptoms of obstruction (eg; bloating; nausea; vomiting) caused by edema and scarring;
Thin complexion;
Epigastric tenderness on palpation;
Upper Endoscopy;
Biopsy for H.pylori;
Normal or low gastric acid level;
+/- high gastrin level;
Serum gastrin;
CT, scintigraphy, or positron emission tomography (PET) to localize;
Gastritis
Epigastric abdominal pain or discomfort; Heartburn; Hematemesis;
Sometimes nausea or vomiting; B12 def - (type A); H.pylori (type B); Most common cause of GI bleeding without pain; Severe pain (medication or alcohol)
Most accurate: esophageal-gastro duodenoscopy (EGD) with H.pylori test (most common infection cause);
Endoscopy;
Gastroenteritis
LUQ pain; Viral: Nausea/Vomiting/Diarrhea; AB pain; cramping; myalgias; Bacterial: diarrhea; Blood in stool; Diarrhea
Tenderness on palpation; Hyperactive bowel sound;
Low-grade fever;
No fecal WBC; Viral culture;
R/O: appendicitis; UC; cholecystitis;
Gastroesophageal reflux disease (GERD)
Epigastric pain; Heartburn; Regurgitation; Dysphagia;
Worse at night; Worse afternoon; Worse after meals (30-90 min);
Bad taste (metallic);Chough; Hoarseness; Sore throat;
Worse with lie down; Dyspnea; Nausea; Swallowing difficulty;
BETTER WITH PPI;
Endoscopy with biopsy; Sometimes pH testing;
Sometimes manometry to r/o Diffuse Esophageal Spasm (DES);
No confirmatory test necessary;
24 h pH monitoring – most accurate test for GERD with uncommon symptoms: chest pain, chronic cough, asthma, sore throat;
When you suspect something more serious run endoscopy with biopsy: >5 y of symptoms to r/o Barrett esophagus -> cancer;
R/O cardiac origin (esp. in elderly): troponin/CK-MP; ECG;
R/O esophageal cancer (esp. with anemia, bleeding, weight loss, PPI not effective for 4-8 weeks, worsening of symptoms, risk or Barrett): endoscopy with biopsy;
Generalized tonic-clonic seizure
Staring.
Jerking movements of the arms and legs.
Stiffening of the body.
Loss of consciousness.
Breathing problems or stopping breathing.
Loss of bowel or bladder control.
Falling suddenly for no apparent reason, especially when associated with loss of consciousness.
EEC;
>10 min --> ER;
Administrate thiamin, after it glucose, naloxone;
Germ cell tumors
Pelvic pain or tenderness;
Swollen belly (abdomen);
Nausea or difficulty eating;
Changes in bowel habits (constipation);
Irregular vaginal bleeding;
Tumor marker: b-hCG
Gestational Diabetes (Diabetes Mellitus in Pregnancy)
Diagnostic test:
Elevated ESR
Most accurate test:
Biopsy of affected artery
Decreased arm pulses, bruits near clavicles, aortic regurgitation
ESR and C-RP elevated, not specific
CT – 95% sensitive, lumber puncture for 5% with false negative result
1/3 are asymptomatic;
Abdominal pain;
Jaundice;
Fatigue;
Loss of appetite;
Feeling sick;
Dizziness;
A general sense of feeling unwell;
ALT/AST - normal;
Bilirubin - elevated (indirect (unconjugated))
Presence of hyperbilirubinemia in the absence of hemolysis; mild decrease in the activity of the enzyme glucuronosyltransferase, causing an increase in the indirect (unconjugated) fraction of serum bilirubin
Gingivitis
Swollen or puffy gums;
Dusky red or dark red gums;
Gums that bleed easily when you brush or floss;
Bad breath;
Receding gums;
Tender gums;
Clinical evaluation;
Glioma
Headaches.
Seizures.
Nausea and Vomiting.
Decline in Brain Function.
Weakness or Problems Moving.
Vision Problems.
Abrupt onset after 3-5 days after unprotected sex;
yellow-green discharge;
classic symptoms reported by males: frequency, urgency, dysuria;
worse during urination
Gram stain, culture;
Urine DNA testing for gonococcus
Gonorrhea (female)
Painful urination.
Pus-like discharge from the tip of the penis.
Pain or swelling in one testicle.
Gonorrhea culture. No sex contacts before test results.
Gout
Sudden excruciating pain, redness, tenderness of big toe at night after binge drinking with beer; Fever; Can affect ankles, feet, knees; MTP most affected
Red, hot, swelling joints (big toe);
Infected joint has redness, warmth, and tenderness;
Tap joint to exclude infection
High uric acid;
Most accurate: aspiration of affected joint (needle shaped crystals with negative birefringence on polarized light microscopy);
2000-50000 WBC (neutrophils);
During ACUTE stage: ESR and leukocytosis elevated;
Uric acid (95%) elevated. Not good for R/O;
Test result of protein, glucose of synovial fluid don’t help for Ddx;
xRay normal in acute gout, later erosion.
Arthrocentesis;
Granulomatosis with Polyangiitis (GPA, Wegener granulomatosis)
Guillain-Barré Syndrome (GBS)
Prickling, pins and needles sensations in your fingers, toes, ankles or wrists
Weakness in your legs that spreads to your upper body
Unsteady walking or inability to walk or climb stairs;
Difficulty with facial movements, including speaking, chewing or swallowing;
Double vision or inability to move eyes;
Severe pain that may feel achy, shooting or cramplike and may be worse at night;
Difficulty with bladder control or bowel function;
Difficulty breathing;
Low or high blood pressure;
Autonomic instability: BP goes up and down
Rapid heart rate;
Autonomic dysfunction in 70% - tachycardia;
Weakness of both legs, loss of DTPs;
Respiratory muscle weakness;
May include bilateral facial paralysis (R/O Lyme);
Facial muscle weakness and/or oropharyngeal weakness – 50%;
ASCENDING symmetric muscle weakness and loss of reflexes, progresses over 2-4 weeks;
No fever, no sensory abnormalities;
Clinical evaluation;
Cerebrospinal fluid (CSF) analysis;
NO CNS involvement!
Most specific test: nerve conduction study/electromyography (EMG): decrease in propagation of electrical impulses along nerves
Evidence of demyelination;
PFT: decrease in FVC – most important to prevent resp failure in ER;
CSF: albumin cytologic dissociation (elevated protein, normal WBC);
Fatigue and sluggishness;
Increased sensitivity to cold;
Increased sleepiness;
Constipation;
Muscle weakness;
Muscle aches, tenderness and stiffness;
Irregular or excessive menstrual bleeding;
Depression;
Problems with memory or concentration;
Dry skin;
Joint pain and stiffness;
Swelling of the thyroid (goiter);
A puffy face;
Brittle nails;
Hair loss;
Enlargement of the tongue;
Laryngoscopy (flexible, if vocal folds);
Biopsy, CT head and neck;
CXR, CT thorax in order to rule out metastases (LUNG, liver, bone, mediastinal lymph nodes);
Head trauma
History of head trauma
CT scan
Heatstroke
Throbbing headache;
Dizziness and light-headedness;
Lack of sweating despite the heat;
Red, hot, and dry skin;
Muscle weakness or cramps;
Nausea and vomiting;
Rapid heartbeat;
Rapid, shallow breathing;
Confusion, disorientation, or staggering;
Seizures;
Unconsciousness;
Hemochromatosis
Feeling very tired all the time (fatigue);
Weight loss;
Weakness;
Joint pain;
Erectile dysfunction;
Irregular periods or absent periods;
Tanning skin (jaundice);
Abdominal pain;
Best initial: ↑serum iron, ↓Iron binding capacity;
↑Ferritin - > 600;
↑ Iron;
↑transferrin saturation; if it normal think about liver disease
Mild ↑AST and ALT;
Best screening: transferrin saturation (serum iron/TIBC) >45%;
Most accurate: LV biopsy;
EKG: conduction defects;
ECOcard: dilated or restrictive cardiomyopathy;
Hemolytic anemia
Pallor, fatigue, dizziness, possible hypotension.
Possible jaundice, and the spleen may enlarge.
Hemolytic crisis (acute, severe hemolysis) is uncommon:
chills, fever, pain in the back and abdomen, prostration, shock. Hemoglobinuria causes red or reddish-brown urine.
All have:
normal MCV;
↑reticulocytes;
↑LDH, ↑indirect bilirubin (can’t go to urine it’s attached to albumin);
Peripheral smear – very helpful;
Sudden ↓Hct;
↑LDH, ↑indirect bilirubin (can’t go to urine it’s attached to albumin);
↑K – b/c K inside cells;
↓serum hemoglobin;
MCV is normal! We can’t change it quick!
Dark urine – Hemoglobin;
Hemolytic uremic syndrome (HUS)
History of gastroenteritis; history of bloody diarrhea; fever
Fever; irritability; can have oliguria or anuria
CBC; platelet count; KI function tests; peripheral blood smear; negative stool culture; PCR testing
Hemophilia
Delayed joint or muscle bleeding in male child;
Uncontrolled bleeding after minor trauma;
GI bleeding;
Urinary bleeding;
CNS bleeding;
Atrophy and joint distraction;
PT – normal;
↑PTT – prolong;
Platelets – normal;
Bleeding time - normal;
Most accurate test factor VIII and IX;
Hemorrhoids
extreme itching around the anus.
irritation and pain around the anus.
itchy or painful lump or swelling near your anus.
fecal leakage.
painful bowel movements.
blood on the tissue after having a bowel movement.
Hep B DNA PCR – best for determine viral replication activity
↑AST ↑ALT
↑ALP
↑bilirubin
Test:
IgM – acute
IgG – chronic
sAg(+), eAg(+) – acute, 90% pass Dz to the child
sAg(+), eAg(-) – acute, 10% pass Dz to the child
CoreAb(+), sAb(+) – chronic, cured
sAb(+) ONLY! - vaccine
Hepatitis C
Bleeding easily;
Bruising easily;
Fatigue;
Poor appetite;
Yellow discoloration of the skin and eyes (jaundice);
Dark-colored urine;
Itchy skin;
Fluid buildup in your abdomen (ascites);
Hep C DNA PCR – best for determine viral replication activity;
ALT rise and fall after 6 m;
Serologic testing;
Hepatitis D
May be asymptomatic. yellowing of the skin and eyes, which is called; Jaundice; Dark urine;
Abdominal pain; Vomiting; Loss of appetite; Joint pain; Fatigue.
PCR blood test
Hepatomegaly
Abdominal discomfort;
Yellowing of the skin or eyes (jaundice);
Fatigue and weakness;
Nausea;
Weight loss;
ALT/AST/bilirubin;
Ultrasound;
CT scan; MRI
Herniated disk
Low back pain radiated down the buttock to below the knee;
Pain/numbness of medial calf or foot;
(+) SLR;
Braggard's test;
Not of them can R/O hertiation;
MRT/CT with symptoms for 4 to 6 weeks;
Herniation
RLQ; LLQ; An incarcerated hernia is usually more painful; and the bulge cannot be reduced; A strangulated hernia causes steady; gradually increasing pain; typically with nausea and vomiting; cannot be reduced; and is tender when touched;
Palpable mass;
US or CT
Herpangina (coxsackievirus)
Painful throat; fever; malaise
Lymphadenopathy;
papulovesicular lesions on soft palate and pharynx, progressing to shallow ulcers. <5 mm in diameter.
Serology
Herpes simplex
Tiny blisters appear on the following:
Skin: Particularly around the mouth or on the genitals
Mucous membranes: Including those lining the eyes, vagina, cervix, or inside of the mouth.
The skin around the blisters is often red.
Viral culture;
Serology AB (blood);
Tzanck smear, you need active lesion (good for rule in).
Normal breath sounds; vesicular rash along dermatome
Tzank smear
Herpetic keratitis
Unilateral or bilateral; Eye is red, swollen, and painful; photophobia
Ciliary flush; discharge;
visual acuity decreased
Fluorescein stain confirms dendritic lesions
Hiatus Hernia
Heartburn;
Regurgitation of food or liquids into the mouth;
Backflow of stomach acid into the esophagus (acid reflux);
Difficulty swallowing;
Chest or abdominal pain;
Feeling full soon after you eat;
Shortness of breath;
Vomiting of blood or passing of black stools;
Barium swallow;
Sometimes upper endoscopy;
Hidradenitis Suppurativa
Hip Dislocations
Hirschsprung disease
Failure or delayed passage of meconium, No meconium (same with cystic fibrosis)
Vomiting, intestinal obstipation;
Failure to pass stool
“blast sign” – excessive stool during rectal exam
Best initial diagnostic test: AXR
Best diagnostic test: biopsy
Barium enema: proximal dilation of megacolon with distal narrowing.
Histoplasmosis
HIV
Acute phase:
Fever; Myalgias; Fatigue; Headache; Sore throat; Rash; Cough (rare); Lymphadenopathy; 2-4 weeks; No symptoms for few years
Late phase:
Opportunistic infection; Weight loss; Night sweats; Neurological changes; Increased risk of infection
HIV antibody and viral load;
CD4 count
CD4+cells:
Macrophages;
Dendritic cells;
CD4+Tlymphocytes;
First test: ELISA (99% sensitive, ab);
Western blot (specific)
WB will come back positive in neonates;
HIV enteropathy
Insidious onset; recurrent large amount of non bloody diarrhea; mild to moderate nausea/vomiting
HIV findings
HIV tests
Human Papillomavirus (HPV) Infection
Pain with large lesion;
Bleeding, discharge, itching with small lesion.
Pink or white warty lesions with papilliform surface;
may extend into anal canal
r/o syphilis;
Pap test. DNA test.
Human parvovirus B19 infection
Swollen and painful joints (more common in adults);
Acute; Inflammatory; Small joints; Symmetrical;
Fatigue;
Low-grade fever;
Headache;
Upset stomach;
Arthritis;
Gloves and socks syndrome (less common and usually in adults);
Fifth disease, also known as “Slapped Cheek” disease;
Clinical evaluation;
Antibody titers for parvovirus B19;
Huntington Disease
Early symptoms:
Trouble learning new things;
Trouble making decisions;
Memory lapses;
Mood swings;
Clumsiness;
Slow or abnormal eye movements;
Muscle problems (dystonia);
Trouble sleeping (insomnia);
Loss of energy and fatigue;
Dementia;
Chorea form movement disorder (dyskinesia);
Clinical diagnosis by: Movement, Memory, Mood;
Genetic test >99% accurate;
Head CT or MRI: caudate nucleus involvement;
Hydrocele
Discomfort from the heaviness of a swollen scrotum.
Pain generally increases with the size of the inflammation.
CT scan; MRI
Hyperemesis Gravidarum
Prolonged and severe nausea and vomiting;
Dehydration;
Weight loss;
Low blood pressure (hypotension) when standing;
Hyperkalemia
Hypermagnesemia
Hypernatremia
May be asymptomatic;
Excessive thirst;
Fatigue;
Confusion;
Muscle twitching or spasms;
Serum sodium;
Hyperosmolar Hyperglycemic State (HHS, Hyperglycemia)
Confusion, hallucinations, drowsiness, syncope.
Dry mouth and extreme thirst that may eventually get better.
Frequent urination.
Fever.
Blurred vision or loss of vision.
High blood sugar level (over 600 mg/dL);
UA for glucose and ketones;
Hyperparathyroidism
Most asymptomatic;
Nausea/Vomiting/abdominal pain;
Hypercalcemia (chronic fatigue, constipation, anorexia, nausea and vomiting, poor concentration, confusion, and depression);
Initial test: PTH;
↑PTH, Ca, Urinary Ca;
ECG: Short QT interval;
↑BUN, ↑creatinine;
↑ALP;
DEXA – better test if suspect;
Preoperative imaging;
R/O: PUD;
Hyperphosphatemia
Hyperprolactinemia
Long or irregular cycles;
Amenorrhea;
Oligomenorrhea;
Infertility;
Production and discharge of breast milk;
Sexual side effects;
Hirsutism;
Pre-meno: hypogonadism -> infertility, oligo/amenorrhea
Post-meno: non;
Both: rare galactorrhea;
Bi-temporal hemianopia;
Male: low libido, low testosterone, rare galactorrhea, gynecomastia
Prolactin;
Thyroxine (T4);
Thyroid-stimulating hormone (TSH);
CT or MRI;
Hypertension
Usually asymptomatic;
Symptoms of end organ damage:
-coronary artery dz;
-cerebrovascular dz;
-CHF;
-visual disturbance;
-renal insufficiency;
-peripheral artery dz.
BP: >140/90
For DM: 130/80
Bruit renal artery
Glomerulonephritis: edema
Coarctation of aorta: upper extremity > lower extremity BP
First test: ECG
Second: UA (protein)
3ed: glucose in blood
4: cholesterol screening
Hypertensive crisis
Confusion;
Severe chest pain (27%);
Severe headache (22%), accompanied by confusion and blurred vision;
Nausea and vomiting;
Severe anxiety;
Shortness of breath (22%);
Seizures;
Unresponsiveness;
Blood pressure
ECG, urinalysis (RBC casts, proteinuria), blood urea nitrogen (BUN), creatinine;
if neurologic findings, head CT.
Lid lag;
Fine thing hair;
Tachycardia;
Palpitation;
Hyperreflexia;
Palmar erythema;
Pretibial myxedema (non pitting);
Thyroid bruit;
T4 high; T3 high; TSH low
Elevated radioactive iodine uptake test
TSH receptor AB
TSI antibody in serum – 95%
Free T4 – best marker for graves
Painless goiter
High uptake on thyroid scan
Hyperventilation syndrome
Dyspnea;
Chest pain;
Peripheral tetany (eg, stiffness of fingers or arms), tetanus b/c respiratory alkalosis causes both hypophosphatemia and hypocalcemia.
High Insulin and low;
Glucose;
Insulin from pharmacy: only high insulin;
Insulinoma: c-peptide and insulin are both high in patient with insulinoma -> CT or MRI -> surgery;
Hypokalemia
Muscle and HT weakness;
Palpitation;
Arrhythmias;
ECG (T-wave flattening, U-wave);
Hypomagnesemia
Hyponatremia
CNS symptoms;
Low glucocorticoid;
High TSH;
K is normal aldosterone normal;
Hypoparathyroidism
Tingling or burning in your fingertips, toes and lips;
Muscle aches or cramps in your legs, feet, stomach or face;
Twitching or spasms of your muscles, particularly around your mouth, but also in your hands, arms and throat;
Fatigue or weakness;
Painful menstrual periods;
Patchy hair loss;
Dry, coarse skin;
Brittle nails;
Depression or anxiety;
Paresthesia;
Dizziness or lightheadedness.
Nausea.
Fainting (syncope)
Dehydration and unusual thirst.
Dehydration can sometimes cause blood pressure to drop. However, dehydration does not always cause low blood pressure. ...
Lack of concentration.
Blurred vision.
Cold, clammy, pale skin.
Shorter than average height;
Shorter than average limbs;
Permanent teeth that develop later;
Puberty that starts later;
Slowed mental development;
heart rate that is slower than average
Hair may be brittle;
Facial features may be puffy;
Tiredness;
Constipation;
Dry skin;
Hypovolemic shock
Cold or clammy skin;
Pale skin;
Rapid, shallow breathing;
Rapid heart rate;
Little or no urine output;
Confusion;
Weakness;
Lightheadedness;
Loss of consciousness;
Temperature, pulse, breathing, and blood pressure;
Color and feel of your skin;
Weak pulse;
Blue lips and fingernails;
Pregnancy test! (r/o ectopic pregnancy);
CBC and platelet count;
Basic metabolic panel (chem-7);
Liver biochemical tests;
PT/PTT;
Upright chest x-ray;
Most important if there is abdominal tenderness;
RLQ; LLQ; Generalized pain; Symptoms vary but often include lower abdominal pain; bloating; gas; and constipation or diarrhea; NO WEIGH LOSS; NO BLOOD IN STOOL; No malnutrition; no anorexia; no progressively worsening bleeding; Constipation cramping with improved or relived with defecation; Connection with stress;
Alternating diarrhea/n AB; Less at night;
ROME III :
Recurrent AB pain/discomfort at least 3 days per month in the last 3 months associated with at least at least 2 of the following:
Relief with defecation;
Onset associated with change in frequency and in form of stool;
Urinary frequency and urgency;
Fibromyalgia symptoms;
No specific tests, diagnosis of exclusion
Anemia; Increased inflammatory markers;
Calprotectin stool test (IBS>50, IBD>150) - not diagnostic;
Idiopathic guttate hypomelanosis
Ig A Deficiency
Not specific symptoms:
Diarrhea;
Sinusitis;
Bronchitis;
Eye infection;
Ear infection;
Pneumonia;
Autoimmune disorders;
Skin infection;
Generalized abdominal pain; bleeding;
Skin: purpura – from the buttocks down
Joint: arthralgia (low extremities, large joints)
Renal: hematuria
Leukoclastic reaction: painless, palpable purpura of buttocks and legs;
Clinical diagnosis; Palpable rush;
Clinical diagnosis.
UA – microscopic hematuria (not specific), proteinuria
PT, PTT;
PLATELETS ARE NORNAL;
Biopsy – most accurate test but never done (leukocytoclastic vasculitis);
Impetigo
Infectious Esophageal Disorders
Odynophagia;
Chest pain;
Swallowing problem or pain with swallowing;
Gradient onset;
Large ulcerations -> CMV;
Small ulcerations -> HSV;
Endoscopy, with cytology or biopsy
No initial tests (90% are fungal) but if no result -> endoscopy;
Inflammatory breast cancer
Swelling (edema) of the skin of the breast.
Redness involving more than one-third of the breast.
Pitting or thickening of the skin of the breast so that it may look and feel like an orange peel.
A retracted or inverted nipple.
Influenza
Fever;
Aching muscles;
Chills and sweats;
Headache;
Dry, persistent cough;
Shortness of breath (SOB);
Tiredness and weakness;
Runny or stuffy nose;
Sore throat;
Eye pain;
Vomiting and diarrhea (children);
Joint pain;
Lymphadenopathy;
Clinical evaluation;
Rapid diagnostic testing;
Insect bite
Insulin Resistance
Extreme thirst or hunger;
Feeling hungry even after a meal;
Increased or frequent urination;
Tingling sensations in hands or feet;
Feeling more tired than usual;
Frequent infections;
Evidence of high blood sugar levels in blood work;
Evidence of high blood sugar levels in blood work;
Interstitial Cystitis
Pain in your pelvis or between the vagina and anus in women;
Pain between the scrotum and anus in men (perineum);
Chronic pelvic pain;
A persistent, urgent need to urinate;
Frequent urination, often of small amounts, throughout the day and night (up to 60 times a day);
Clinical evaluation;
Cystoscopy with possible biopsy;
Interstitial Lungs Disease
Dyspnea; Non productive cough;
Fatigue; History of RA, systemic sclerosis, SLE;
Progressive exercise intolerance;
Dyspnea;
Dry crackles;
JVD;
Tachypnea;
Possible digital clubbing;
UA;
ANA;
RF;
xRay: Ground glass;
CT better compare with x-ray;;
Biopsy - gold standard, but not required for every pt:
Fibrosis – shows stage of the dz;
Spirometry - how bad is situation?
xRay and CT – best initial tests (honeycomp);
PFT:
Restrictive lung dz
↓TLC
↓FRC
↓RV
Decreased TLC, VC and normal or increased FEV1/FVC ratio;
Lavage: Neutrophils;
Loss of parenchymal architecture;
Intestinal Obstruction
Generalized pain;
Umbilical area of epigastrium;
Vomiting (75%) occurs early with small intestinal obstruction and late with large bowel obstruction; Nausea;
Obstipation (constipation-95%) or diarrhea;
Abdominal distention (89%);
Hyperactive; high pitched bowel sounds; fecal mass can be palpated; abdominal distention; empty rectum on digital examination
Imaging: dilated colon before abstraction on x-Ray (diagnostic test);
CT with oral contrast;
Barium enema (water soluble);
Electrolytes (K and Mg);
BUN; CBC with dif;
Intraductal papilloma
Intussusception
Generalized pain; Sudden onset; Episodes of stomach pain and vomiting that start suddenly and come and go several times per hour; and then later; stools may become bloody; Fever;
Currant jelly stool;
An air enema can confirm the diagnosis and also treat the condition;
Iodine Deficiency
Iodine Toxicity
Iron toxicity
Generalized abdominal pain after iron overdose;
Iron levels and other blood tests; Sometimes x-rays
Jarisch Herxheimer Reaction
Joint dislocation
History of trauma
x-ray
Joint injury
History of trauma
x-ray
Juvenile rheumatoid arthritis
Young patient with high spiking fever (>104F) without clear etiology and associated with rash
Splenomegaly, pericardial effusion, mild joint symptoms;
Morning stiffness;
Easy fatigability;
Joint pain later in day;
Rash: salmon in color and appears on chest and abdomen; SKIN RASH; Joints warm; Pain in motion; Decreased ROM;
Clinical diagnosis
Age < 16 y/o
Arthritis >=2
At least 6 weeks
No clear diagnostic tests:
Anemia, leukocytosis, ANA normal,
Ferritin elevated
Kallmann syndrome (KS)
↓ FSH, LH;
↓ GnRH;
Anosmia – no smell;
Kaposi's Sarcoma
Kawasaki disease
1st phase:
A fever that is often is higher than 39 C and lasts more than three days;
Extremely red eyes without a thick discharge;
A rash on the main part of the body and in the genital area;
Red, dry, cracked lips and an extremely red, swollen tongue;
Swollen, red skin on the palms of the hands and the soles of the feet;
Swollen lymph nodes in the neck and perhaps elsewhere
Irritability;
2nd phase:
Peeling of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets;
Joint pain;
Diarrhea;
Vomiting;
Abdominal pain;
Clinical criteria;
ECG and echocardiography;
Keloid
Keratoacanthoma
Keratoconjunctivitis sicca (Dry eye)
Patients report itching; burning; a gritty, pulling, or foreign body sensation; or photosensitivity.
A sharp stabbing pain, eye strain or fatigue, and blurred vision may also occur.
Some patients note a flood of tears after severe irritation.
Typically, symptoms fluctuate in intensity and are intermittent.
Schirmer test and tear breakup test (TBUT)
Labyrinthitis
Sudden onset or vertigo; lasts hours to days;
Nausea, Vomiting, Nystagmus;
Hearing loss; Tinnitus;
Usually 2 weeks;
Can currently be ill; lateral nystagmus; hearing loss; rarely tinnitus; nausea and vomiting can be present
Positional maneuvers, positive VOR test, audiometry
MRI if >60y/o with focal neurological signs
Lactose Intolerance (Carbohydrate Malabsorption)
Intermittent symptoms; Very common;
Generalized abdominal pain (100%);
No weight loss; Normal vitamins level;
Flatulence (100%); Bloating;
Watery Diarrhea (70%); Constipation (30%);
EVER BLOOD OR FEVER;
Nausea (78%); Vomiting (78%);
Rumbling or gurgling sounds in the bowel - borborygmi (100%); and an urgent need to have a bowel movement between 30 minutes and 2 hours after eating a meal containing lactose.
Usually chronic, the symptoms may be acute or subacute in the setting of recent infection or dietary changes.
Best initial: stool osmolarity test (>5 days diarrhea);
Most accurate: cessation of symptoms after diet change;
Lactose tolerance test;
Laryngeal Cancer
Lump or swelling in your neck.
Long-lasting cough.
Persistent sore throat or earache.
in severe cases, difficulty breathing.
Hoarseness (worsens over time);
Dysphagia
Ear pain;
Hemoptysis;
laryngoscopy with biopsy
Laryngeal papilloma
Hoarseness
Laryngoscopy;
Biopsy (R/O cancer);
Laryngitis
Weakened voice;
Loss of voice
Hoarseness, Dry throat;
Dry cough;
Constant tickling or minor throat irritation.
Sore throat;
Swallowing problems;
Clinical evaluation (r/o cancer: hoarseness)
Lead Poisoning
Joint and muscle pain;
Difficulties with memory or concentration;
Headache;
Abdominal pain;
Mood disorders;
Reduced sperm count and abnormal sperm;
Miscarriage, stillbirth or premature birth in pregnant women;
High blood pressure;
Legg-Calvé-Perthes Disease
Limping;
Pain or stiffness in the hip, groin, thigh or knee;
Limited range of motion of the hip joint;
Pain that worsens with activity and improves with rest;
Legionella Infections (Legionnaires' Disease)
Develops two to 10 days after exposure to legionella bacteria:
Headache;
Muscle aches;
Fever that may be 40 C or higher;
Slow onset of classic symptoms;
By the second or third day:
Cough, which might bring up mucus and sometimes blood;
Shortness of breath;
Chest pain;
Nausea;
Vomiting;
Diarrhea;
Confusion or other mental changes;
Pontiac fever, mild form: fever, chills, headache, muscle aches, doesn't infect your lungs, symptoms usually clear within two to five days.
Chest x-ray;
Urine test;
Lemierre syndrome
Swelling in your neck around your lymph nodes;
Abnormal headaches;
Pains that feel like they’re shooting down your neck;
Fever;
Feeling stiff, weak, or exhausted;
Feeling more sensitive to light than usual (known as photophobia)
trouble breathing;
Trouble swallowing;
Inflammation of your tonsils (known as tonsillitis), two lymph nodes in your throat that protect your body against infection;
Coughing up blood or bloody mucus;
Losing your appetite or feeling nauseous;
Throwing up;
Lentigo maligna
Lesch Nyhan Syndrome
Orange colored deposits (“orange sand”) in the diapers of infants (3 m);
Irritability
Nervous system impairment:
4 to 6 months—lack of muscle tone and inability to lift the head;
6 months—unusual arching of the back;
9 months—inability to crawl or stand;
12 months—inability to walk;
12+ months—spasms of the limbs and facial muscles;
Delayed development;
Behavioral problems occur in all cases and self injury in about 85%;
Self-injurious behavior may include repeated biting of the lips, fingers, and/or hands, and repetitive banging of the head against hard objects. Some children may scratch their face repeatedly.
Pain and swelling of joints may become progressively more frequent once they begin;
Difficulty swallowing and vomiting;
Muscle spasm;
Blood in the urine from kidney stones;
Hematuria;
Learning disabilities;
Aggression;
Manipulative behavior;
In older children: tophi in joints and in the ears (visible “bulges”);
Dystoma: tensing of muscles;
Spastic Cerebral Palsy: contraction of muscles;
Uric acid overproduction - not specific;
Reduced levels of the HPRT enzyme - diagnostic.
Leukemia
Bone pain
Frequent infections
Anemia
Joint pain
Fatigue
Infection
Bleeding
Pancytopenia;
Best initial test: blood smear (blasts);
Most accurate test (flow cytometry);
Lewy body dementia (LBD)
Changes in thinking and reasoning;
Confusion;
Slowness, gait imbalance;
Well-formed visual hallucinations;
Delusions;
Trouble interpreting visual information;
Lichen planopilaris
Lipoma
Situated just under the skin, commonly occur in the neck, shoulders, back, abdomen, arms and thighs.
Soft and doughy to the touch, move easily with slight finger pressure.
Sometimes painful (if they grow and press on nearby nerves)
(biopsy) for lab examination.
MRI or CT scan, if the lipoma is large
↑Bilirubin; ↑ALP
CT of chest/ab/pelvic;
Colonoscopy;
↑AST, ALT;
↑alpha-fetoprotein (AFP) – marker of hepatocellular carcinoma (screening test);
Abdominal US (screening test);
Biopsy to confirm diagnosis – if no other way around!
Lung abscess
Sputum with foul smell;
Weigh loss:
Long duration of symptoms;
Best initial test: xRay: cavity with air/fluid level;
Chest CT – most accurate;
LUNG BIOPSY for etiology;
Sputum culture – WRONG!
Lung cancer
Chest pain; SOB;
Cough (most common symptom); hemoptysis; history of cigarette smoking; history of pneumonia, PE, wheeze;
Pleuritic chest pain;
Fatigue; Weigh loss; Fever;
Frequent pulmonary infections
Hoarseness – metastatic cancer already; Horner syndrome (Miosis, Ptosis
Anhidrosis);
Normal examination or diminished breath sounds over tumor and dull percussion sound over tumor; Lung Effusion
Chest xRay;
Spiral CT of chest (screening test);
Upper ab ST;
Bronchoscopy with biopsy;
CXR or CT: pulmonary nodule;
Follow by bronchoscopy with FNA;
Sputum cytology; Effusion drainage and cytology;
Is cancer respectable?
CT, MRI, PET scan – elevate glucose uptake check;
Pulmonary function test before the surgery;
Lyme disease
1 stage (1 m)
Target lesion
+/- fatigue, HA, myalgia , arthralgia
Early disseminated dz (weeks to months)
Meningitis
Bell’s palsy
Radiculopathy
Peripheral neuropathy
Carditis
Heart block
Late Lyme:
Arthritis
Subacute encephalitis
ELISA;
WB;
Lymphedema
Swelling of part or all of your arm or leg, including fingers or toes;
A feeling of heaviness or tightness;
Restricted ROM;
Aching or discomfort;
Recurring infections;
Hardening and thickening of the skin (fibrosis).
Observation
MRT
Lymphogranuloma Venereum (LGV)
Lymphoma
Painless swelling of lymph nodes in your neck, armpits or groin;
Persistent fatigue;
Fever;
Night sweats;
Shortness of breath;
Unexplained weight loss;
Itchy skin;
Normal CBC;
For stage: CT, MRI;
Best initial test: excisional biopsy of lymph nodes;
Bone marrow;
Hopkin's Lymphoma: Reed-Sternberg cells in pathology;
Non-Hopkin's Lymphoma: NO Reed-Sternberg cells
Macrophage activation syndrome
Macular degeneration
Bilateral central vision loss;
Peripheral vision remine intact;
Fluorescein dye retinal angiography
Malaria
Mosquito (P.falciparum) transmission
Fever (periodic 1 in 3 days)
Headache
Chills, Myalgia
AB pain,
Vomiting/Diarrhea
Diaphoresis
CNS problems
Renal insufficiency
PE
P. malaria – fever 72 h cycle
P.ovale and P.vivax – fever 48 h cycle
P.flaciparum – irregular fever + neurological symptoms + LU and KI affected
Splenomegaly
PCR
Blood smear (ring inside cell)
Anemia
Male Hypogonadism
Malignant melanoma
A is for asymmetry: Does the mark look different on each half?
B is for border: Are the edges jagged or irregular?
C is for color: Is your lesion uneven in color with specks of black, brown and tan?
D is for diameter: Is your lesion getting larger?
E is for evolving or elevation: Has your lesion changed in size, shape or texture over the past few weeks or months?
Biopsy;
Mallory-Weiss Syndrome
Vomit that is bright red or that looks like coffee grounds.
Black or tar-like stools.
Stools with blood present.
Weakness, dizziness, faintness.
Shortness of breath.
Diarrhea.
Paleness.
Abdominal or chest pain.
Upper endoscopy
Mammary duct ectasia
Redness or tenderness around your nipple and areola;
An inverted nipple (a nipple that turns inward);
Unusual nipple discharge;
Pain in the affected nipple (this symptom isn’t as common as the other symptoms);
Mammogram; US;
Manganese Deficiency
Manganese Toxicity
Mast Cell Activation Syndrome (MCAS)
Mastitis
Infection in the milk ducts that occurs during breastfeeding; Fever; Myalgias; Malaise
PE: redness, warmth, swelling
US to r/o abscess
Mastoiditis
Erythema;
Edema;
Tenderness behind the ear;
External ear displacement
CT of mastoid process
Measles (Rubeola)
Meckel's diverticulitis
RLQ abdominal pain and tenderness typically localized below or adjacent to the umbilicus; it is often accompanied by vomiting and is similar to that of appendicitis
Based on symptoms; For bleeding: Radionuclide scan; wireless capsule endoscopy; and enteroscopy; For pain: CT
Begins hours to months after starting ACEI; Cough is the angiotensin converting enzyme (ACE) inhibitors, 75% of cases of drug-induced cough;
BB;
NSAIDs;
ASA;
Worsening laryngopharyngeal reflux (including bisphosphonates, calcium antagonists, and systemic steroids).
normal exam
Medication induced dementia
High risk:
Anticholinergics (e.g., antihistamines, muscle relaxants, antipsychotics);
Benzodiazepines;
Dopamine agonists;
Meperidine (Demerol);
Moderate to low risk:
Antibiotics (e.g., quinolones, antimalarials, isoniazid, linezolid, macrolides);
Anticonvulsants;
Antidizziness agents;
Antiemetics;
Antihypertensives (e.g., beta blockers, clonidine);
Antivirals (e.g., acyclovir, interferon);
Corticosteroids;
Low-potency antihistamines (e.g., histamine H2 blockers, urinary and gastrointestinal antispasmodics);
Metoclopramide (Reglan);
Narcotics other than meperidine;
NSAIDs;
Sedatives/hypnotics;
Tricyclic antidepressants;
Lithium;
Bismuth: An elevated serum bismuth level of 242 μg/L (normal is 5 μg/L) established bismuth toxicity as the cause of the dementia;
Rarely, drug-induced esophagitis can occur due to an anatomical factor or underlying esophageal disorder, for example, undiagnosed vascular ring, scleroderma, etc.
- Antibiotics: One of the most common causes of drug-induced esophagitis. These include tetracyclines, especially doxycycline. Other antibiotics that can cause esophagitis include clindamycin, amoxicillin, metronidazole, ciprofloxacin, rifaximin, etc.
- Non-steroidal anti-inflammatory drugs (NSAIDs): aspirin and aceclofenac can lead to esophageal mucosal injury.
- Bisphosphonates: alendronate, ibandronate. Risedronate seems to be slightly safer than alendronate in terms of gastrointestinal side effects[5].
- Ascorbic acid;
- Potassium chloride and ferrous sulfate;
- Acetaminophen;
- Warfarin;
- Chemotherapeutic regimens: dactinomycin, daunorubicin, bleomycin, methotrexate, 5-fluorouracil, cytarabine, and vincristine cause esophagitis perhaps due to oropharyngeal mucositis;
- Thoracic irradiation • Other medications: anti-hypertensives, quinidine, glimepiride, tiropramide, pinaverium bromide, esomeprazole, etc.
Drugs that cause sodium and fluid retention:
Androgens;
Corticosteroids;
Drugs with high sodium content;
Licorice-containing products;
Minoxidil;
NSAIDs including selective COX-2 inhibitors and high-dose salicylates (ketorolack, indomethacin, piroxicam, diclofenac, ibuprofen, naproxen);
Thiazolidinediones (pioglitazone, rosiglitazone);
Negative inotropes:
Antiarrhythmic agents except amiodarone and dofetilide;
Beta-blockers;
Calcium channel blockers:
- diltiazem, nifedipine, verapamil;
- but not amlodipine or felodipine;
Itraconazole;
Some anesthesia medications, e.g. ketamine, propofol;
Cardiotoxic drugs:
5-fluorouracil;
Alcohol;
Alkylating agents (cyclophosphamide, ifosfamide);
Anthracyclines (doxorubicin, epirubicin, mitoxantrone);
Bevacizumab;
Clozapine;
Cocaine;
Trastuzumab;
Tyrosine kinase inhibitors (imatinib, sunitinib);
Medication induced hemolytic anemia
Cephalosporins (a class of antibiotics), most common cause
Dapsone;
Levodopa;
Levofloxacin;
Methyldopa;
Nitrofurantoin;
Nonsteroidal anti-inflammatory drugs (NSAIDs);
Penicillin and its derivatives;
Phenazopyridine (pyridium);
Quinidine;
Coomb’s positive
Medication induced hypercalcemia
Thiazide diuretics (usually mild)*;
Lithium;
Milk-alkali syndrome (from calcium antacids);
Vitamin A intoxication (including analogs used to treat acne);
Vitamin D hypervitaminoses;
Hormones (androgens, antiestrogens, estrogens, progestins);
Ingestion of >3g elemental calcium per day;
Parenteral nutrition;
Medication induced hyperkalemia
ACE inhibitors;
Aliskiren;
Aminocaproic acid;
Angiotensin II receptor blockers (ARBs);
Beta blockers;
Cyclosporine;
Digoxin overdose;
Dropirenone;
Heparin;
K supplements;
K sparing diuretics;
Ketoconazole;
NSAIDS;
Penicillin G potassium;
Pentamidne;
Succinylcholine;
Tacrolimus;
Trimethoprim, TMP/SMX (high dose or in susceptible patients ie elderly, renal failure);
some herbal and nutritional supplements (eg alfalfa, nettle) especially in the presence of renal failure;
Medication induced hyperlipidemia
β-blockers without intrinsic sympathomimetic or α-blocking activity;
Corticosteroids;
Highly active antiretroviral therapy (HAART);
Hormone replacement therapy (HRT);
Oral contraceptives;
Thiazide diuretics;
Sudden onset; lasts hours, recurrent;
Tinnitus and fullness in ears;
Acute vertigo lasting hours;
Nausea/Vomiting;
Decreased hearing (low frequency hearing loss during attack)
Lateral or rotary nystagmus;
Fluctuating hearing loss;
Low tones; sensorineural;
Positional maneuvers;
Positive VOR test;
Audiometry;
ENG;
R/O syphilis;
Meningiomas
May be asymptomatic;
Headaches;
Seizures;
Blurred vision;
Weakness in arms or legs;
Numbness;
Speech problems;
Gradual onset;
MRI;
Meningitis
Headache;
Neck stiffness and pain;
Photophobia;
Malaise;
Vomiting;
Confusion;
Fever;
Change in mental status
Seizures
Decreased consciousness
Petechiae, purpura (Nassirian m.)
(+)Brudzinski’s Sign (neck flexion)
(+)Kernig Sign
Both can’t R/O meningitis!
↑WBC with left shift 1000 neutrophils;
Lumbar puncture;
CSF culture – diagnostic;
CSF:
Bacterial;
↑WBC(neutrophils);
↑CSF pressure;
↓glucose;
↑protein;
Serum Protein: sensitive, best initial;
Low glucose – not sensitive;
Blood Culture – most specific and accurate;
Viral:
↑some WBC(lymphocytes);
↑CSF pressure;
Normal glucose;
Normal protein;
Fungal or TB:
↑WBC(lymphocytes);
↑CSF pressure;
↓glucose;
↑protein;
If seizures or focal neurological defects or papilledema – order CT before CSF;
Menopause
Irregular periods;
Vaginal dryness;
Hot flashes;
Chills;
Night sweats;
Sleep problems;
Mood changes;
Weight gain and slowed metabolism;
Abdominal obesity.
High blood pressure of 130/80 mm Hg (millimeters of mercury) or higher.
Impaired fasting blood glucose.
High triglyceride levels of more than 150 mg/dL.
Low HDL (good) cholesterol.
Abdominal obesity;
High BP;
High triglycerides;
Low HDL;
High fasting serum glucose (100 mg/dL ) or 2h past oral glucose >= 140mg/dL;
Microscopic polyangiitis (MPA)
Migraine headache
Headache history;
Can last days;
Unilateral - 50%;
Pulsating;
Nausea/vomiting;
Photo/phonophobia;
With “aura” (classical): visual disturbance, flashes of light, blind spots and other vision changes or tingling in your hand or face.
Can have symptoms of vertebrobasilar vascular abnormalities;
Rare cases: aphasia, numbness, dysarthria, weakness;
none
Milia
Mitral regurgitation
Chest pain on exertion;
Fatigue;
Palpitation;
Dizziness;
Syncope;
Systolic murmur;
Pansystolic (holosystolic) murmur, radiates to axilla and possibly back; often loud murmur heard best at apex in left lateral position and decreased with inspiration
Handgrip ↑ afterload - MR
Squatting and leg raising increase it – it increases venous return, it ↑murmur
Chest xRay, ECG; echocardiography
Mitral stenosis
Shortness of breath, especially with activity or when you lie down;
Fatigue, especially during increased activity;
Swollen feet or legs;
Palpitations;
Chest discomfort or chest pain;
Coughing up blood;
Dizziness or fainting;
Heart murmur;
Fluid buildup in the lungs;
Arrhythmias;
Diastolic murmur;
Opening snap in early diastole, radiates in axilla;
Squatting and leg raising increase it – it increases venous return, it ↑murmur;
Echocardiography;
x-ray shows left arterial hypertrophy;
Mitral valve prolapse
Atypical chest pain; NOT ON EXERTION; varies in location and intensity; palpitation; anxiety; nonexceptional pain of short duration; Panic attack; Syncope
Arrhythmia; possible midsystolic click heard over apex; heard best while patient is in sitting or squatting position;
Valsalva and standing worsen;
Squatting and handgrip improve;
ECG; echocardiogram
Molluscum contagiosum
Are generally painless but can itch.
Are small (2 to 5 millimeters in diameter)
Have a dimple in the center.
Are firm, dome-shaped, and flesh-colored at first.
Become softer with time.
May turn red and drain over time.
Have a central core of white, waxy material.
Clinical evaluation
Molybdenum Deficiency
Molybdenum Toxicity
Mononucleosis (Epstain-Barr virus, EBV)
90-95% adults are seropositive for EBV
Muscle fatigue
Sore throat
Malaise
Fever
Tonsils exudate
Positive heterophil AB (Monospot test);
Positive EBV serology;
Elevated Liver enzymes;
R/O HIV if EBV tests are negative;
Multiple myeloma
Bone pain, especially in your spine or chest.
Nausea.
Constipation.
Loss of appetite.
Mental fogginess or confusion.
Fatigue.
Frequent infections.
Weight loss.
Bone pain from pathologic fracture;
Radicular pain – from compression;
Anemia; Pallor
From high Ca: polyuria, polydipsia, altered mental status;
First test: x-Ray (lytic lesion) back or ribs;
Makes IgG and IgA;
M spike of electrophoresis (see monoclonal Igg spike);
Anemia ↓WBC;
Renal insufficiency;
OAF -> hypercalcemia (mild the bone);
Most accurate test: plasma cells on bone marrow biopsy >10%;
Rouleaux – in blood smear;
Decrease anion gap;
Multiple sclerosis (MS)
Onset is often in third or fourth decade of life;
Multiple neurological deficits of CNS;
Affects any aspect of CNS;
Most common presentation:
Blurry vision;
Visual disturbance from optic neuritis;
Inability to adduct one eye and another eye has nystagmus;
Fatigue;
Spasticity and hyperreflexia;
Cerebellar deficits;
Stiffness and weakness of muscles,
Difficulty with cognition;
But almost NO dementia;
Sex dysfunction;
Urinary symptoms;
Optic neuritis: eye pain that worsens with eye movement;
Central vision loss;
Brain fog;
Can have no other findings can have other neurological symptoms;
Afferent pupillary defect:
No constriction with direct light, constriction of both pupils with indirect light;
Internuclear ophthalmoplegia;
Eye on the side of the lesion can’t adduct;
Contralateral eye has nystagmus;
Lhermitte's sign (pronounced Ler-meets) is a sudden sensation resembling an electric shock that passes down the back of your neck and into your spine and may then radiate out into your arms and legs. It is usually triggered by bending your head forward towards your chest.
Problem with coordination;
Tremor;
Tightness around ribs;
Ribs contraction;
Most accurate and best initial test: MRI;
MRI shows new, multiple white matter hypodense lesion: progressive multifocal leukoencephalopathy (PML);
Initial diagnostic test: CSF;
Mild elevation in protein;
<50-100 WBC:
Oligoclonal bands found in 85% of MS;
CSF:
↑Protein;
↑mildly increased WBC;
Oligoclonal bands;
R/O: Vitamin B12 deficiency may mimic MS;
Mumps (Epidemic Parotitis)
Muscle strain
Pain or tenderness.
Redness or bruising.
Limited motion.
Muscle spasms.
Swelling.
Muscle weakness.
Myasthenia Gravis
Double vision, difficulty with chewing;
Weakness of limb muscles worse at end of the day;
Ptosis, diplopia (50%);
Worse with exercises!
Dysarthria (difficulty to speak);
Dysphagia (difficulty swallowing);
DTR – normal;
Sensory – normal;
Motor weakness;
Normal pupillary responses!
Ach receptors Abs (80-90% sensitivity);
Most accurate test: electromyography (EMG)– show decreased strength with repetitive stimulation;
Chest xRay, CT, MRI (thymoma or thymic hyperplasia);
Mycoplasma pneumonia
Less severe symptoms, don’t appear ill
Sore throat; Feeling tired; Fever; Slowly worsening cough that can last for weeks or months; Headache; Cough that may produce mucus; Fever and chills; Shortness of breath; Chest pain; Feeling tired;
Children younger than 5 years old: Sneezing; Stuffy or runny nose; Sore throat; Watery eyes; Wheezing; Vomiting; Diarrhea
Diffuse bilateral patchy infiltrative (xRay)
Positive cold-agglutinin test (IgM) – 50-70% of patients
Serology
Myocardial infarction
LUQ RUQ pain; Sudden onset; Chest pressure or ache; SOB; fatigue; can be nausea; vomiting; Pain or discomfort in areas of the body; including the arms; left shoulder; back; neck; jaw; or stomach; Syncope;
Transient MR murmur; hypotension; diaphoresis; pulmonary edema; or rales;
Cardiac markers: troponin I and troponin T; CK-MB (creatinine kinase; myocardial band subunit);
Troponin - after 7 h; up to 2 weeks;
CK-MB - after 4h BEGIN to elevate; stay for 12 h;
ECG: ST segment elevation;
Best test: Angiography
Myocarditis
Chest pain; history of fever; SOB
Heart murmur; friction rub; fever
ECG; chest xRay; echocardiogram
Myxedema Coma
Weakness or lethargy.
Confusion or non-responsiveness.
Feeling cold.
Low body temperature.
Swelling of the body, especially the face, tongue, and lower legs.
Difficulty breathing.
Myxoid cyst
Narcolepsy
Excessive daytime sleepiness;
Sudden loss of muscle tone;
Sleep paralysis;
Hallucinations;
Sleep study;
Nasal polyp
A runny nose;
Persistent stuffiness;
Postnasal drip;
Decreased or absent sense of smell;
Loss of sense of taste;
Facial pain or headache;
Pain in your upper teeth;
A sense of pressure over your forehead and face;
Snoring;
Frequent nosebleeds;
Nasal endoscopy; CT scan
Necrotizing enterocolitis
Premature or low-birth-weight infants with feeding intolerance
Vomiting; abdominal distension; lethargy; loose stools with blood and mucous
Severe unilateral and colicky flank pain (renal colic);
Hematuria;
Nausea, vomiting;
Dysuria, frequency, and urgency;
Urine dipstick and urinalysis: gross or microscopic hematuria;
Urine microscopy: to detect crystals;
Abdominopelvic CT: Nonenhanced CT scan is the gold standard.
Ultrasound: method of choice for patients in whom radiation exposure should be minimized (e.g., pregnant patients, children, recurrent stone formers)
Nephrotic syndrome
Severe swelling (edema), particularly around your eyes and in your ankles and feet.
Weight gain due to fluid retention.
Fatigue.
Loss of appetite.
Dyspnea (pleural effusion or laryngeal edema);
Arthralgia (hydrarthrosis);
Abdominal pain (ascites or, in children, mesenteric edema);
Urine random (spot) protein/creatinine ratio ≥ 3 or proteinuria ≥ 3 g/24 hours;
CBC
Kidney and liver function, serum albumin;
PT/INR, PTT;
Fasting glucose, HbA1C;
Antinuclear antibody;
Electrolytes;
Foamy urine, a result of excess protein in your urine.
Neuroleptic Malignant Syndrome (Drug-Induced Movement Disorder;
Neuroleptic-Induced Acute Dystonia)
Visual symptoms, headache; Dementia;
Abnormal walk (gait), or unable to walk;
Numbness in the toes, feet, or legs;
Problems with thinking, such as confusion or poor concentration;
Mental problems, such as depression or irritability;
Seizures, or stiff neck;
Loss of bladder control (incontinence);
Tremors, or weakness;
normal
< 45-55 y/o – empirical PPI, scope only if problem persistent
>45-55 y/o – PPI and EGD to r/o cancer
Nonalcoholic Fatty Liver Disease (NAFLD)
Fatigue;
Abdominal pain or discomfort RUQ;
Abdominal swelling (ascites);
Enlarged blood vessels just beneath the skin's surface;
Enlarged spleen;
Red palms;
Jaundice;
Chronically elevated LFT;
Diagnosis: US;
Most accurate: biopsy – not for everyone;
Nonallergic Rhinitis
Runny nose; sneezing; congestion; postnasal drip; cough; and a low-grade fever.
Allergy testing
Nongonococcal urethritis
Unprotected sexual activity 8-21 days before the onset;
meatal itching or irritation;
scant mucoid-like discharge, if present;
Dysuria;
Thin mucoid discharge may be absent or minimal with penile milking or stripping;
Gram stain; culture; urine DNA testing for Chlamydia
Normal grief
OCD
Open angle glaucoma
Usually asymptomatic in the beginning ;
Usually bilateral;
Gradual loss of peripheral vision;
Red eye hard to palpation;
Walking into dark room precipitates pain because of pupillary dilation;
Increased cup-to-disc ratio on phonoscope exam (cup ½ of the disc);
Pupil doesn’t react to light because it’s stuck;
Tonometry (measure intraocular pressure);
Elevated intraocular pressure;
Cup to disc ratio >0.3;
Opioid overdose
Unconsciousness, or inability to wake up;
Limp body;
Falling asleep, extreme drowsiness;
Choking, snoring or gurgling sounds;
Slow or no heart beat;
Pale, blue, cold and/or clammy skin;
Slow, shallow, irregular or no breathing;
Optic neuritis
Dill pain worsened by eye movement; Vision loss in one eye usually develops over hours or days and improves over several weeks to months, sometimes permanent. Visual field loss. Loss of color vision. Optic neuritis often affects color perception. Flickering lights with eye movements.
MRI
Oral Squamous Cell Carcinoma or Leukoplakia
Pre-malignant;
White – benign;
Red – malignant;
Can’t BE WIPED AWAY;
Ulceration -> progression to SCC;
Biopsy to r/o malignancy;
Test for HIV and EBV;
Orbital cellulitis
Unilateral; Proptosis;
Pain with eye movement;
More severe disease, involves the content of the orbit;
CBC with dif (leukocytosis);
blood culture;
CT scan;
Orchitis
Swelling in one or both testicles.
Pain ranging from mild to severe.
Fever.
Nausea and vomiting.
General feeling of unwellness (malaise)
Early start form (more often):
Lacking in energy (dull);
Low appetite;
Problems in breathing rate or body temperature;
Abnormal body activities;
Developing delay, intellectual inefficiency;
Autism-like symptoms;
Late form (rare):
Confusion episodes, irregular behavior, or less consciousness;
Headache;
Vomiting;
A deviation for high food in protein;
Seizure;
Skin problems and brittle hair;
High blood ammonium (not diagnostic);
Genetic testing (diagnostic);
Osgood-Schlatter Disease
Knee pain and tenderness at the tibial tubercle;
Swelling at the tibial tubercle;
Tight muscles in the front or back of the thigh;
Clinical evaluation;
Sometimes x-rays;
Osteoarthritis (OA)
Weigh bearing joints affected; Hand less affected;
Chronic; noninflammatory; symmetrical or not symmetrical;
Lower extremity joints, proximal and distal interphalangeal joints, first carpometacarpal joint;
DIP>PIP>MCP; Heberden’s – DIP; Bouchard’s – PIP;
Crepitation of joints;
Effusion (rare);
Stiffness for short time (<15m);
Affects articular cartilage: hips, knees, ankles, wrists, shoulders;
Pain worsen with activity, better with rest;
Scour test
Normal Labs: ESR;
CBC; Antinuclear AB;
Rheumatoid factor;
Most accurate: radiography of affected joints
xRay: joint space narrowing, osteophytes, dense subchondral bone, bone cysts
Osteoblastoma
Neck and back pain not relived by aspirin; occurs in older adolescents and young adults
Localized tenderness; may have scoliosis; with muscle pain
xray shows an expansive osteoblastic lesion surrounded by thin peripheral rim or bone; bone scan; CT scan
Osteochondroma
A hard, mass that is painless and does not move.
Pressure or irritation with exercise.
Soreness of the nearby muscles.
Lower-than-normal-height for age.
One leg or arm that is longer than the other.
xRay: bonny spore arises from the surface of the bone;
Well-localized pain that may be more severe inhibitors at night and relived by aspirin or other prostaglandins.
Painful, well localized scoliosis may be present.
Bone scan
Osteomyelitis
Bone pan; Tenderness; Fever; Chills; Possible skin involvement
Best initial test: xRay – not helpful often to r/o infection;
If normal: MRI – bone edema(only for pts with CI to MRI - bone scan);
Most accurate: bone biopsy;
ESR: good to see response to therapy;
↑WBC;
↑CRP;
Osteoporosis
Chronic, poorly localized back pain; postmenopausal; slight build; history of inactivity or endocrine disorder
Fractures; Falls; Loss of height; Spontaneous fractures of weigh bearing bones
Palpable tenderness over area or compression fracture; kyphosis or lordosis; loss of height
Bone densitometry; spinal radiograph to r/o fracture
Routine DEXA scan >65 – most accurate test;
Osteopenia: bone density (T-score) is between 1 and 2.5 standard deviation below normal;
Osteoporosis: T-score > 2.5 standard deviation < normal;
LABS ARE NORMAL!
Otitis media (acute)
Fever
Ear pain esp. At night
Decreased hearing
Decreased mobility
+/- bloody discharge
Bulging of tympanic membrane – most diagnostic finding
Poor light reflex
Otitis media with effusion
No symptoms or portal hearing loss.
Patients may experience: feeling of fullness, pressure, popping in the ear with swallowing;
Otalgia (rare).
Possible changes to the tympanic membrane: amber or gray color; displacement of the light reflex; mild to severe retraction and accentuated landmarks. On air insufflation, the TM may be immobile. An air-fluid level or bubbles of air may be visible through the TM.
Otosclerosis
Progressive hearing loss;
Particular difficulty hearing low, deep sounds and whispers;
Speaking quietly because your voice sounds loud to you;
Finding it easier to hear when there's background noise (unlike many other types of hearing loss);
Ovarian cancer
Often asymptomatic early;
None – most are detected when disseminated;
Nonspecific abdominal symptoms;
Bloating, worse around evening;
Nausea, dyspepsia;
Anorexia, early satiety;
Only later: abdominal pain, fatigue, weight loss, change in bowel habits, menstrual irregularities, ascites;
Increased abdominal girth from ascites or tumour
Urinary frequency or constipation (mass effect)
RLQ; LLQ abdominal pain; Most functional cysts and benign tumors are asymptomatic; Sometimes they cause menstrual abnormalities; Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis; particularly when they rupture;
RLQ; LLQ; Sudden; severe pelvic pain and sometimes nausea and vomiting; For days or occasionally weeks before the sudden pain; women may have intermittent; colicky pain; presumably resulting from intermittent torsion that spontaneously resolves;
Cervical motion tenderness; a unilateral tender adnexal mass; and peritoneal signs are usually present;
Clinical diagnosis; Transvaginal ultrasonography that shows an enlarged ovary or an ovarian mass; Adnexal torsion is suspected based on typical symptoms (ie; intermittent; severe pelvic pain) and unexplained peritoneal signs plus severe cervical motion tenderness or an adnexal mass; The pain may be unilateral; Other common causes of pelvic pain (eg; appendicitis; ectopic pregnancy; pelvic inflammatory disease; tubo-ovarian abscess) should be ruled out;
Paget Disease of Bone (Paget's Disease of Bone; Osteitis Deformans)
Bone pain;
↑fractures;
Pelvis. Paget's disease of bone in the pelvis can cause hip pain.
Skull. An overgrowth of bone in the skull can cause hearing loss or headaches.
Spine. If your spine is affected, nerve roots can become compressed. This can cause pain, tingling and numbness in an arm or leg.
Leg. As the bones weaken, they may bend — causing you to become bowlegged. Enlarged and misshapen bones in your legs can put extra stress on nearby joints, which may cause osteoarthritis in your knee or hip.
Bowing of tibia;
Kyphosis;
Narrowing of auditory foramen;
↑cranial diameter;
Plain x-rays – most sensitive test;
Bone scan;
↑alkaline phosphatase;
Normal Ca and P;
Paget's disease of the breast (Paget's Disease of the Nipple)
Itching;
Redness;
A tingling or burning sensation;
Straw-colored or bloody nipple discharge;
A flattened or turned-in (inverted) nipple;
Eczema like patches on the nipple and areola;
A lump in the breast;
Thickening skin on the breast;
Flaky or scaly skin on your nipple;
Crusty, oozing or hardened skin resembling eczema on the nipple, areola or both;
Mammogram;
US;
Biopsy (malignant cells infiltrate the epidermis);
Pancreatic cancer
Ab pain radiating to the back;
Jaundice, painless;
Weight loss;
Dark urine, white stool;
Itchy skin;
Abdominal mass;
Migratory superficial venous thromboembolism (Trousseau’s syndrome);
Left supraclavicular lymphadenopathy (Virchow’s node),
Periumbilical lymph (Sister Mary Joseph’s node);
Splenomegaly;
Palpable not tender GB (Courvoisier sign);
Palpable deep ab mass.
ALP elevated;
CA 19-9 elevated – not specific, not elevated with small tumor;
Tumor markers:
↑CEA;
↑Bilirubin conjugated (direct)
↑ALP and ↑GGT;
Mild elevation AST/ALT;
Ab US -> duct dilation (double duck sign), not diagnostic.
Contract CT is diagnostic;
Insulinoma: ↑fasting insulin; ↑c-peptide;
Glucagonoma:
Pancreatic tumor, Insulinoma
Confusion;
Sweating;
Weakness;
Rapid heartbeat;
Low blood sugar;
PANDAS / PANS
Sudden onset OCD, which can manifest as an eating disorder;
General anxiety and/or separation anxiety;
Emotional lability (sudden unexplained mood changes);
Aggression, irritability, and oppositional behaviors;
Behavioral regression (baby talk, drawing like they did when they were younger);
Sudden drop in school performance;
Sensory/motor abnormalities (decreased handwriting skills or tics);
Somatic signs and symptoms (bedwetting, sleep disturbances);
Panic disorder
At least 4 symptoms:
Diaphoresis;
Trembling;
Chest pain;
Fear of dying;
Chills;
Palpitation;
SOB;
Nausea;
Dizziness;
Dissociated symptoms;
Paresthesia;
Tremor (trembling) in hands, arms, legs, jaw, or head;
Cogwheel rigidity (slowing of movement on passive flexion or extension of extremity);
Limited facial expression;
Slowness; Difficulty walking;
Can progress to cognitive and behavioral;
Gait disturbance;
Problem with initiating gate, problem with stopping;
Lightheadedness when getting up from seating position;
Depression
Writing is small – micrographic.
Postural instability or orthostatic hypotension.
Inability of pulse and BP to reset.
Pill-rolling tremor.
Resting tremor.
Shuffling gait (difficulty initiating and stopping ambulation, small
steps, no swinging of the arms);
Masked facies, rare blinking, cogwheel rigidity.
Clinical diagnosis.
No test.
Patent Ductus Arteriosus (PDA)
Pelvic Inflammatory Disease (PID)
RLQ; LLQ abdominal pain; a vaginal discharge; and irregular vaginal bleeding; STI; fever (>101F)
New/unusual purulent cervical or vaginal discharge;
Check pregnancy! hCG
Increased WBC(Leukocytosis);
CRP and ESR;
Culture;
Trance vaginal US;
Most accurate: laparoscopy;
Pemphigus Vulgaris
Peptic ulcer disease (PUD)
70% - not symptomatic;
Epigastric pain or discomfort;
Duodenal ulcer: pain relieved with food after 30+min; weight gain;
Gastric ulcer: pain exacerbated by food; weight loss;
Signs of GI bleed: Melena, Anemia;
History of NSAID intake;
Anemia, positive FOBT (in cases of bleeding ulcer);
Most accurate: Urea breath test for H. pylori: positive in most cases of PUD;
H.Pylori: (90% of duad and 70% of gastric);
EGD(Esophagogastroduodenoscopy): Mucosal erosions and/or ulcers are required for a definitive diagnosis.
Peptic ulcer perforation
LUQ pain; severe pain in the belly; Sudden onset; severe intense; steady epigastric pain that radiates to sides; back; or right shoulder; pain worse with empty stomach;
Epigastric tenderness; rebound tenderness; bowel sound can be absent;
An abdominal series (supine and upright abdominal x-rays and chest x-rays) may be diagnostic; showing free air under the diaphragm in 50 to 75% of cases; If nondiagnostic; abdominal CT;
Pericarditis
LUQ pain; sharp, stabbing pain referred to left shoulder or trapezius ridge; Pleuritic pain;
usually worse during coughing or deep breathing;
worse lying down;
can be relieved by sitting;
Fever before onset of pain;
Increased pain when you take a deep breath, or change positions especially when you lean forward (DDx with angina/MI);
Tachycardia;
Pericardial friction rub (20-30% of cases);
Constrictive pericarditis: Kussmaul sign;
WBC; ESR; ECG; chest xRay; Echocardiogram;
ECG – best initial test. Diffused ST sig elevation EVERYWHERE, without Q wave
PR depression - most specific;
Perilymph fistula
Mild pain during defecation;
Visible site draining pus;
Changes in the color of your legs;
Erectile dysfunction, most often in men with diabetes;
Leg weakness;
Slow toenail growth;
Wounds or sores on your toes or feet that don’t heal well;
Loss of hair on your legs;
Fainter pulse in your feet;
Shiny skin on your legs;
Skin that looks pale or kind of blue;
Legs that are cooler than your arms;
One leg that feels colder than the other;
Wounds or sores on your toes or feet that don’t heal well;
Pain in calves on extension;
Reversed by rest;
Walking up or down hills;
Low Ankle-brachial index --> quick, noninvasive; best initial test;
No blockage (1.0 to 1.4).
Borderline blockage (0.91 to 0.99).
PAD (less than 0.90).
Doppler US;
Angiography before surgery;
Peripheral neuropathy
Numbness or reduced ability to feel pain or temperature changes;
Tingling or burning sensation;
Sharp pains or cramps;
Increased sensitivity to touch;
Serious foot problems: ulcers, infections, bone and joint pain;
Filament test;
Nerve conduction testing;
Peritonitis
Generalized pain;
Sudden onset;
Severe pain that is diffuse and worsens with movement or coughing;
Fever;
Confusion;
Nausea and vomiting;
Rebound tenderness;
Absent bowel sounds
CBC with diff; (neutrophils);
abdominal x-ray;
sample or peritoneal fluid (culture);
Peritonsillar abscess
Dysphagia; Fever; Malaise; Odynophagia; Otalgia (ipsilateral); Drooling;
Severe sore throat, worse on one side; Muffled voice (“hot potato” voice);
Cervical lymphadenitis;
Erythematous, swollen soft palate with uvula deviation to contralateral side and enlarged tonsil;
Uvula deviation to the opposite side
CT
Pertussis
Uncomplicated disease lasts about 6 to 10 weeks and consists of 3 stages:
Catarrhal - begins insidiously, generally with sneezing, lacrimation, or other signs of coryza; anorexia; listlessness; and a troublesome, hacking nocturnal cough that gradually becomes diurnal. Hoarseness may occur. Fever is rare.
Paroxysmal stage: after 10 to 14 days, begins with an increase in the severity and frequency of the cough
Convalescent stage: symptoms diminish, usually within 4 weeks of onset. Average duration of illness is about 7 weeks (range 3 weeks to 3 months or more).
Clinical diagnosis
Phenylketonuria
Seizures;
Tremors, or trembling and shaking;
Stunted growth;
Hyperactivity;
Skin conditions such as eczema;
Musty odor of their breath, skin, or urine;
plasma free metanephrine – most accurate;
Chest and abdomen imaging (CT or MRI) if catecholamine screen positive;
MIBG scanning for localisation (if they are negative);
Best test: free catecholamines during crisis the best (when they are symptomatic);
Physical or sexual abuse
RLQ; LLQ; LUQ; RUQ; Generalized pain;
Test STD:
Syphilis;
Culture (Gonorrhea; trichomonas; herpes);
DNA testing (Gonorrhea; Chlamydia; herpes)
Pinguecula and Pterygium
Pituitary adenoma
Delayed puberty; history of vision changes; increasing headaches
Visual field defects; galactorrhea
Prolactin high;
High TSH, high T4;
MRI or CT with contrast positive;
Pityriasis rosea
Pityriasis versicolor
Placenta abruptio
Vaginal bleeding, although there might not be any.
Abdominal pain.
Back pain.
Uterine tenderness or rigidity.
Uterine contractions, often coming one right after another.
Clinical evaluation, sometimes plus laboratory and ultrasonographic findings;
Placenta previa
Placenta inserted in lower uterus
Bright red vaginal bleeding
Pleural effusion
SOB; Dyspnea on exertion;
Pleuritic chest pain;
Fatigue;
Weakness;
Dullness to percussion;
Decreased breath sounds;
Decreased tactile fremitus;
Egophony (E to A changes);
Tracheal deviation away from effusion;
Fever (It's usually low if you have HIV and higher if you don't.);
Dry cough or wheezing;
Shortness of breath (SOB);
Fatigue;
Chest pain or tightness when you breathe;
Chills;
Weight loss;
Pulse oximetry;
Best initial test: chest xRay: bilateral interstitial infiltrates;
Histopathologic confirmation;
ALWAYS elevated LDH >220
Most accurate test:
Bronchoalveolar lavage;
Can last up to 10 days:
Fever;
Sore throat;
Headache;
Vomiting;
Fatigue;
Back pain or stiffness;
Neck pain or stiffness;
Pain or stiffness in the arms or legs;
Muscle weakness or tenderness;
Lumbar puncture;
Viral culture (stool, throat, and cerebrospinal fluid);
Polyarteritis nodosa (PAN)
Very nor specific!
Petechiae; purpura; ulcers; livedo reticularis; nodules;
Generalized abdominal pain worsen by eating: mucosal bleeding; nausea; vomiting;
Symptoms depend on location and severity of the arteritis and extent of secondary ischemia;
Only one organ or organ system may be affected;
General symptoms: fever; fatigue; night sweats; loss of appetite; weight loss; and generalized weakness;
History Hepatitis B or C (20%);
Spear lungs!
Peripheral neuropathy any large nerve can be involved (foot drop)
Most appropriate test: Hep B surface antigen;
Most accurate: biopsy of affected site;
Blood test:
Anemia, leukocytosis;
↑ESR, CRP;
P-ANCA – negative, only 20% positive;
Angiography: renal, mesenteric, hepatic artery – aneurysmal dilation;
Biopsy: most accurate for renal dz;
Polycystic kidney disease
High blood pressure.
Back or side pain.
Blood in your urine.
A feeling of fullness in your abdomen.
Increased size of your abdomen due to enlarged kidneys.
Headaches.
Kidney stones.
Kidney failure.
Ultrasonography;
Sometimes CT or MRI or genetic testing;
Polycystic ovarian syndrome (PCOS)
irregular periods; infertility; heavy bleeding; headaches
Acne; weight gain; darkening of the skin; hirsutism; male-pattern baldness
LH:FSH ratio 3:1; (2-5 days from the beginning of the menses)
DHAE-S may be elevated
Transvaginal US;
Polycythemia Vera
Headache, blurred vision, tinnitus;
Fatigue;
Itchiness after shower b/c of histamine release from basophils;
Burning pain in hands and feet;
Rush;
Splenomegaly;
Hepatomegaly;
Hypertension;
Hematocrit >60%;
↑platelets;
↑WBC count;
↓MCV;
B12 elevated (???);
↓Iron;
↓Erythropoietin;
(MUST r/o hypoxia);
Bone marrow biopsy show hypercellular marrow;
Polymyalgia rheumatica
Pain and stiffness in shoulder and pelvic girdle muscles;
Difficulty combing hair and rising from chair;
Malaise; Fatigue;
Unexpected weigh loss;
Fever;
Joint swelling in affected areas, particularly in the morning or after being inactive for a time;
Limited range of motion in affected areas;
Depression;
↑ESR;
Normochromic, normocytic anemia;
CPK and aldolase are normal;
↓Hematocrit;
RF(-);
MRI;
PET scan;
Polymyositis
Do not affect facial muscles;
Dysphasia;
Symmetric progressive, proximal muscle weakness;
Occurs in legs first;
Myalgias;
Muscle atrophy (later stages);
Best initial test: ↑CPK and aldolase;
↑ALT, AST;
Most accurate test: muscle biopsy;
Anti-Jo-1 Abs;
ANA frequently positive;
MRI: patch muscle involvement;
Electromyography abnormal;
Muscle biopsy ;
Polyps of the Colon and Rectum
Rectal bleeding;
Change in stool color;
Change in bowel habits;
Pain;
Iron deficiency anemia;
Hematocrit increased or decreased; low serum ferritin
Poor sleep and rest
Fatigue; history of overwork; psychological stress; disturbed sleep
Normal examination
None
Portal hypertension
Black, tarry stools or blood in the stools;
Vomiting of blood;
Esophageal varices;
Ascites;
Caput medusae;
Hepatomegaly;
Splenomegaly;
Clinical evaluation;
Postnasal drainage
Feeling that you need to constantly clear your throat or swallow;
Cough that’s worse at night;
Nausea from excess mucus moving into your stomach;
Sore, scratchy throat;
Bad breath.
Postpartum
Abdominal cramps;
Sore perineum;
Trouble urinating;
Constipation;
Fatigue;
Body aches;
Night sweats;
Engorged breasts;
Sore nipples;
Back pain;
Depression;
Vaginal bleeding (lochia);
Bloodshot or puffy eyes;
Leaking breasts;
Hemorrhoids;
Poststreptococcal glomerulonephritis
History of throat infection or skin infection (impetigo) by 1-3 weeks;
Cola-colored urine;
Edema (periorbital);
HTN;
Oliguria
Best first test: UA;
Dysmorphic RBC, RBC cast, proteinuria, hematouria
2nd test: ↑antistreptolysin O (ASO) titers;
anti-DNAse Abs titers (others strep spices);
Most accurate: Biopsy: deposit of IgG on basement membrane;
Posttraumatic Stress Disorder (PTSD)
Prader-Willi syndrome
Almond-shaped eyes;
Eye problems;
Narrow forehead at the temples;
Narrow bridge of the nose;
Thin upper lip and a downturned mouth;
Unusually fair hair, skin and eyes;
Small hands and feet;
Preeclampsia and Eclampsia
Pregnancy
Missed period;
Tender, swollen breasts;
Nausea with or without vomiting;
Increased urination;
Fatigue;
Enlarged uterus; soft, bluish color cervix
beta-hCG (+); US
Premenstrual Syndrome (PMS)
Mood swings;
Feeling upset, anxious or irritable;
Tiredness or trouble sleeping;
Bloating or tummy pain;
Breast tenderness;
Headaches;
Spotty skin;
Greasy hair;
Diagnosed based on physical symptoms (eg, bloating, weight gain, breast tenderness, swelling of hands and feet);
Primary Biliary Cholangitis (PBC)
Early symptoms:
Fatigue;
Itching;
Later symptoms:
Pruritus;
Dermographism;
Steatorrhea;
Dry eyes and mouth;
Pain in the upper right abdomen;
Bone, muscle or joint (musculoskeletal) pain;
Weight loss;
Muscle cramps;
Weakness/dizziness;
Fatigue;
Headache;
Blurred vision;
A frequent need to urinate, nocturnal;
Excessive thirst;
↑BP - Hypertension (secondary);
No pitting edema;
↓renin;
↓ K;
Best initial: renin/aldosterone ratio (ratio > 20-30 - positive test);
CT or MRI – only after lab work!
Most accurate: adrenal venous blood sample;
PAC:PRA;
High:Low;
Prostate cancer
Asymptomatic or looks like BPH;
Weight loss, back pain (end stage);
Most often: posterior. Which doesn’t cause urinary symptoms;
Hematuria painless; Dysuria (pain urinating);
Metastasis (bone pain most common);
Nodularity or irregular areas of induration;
Rectal exam may be normal (screening test);
↑PSA (prostate-specific antigen, screening test);
UA: hematuria, pyuria;
↑alkaline phosphatase;
Biopsy (guided by US);
Bone scan, CT scan, Chest x-ray;
Prostatitis acute or chronic
Dysuria;
Urgent need to urinate;
Frequent urination, particularly at night (nocturia);
Cloudy urine;
Blood in the urine;
Pelvic of perineal pain;
Flu-like signs and symptoms (with bacterial prostatitis);
Acute: fever, systemic symptoms;
Chronic: recurrent episodes of infection with or without complete resolution between bouts. Symptoms and signs tend to be milder than in acute prostatitis.
Rectal exam: tender and boggy prostate;
UA: ↑WBC;
Urine culture;
Pseudohypoparathyroidism
Short statue;
Shortness of 4th metacarpal;
Developmental delay;
Obesity;
Autosomal GNSA1 gene mutation;
↓Ca
↑PTH
↑P
Pseudomembranous colitis
Symptoms range from transient mild diarrhea to active colitis with bloody diarrhea, abdominal pain; fever
Vision changes (like double vision) or vision loss;
Dizziness, nausea and/or vomiting;
Neck stiffness;
Persistent ringing in the ears (tinnitus);
Forgetfulness and/or depression;
Obesity
Headache;
Papilledema
MRI with magnetic resonance venography;
Lumbar puncture
Psoriasis
Silvery scaly plaques on extensor surfaces;
NOT itchy (most of the time);
Thickened, pitted or ridged nails;
Swollen and stiff joints (Psoriatic arthritis);
R/O eczema;
Auspitz's sign;
Clinical;
Skin biopsy;
Psoriatic arthritis
Asymmetric
Worse in morning, improve with activity.
Chronic;
Noninflammatory;
Large joints symmetrical of not symmetrical;
SI joint involvement;
Sausage digits;
Nail pitting;
+/-uveitis;
Clinical evaluation;
(-)ANA;
Rheumatoid factor (-)RF;
ESR;
DIP, PIP on xRay;
Best initial test: xRay of the joint showing a “pensile in a cup” deformity;
Uric acid elevated from increase skin turn over;
Psychogenic origin
Precordial chest pain; history of stressful situation
Normal examination
ECG; chest xRay; stress test
Pulmonary edema
Extreme dyspnea, SOB;
Restlessness, and anxiety with a sense of suffocation;
Cough producing blood-tinged sputum;
Orthopnea
Paroxysmal nocturnal SOB
Frothy pink sputum
Tachycardia
Wheezing
Pallor, cyanosis;
Diaphoresis;
Pulse is rapid and low volume;
Blood pressure (BP) is variable.
Noisy respiratory efforts often make cardiac auscultation difficult;
3rd (S3) and 4th (S4) heart sounds;
Signs of right ventricular (RV) failure: neck vein distention, peripheral edema;
Sudden onset; Dyspnea;
SOB with clear lungs on exam and normal chest xRay;
Chest pain increases with deep breathing;
Cough, Hemoptysis (not always);
If DVT is present – leg pain;
Pleuritic chest pain from lung infarction;
Feeling that something terrible happen to them;
Fever;
Big clot -> hypotension;
Altered mental status;
Specific test:
Spiral CT – best initial test;
V/Q scan – old test if test is normal – no PE;
D-dimer can help to r/o DVT and PE, not specific;
CT angiography;
ABG: hypoxia and resp. alkalosis;
Chest xRay – often normal;
ECG
ECG: Sinus tachycardia;
Most common abnormality: ST-T wave changes;
xRay may show atelectasis, pleural infusion or “Hampton’s hump”
5% will show right axis deviation, RV hypertrophy or RBBB
Most accurate test: angiography (0.5% mortality) almost never used
Wells risk score :
Clinical signs and symptoms of DVT;
PE is #1 diagnosis OR equally likely;
Heart rate > 100;
Immobilization at least 3 days OR surgery in the previous 4 weeks;
Previous, objectively diagnosed PE or DVT;
Hemoptysis;
Malignancy w/ treatment within 6 months or palliative pneumo
Pulmonary hypertension
Dyspnea, SOB, often long-standing;
Obesity;
Edema;
Fatigue;
Exertional syncope and chest pain;
Cough;
Cyanosis;
Clubbing of fingers;
Wide splitting of S2, loud S2;
Sign of right sided HF.
JVD;
Hepatomegaly;
Best initial:
Showing dilation of proximal pulmonary artery with narrowing distal vessels.
Echocardiogram;
Right heart catheterization;
EKG, ECHO, Doppler US
CBC: polycythemia with pts with severe hypoxia
Pulmonic Stenosis
Fatigue.
Shortness of breath, especially during exertion;
Chest pain;
Loss of consciousness (fainting);
Heart murmur;
Echocardiography;
Pyelonephritis (Upper UTI)
RUQ; LUQ; pain in the lower part of the back on either side; Flank pain; Symptoms of pyelonephritis often begin suddenly with chills; fever; nausea; and vomiting; 1/3 have symptoms of cystitis: frequent; urgent need to urinate and a burning or painful sensation while urinating (dysuria)
Costovertebral angle (CVA) pain;
↑ WBC; ↑ ESR; ↑ CRP; WBC casts in UA; Positive urinary culture;
Renal ultrasound: edema and focal hypoechogenic areas
CT pelvis with IV contrast: focal area(s) of hypoenhancement that extend to the cortical periphery
Pyloric Stenosis
Vomiting after feeding.
Persistent hunger.
Stomach contractions.
Dehydration.
Changes in bowel movements.
Weight problems.
Cold fingers or toes;
Color changes in your skin in response to cold or stress;
Numb, prickly feeling or stinging pain upon warming or stress relief;
Increased vascular reactivity of fingers beginning with pain and pallor (white) or cyanosis (blue) followed by reactive hyperemia (red);
Clinical criteria;
Nailfold capillaroscopy;
Reactive Arthritis (Reiter's Syndrome)
Pain and stiffness.
Eye inflammation.
Urinary problems.
Inflammation of soft tissue where it enters bone (enthesitis).
Swollen toes or fingers.
Skin problems.
Low back pain.
Joint pain;
Ocular findings (uveitis, conjunctivitis);
Genital abnormalities (urethritis, balanitis);
Clinical diagnosis;
DDx: R/O septic joint!
No specific teats;
Renal artery stenosis
Hypertension that begins before age 30 or is refractory to treatment with > 3 antihypertensive drugs
Doppler US;
CT angiography;
Renal Cell Carcinoma
Asymptomatic;
Blood in your urine, which may appear pink, red or cola colored;
Pain in your back or side that doesn't go away;
Palpable abdominal mass;
Loss of appetite; Malaise;
Unexplained weight loss;
Tiredness;
Fever;
Weakness;
Male may have left sided varicocele;
CVA (+)
UA (RBC): Renal labs, urine dipstick, urine microscopy, blood, high Ca;
CT of Chest/Abdominal/Pelvis with contrast;
US - less sensitive;
MRI for spread or if contrast is not tolerated, biopsy;
Restless Legs Syndrome (RLS, Willis-Ekbom disease)
Leg (or arm) discomfort (creeping, itching, pulling, crawling, tugging, throbbing, burning, or gnawing);
Urge to move legs (or arms) especially when resting, such as when sitting or lying down;
Sometimes staying asleep may also be difficult;
Daytime sleepiness;
Behavior and work performance problems (irritability, moodiness, difficulty concentrating, hyperactivity, etc) and work performance.
Clinical diagnosis;
Retinal detachment
Painless, sudden loss of vision;
Sudden onset of flushing lights and floaters;
Reduction of vision;
Ophthalmologist evaluation
Retinoblastoma
Decrease in vision;
Eye inflammation;
Strabismus ;
Family history of eye problem or other solid cancers;
Poor red eye reflex in the affected eye;
WHITE PUPIL (not red) - leukocoria;
MRI, US to determine the side.
CT – worse choice because of level or radiation
Retropharyngeal abcess
Breathing difficulty.
Difficulty swallowing.
Drooling.
High fever.
High-pitched sound when inhaling (stridor)
Muscles between the ribs pull in when breathing (intercostal retractions)
Severe throat pain.
Difficulty turning the head.
X-rays --> CT;
Rett syndrome
Loss of speech;
Loss of purposeful use of hands;
Involuntary hand movements such as handwashing;
Loss of mobility or gait disturbances;
Loss of muscle tone;
Seizures or Rett “episodes”;
Scoliosis;
Breathing issues;
Sleep disturbances;
Slowed rate of growth for head, feet and hands;
Rheumatic Fever
Presents 1-5 weeks after throat infection:
b. Clinical diagnosis based on Jones criteria (2 major or 1 major and 2 minor)
(1) Major: Carditis, arthritis, chorea, subcutaneous nodules, erythema marginatum
(2) Minor: Fever, arthralgia, elevated acute phase reactants, prolonged PR interval on ECG
Rheumatoid arthritis (RA)
Morning stiffness, multiple small, inflamed joints, better with use;
Morning stiffness >30min for 6 weeks;
Symmetrical;
Multiple joints of hand and feet;
Bilateral, PIP, MCP;
Inflammatory condition;
Some well have rheumatic nodules, episcleritis, lung nodules end effusions, vasculitis, sclerites;
Boutonniere and swan neck hand deformities;
NO DJD involvement!
Ulnar deviations;
For diagnosis:
ACPA Abs (anti-citrullinated peptide/protein antibody ) and/or;
RF – IgG ABs;
3+ joints;
Anti-cyclic citrullinated peptide (anti-CCP);
anti-CCP: positive only in 25-50%, not R/O RA;
Predict aggressive joint erosion.
↑ESR;
↑CRP;
Anemia of chronic dz;
RF is not specific;
xRay: joint space narrowing, physical deformity of joints;
MRI more accurate for early stage;
Rhinophyma
Riboflavin Deficiency (Vitamin B2 Deficiency)
Rosacea
Facial rash.
Roseola infantum
Herpes virus 6,7
Children 2 m-2 years, starts with high fever
Rash after fever
Starts on trunk
Spreads to legs and neck
1-2 days, not itchy
Sudden high fever for 3-4 days
Fever disappear -> rash appear, gone in 24 h
Clinical evaluation;
Rubella
Headache;
Stuffy or runny nose;
Inflamed, red eyes;
Aching joints, especially in young women;
Mild fever of 102 F (38.9 C) or lower;
A fine, pink rash that begins on the face and quickly spreads to the trunk and then the arms and legs, before disappearing in the same sequence;
Enlarged, tender lymph nodes at the base of the skull, the back of the neck and behind the ears;
Clinical evaluation;
Serologic testing;
Rubinstein-Taybi syndrome
Broadening of the thumbs and big toes;
Constipation;
Excess hair on body (hirsutism);
Heart defects, possibly requiring surgery;
Intellectual disability;
Seizures;
Short stature that is noticeable after birth;
Slow development of cognitive skills;
Ruptured implant
History of breast implant surgery.
Changes in breast shape and size, and increasing pain, firmness, and swelling over a period of weeks. May be asymptomatic: “silent rupture.”
MRI
Ruptured spleen
Abdomen painful and tender;
LUQ radiate to left shoulder (Kehr's sign);
The manifestations of major hemorrhage; including hemorrhagic shock;
Dizziness, blurred vision, confusion, syncope;
History of recent trauma;
Ballance's sign: dullness on percussion in the LUQ;
Hemorrhagic shock (often delayed): tachycardia and hypotension;
(+) Kehr's sign;
Low Hb, leukocytosis, and thrombocytosis;
Imaging (CT or ultrasonography);
Sarcoidosis
Tender reddish bumps or patches on the skin;
Red and teary eyes or blurred vision – 25%;
Swollen and painful joints;
Hoarse voice;
Erythema nodosum – 25%;
Fever;
Fatigue;
Not productive cough;
Dyspnea;
Malaise;
Weigh loss;
CNS involvement
Chest pain;
Parotid gland enlargement;
Cranial nerve palsies;
Enlarged and tender lymph glands in the neck, armpits, and groin.
Enlarged lymph glands in the chest and around the lungs.
Fine rales, no wheezing.
Best initial test: xRay: bilateral hilar adenopathy , pulmonary infiltrates on xRay (ground glass appearance)
Biopsy;
Exclusion of other granulomatous disorders;
Hilar adenopathy bilateral on xRay
ECG: Heart block and restrictive cardiomyopathy;
AV heart block – not common, but deadly
Most accurate test: biopsy of lymph node (involved) : noncaseating granulomas
B/c granulomas and sarcoidosis make vitamin D:
Hypercalciuria 20% -> nephrolithiasis
Hypercalcemia: 5%
↑serum ACE: 60% - do not use it for diagnosis! Not specific and not sensitive;
↑Alp phos;
↓WBC;
↑ESR;
PFTs: restrictive lung dx;
Decreased FEV1, FEC, TLC with normal FEV1/FVC ratio;
Scabies
Scarlet fever
Very red, sore throat.
Whitish coating on the tongue early in the illness.
“Strawberry” (red and bumpy) tongue.
Red skin rash that has a sandpaper feel.
Bright red skin in the creases of the underarm, elbow, and groin (the area where your stomach meets your thighs)
Swollen glands in the neck.
Fever (39C or higher)
Throat swab
Schizophrenia
Sciatica
Acute back pain with radiculopathy; history of trauma
(+) SLR; sitting knee extension; sensory findings
CRP/ESR (any inflammation?);
Scleroderma
Calcinosis;
Esophageal dysmotility (Reflux, Dysphagia, Achalasia, GERD);
Sclerodactyly;
Telangiectasia;
Renal: sudden hypertensive crisis;
Lung: fibrosis lead to restrictive lung dz and pulmonary hypertension fibrosis;
Cardiac: myocardial pericarditis, heart block, lung dz --> R. ventricular hypertrophy;
Female, organ fibrosis of skin and internal organs (lung, KI, GI);
Tightness of the skin;
CREST: limited;
Skin involvement below the knees and elbows;
Manometry;
R/O Barrett’s esophagus which can lead to cancer;
ANA – not specific;
ESR normal;
SCL-70 (anti-topoisomerase) –specific;
Anticentromere AB – most specific to CREST;
↑ACTH; ↓Cortisol.
After ACTH stimulation test:
↑Cotricol(primary) - problem with production of ACTH hormone;
↓Cortisol(secondary and tertiary) - adrenal glands are damaged;
Low blood sugar;
Low cortisol --> low Na;
Decrease in facial expressions;
Difficulty starting and controlling movement;
Loss or weakness of movement (paralysis);
Soft voice;
Stiffness of the trunk, arms, or legs;
Tremor;
Joint is red, warm, immobile, palpable effusion;
Chills and fever b/c of bacteremia;
Pain with any motion
Best initial test: arthrocentesis of the joint (joint aspiration);
xRay, CT MRI – NEVER!
Leucocytosis (neutrophils);
↑ESR↑CPR;
Blood culture is less sensitive test;
Recent history of postpartum hemorrhage; shock during delivery
Hair loss; depigmentation of skin; mammary genital atrophy
Pituitary hormones low; hemoglobin low
Shift work sleep disorder
Sickle cell disease
Acute painful vaso-occlusive crisis caused by:
Hypoxia;
Dehydration;
Infection;
Trauma;
Cold temp;
Pain in chest, back, thighs;
May have fever;
Anemia;
Jaundice;
Cholelithiasis;
Murmurs;
Delay growth;
Best initial test: peripheral smear (sickle cells);
(Howell-Jolly bodies – after splenectomy);
Most accurate test: electrophoresis (HbS);
↑LDH, ↑indirect bilirubin;
Renal manifestation is a only significant manifestation - blood in UA;
RCC is high if pt doesn’t has folate or B12 deficiency, parvovirus;
If Hematocrit drops too fast in few days think about PB19 virus --> PCR test (most accurate) or ABs;
Sideroblastic anemia
Iron study, CBC
Silent Lymphocytic Thyroiditis
Postpartum period, usually within 12 to 16 weeks;
WNL;
↓uptake on the thyroid scan;
Sinusitis (acute, chronic, allergic)
Sinus pain;
Purulent nasal discharge;
Maxillary tooth pain;
Face pain
Sinus tenderness to palpation;
Illumination test;
Headache worse with bending over;
CT may be ordered for chronic infection;
Most accurate: biopsy or aspiration
Schirmer test – best initial test
Most accurate test: lip or parotid gland biopsy;
Best initial blood test: SS-A and SS-B Abs (not specific, also positive in SLE);
Positive anti-Ro AB;
Positive anti-La AB;
(+ANA);
RF;
Anemia;
Leukopenia;
Eosinophilia;
Skin tags
Sleep apnea
Partner reports periods of no breathing during sleep; fatigue; day time sleepiness; snoring
High blood pressure; narrowed upper airway
Sleep study; scope with nighttime pulse oximetry
Small intestinal bacterial overgrowth (SIBO)
Bloating; Abdominal discomfort, diarrhea, excess flatulence, weight loss, symptoms of nutritional deficiencies. Some people may have steatorrhea (light-colored, soft, bulky, greasy, and unusually foul-smelling stool).
Breath test (measures the amount of hydrogen or methane that you breathe out after drinking a mixture of glucose and water)
Smith-Magenis syndrome
Physical characteristics:
facial features that include a broad, square face with deep-set eyes, full cheeks, a prominent lower jaw, a flattened bridge of the nose, a downturned mouth, and eyes looking in different directions (strabismus);
low muscle tone;
short stature;
curved spine (scoliosis);
hoarse voice;
myopia (short-sightedness);
flat feet;
Cognitive signs:
developmental delay;
mild to moderate intellectual disability;
speech delay;
Behavioural signs:
sleep problems – for example, they might sleep during the day and be awake at night;
temper tantrums and aggression problems;
anxiety;
attention difficulties;
a tendency to injure themselves deliberately;
a tendency to hug themselves repeatedly;
reduced sensitivity to pain and temperature;
eating difficulties, with a preference for soft foods.
Medical concerns:
ear abnormalities (sometimes leading to hearing loss);
heart and kidney defects;
retinal detachment.
Smoking
Smoking cessation
Snake bites
Pain and swelling at bite site;
Progressive dyspnea;
Toxin-induced DIC;
More severe in children;
Identification of the snake;
Grading severity of envenomation;
Snoring
Witnessed breathing pauses during sleep;
Excessive daytime sleepiness;
Difficulty concentrating;
Morning headaches;
Sore throat upon awakening;
Restless sleep;
Gasping or choking at night;
Chest pain at night;
Your snoring is so loud it's disrupting your partner's sleep;
In children, poor attention span, behavioral issues or poor performance in school;
HTN;
Hight/weight (BMI ≥ 35 kg/m2);
Head exam:
- Nasal polyps and engorged turbinates;
- A high, narrow arched palate;
- Enlargement of the tongue, tonsils, soft palate, lateral pharyngeal walls, or uvula;
- A small or posteriorly displaced mandible (retrognathia);
Sleep study;
Solar lentigo
Spermatocele
A spermatocele usually causes no signs or symptoms and might remain stable in size. If it becomes large enough, however, you might feel:
Pain or discomfort in the affected testicle;
Heaviness in the testicle with the spermatocele;
Transillumination.
Ultrasound.
Spinal stenosis
Sudden onset of focal neurological deficits
Pain with walking or standing;
Radiating pain;
Better with leaning forward;
Hyperactive DTR;
Sensory loss BELLOW the lesion;
Vertebral tenderness;
Muscle weakness;
Pain and temp: contralateral side
Position and vibration – ipsilateral side
Request imaging! – best initial test;
With pacemaker - CT but we will need contrast
MRI (R/O herniation, cancer) – most accurate test
Splenomegaly
LUQ abdominal pain or fullness that may spread to the left shoulder; Feeling full without eating or after eating only a small amount from the enlarged spleen pressing on your stomach;
Splenic enlargement is 60 to 70% for palpation and 60 to 80% for percussion; Up to 3% of normal; thin; people have a palpable spleen; Also; a palpable left upper quadrant mass may indicate a problem other than an enlarged spleen such as a hypernephroma;
US is the test of choice because of its accuracy and low cost; CT and MRI may provide more detail; MRI is especially useful in detecting portal or splenic vein thromboses;
Spondylolisthesis
Abnormal gait (knee/hip flexed)
Young person in a sport that demands rapid movement between hyperflexion and hyperextension or requires excess loading in hyperextension
no neurologic sign; pain localized to low back; just below level of iliac crest; tight hamstrings
low back x-ray; MRI
Spontaneous abortion (miscarriage)
Vaginal spotting or bleeding;
Pain or cramping in your abdomen or lower back;
Fluid or tissue passing from your vagina;
Squamous cell carcinoma (SCC)
Stable angina
Sternal chest pressure after exercise or stress, relived by rest or nitroglycerin. Nausea, SOB, diaphoresis;
Fatigue; dizziness; rapid breathing; heart palpitations; sweating; anxiety;
Normal physical exam. S4 may be present
ECG during episode of chest pain;
Stress test;
Lipid profile;
Coronary angiography;
Stasis Dermatitis
Stress
Stroke
Sudden onset;
Numbness or weakness in the face, arm, or leg, especially on one side of the body;
Confusion, trouble speaking, or difficulty understanding speech;
Trouble seeing in one or both eyes;
Trouble walking, dizziness, loss of balance, or lack of coordination;
Severe headache with no known cause;
Visual or auditory hallucinations or deficits;
Hemorrhagic stroke:
Acute onset of “worst Headache of life”;
Nausea/vomiting;
Meningeal irritation;
Rapidly deteriorating LoC;
Also localizing neuro signs;
Face weakness, LOWER part of the face may be paralyzed; Arm drift; Abnormal speech
Best I/T: CT without contrast;
PRIOR treatment! Excludes hemorrhage;
Most accurate: MRI;
ECG:
Damaged valves? -> surgery;
Thronbi? –> Heparin followed by warfarin to INR to 2-3;
Holter monitor for 24H if ECG is normal;
Carotid or transcranial doppler;
Cerebral angiogram;
CBC, coagulation labs, blood chemistry (sugar + electrolytes), lipids
Subacute thyroiditis
Pain in the anterior neck and fever;
Neck pain characteristically shifts from side to side and may settle in one area, frequently radiating to the jaw and ears.
Often confused with dental pain, pharyngitis, or otitis and is aggravated by swallowing or turning of the head;
Symptoms of hyperthyroidism(common early in the disease because of hormone release from the disrupted follicles);
Asymmetrically enlarged, firm, and tender thyroid
Clinical findings;
↑ESR;
↓uptake on the thyroid scan;
↑Free T4;
↑Triiodothyronine (T3);
↓Thyroid-stimulating hormone (TSH);
Radioactive iodine uptake;
Subarachnoid Hemorrhage
Sudden onset of severe headache “Worse headache in my life” with meningeal irritation (stiff neck, photophobia);
Fever;
Loss of consciousness in 50% - rupture of aneurism, cerebral perfusion decreased;
Focal neurological complications in 30%
Best initial test: CT without contrast
Most accurate test: Lumbar puncture showing blood (only necessary for 5% false negative CT) – may be negative in the beginning
Normal WBC/RBC ratio
WBC can mimic meningitis. But RATIO IS NORMAL:
1 WBC for every 500 to 1000 RBCs.
Angiogram – shows where is the problem?
Subdural hematoma
Persistent headache;
Fluctuating drowsiness, confusion, memory changes;
Paralysis on the side of the body opposite the hematoma, and speech or language impairment;
Syncope
CT scan
Substance abuse
Maladaptive pattern leads to tolerance;
Withdrawal when trying to cut down;
Urine toxicology
Superficial Thrombophlebitis
Swelling of the leg or arm (sometimes this happens suddenly);
Pain or tenderness in the area of the clot;
Feeling of increased warmth in the area of the clot;
Red or discolored skin in the area of the clot.
Painless ulcer (1 stage)
Fever;
Malaise;
Lymphadenopathy- painless;
Rash (palms, soles, oral (condyloma latte);
Secondary:
Sore throat;
Fever;
Swollen lymph glands;
Headaches;
Fatigue;
Muscle aches;
Wart-like patches around skin folds or genitals;
Loss of appetite;
Joint pain;
Enlarged lymph nodes;
Tertiary syphilis;
CVD: aneurysms of ascending aorta;
Aortic valve insufficiency;
Gummas(granulomatous lesions in skin, bones, internal organs);
CNS: general paresis, tabes dorsalis (affects proprioception-> gait and balance), Argyll-Robertson pupil;
Romberg test – test for Tabes dorsalis, not for cerebellum!
For primary: Dark field microscopy – best initial test;
RPR;
VDRL – screening test, not specific FTL Ab test - Trapinials testchlom;
False positive for Syphilis:
Mono;
Rheumatoid factor;
SLE;
Leprosy;
IV drug users;
Systemic lupus erythematosus (SLE)
Great imitator! Fever; Malaise; Joint pain; Myalgia; Fatigue;
Chronic; inflammatory; small joints; symmetrical;
Dermatological: photosensitivity rash; oral ulcers; UV light cause flares;
MSK: arthritis (symmetrical);
Neurologic: seizures, psychosis;
Hematologic: hemolytic anemia;
Serositis (pleuritis or pericarditis);
Renal involvement;
(+)ANA – not specific, but negative test r/o lupus;
Specific: (+)anti-dsDNA – 60%; (+)Anti-Smith;
(Associated with anti-histone AB) – drug induced lupus;
R/O syphilis: lupus causes false positive RPR and VDRL tests;
CBC: Hemolytic anemia, lymphopenia, leukopenia, thrombocytopenia;
Decreased C3 and C4;
KI biopsy for severity of lupus nephritis;
Anxiety and restlessness;
Weakness
Chest pain radiating to your neck, shoulders, or back;
Trouble breathing or taking deep breaths;
Rapid breathing;
Fainting, dizziness, and loss of consciousness;
Hypotension;
Tachycardia
Distended neck veins
Clear lungs
Pulses paradoxus – decrease of more that 10 mmHg in systolic BP on inhalation (most specific)
Discomfort that’s relieved by sitting or leaning forward;
Echocardio: right atrial and ventricle diastolic collapse (most appropriate initial test);
EKG (different height of QRS);
xRay – global heart ;
R side catherization - most accurate test (not used);
Tardive Dyskinesia
Uncontrolled movements in your face: namely your lips, jaw, or tongue:
Stick out your tongue without trying;
Blink your eyes fast;
Chew;
Smack or pucker your lips;
Puff out your cheeks;
Frown;
Grunt;
Tarsal tunnel syndrome
Tingling, burning or a sensation similar to an electrical shock;
Numbness;
Pain, including shooting pain.
Temporomandibular joint (TMJ) disorder
50% related to dental problems; discomfort to severe pain; unilateral; pain worse in morning
Malocclusion; bruxism; normal external and middle ear structures and function; jaw click; abnormal cranial nerve function; ear examination normal
None
Tension headache
Constant pressure, band like tightness;
Mild to moderate pain;
mainly bilateral;
4-6 hours;
Occiput or neck.
No tests!
Testicular cancer
A lump or enlargement in either testicle (usually affects only one testicle);
A feeling of heaviness in the scrotum;
A dull ache in the abdomen or groin;
A sudden collection of fluid in the scrotum;
Pain or discomfort in a testicle or the scrotum;
Enlargement or tenderness of the breasts;
Back pain;
Usually affects only one testicle;
Painless enlargement of testicles;
Testicular US, pelvic CT;
b-hCG;
AFT;
Testicular torsion
RLQ; LLQ pain; Immediate symptoms are sudden onset of severe local pain; nausea; and vomiting; followed by scrotal edema and induration; Fever and urinary frequency may be present; The testis is tender and may be elevated and horizontal;
The testis is tender on palpation and may be elevated and horizontal; The contralateral testis may also be horizontal because the anatomic defect is usually bilateral; The cremasteric reflex is usually absent on the affected side;
Clinical evaluation; Often color Doppler ultrasonography;
Tetanus (Lockjaw)
Jaw cramping;
Sudden, involuntary muscle tightening (muscle spasms) – often in the stomach;
Painful muscle stiffness all over the body;
Trouble swallowing;
Jerking or staring (seizures);
Headache;
Fever and sweating;
Changes in blood pressure and fast heart rate;
Clinical evaluation
Tetralogy of Fallot
Thalassemia
Slow growth in children;
Wide or brittle bones;
Splenomegaly;
Fatigue;
Weakness;
Pale or yellow skin;
Dark urine;
Poor appetite;
Heart problems;
Jaundice;
Microcytic anemia;
Target cells – not specific, can be liver dz;
Normal iron study;
Normal RDW – small but same;
Most accurate test for thalassemia: electrophoresis;
Most accurate test for alpha or beta thalassemia: genetic study;
3 gene deletion alpha has high reticulocytes count;
Tingling or numbness in the hands or feet.
Pale, reddish or blue-tinted hands or feet.
Pain that may come and go in your legs and feet or in your arms and hands. This pain may occur when you use your hands or feet and eases when you stop that activity (claudication), or when you're at rest.
Inflammation along a vein just below the skin's surface (due to a blood clot in the vein).
Painful open sores on your fingers and toes.
Allen's test
Angiogram with CT or MRI;
Thyroid cancer
If thyroid nodule is not toxic, not functional --> cancer until proven otherwise;
More likely malignant if sono/Doppler shows:
Irregular margin;
intranodal vascular pattern;
microcalcification;
Fine needle aspiration;
US doesn’t allow to recognise cancer behind the cyst;
High thyroid hormone;
TSH, T4;
Fine-needle if normal thyroid function;
Thyroid storm
Chest pain;
Anxiety;
Mental status changes;
Panic attack;
Palpitation;
Diaphoresis;
High Fever;
Tachycardia;
↓TSH;
↑free t4, free T3;
Tinea Versicolor (Pityriasis Versicolor)
Tonsillopharyngitis (Tonsillitis; Pharyngitis)
Sore throat;
Lymphadenopathy;
Nasal congestion;
Fever;
HA, GI;
Red and swollen pharynx;
Tonsillar exudates;
ABSENCE OF COUGH (lung) and HORSENESS (laryngitis)!!!
Centor criteria:
C - cough;
E - exudate;
N - nodes;
T - temperature;
OR - age
<15 y/o +1
>44 y/o -1
0-1 no treatment
2-3 culture-antibiotic
4-5 empirically
Most accurate: culture (can use positive rapid strep test);
Negative RST – for adult it’s negative. For child – not 100%;
Toxic Shock Syndrome (TSS)
Dizziness;
Vomiting or diarrhea;
Confusion;
Muscle aches;
Seizures;
Headaches;
Redness of your eyes, mouth and throat;
A rash resembling a sunburn, particularly on your palms and soles;
A sudden high fever;
Low blood pressure;
Clinical evaluation;
Cultures;
Toxoplasmosis
Swollen lymph glands, especially around the neck.
Muscle aches and pains.
Headache.
Fever.
Generally feeling unwell.
Inflammation of the lungs.
Inflammation of the heart muscle.
Inflammation of the eye, for example, the retina (at the back of the eye).
Serologic testing;
CT or MRI and lumbar puncture;
Transient ischemic attack (TIA)
Numbness or weakness, especially on one side of the body;
Sudden confusion;
Difficulty understanding what others are talking about;
Vision problems; Brief unilateral blindness (amaurosis fugax);
Dizziness; problems with coordination; Difficulty walking;
Very bad headache;
Syncope, in some cases;
Face weakness, arm drift;
Abnormal speech.
ECG: arrhythmia (A-fib);
MRI better for infarction;
CT better for hemorrhage, NOT USEFUL FOR ISCHEMIA;
US of carotid artery;
MRI or CT angiogram.
Trauma
RLQ; LLQ; LUQ; RUQ; Generalized pain;
History of blunt trauma, penetraiting trauma
Perforation of TM (ear trauma)
CT if internal damage can't be excluded
Trichomoniasis
An often foul-smelling vaginal discharge — which might be white, gray, yellow or green.
Genital redness, burning and itching.
Pain with urination or sexual intercourse.
History of new sex contact;
Strawberry cervix;
Culture
Trichotillomania
Tricuspid Regurgitation
Fatigue;
Declining exercise capacity;
Swelling in your abdomen, legs or veins in your neck;
Abnormal heart rhythms;
Pulsing in your neck;
Shortness of breath with activity;
Holosystolic murmur heard best at the left middle or lower sternal border (frequently not heard)
Echocardiography
Tricuspid Stenosis
Fluttering discomfort in the neck and an irregular heartbeat;
Cold skin;
Fatigue;
Shortness of breath with activity;
Enlarged liver;
Soft opening snap;
Mid-diastolic rumble with presystolic accentuation;
Echocardiography;
Trigeminal neuralgia
Severe, overwhelming “knife-like” facial pain precipitating by:
Chewing, touching the face, even light tough, talking
None
Tropical sprue
Abdominal cramps;
Chronic diarrhea, which may get worse on a high-fat diet;
Excessive gas;
Indigestion;
Irritability;
Muscle cramps;
Numbness;
Paleness;
Weight loss.
CBC (anemia);
Endoscopy with biopsy
Tuberculosis (TB)
History of exposure; weakness; malaise; weight loss.
Pleuritic chest pain; fatigue; joint pain; lymphadenopathy; sore throat (rare)
Brassy cough;
Weight loss;
Night sweats;
Mantoux test;
Sputum culture - M.Tuberculosis;
Chest x-ray – apical infiltrate;
CT is better than x-ray;
PPD – screening, not for acute symptoms! Risk groups!
R/O Lung Cancer (weight loss, night sweet, cough);
Turner syndrome
Congenital; short stature; abnormal sexual development
webbed neck; low-set ears; shield-like chest; short fourth metacarpal
Karyotype (45, X)
Ulcerative colitis (IBD)
Fecal urgency; Tenesmus; Incontinence; Entirely mucosal, Ab tenderness, pain; Fatigue;
No fistulas, No abscesses; No obstruction; No anal problems
BLOODY DIARRHEA;
B/c of inflammation:
Arthralgia;
Uveitis;
Skin (erythema nodosum, pyoderma gangrenosum);
Liver dz;
Sclerosing cholangitis (more in UC);
Fever, Blood on oral exam, Orthostatic hypotension, Tachycardia
Stool cultures and microscopy (to exclude infectious causes);
Colonoscope with biopsy;
Calprotectin stool test (IBS>50, IBD>150) --> not diagnostic;
CD:
ANCA: CD negative;
ASCA: CD positive;
UC:
ANCA: CD positive;
ASCA: CD negative;
RLQ and LLQ pain; Sudden onset; Excruciating intermittent colicky pain that can progress to constant pain; pain in lower abdomen and flank and radiates to groin; nausea; vomiting; abdominal distention; chills; fever; frequent urination;
Costovertebral angle (CVA) tenderness with big stone; increased sensitivity in lumbar and groin areas;
UA (hematuria); noncontracted-enhanced helical CT; (can pick up uric acid stones); US - can be used for pregnant;; Serum Ca; Na; uric acid; PTH; Mg; P level; 24h urine collection for volume; Ca; Oxalate; Citrate; Cystine; pH; Uric Acid; Phosphate; Mg
PCR (cervical swab, urine);
Gram-stain of discharge;
DNA amplification testing;
Urticaria (Hives; Wheals)
Red, raised welts or bumps on the skin.
Blanching (the center of the hive turns white when pressed).
Itchy skin.
Swelling (angioedema).
Uterine fibroids (Leiomyomas)
RLQ; LLQ pain related to menses and intercourse;
Heavy menstrual bleeding;
Menstrual periods lasting more than a week;
Pelvic pressure or pain;
Frequent urination;
Difficulty emptying the bladder;
Constipation;
Backache or leg pains;
Palpable myomas; The diagnosis of uterine fibroids is likely if bimanual pelvic examination detects an enlarged; mobile; irregular uterus that is palpable;
hCG (pregnancy); CBC (anemia);
Transvaginal US or saline infusion sonography (sonohysterography);
Uterus Adenomyosis
Heavy or prolonged menstrual bleeding;
Severe cramping or sharp, knifelike pelvic pain during menstruation (dysmenorrhea);
Chronic pelvic pain;
Painful intercourse (dyspareunia)
Tender, soft, symmetrical uterus;
Ultrasound of the uterus;
Magnetic resonance imaging (MRI) of the uterus;
Biopsy for r/o cancer
Uveitis
Anterior uveitis: pain and redness of the iris; photophobia;
Posterior uveitis: mild vision abnormalities
Slit lamp examination;
Vaginitis
Abnormal vaginal discharge with an unpleasant odor;
Burning feeling outside of the vagina during urination;
Itching around the outside of the vagina;
Discomfort during intercourse;
Vaginal fluid pH is > 6;
Whiff test is negative;
Microscopy shows predominantly white blood cells and parabasal cells;
Valve disorders (murmurs)
Chest pain;
SOB;
Fatigue;
Fainting;
Palpitation (any signs of valve disease or heart failure);
R-side: ↑with inhalation;
L-side:↑with exhalation;
Left ventricle deletion;
Best initial test: transthoracic ECG;
Echo (best);
Transesophageal more sensitive and specific;
Most accurate test: catheterization (can measure diameter);
EKG: not specific for valvular HD;
x-ray;
Variant angina (Prinzmetal)
Usually occurs while resting and during the night or early morning hours;
Are usually severe;
Can be relieved by taking medication;
ECG
Varicella zoster (chickenpox, shingles)
Varicocele
Pain: from sharp to dull; worse with standing or physical exertion, especially over long periods; Worsen over the course of a day;
Relieved when you lie on your back;
Valsalva maneuver
Scrotal US
Varicose veins
Can cause a sense of fullness, fatigue, pressure, and superficial pain or hyperesthesia in the legs.
Observation: varicose veins may initially be tense and palpable but are not necessarily visible. Later, they may progressively enlarge, protrude, and become obvious. Varicose veins are most visible when the patient stands.
Doppler US
Vascular dementia
Confusion;
Trouble paying attention and concentrating;
Reduced ability to organize thoughts or actions;
Decline in ability to analyze a situation, develop an effective plan and communicate that plan to others;
Difficulty deciding what to do next;
Problems with memory;
Restlessness and agitation;
Unsteady gait;
Sudden or frequent urge to urinate or inability to control passing urine;
Depression or apathy;
CT or MRI of the head
Vasovagal syncope
Pale skin;
Lightheadedness;
Tunnel vision;
Nausea;
Feeling warm;
A cold, clammy sweat;
Blurred vision;
Cleft palate;
Heart problems;
Long face;
Nose with a bulbous tip and small nostrils;
Immune system problems;
Long fingers;
Speech disturbance;
Dental decay;
Nystagmus;
But hearing preserved;
loss of equilibrium always to the same side;
Positional maneuvers; (+) VOR test;
MRI with an additional neurological symptoms (R/O stroke)
Vestibular schwannoma (acoustic neuroma)
Hearing loss, usually gradually worsening over months to years;
Ringing (tinnitus) in the affected ear;
Unsteadiness or loss of balance;
Dizziness (vertigo);
Facial numbness and weakness or loss of muscle movement;
Bilateral;
Watery discharge, most time of the day;
Easy transmission;
NORMAL vision;
Itchy;
May have fever, lymphadenopathy, pharyngitis;
Viral gastroenteritis
Nausea/Vomiting/Diarrhea, AB pain, cramping, myalgias, low-grade fever
Dehydration; hyperactive bowel sounds;
diffuse pain on abdominal palpation
no fecal WBC;
Viral culture;
PCR test;
Viral infection
CBC with dif, PCR
Viral Pleuritis (pleuritis)
Mild, localized chest pain worse with deep breathing;
History of recent URI;
Sharp pain increased with inspiration;
Fever;
Shallow respirations;
Local tenderness;
Pleural friction rib;
Chest xRay
Vitamin A deficiency (Retinol Deficiency)
Vitamin A Toxicity (Retinol Toxicity)
Acute toxicity:
Gastrointestinal: nausea, vomiting, loss of appetite, abdominal pain;
Neurological: dizziness, irritability, drowsiness, increased intercranial pressure due to cerebral oedema, and headache;
Dermatological: rash or desquamation (peeling skin);
Coma and death;
Chronic toxicity:
Gastrointestinal symptoms: hepatomegaly, splenomegaly;
Neurological symptoms: severe headache, pseudotumour cerebri;
Dermatological symptoms: rash, thin and coarse hair, alopecia of the eyebrows, itch, skin that is dry, rough or cracking, and dry or cracked lips;
Musculoskeletal: weakness, cortical hyperostosis of the bone, arthralgia, easy fractures;
Vitamin B12 deficiency (Pernicious Anemia)
Neurological problems (peripheral);
Dementia;
Bilateral spastic paralysis of arms.
Dorsal columns and corticospinal tract affected:
Bilateral loss of vibration, proprioception, fine touch;
Glossitis (including pain, swelling, tenderness, and loss of papillae of the tongue)
Megaloblastic anemia ↑MCV;
Hyperpigmented neutrophils;
B12 level;
↑LDH; ↑indirect bilirubin;
↑Methylmalonic acid;
↑Homocysteine;
Schain’s test – we don’t use it. Is it any problem with intrinsic factor;
Same symptoms except hyperpigmented neutrophils:
R/O alcoholism, liver disease (AST/ALT/bilirubin);
R/O hypothyroid (TSH);
R/O: pernicious anemia (Anti-intrinsic factor antibodies);
R/O: MS;
Vitamin B6 Deficiency and Dependency (Pyridoxine Deficiency and Dependency)
Peripheral neuropathy and a pellagra-like syndrome;
Seborrheic dermatitis, glossitis, and cheilosis;
Depression, confusion, heart problems, seizures.
Rarely: seizures in infants.
Normocytic, microcytic, or sideroblastic anemia;
Clinical evaluation;
Vitamin C deficiency (Scurvy)
Anemia;
Myalgia, or pain, including bone pain;
Swelling, or edema;
Petechiae, or small red spots resulting from bleeding under the skin;
Corkscrew hairs;
Gum disease and loss of teeth;
Poor wound healing;
Shortness of breath (SOB);
Mood changes, and depression;
Skin or gingival findings;
Clinical based on risk factors;
Vitamin D Deficiency and Dependency (Rickets; Osteomalacia)
If only one vocal cord is paralyzed: the voice is hoarse and breathy.
When both vocal cords are paralyzed: the voice is reduced in strength but otherwise sounds normal.
Laryngoscopy;
Imaging studies
Vocal cord polyp
Hoarseness and a breathy voice.
Laryngoscopy
Sometimes biopsy
von Willebrand disease
Bleeding of epistaxis, gingival, gums – superficial bleeding;
Worse after aspirin;
Menorrhagia;
NO PETECHIAE;
Platelets type of bleeding with normal platelets count;
↑PTT in 50% of Pts;
↑bleeding time;
VWF antigen level test – may be decreased, best test;
Ristocetin cofactor activity test – detects VWF dysfunction;
Vulvar cancer
Bleeding or discharge not related to menstruation;
Severe burning, itching or pain;
An open sore that lasts for more than a month;
Changes in the color and the way the vulva looks;
Skin of the vulva looks white and feels rough;
Inguinal nodes – stage 3 and 4;
Biopsy (90% - SSC, 5% - melanoma);
Warts (Verrucae Vulgaris, Common warts)
Weak pelvic floor muscles
leaking urine when coughing, sneezing, laughing or running.
failing to reach the toilet in time.
passing wind from either the anus or vagina when bending over or lifting.
reduced sensation in the vagina.
tampons that dislodge or fall out.
a distinct bulge at the vaginal opening.
Wernicke-Korsakoff Syndrome (WKS)
Double vision;
Ptosis;
Loss of muscle coordination;
Amnesia for events that happen after the onset of the disorder;
Difficulty understanding the meaning of information;
Difficulty putting words into context;
Hallucinations;
Clinical evaluation;
Williams syndrome
Wide forehead;
Bridge of the nose is flattened;
Short nose with a large tip;
Wide mouth with full lips;
Small chin;
Small, widely spaced teeth;
Missing or crooked teeth;
Uneven eyes;
Folds over the corners of the eyes;
White starburst pattern around the iris, or colored part of the eye;
Long face and neck (in adulthood);
Wilms Tumor (Nephroblastoma)
Fever.
Blood in the urine.
Nausea or vomiting or both.
Constipation.
Loss of appetite.
Shortness of breath.
High blood pressure.
Wilson disease
Jaundice;
Golden-brown eye discoloration (Kayser-Fleischer rings, for 5-10% the first symptom);
Fluid buildup in the legs or abdomen;
Problems with speech, cognitive, psychiatric, swallowing or physical coordination;
Uncontrolled movements or muscle stiffness;
Hepatitis (for 50% of patients, mostly adolescents, the first symptom)
Slit-lamp examination for Kayser-Fleischer rings;
Serum ceruloplasmin;
Sometimes serum copper, and 24-hour urinary copper excretion;
Sometimes confirmation by penicillamine provocation test or liver biopsy;