Approach Internal Med

Differential diagnostic algorithm in internal medicine
Differential diagnostic algorithm

in internal medicine

ISBN

iamnutmd@hotmail.com


iamnutmd@hotmail.com

Content

3
4

6
8
9

3.3 Vomiting..........................................................................................................................................................

30

33

36

38
40

43
44


46

63

64

6.4 Bleeding disorder................................................................................................................................

66

68

69

83
84

86
88
90

Content

93
94

96

98
99

9.9 Visual disorder

9.9.3 Visual field defect..................................................................................................................................

Differential diagnostic algorithm in

1

Cardiovascular

disorder


1.1 Chest pain

Chest pain

Cardiac Non-Cardiac

Ischemic Non-Ischemic

ACS
Stable angina

Endocardium Myocardium Pericardium

Severe AS
organ . Pericarditis

Great vessel Pulmonary GI Musculoskeletal Skin

Aortic dissection Pleura Esophagus Costochondritis
Pneumothorax
Pneumonia tear
thoracis Boehavve
Vascular
Stomach
embolism
PU perforate
Pancreatitis
Pancreatitis

202

2

Chapter 1

1.2 Palpitation

Palpitation ...

Organic Psychiatric

Cardiac Non-Cardiac

High output state Metabolic Drug & Med

2 agonist
Volume depletion K Ca Anitcholinergic ephredine

Arrhythmia Non-Arrhythmia

Structural Functional

CHF

Premature beat Irregular Tachyarrhythmia Bradyarrhythmia

PAC AF SVT
PVC VT SSS

Cardiovascular disorder 3

1.3

Syncope

be
Reflex Orthostatic Cardiac
syncope hypotension syncope

Vasovagal Situational Carotid sinus Non-cardiac Cardiac
syncope

Emotion Aortic dissection
Pain PHT
Fear defecation
Phobia visceral pain
Autonomic Volume
Drug - Arrhythmia Structural
Post exercise induced failure depletion

Endocardium
Alcohol Primary Bleed VHD
Vasodilator Diarrhea Atrial
Diuretic Myocardium
Antidepress Secondary

Uremia Pericardium
Cardiac tamponade

Brady Tachy

SSS SVT
VT

Chapter 1

Claudication

Claudication

Vascular Neurogenic
claudication claudication
Cause: Cause:
PE: “Signs of 6P” PE: Paresthesia of leg
P P P
Paresthesia P
Pulseless
Hx: Hx:

LS radiculopathy
Abnormal Thrombophillia Vasospasm Spinal stenosis
vessel Herniated disc
Thrombosis Ergotamine
Atherosclerosis Embolic Iliac or popliteal stenosis
Vasculitis Cardiac origin
arteritis

origin
Thromboangiitis
obliterans

Cardiovascular disorder

Congestive heart failure
aha
Hx Fatigue
3 Hepatojugular reflux
.
±Pleural effusion
1. Precipitating factor 2.

Etiology Precipitating factor

Mnemonic “DIE HEART”
Valvular heart dz Cardiomyopathy Pericardial dz D: Diet
antiHT
Constrictive
pericarditis I: Infection
E: Exercise
Congenital heart Pericardial
effusion H:
Exclude: E:
A: Anemia
R: Valvular
Valvular heart T:

DCM: HCM: RCM: ARVC: Unclassified
V

Alcohol Athletic train Scleroderma Inflammation?

fibrosis
Preg

Chapter 1

Cardiomyopathy
Exclude:

Valvular heart

Familial Nutrition/ Inflammation Deposition Miscellaneous
Metabolic/Toxin

Fe overload induced

Peripartum
Infection Non-Infection

Cardiac sarcoidosis
AIDS
Chagas
Scleroderma

Nutritional Metabolic Toxic
Deficiency (Endocrine)
Alcohol
Thiamine def
L carnitine def Diabetic
Doxorubicin
High dose CY
Taxoid C


HT in the young

SBP or DBP mmHg

Consider secondary HT
EsEssential HT
Still most common

CVS Renal Endocrine Miscellaneous

Coarctation of aorta Adrenal OSA
arteritis - Drug

Pituitary Decongestant
Cushing

Thyrotoxicosis Genetic

Von hippel lindau

Renovascular HT Abnormal kidney Glomerulonephritis
Atherosclerosis CKD
Fibromuscular Abnormal structure
PCKD
Horseshoe

Chapter 1

Pericardial effusion

Pericardial effusion

tamponade
Cardiac tamponade Pulsus paradoxus 20 mmHg

alternan


- Virus: Adeno Trauma Non-Trauma
- Bact:
- High bact: actino
- Ricketsia Borrelia
- Mycobacteria
- Fungus: Histo Coccidio

Tumor CNT Metabolic Drug & toxin CVS

SLE Uremia
Vasculitis
Lung Procainamide Dissecting

Breast aortic



disorder


2.1

Dyspnea

Respiratory Other

Airway Parenchyma Pleura Vascular

COPD Infection Pneumothorax PE
Asthma Pneumonia Hemothorax PHT
Pleural effusion
1 or
ILD

Cardio Metabolic Neuromuscular Psychi

CHF Anemia
Acidosis Panic
.
DKA
ALS
C cord inj

12

Chapter 2

Positional related dyspnea

Lying -> Dyspnea Sitting -> Dyspnea

Orthopnea Trepopnea orthodeoxia
to Lt shunt
Unilateral lung disease Intracardiac shunt
shunt
tumor

Endobronchial tumor
- Intracardiac shunt: PFO or ASD

Abd
to Lt shunt
- Intrapulmonary shunt:

Respiratory disorder 13

2.2 Cough

Cough
Duration of cough
3 Subacute 3

Respiratory Other

Airway Parenchyma

Infection
Bronchitis Pneumonia
TB
1 or
Foriegn ILD
Bronchiectasis

Cardio GI ENT Drug Other

CHF Allergic rhinitis ACEI mass
Sinusitis

reflux

Duration of cough Acute Subacute Chronic
Common causes Post infectious cough
Acute decompensate HF

Chapter 2

Respiratory disorder

2.3

Hemoptysis

Systemic bleeding
Local v.s. Systemic bleeding

Pseudohemoptysis
True v.s. Pseudohemoptysis Epistaxis
Hematemsis

True hemoptysis
Massive hemoptysis criteria
1. 200
2. hr
resuscitation close observe

Airway Parenchyma Vascular Miscellaneous

Infection Infection
Bronchitis Lung abscess
Bronchiectasis Pneumonia hemosiderosis
Tumor
Tumor
- Bronchogenic CA vs
Trauma
Lung contusion
Small vascular

Chapter 2

Cyanosis

Peripheral cyanosis Central cyanosis

Spare mucous membrane

Cold exposure Low O2 sat Hb abnormal
Venous obstruction
Arterial obstruction
PAD Sulfhemoglobinemia
Emboli

RS Low FiO2 Cardio

Cyanotic heart Dz “5T+2E”
Parenchyma Vascular
5T
Alveolar TOF fallot
PE
Diffusion defect TA Truncus Arteriosus
Tricuspid atresia

2E
Ebstein

Einsenmenger


Clubbing of finger

Clubbing of fingers
5 signs of clubbing of fingers
Floating nail sign
sign

Primary Secondary

Familial or idiopathic

Cardio Pulmonary GI Miscellaneous

- Neoplasm Cirrhosis - Endocrine
Infective endocarditis Bronchial carcinoma
Lung metastasis disease
Ulcerative colitis - Hematologic
- Chronic lung disease Celiac disease
Bronchiectasis Esophagus

IPF - Autoimmune
-Infection
Lung abscess

Chapter 2

Pleural effusion

Pleural effusion
Inspection:
Percussion: Dullness on percussion
CVS
Palpation:
CHF
Auscultation: Decr Decr

Exudate Transudate Cirrhosis

13 Cirrhosis
Prot Renal
odorless
LDH pleua 2 3 Peritoneal

Urinothorax

Myxedema

Malignancy Infection CNT Drug GI Other

thoracis Pancreatitis - OB-GYN:
Parapneumonic SLE Amiodarone Abscess
effusion CSS Ergotamine liver abscess Vascular: PE
TB pleuritis Splenic abscess Hemothorax
Sjogren Subphrenic - Chylothorax
Parasite absces - Pseudochylothorax


Congestive heart failure
Signs of chronic liver disease and ascites

Connective tissue disease
Drug induce

pain

20


3

disorder


3.1

Jaundice
3

Hemolytic jaundice Hepatocellular jaundice Obstructive jaundice
Hx: Anemic sx FamHx Hx: Flu sx Hx Hx: Abd
Drug Hx
PE: person PE: ± mass in abdomen
LFT: indirect bilirubin PE: signs chronic liver LFT: ALP

LFT: Isolated Bilirubin or
and Bilirubin
- Intrinsic Factor - Choledocholithiasis
Str - Bile duct dz
1 Sclerosing cholangitis
Hb Post surg
AIDS
- Extrinsic factor Cholangiocarcinoma
- Extrinsic compression

-”Periampullary CA”
1. CA head of pancreas
2. CA Ampulla of Vater
3. CA 2nd part duodenum
. Cholangiocarcinoma

Hemolytic jaundice

Obstructive jaundice

Hepatocellular jaundice

22

Chapter 3

Hepatocellular jaundice

Isolated hyperbilirubinemia Hepatocellular injury Hepatic d/o with
prominent cholestasis

Direct Indirect - Diffuse infiltration
% % sarcoidosis

Dubin - Increase production
- Cholangiocyte injury

- Decrease Uptake Bactrim
rifam - Other
- Decrease conjugation Benign recurrent intrahep
Crigler
indinavir

Acute liver injury Chronic liver injury
- Viral:
Liver cirrhosis
Non viral: Lepto
Alcohol
Drug: Paracetamol Alcohol Virus Genetic Cardiac Biliary Other
Toxin: Cirrhosis Cirrhosis
HBV AIH
HCV Hemochromatosis PBC
1 def PSC
Autoimmune

Gastrointestinal disorder 23

3.2

Dysphagia

Oropharyngeal Esophageal

Structural Propulsive

Intrinsic narrowing
Neuro Muscular
Plummer Vinson
diverticulum CNS NMJ

Extrinsic compression Muscle
Brainstem lesion -
PNS:
ALS, MS

Structural Propulsive

Progressive Intermittent Variable
Achalasia
Eosinophilic DES
ring esophagitis Scleroderma
Peptic stricture
Hiatal hernia

Chapter 3

3.3 Vomiting

Vomiting

Intracranial and Pericranial Extracranial

Brain Vestibular Eye

Increase ICP
“
”

:
:
: Tumor
:
idiopathic: Pseudotumor cerebri

GI GU Metabolic Drug & toxin
Endo: Drug
Functional Organic Stone -
IBS “Obstruct Inflam” PID Nephro:
Toxin
Organophosphate
Obstruction Inflammation
- Stomach:
- Hep-Bili:
- Pancreas: Pancreatitis
- Bowel:

Gastrointestinal disorder

Hiccup

Hiccup

2 3 minutes

1 Hr
1 Hr * *

Diaphragm Mediastinum CNS Metabolic Drug & toxin
Irritation Irritation

- Vascular Uremia Alcohol
Subphrenic abscess Ischemic
Peritonitis ICH Ca Barbiturate
- Infection Dexamethasone

Encephalitis

- Tumor
- Autoimmune

organic

Chapter 3

Upper Gastrointestinal bleeding

Hx:
Stools:

Variceal bleeding Non-Variceal bleeding

Signs of portal HT medusae

Esophageal varices
varices
Duodenal varices

Ulcer/erosive Traumatic/Post Surg Tumor Vascular malformation

Adenocarcinoma lesion
Peptic ulcer disease Esophagitis Aortoenteric Vascular lesion
fistula
Hemobilia telangiectasia
Osler
Ellison antral vascular ectasia


Lower Gastrointestinal bleeding

Hx: 6
Stools:

anogenital cause
Hemorrhoid

Diverticular disease Angiodysplasia Colitis Neoplasm
Infection
Ischemic colitis Carcinoma
Crohn

small intestine bleeding

Chapter 3

Acute diarrhea

Acute diarrhea

2 2

Infection Non-Infection 10

Drug
Watery diarrhea Mucous bloody diarrhea
Organophosphate
Toxin

Virus
Vomiting Abd pain
dominant dominant Bacteria Food Anaphylaxis
- Cytotoxin Allergy
Disease caused Disease caused difficile diverticulitis
Toxin Organism V. Inflam. IBD
- Mucosal invasion

Virus Shigella
Food poisoning Salmonella Infarct Ischemic colitis
Bacteria Aeromonas
Enterotoxin from Plesiomonas
S. aureus
Aeromonas Protozoa
B. cerues E.
C. perfringen C. difficile

Protozoa
lambia


Chronic diarrhea

1

Exclude Fecal incontinence
Feces impact
IBS: Irritate bowel syndrome
Abd 3 mo in last 3 mo + 2 3
Step 1 Functional
Organic vs Functional
Change form of stool

Organic
Bacteria Salmonella

TB
Infection

Parasite
Step 2
HIV
HIV vs non HIV Isospora Belli
parvum

Non-HIV
Kaposi
Drug Protease inhibitor
Step 3
vs vs
AIDS

30

Chapter 3

2
Step 3 vs vs

Watery Bloody Fatty
Step 4.1: Osmotic vs Step 4.2: Step 4.3
- Cancer vs
- Infection
Osmotic Secretory

Fasting Fasting
- IBD: Crohn
Stool large vol - Ischemic bowel
- Laxative agent
- Autoimmune
- Other drug - Endocrine
SpA
neuro.
- Lactose/Maltose/ - Neuroendocrine
Fructose/Sucrose VIPoma 1
intolerance
- Hyperosmol - Infection

enteral feeding

Intraluminal maldigestion Mucosal malabsorption Post-mucosal
D D Lymph obstruction

Pancreatic enz Bile Bacteria Local mucosa
overgrowth Capilaria
Pancreatitis Cirrhosis
Pancreatic duct

obstruction


Abdominal swelling
F

Fetus
Fat Flatus Feces Fluid Fatal growth
(Ascites) Abd

Constipation
Ileus

AAA
Full bladder

Common etiology
Cirrhosis %
Other PHT related disorder %
Cardiac disease 3%
Peritoneal Carcinomatosis 3%
other nonPHT related disorder 2 %

32

Chapter 3

3.10 ascites

Ascites
Abd
ve
ve

Portal Hypertension Non-Portal Hypertension
1.1 1.1

Hepatic congestion Liver dz Portal vein
occlusion

CHF Cirrhosis
Constrictive Alc hepatitis
pericarditis
metastasis
Budd Chiari
liver of preg

Peritoneal disease Hypoalbuminemia Miscellaneous
1.1 1.1 1.1

ascites
carcinmatosis peritoneii Prot losing Pancreatic ascites
Vasculitis Severe malnutrition urine ascites
Ovarian
1.1




Reduction in urine volume

Exclude: Urinary retention

Anuria Oliguria

100

Total Bilateral Other Prerenal Intrinsic Post renal
renal obstruction
obstruction occlusion
Cortical necrosis

Stone
obstruction
Tumor

Chapter 4

Urinary tract obstruction

Lower urinary tract obstruction Upper urinary tract obstruction
vesicoureteral junction vesicoureteral junction

Acute urinary retention Oliguria/Anuria
From upper tract obstruction

Anatomical Functional
obstruction obstruction Intrinsic Extrinsic
obstruction obstruction
- Bladder - Neurogenic bladder
- GU
Preg
-Prostate - Urethral valve - Vascular
Anticholinergic
Prostatitis Antidepressant -GI
-Urethral stricture Levodopa Tumor
-Retroperitoneum
Intraluminal Extraluminal
Tumor
Stone - Functional
Blood clot Uerteral Vescicle

- Anatomical

Renal disorder

Azotemia = Cr Out of proportion BUN Out of proportion Cr
1. Urea generation 1. Creatinine generation
Catabolic state
Step 1: Exclude out of proportion
2. Creatinine secretion
Aminoacid infusion Cimetidine
Trimethoprim
2. Steroid 3. Jaffe reaction

Step 2: CKD definition: or function
disease

Feature of CKD:

AKI definition:
SCr 48 hrs
SCr 7 days
Urine hr for 6 hours

Step 3: Post renal

Pre renal Intrinsic Renal Post renal obstruction

tract obstruction

Hypovolemia Decrease effective Decrease Impair renal
Circulatory volume Cardiac output Autoregulation

Liver failure
Cardiac failure
Cisplatin

Chapter 4

Intrinsic renal causes

Vessel Glomerulus Tubule Interstitium

Mnemonic “A+3I”
Allergic:
Infection:
Large vessel Small vessel Infiltration:
Inflammation: Sjogren
Renal artery Vasculitis
Tubular Intratubular obstruction
Vasculitis DIC
Renal vein
Thrombosis Atheroemboli Endogenous Exogenous
Abdominal compartment Calcineurin
syndrome inhibitor
Uric acid
Cellular debris

Ischemic ATN Nephrotoxic ATN

Endogenous

Exogenous

Renal disorder

Polyuria

3

Water diuresis Mix Solute diuresis

Uosm Uosm Uosm
mOsm 2O mOsm 2O mOsm 2O

Water deprivation test 2 Una +
Uosm

Central
DI DI Non Electrolyte Electrolyte
Diuresis
Diuresis

Diuretic
Contrast Anion
Urea

Chapter 4

DDAVP
1 Central DI

10%
10% 2

Partial Central DI

Renal disorder

Edema

Edema

Localized Generalized
eg

Venous Lymphatic Other
obstruction obstruction
- Inflammation
DVT CA infiltration Cellulitis
Irradiation
Scar from trauma - Trauma
Filariasis

Heart failure Renal disease Liver cirrhosis Hypoalbuminemia Other

Protein losing
Drug

volume overload Estrogen
CCB
Idiopathic

High altitude

Chapter 4

Red urine

Centrifuge urine result

Supernatent

Hematuria Heme

Positive

Supernatent Plasma color Heme –ve red urine

Sediment Beeturia
Clear Red
Food color
Centrifuge urine Myoglobinuria Hemoglobinuria
Doxorubicin

Renal disorder

Hematuria

Hematuria
3

Exclude: Bleeding disorder
Plt Plt
Exclude:

Glomerular Non-Glomerular
Micro: Micro:
Proteinuria: variable Proteinuria:
Appearance: no clot Appearance: Clot

Isolated With
Hematuria proteinuria

Alport
Thin basement
membrane

Vascular Interstitial Uroepithelium Site unspecified

Arterial thrombosis
or embolism Interstitial neprhitis Trauma
AV malformation
Exercise

Chapter 4

Asymptomatic proteinuria

Proteinuria 3 000

Intermittent Persistent

Functional proteinuria Orthostatic proteinuria

Heart failure 1 gm

reninemic state

Overflow proteinuria Tubular proteinuria Fixed non-nephrotic
Glomerular proteinuria
Light chain Tubulointerstitial disease

Renal disorder

Neprhotic syndrome

gm
gm
lipiduria

Primary Glomerular Secondary Glomerular
w/o ->

4M + 1F
M: M:
M: M:
F:

Med/Chemical Infection Neoplasm Autoimmune Metabolic
& Miscellaneous

- Virus - Solid SLE
Heroin - DM***
- Med - Bacteria Colon Vasculitis
- Leukemia
Captopril - Malaria - Lymphoma Pre eclampsia
Probenecid
Penicillamine
Pamidronate

MCD: change disease IgMN: MN:
FSGS: Focal segemental glomerulosclerosis MPGN: glomerulonephritis

Chapter 4

Rapidly Progressive Glomerulonephritis (RPGN)

Histo Cresentic

ANCA associated AntiGBM Immune complex
ve
ve C3
Histo Pauci immune Histo Histo

P ve C ve + ve Lung ve Lung
3S”
hemorrhage hemorrhage
MPA
Anti C
CSS Churg I

M
F
I
S
S
S

CML

Renal disorder


Endocrine

disorder


Short stature

Short Stature

Height < 3rd percentile: cm

arm span ±
Pubertal staging

Normal variant Pathological Idiopathic
adult 11
FSS
Disproportion Proportion

Short Limb Short Trunk Prenatal Postnatal

Scoliosis
Chronic
Turner thalassemia
MPH: Mid Parental Height
Endocrine
Prader def
Silver
Cushing
Pseudo

Chapter 5

Tall stature

Tall Stature

Height > 98th percentile: cm

arm span ±

Variation of normal Primary growth disorder Secondary growth disorder
growth
Sex chromosome Overgrowth Syndrome with
Familial tall stature
disorder syndrome tall stature

Klinefelter Sotos

XYY 2B
XXX

Growth hormone Hypogonadism Hyperandrogenism Hyperthyroidism
Precoccious
excess Pubery

Adrenal tumor
Sex hormone def.
Estrogen resistance

Gonadotropin dependent Gonadotropin independent

Idiopathic

Testotoxicosis
Testicular tumor

Endocrine disorder

FreeT4

Normal

or Subclinical

TSH

ormal

Subclinical Free T3 Subclinical
TSH TSH

ormal ormal
Normal

ormal
Inappropriate
TSH secretion illness

Chapter 5

Hypoglycemia
Whipple’s Triad
1. Low Plasma glucose: or
2. Hypoglycemic Symptoms

3. Resolution of symptoms: after Plasma glucose

Non-DM DM

Drug

Critical illness Medication Endocrine disorder

Adrenal insufficiency
Hepatic failure Alcohol Islet cell tumor
Cardiac failure Other Endogenous Hyperinsulinism
Sepsis Insulinoma
indomethacin Functional B
insulinoma pancreatogenous

Post

Endocrine disorder

Breast enlargement in male
lipomastia in obese
subareolar mass
Other Breast Mass subglandular tissue

True gynecomastia
Physiologic

Drug Systemic disease Endocrinopathy Tumor

- Spironolactone* Cirrhosis Testicular tumor
- GI drugs: CKD Androgen cell
- Hypogonadism
Adrnocortical tumor
- CVS drugs: Ectopic ACTH secreting
Amiodarone tumor

- ATB
Prepubertal testicular failure Destructive lesion of Testes

- Antidepress: TCA
- Antipsychotic
- Hormone: Estrogen Orchitis

Chapter 5

Nipple discharge

Serous fluid Galactorrhea Bloody fluid

Duct ectasia Intraductal carcinoma
Duct papilloma Duct papilloma
Physiologic
cause

Breast feeding

Pathologic galactorrhea

Drug Systemic disease Endocrinopathy

- GI drugs: CKD
Cimetidine
Cirrhosis
Domperidone
- CVS drugs:
Hypothalamus Pituitary

- Antidepress: Trauma Prolactinoma
- Antipsychotic Tumor
- Hormone: Estrogen Infiltration adenoma

Endocrine disorder

Amenorrhea

Amenorrhea

Exclude:

Primary Amenorrhea Secondary amenorrhea

1. 2 sex characteristics 1.
2. 2 sex characteristics 2. 3

Abnormal Normal
Uterus & outflow tract Uterus & outflow tract

Imperforated Hypergonadotropic Hypogonadotropic Eugonadotropic
Hypogonadism Hypogonadism Hypogonadism
agenesis Androgen LH

Kuster Hauser Vanishing testes 46,XO Congenital Prolactinoma
Turner Kallman CAH
reductase 46,XX Cushing
Premature Systemic illness
ovarian failure Tumor
PTH

Eating d/o

Chapter 5

Secondary Amenorrhea

Exclude:

Exclude Abnormal outflow tract:
Uterine

Hyperandrogenism Hypogonadism
Hirsutism, acne

Androgen secreting tumor FSH
21

ormal

Hypergonadotropic Eugonadotropic Hypogonadotropic
Hypogonadism Hypogonadism Hypogonadism

Prolactinoma

Asherman Isolated

amenorrhea
Chronic illness

Endocrine disorder

amennorrhea

1. 2. 3

+ve
Step 1: Perform pregnancy test Pregnant

ve TSH or

Step 2: Check serum TSH, abnormal
Prolactinemia
Prolactin, FSH

normal FSH Ovarian failure

Step 3: Progestin challenge test
acetate
Bleeding
Primolut 10 mg Anovulation

10 mg
ve Idiopathic
Hirsutism anovulation
+ve
Step 4: Estrogen +
PCOS:
Progesterone challenge test
Androgen secreting tumor
2 mcg 21
20
Progestogen 21
2

Bleeding

Amenorrhea

Chapter 5

Hirsutism
Androgen dependent excessive male
Step approach
1. Hirsutism scoring scale of Ferriman and
2.
3.

Hyperandrogenism Other endocrine d/o Drug True hermaphroditism

Androgens
OCP containing
androgenic progestins

Gonadal Adrenal Peripheral
conversion
PCOS CAH
Ovarian Adrenal
neoplasm Idiopathic
Ovarian neoplam

Virilization

High level of androgen
Increase Libido
deepening

Ovarian neoplasm Adrenal neoplasm

Endocrine disorder


Hematologic

disorder


Anemia

Anemia
Anemic sx Hb in same population

Normal Hb > 11 g/dl > 11.5 g/dl > 12 g/dl > 13 g/dl

Population mo 12

Decrease production Increase destruction Blood loss

Trauma

Nutritional deficiency Anemia in BM disorder Ineffective
anemia systemic dz Hematopoiesis

ACD Thalassemia
anemia Anemia of CKD
B12

Intrinsic cause Extrinsic cause

aplsia Drug

Chapter 6

Hemolytic anemia

Intrinsic RBC cause Extrinsic RBC cause

Structural Acquire

Membranopathies Enzymopathies Hemoglobinopathies

HS Hb CS
HE Thalassemia

Immune Microangiopathies Infection Chemical agent

TTP Spider venom
Autoimmune Alloimmune HUS Clostridium
DIC
Lymphoproliferative Transfusion Severe PreEclampsia
reaction
CLL
Autoimmune Prosthesis valve

Infection

CA:
Drug:

Hematologic disorder

Pancytopenia

Hypocellular marrow Hypercellular marrow

Aplastic anemia
Primary BM dz Secondary to systemic
Fanconi anemia
disease

Diamond

Osteoporosis

Metastatic Autoimmune Nutritional Infection Other
Solid tumor & toxin
SLE Storage
Common cause Sjogren B12 sepsis
1.
2. Alcohol Brucellosis Sarcoidosis
3.
Ehrlichiosis

anemia
Splenism
SLE

Chapter 6

Bleeding disorder

Bleeding disorder
Bleeding disorder

Platelet disorder Coagulation disorder

Clinical feature Clinical Feature

Petechiae Hemarthrosis

Platelets count


Platelet dysfunction

Congenital Acquire

Defect in Coagulation factor
von disease Extrinsic Platelet d/o Intrinsic Platelet d/o
Afibrinogenemia

Defect in Platelet receptor
thrombasthenia
Bernard Soulier
Systemic dz Drug induced
Defect in granule content Uremia Antiplatelet
Inh TXA2
Paraproteinemia Inh Clopidogrel
DIC Inh Abciximab
Other
Inh TXA2

Inh Ca
Inh

Chapter 6

Thrombocytopenia

Exclude:

Production Destruction Splenic Dilutional
sequestration Thrombocytopenia

Congenital Acquire Non-Immune Immune

Aldrich DIC
Hgglin
Severe Idiopathic Secondary
Preeclampsia
ITP

Primary BM dz Secondary to Autoimmune Infection Drug
systemic disease
Aplastic anemia SLE HIV HIT
HCV
Penicillin

Malignancy Nutritional Infection Medication Other
deficiency
Solid tumor Alcohol
B12 Sulfonamide

Alcohol Estrogen
Procainamide


Coagulopathy

Isolated PT PT & aPTT Isolated PTT

Congenital Acquire Heparin

Factor VII Liver disease
Bleed
DIC Clot

FVII inhibitor
TT

Correct Not correct Correct Not correct

Factor 11 Factor 11 Factor 12 def Antiphos
inhibitor def pholipid
PK def

TT normal TT Heparin

Inhibitor Deficiency Congenital Acquire

Factor 10,5,2 Factor 10, 5, 2 def Afibrinogenemia DIC
inhibitor Liver disease Hypofibrinogenemia Liver disease
Vit K def Dysfibrinogenemia
Venom

Chapter 6

Venous thrombosis

Venous thrombosis
Presentation:
Etiology: 3
1. Venous stasis 2 3. state

Vascular injury Hypercoagulable state
Venous stasis
“Thrombophilia”
Varicose vein
Venous vascular
Congenital Acquire
anomalies
disease
Antithrombin
Orthopaedic

Factor V Leiden
Prothrombin 2010A

Active Hematologic Medication Autoimmune Miscellaneous
Malignancy disease
Hormone Antiphospholipid
Estrogen
Myeloproliferative
disease Progesterone SLE
PV Oral contraceptive HIV infection
ET pill
Other SERM
DIC, TTP, PNH Chemotherapy

- HIT L asparginase
Thalidomide
Antiangiogenesis


Lymphadenopathy

Generalized Localized

Malignancy Infection Immunologic Miscellaneous

SLE
Hematologic Metastasis Sarcoidosis
Castleman disease
Kimura disease

Indolent Aggressive
SLL DLCL
FCL
Virus Bacteria Mycobacteria Other
HIV Steptococcus TB Toxoplasma

Infectious
mononucleosis
FCL
L DLCL
Chapter 6
Localized Lymphadenopathy of head and neck region
Lolcation Drainage Etiology

Submandibular
Submental
Jugular
Posterior cervical
nodes
Suboccipital Scalp and head Local infection
Postauricular Local infection
Preauricular
Right supraclavicular node lungs, esophagus

cancer
Left supraclavicular node abdomen via thoracic duct
Localized Lymphadenopathy of upper and lower limb region
Location Drainage Etiology
Axillary
Epitrochlear Ulnar aspect of forearm and hand
Inguinal
plague
Chapter 6
Splenomegaly
Massive Moderate Small

Splenomegaly Splenomegaly Splenomegaly
- Chronic Myeloid Leukemia

- Myelofibrosis - Portal hypertension - Infection
- Thalassemia major - Hematologic disease Hepatitis
Bacterial endocarditis
- Storage disease -Hematologic disease
disease anemias
Hepatosplenomegaly -Connective tissue diseases

Chronic
- Hematologic disease
- Infiltration
- Infection sarcoid
acute viral hepatitis - Cyst
infectious mononucleosis
- Infiltration
sarcoid
- Connective tissue disease: SLE
Infectious
disease
Prolonged fever and classic FUO
Prolonged fever and Classic FUO

Prolonged Fever = Fever more than 3
Classic fever of unknown origin (Classic FUO) = 3 criteria
1 ° 2. Duration 3 3. failure to reach a diagnosis despite 1 investigation
FUO neutropenic FUO HIV
Malignancy CNT dz Miscellaneous
Localized abscess Vascular infection Systemic infection
Bacterial endocarditis
Bacterial aortitis
Vascular Catheter related infection
GI Hepatobiliry GU Other
Diverticulitis Liver abscess Perinephric abscess

Appendiceal Prostatitis Cat scratch disease
abscess Cholangitis PID ThromboPhlebitis
Pancreatic abscess
Virus Bacteria Microbacteria Tropical infection Other
Infectious Salmonellosis Tuberculosis Fungus

mononucleosis Bartonellosis Leptospirosis Aspergillosis
HIV infection Brucellosis PCP
Legionnaires disease intracellurae Histoplasmosis
Yersinia infection Tularemia
Chapter 7
Prolonged fever and Classic FUO: Non infectious cause
Connective tissue disease Malignancy Other
Malignant
Vasculitis
SLE
and D
Sarcoma
Hepatocellular carcinoma
Benign
Atrial
disease
Drug fever Thermoregulatory disorder Miscellaneous
Antibiotic Central cause arthtitis

Sulphonamide Brain tumor Bullous pemphigoid
Cerebrovascular accident
Encephalitis malingerer
Peripheral cause
Infectious disease
Fever with jaundice
Alcoholic hepatitis
Hepatobiliary infection Systemic infection Sepsis with

other cause of jaundice
Viral hepatitis - Virus:
Liver abscess Infectious mononucleosis Hemolytic jaundice
Cholangitis - Severe bacterial sepsis HbH
Streptococcus AIHA
Klebseilla. E. coli Hepatocellular jaundice
Salmonella Liver cirrhosis
- Mycobacteria
TB
- Tropical dz
Leptospirosis Dubin
Chapter 7
Fever with Splenomegaly
- Autoimmune
SLE
Still disease
- Malignancy:
Virus Bacteria Microbacteria Tropical infection Sepsis with

other cause of
Infectious Infective TB splenomegaly
mononucleosis endocarditis
Enteric fever Thalassemia
anemia
Infectious disease
disease
Joint pain
Referred pain
Extra pain
articular
Periarticular Tendinitis
Arthritis
Bursitis
Acute (< 6 weeks) Chronic (> 6 weeks)
Mono Oligo Poly Mono Oligo Poly
Infection Migratory pattern Infection Infection SpA

Bacteria virus TB SpA
Crystal Fungus
Crystal
CPPD Additive pattern PsA
Trauma
Intermittent
Palindromic
Chapter 8
Low back pain
Mechanical LBP (97%) Non-mechanical Referred pain(2%)

spinal condition (1%)
Lumbar sprain/strain Pelvic organ
Lumbar Disc Prostatitis
Degeneration Endometritis
Herniated disc Chronic PID
Bone Renal disease
Osteoporotic compression Fx
Traumatic Fx Perinephric abscess

AAA
GI disease
Pancreatitis
Penetrating ulcer
Neoplasm Infection Inflammatory arthritis
Septic Psoriatic
Paraspinous abscess
Cord tumor Epidural abscess
1 vertebral tumor
Rheumatologic disorder
Raynaud’s phenomenon
Primary Secondary
Feature Primary Secondary
Digital involvement
gangrene Absent Present
Lab Abnormal
Other
CNT dz Arterial occlusion Drug Other
Occupation
Ergotamine
Sjogren PVC exposure
SLE Cocaine Vibration exposure
Vascular dz Micro Hyper Metabolic
emboli coagulable state
Atherosclerosis
Antiphospholipid Infection
Thromboangiitis Protein C or S
Obliterans
Paraproteinemia Kimura dz
disorder
Headache
Headache
Primary headache Secondary headache
Tension
Organic Psychiatric
Cluster headache
Other
Exertional headache Non-trauma Head or Neck Trauma
Stabbing headache
Cough headache Post traumatic headache
Post
Paracranial Intracranial Systemic
Systemic Infection Non-Infection

intracranial cause
of headache Bacteria
Virus
Eye Ear Nose Other Hypertension Substance Homeostasis disorder
Otitis media Toothache HT crisis
Ocular inflam Fasting

Pre eclampsia
Use Withdraw
Alcohol Caffeine
PDE inhibitor Opioid
Food Estrogen
Chapter 9
Intracranial cause of Headache
Brain abscess Vascular Non-vascular

Encephalitis
Hemorrhage Vascular Arteritis

malformation
ICH
SAH Cerebral angiitis
Neoplasm High CSF pressure Low CSF pressure
Benign Post dural puncture

CSF fistula
12 Pseudotumor cerebri Idiopathic intracranial
Acoustic neuroma
Malignant
3 glioma
Neurologic disorder
Drop attack
Without loss of consciousness Loss of consciousness
- Presyncope
Transient
Vertebrobasilar
ACA Coma
Short duration
3rd Aborted SCD
Spontaneous
Chiari malformation
Otolithic crisis
Yes
T-LOC: Transient
Loss of consciousness
Non-trauma Trauma
Brain concussion
Chapter 9
Syncope Seizure
Trigger Common
Sweating and nausea Common

Aura Common
Pallor Common
Cyanosis Common
Duration of LOC
Movements
Automatisms Occasional
Tongue biting, lateral Occasional

Frothing/hypersalivation Common
Confusion/disorientation
Diffuse myalgias
Neurologic disorder
=
2
Seizure like symptoms
Step 1:
Sleep Disorders
Neurologic disorder
Metabolic/Drug/toxin
Step 2: Precipitating factor Other
Sleep deprivation
Catamenial
Recurrent unprovoked seizure

Step 3: New VS Recurrent
New onset seizure
Neurologic disorder Systemic disorder
Stroke Head trauma Vascular Infection Brain

tumor
Vascular Encephalitis
malformation
Metabolic Medication Drug abuse and toxin Other
AED poor compliance Alcohol intoxication

Ca Eclampsia
Uremia
Cocaine
Chapter 9
Epilepsy in adult
2
Genetic Structural/metabolic Unknown cause
1. Idiopathic generalized epilepsy
2. Benign childhood with centrotemperal seizure

3. Neurocutaneous
Tuberous sclerosis
Sturge
4. Epileptic encephalopathies
Lennox
Mesial temporal Localized lesional Hemispheric Other

lobe epilepsy epilepsies epilepsies
Cavernoma Post traumatic

encephalomalacia
Tumor
Neurologic disorder
Alteration of consciousness
1.Level of consciousness:
2.Content:
deficit
Alteration of consciousness
Abnormal level of consciousness Abnormal cognitive function

3
1. Drowsiness: Delirium
acute mental status change
Alertness in brief period abnormal and fluctuating attention
2. Stupor:
3. Coma:
can not be aroused
Delirium
Abnormal level of consciousness

Chapter 9
Abnormal level of consciousness
Exclude condition mimic coma
Persistent vegetative state

Abulia mutism
Catatonia
Without focal With signs of With focal

neurological signs meningeal irritation neurological signs
Infection Vascular Other
SAH due to Carcinomatous

meningitis
Trauma embolism
Infection Vascular Tumor Other
Brain abscess Ischemic/Hemorrhage

Cerebral hemisphere surrounding edema Venous sinus
Brain stem thrombosis
Cerebral vasulitis
Neurologic d/o Systemic d/o
Infection Trauma Vascular Other
Encephalitis Brain concussion Status epilepticus

Eclampsia
TTP
Intoxication Electrolyte Endocrine Metabolic Severe Other

sepsis
Alcohol
Sedative Ca
Opiate
Adrenal crisis
Neurologic disorder
Delirium
Delirium
DSM-V 2013 criteria for delirium due to a general medical condition
1.
2. Change in cognition
3. Caused consequences of general medical condition
. Develops over a short period of time
Fluctuate
Neurologic disorder Systemic disorder
Cerebrovascular Autoimmune Tumor Infection

disorder
vasculitis Diffuse brain
metastasis Encephalitis
cerebri Brain abscess
Medication Electrolyte Endocrine Metabolic Sepsis Other

Drug/toxin
BS Perioperative
Ca
PTH
Adrenal insuff.
12
Medication Drug Toxin

abuse
Inhalant
Alcohol CO
Anticholinergic Cocaine Pesticide
opiates
Ketamine
Chapter 9
Neurologic disorder
Quadriparesis Paraparesis
2
Hemiparesis Monoparesis
Proximal muscle weakness Distal muscle weakness

Chapter 9
Approach to Hemiparesis
Hemiparesis
Cerebrum Brainstem
Cortical Subcortical Brain stem level
Characteristic Cortical lesion Subcortical lesion Oculomotor hemiplegia
Weakness Abducen hemiplegia
Cortical signs
Stroke Demyelination Tumor
Embolic
Thrombosis
Hemorrhagic
Vascular Trauma Tumor Infection Other
Brain contussion Brain abscess

Subdural hematoma
Epidural hematoma Hemiplegic
migraine
Clinical characteristics Lesion
Contralateral ventroposterolateral nucleus of the thalamus

Contralateral posterior limb of the internal capsule or
contralateral basis pontis
thirds
Neurologic disorder
Approach to paraparesis
Paraparesis
UMN lesion LMN lesion
Cerebral cortex Spinal cord
Parasagittal lesion
Spinal cord disorder
Artery Vein Tumor
Cerebral venous Parasagittal

thrombosis
Anterior horn cell Conus medullaris Cauda equina Bilateral LS Polyneuropathy

plexopathy
Tumor Tumor
Infiltrative disease
Spina bifida Infection
Arachnoiditis Diabetic
ALS
Abscess
Trauma
Characteristic Conus medullaris Cauda equina

Weakness
Sensory loss
Bowel-Bladder involvement Late onset
Other
Chapter 9
Proximal muscle weakness

Hx:
PE: Tricep
NMJ Myopathy Polyneuropathy

Hx: Hx: Hx:
PE: Proximal muscle weakness autonomic sx
PE: Areflexia PE:
Areflexia
- Guillain-Barre syndrome
- CIDP
Pre synaptic Postsynaptic - Porphyria
Lambert Eaton
Botulism
venom
Congenital Muscular Metabolic Inflammation Drug & Toxin Elyte + endo

dystrophy disease
Immune Electrolyte
Central core def. Chloroquin
Centronuclear Duchene Lipid storage Steroid Ca
Tetradotoxin P
dreifuss Endocrine
Limb girdle
Fascioscapulohumeral Non-immune PTH
infection
Neurologic disorder
Distal muscle weakness

Hx:
Peripheral neuropathy Myopathy
Myotonic Distal Nemaline Metabolic

dystrophy myopathy myopathy disorder
Early adult onset Late adult onset def

Debrancher def
1 1
2 2
3 Laing
3
Hereditary Demyelination Metabolic Drug/toxin Infection Other
Charcot Tooth CIDP HIV def

HBV Paraneoplastic
HCV Vasculitis
Drug Toxin
Alcohol
Colchicine Lead
Arsenic
Placlitaxel
100
Chapter 9
Approach to quadriparesis
Quadriparesis
UMN lesion LMN lesion
Polyneuropathy Myopathy
Etiology: Etiology:
Proximal mucle
Cerebrum Brainstem Spinal cord
Lesion : Bilateral - Vascular Lesion : Cervical level

Bilat. Basal ganglion
Bilateral Cortex
- Infection Etiology:
Etiology Brainstem abscess Spinal cord disorder
Brainstem encephalitis
- Tumor
- Multiple sclerosis
Wrist drop
Brachioradialis m. interosseous
Abnormal
Tricep
Abnormal
Deltoid
Abnormal
Posterior cord of brachial plexus
Neurologic disorder 101

Approach to foot drop
Foot drop
Upper motor neuron Lower motor neuron

Muscle: Spastic Muscle:
Reflex: Reflex:
Babinski: Present Babinski: Absent
Cerebral cortex Spinal cord Unilateral Bilateral
Parasagital lesion bladder

ACA infarction “spinal cord disorder” involvement
Yes
Cauda equina lesion

Peripheral neuropathy
Gluteus Hamstring Plantar flexion
Yes Yes Yes
LS Plexus Proximal Distal Foot eversion Common peroneal n. lesion

Sciatic n. Sciatic n.
lesion lesion
Yes
Superficial peroneal n. lesion
102
Chapter 9
Step 1: Localized level Root lesion C5 C6 C7 C8

Muscle Deltoid Bicep Triceps Finger
Weakness extension
Reflex Biceps Triceps
Root lesion L4 L5 S1
Muscle toe Plantar
Weakness extension flexion
Reflex Knee
Step 2: Extramedullary lesion Characteristic Intramedullary Extramedullary

v.s. Intramedullary lesion
Vertebral and Unusual Common
Radicular pain
UMN signs Late
LMN signs Prominent Unusual
Paresthesia’s Descending Ascending
progression
Sphincter involve Late
Step 3: Determine etiology Etiology categories Intramedullary Extramedullary

Infection Epidural abscess
Pott disease
Herpes
Intradural abscess
Vascular Spinal infarction AV malformation
Demyelination
Inflammation
Post
Developmental/
Degenerative Herniated disc

Chapter 9
Neurologic disorder
Peripheral neuropathy: weakness predominant
Symmetrical weakness Asymmetrical weakness
Proximal+Distal weakness Distal weakness Proximal+Distal weakness Distal weakness
Polyradiculopathy
With Without
Sensory loss Sensory loss carcinomatosis
idiopathic
CIDP
C Sensory loss w/o Sensory loss c Sensory loss w/o Sensory loss
Hereditary:
Metabolic:
Drug/Toxin:
Infection: HIV
Idiopathic
Other: Multiple nerve Single nerve
Vasculitis
Paraneoplastic Multifocal CIDP Compressive
Vasuclitis/ Cryoglobulinemia
Infiltration: multiple nerve
sarcoidosis
Infection:
Without With
Hereditary:
UMN signs UMN signs
monomelic disease
HNPP
Chapter 9
Peripheral neuropathy: Sensory impairment predominant
Symmetrical sensory impairment Asymmetrical sensory impairment
Propioceptive sensory loss

+/- Distal weakness Areflexia + UMN w/o weakness
Hereditary: - Nutrition: B12 def vit E def Sensory ganglinopathy

Metabolic: Copper def Paraneoplastic
Drug/Toxin: - Combined system degeneration Sjogren
Infection: HIV c peripheral neuropathy Cisplatin
Idiopathic - Hereditary leukodystrophies HIV related
Other:
Vasculitis
Paraneoplastic
Peripheral neuropathy: autonomic symptoms predominant
Hereditary DM Idiopathic Other

pandysautonomia
HIV
Vincristine
Neurologic disorder
Classification of movement disorder

Movement disorder classification
1.
2
3
Hyperkinetic Hypokinetic
Rhythmic Non-Rhythmic
ABCD-MT”
Tremor Athetosis
Ballism
semipurposive Sustain muscle

contraction
Proximal limb Distal limb
Ballism Chorea Tic
Athetosis Chorea
Chapter 9
Tremor
Tremor
Resting Postural Intention
- Parkinson disease (PD) - Cerebellar disease

- - Essential tremor (ET) Drug and toxin
-
Sleep deprivation
Alc
Clinical Feature Parkinson disease Essential Tremor

Type tremor
Family history
Unilateral or bilateral involvement
Response to treatment
neurontin
Alcohol consumption
Neurologic disorder
Chorea
Chorea
semi movement
Primary “Hereditary” Secondary
Extracranial Intracranial
Metabolic Drug Toxin
CO
Anticonvulsant Basal ganglion
Ca Lesion
2
Vascular Tumor Autoimmune Infection Other
Vasculitis SLE Encephalitis

Antiphospholipid
110
Chapter 9
Myoclonus
Exclude
Hiccup
Exclude Physiologic myoclonus
Psychogenic myoclonus
Essential myoclonus Epileptic myoclonus Symptomatic or Secondary Myoclonus
Sporadic
Familial
or DYT11
Neuro Autoimmune Storage Metabolic ID/Post ID Other
Posthypoxic myoclonus Limbic Endocrine Toxin

encephalitis Sachs Herpes Alcohol
Neurodegenerative dz Hashimoto Lafora or encephalitis Aluminium
Renal 1 Toluene
Eosinophilic Drug
Spinocerebellar Ataxia Levodopa
Hunt Celiac disease Ca
Friedreich Liver failure
Ataxia telangiectasia Nutrition Paraneoplastic
Dementia Vit def
PD c dementia Mitochondrial
Dementia c bodies dysfunction

Visual disorder
Blurred vision
Visual field defect Visual acuity defect Diplopia Oscillopsia

Hx: Hx: Hx:
Hx:
PE: Visual field defect PE: VA PE:

PE:
Visual field defect Anatomical Diplopia Cerebellar lesion

approach Brain stem lesion
Ocular disorder Neurologic disorder
Anterior segment Posterior segment Optic n. lesion Occipital lobe lesion
Optic neuritis
Cornea Anterior chamber Lens
Corneal ulcer Cataract Tumor
Vitreous humour Retina Retinal vascular
Vitreous Papilledema
hemorrhage
detachment
Embolic
Hemorrhage BP
112
Chapter 9
Time based approach to Visual acuity loss
Sudden visual loss Progressive visual loss
Ant visual pathway

inflammation
Transient Without progression Optic neuritis
Sarcoidosis
meningitis
Ant visual pathway

compression
Monocular Binocular Monocular Binocular Tumor
Cerebral Vascular d/o Bilat ass.

Blood supply Other Glaucoma
to retina Chronic papilledema
Occipital Toxic
- Embolic CVD Head trauma Ethambutol
Amaurosis fugax Impending Visual Retina d/o Head trauma Paraneoplastic
Hypoperfusion obscuration Functional retinopathy
BP
Optic n. d/o
Vascular disease
Vasospasm Vitreous hemorrhage
Vasculitis

Diplopia
Diplopia
Hx PE
1 v.s. Binocular 1
2. Vertical v.s 2 Vergence?
3 3
. Oculocephalic maneuver
Monocular Diplopia Binocular Diplopia
Ophthalmic Neurologic Functional Disconjugated eye
Occipital lobe lesion

Drug induce visual
hallucination
Neurologic Orbital processing Congenital

disorder Causing diplopia strabismus
Orbital floor fracture Esotropia

Exotropia
pseudotumor
Supranuclear Cranial nerve NMJ Ocular myopathy
CPEO
Isolated CN Multiple CN Kearns
Brainstem
Chapter 9
Common cause of Binocular Diplopia
Horizontal Diplopia vertical Diplopia
Supranuclear Cranial nerve
Cranial nerve NMJ
NMJ Ocular
associated
Ocular
Decompensated Strabismus
Painful ophthalmoplegia
Orbit Cavernous sinus Sellar and posterior fossa Other
- Tumor -Tumor: Diabetic Ophthalmoplegia

Ophthalmoplegic
- Orbital pseudotumor - Inflammation
- Infection Tolosa
Sinusitis - Vascular
Cavernous sinus thrombosis

Arteriovenous fistula
Neurologic disorder
Visual field defect

Lt Rt
Lt Rt Central scotoma
Lesion:
Etiology: etrobulbar neuritis
1
2
Optic nerve 2
Total blindness of Rt eye
3 Lesion: Complete lesion of optic nerve
Optic Chiasm
Etiology:
Optic tract
3
Right nasal hemianopia

Optic radiation Lesion: Perichiasmal
Etiology:
Occipital lobe Bitemporal hemianopia

Lesion: Chiasmatic lesion
Etiology: 1
prolactinoma
Corticotrophic adenoma
functioning
2.
3
Chapter 9
Lt Rt
Lt Rt Left Homonymous hemianopia

Lesion: Optic tract or Optic radiation
Etiology: parietal lobe
Optic nerve
Left homonymous superior quadrantanopia
Lesion: Partial involvement of optic radiation
Optic Chiasm
Etiology: Lesion in right temporal lobe
Optic tract
Left homonymous Inferior quadrantanopia

Optic radiation Lesion: Partial involvement of optic radiation
Etiology: Lesion in right parietal lobe
Occipital lobe Left homonymous hemianopia with macular sparing

Lesion: Occipital lobe lesion
Etiology: PCA infarction
Neurologic disorder
Ptosis
Ptosis
Unilateral Bilateral
Pupil Pupil Pupil Pupil Pupil

normal dilate Constrict normal Dilate
Diabetes
Isolated CN III palsy Cavernous sinus Superior Orbital Fissure Orbital apex
lesion Lesion Lesion
Involved Involved Involved
+ V1 V2 + V1 + V1 + Optic nerve
- Tumor:
- Inflammation - Tumor:
Tolosa - Infection:
- Vascular Sinusitis
Carotid
Cavernous sinus thrombosis
Arteriovenous fistula - Trauma
Chapter 9
Vertigo
Vertigo
Central peripheral vertigo

Exclude:
Headache
Central vertigo Peripheral vertigo
Vascular Non-vascular Vestibular Inner ear Vestibular

migraine nerve
Vestibular
Brain stem tumor
Cerebellum Brainstem With Without

Hearing loss Hearing loss
Infarction Vertebrobasilar TIA
Hemorrhage BPPV
Vestibular neuritis
Otosclerosis
Peripheral Central
Vertigo
Nystagmus
vertical
Associated findings
Hearing loss or tinnitus Often present
Intrinsic brainstem signs Absent
Neurologic disorder
120
Chapter 9
Stroke in the young
Exclude: stroke mimic
Embolism Arteropathy Hematologic disease Systemic hypotension
Cardiac origin Other Hyperviscosity Hypercoagulable
Acquire vera Congenital

malformation
AF Transient embologenic
aortitis Unruptured Antithrombin III def.
Congenital Cholesterol embolism Acquire

Fat embolism Antiphospholipid
PFO
Oral contraceptives
Atherosclerosis Non- Atherosclerosis
Inflammatory Non-inflammatory
Fibromuscular dysplasia
Primary vasculitis Secondary vaculitis Trauma
Carotid a dissection
arteritis Infection Vertebral a dissection
Other
Drug abuse
Amphetamine
Cocaine

122
10
10.1
% In 12 months
Exercise
Bulimia
Diet control
Adequate Diminish
food intake food intake
Utilization Absorption calorie loss
Chronic infection Pancreatitis intestine Parasite

IBD Fistula
Malignancy Autoimmune Infection Endocrine Other
TB COPD
HIV Uremia
Vasculitis Alcohol
Lung addict
Depression
Chapter 10
10.2
Fluid Lymphatic Excess Fat excess Organ

Retention Obstruction Muscle enlargement
Obesity
Congestive Heart Filariasis
failure Androgneic steroid
Cirrhosis
CKD
Obesity
Genetic Neuro Endocrine Medication
Prader Pituitary Insulin

Hypothalamic lesion
Laurnece Biedl Thyroid Antidepressant
Trauma
Angelman Tumor Parathyroid Anticonvulsant
PTH Valproic a
Pseudo Pseudo
Inflammation Steroid
Adernal
Encephalitis
Infiltration Pancreas
Sarcoidosis Insulinoma
X
Miscellaneous
AA Aplastic anemia CCB

AAA CDGP
AACG Acute angle closure glaucoma CHF Congestive heart failure
ACA CIDP
ACD Anemia of chronic disease
ACS CJD
AD Autosomal dominant CKD
AED Antiepileptic drug CLL
AF Atrial fibrilllation CM
AGE Acute gastroenteritis CMT
AI CMV
AIH Autoimmune hepatitis CNS
AIHA CNT Connective tissue
AION COPD
ALL CPEO Chronic progressive external ophthalmoplegia
ALP CQ Chloroquin
ALS CRAO
AML CRVO Central retinal vein occlusion
ANS CSS
AR Aortic regurgitation CVD Cerebrovascular disease
AR Autosomal recessive CVS
AS Aortic stenosis CY
ASD Atrial septal defect d/o disorder
ATB Antibiotic DB Direct bilirubin
ATN Acute tubular necrosis DES Diffuse esophageal spasm
AV Atrioventricular DI Diabetes insipidus
AVF Arteriovenous fistula DIC
AVM Arteriovenous malformation DIP Distal interphalangeal
BB DKA
BM DM
BPPV DVT Deep venous thrombosis
BZD dz disease
CA Cancer EBV
CAH EDH Epidural hematoma
ET IE Infective endocarditis
ETB Ethambutol IF Immunofluorescence
FC Functional class IFN Interferon
FSGS Focal segmental glomerulosclerosis IgMN
FSS Familial Short Stature ILD Interstitial Lung disease
FUO IMF
Fx Fracture INH
GBM INO Internuclear ophthalmoplegia
GBS IPF
GERD ITP
GH JVP
GI Jx jaundice
GIST LMN
GN LN
GU LRTI
GVHD LS Lumbosacral
HAV Hepatitis A virus Lt Left
Hb Hemoglobin M
HbCS Hemoglobin constant spring MAC
HBV Hepatitis B virus MAHA
HCV Hepatis C virus MAT
HE MCD
HIT MCTD
HMWK MDS
HNPP MEN
palsies MG
HOCM MI
Hr Hour Mn
HS MN
HT MPGN
HTLV MPH
HUS MR
Hx MS
IBD MSG
ICH Intracerebral hemorrhage n.
ICP Intracranial pressure NASH
Appendix
NMJ PTH
NTM PU Peptic ulcer
obs obstruction PV
OCP Oral contraceptive pill PVC Premature ventricular contraction
OPMD RA
OSA Obstructive sleep apnea RBC
PAC Premature atrial contraction RPGN
PAD Peripheral arterial disease RS
PAN Rt
PANDAS S/S
SAAG
PBC SAH Subarachnoid hemorrhage
PCKD SCA Spinocerebellar ataxia
PCOS SCD Sudden cardiac death
PCP SDH Subdural hematoma
PD SGA Small for gestational age
PDA Patent ductus arteriosus SI Sexual intercourse
PDE Phosphodiesterase SMA
PE SSRI
PFO Patent foramen ovale SSS
PHT Str Structure
SU
PID
SVC Superior vena cava
PION
SVT
PK
Sx
PM
Synd
PMC Pseudomembranous colitis TB
PND
TB Tuberculosis
PNH
TCA
PNH
TIA
PNS
T-LOC Transient loss of consciousness
PRCA Pure red cell aplasia TON
PRES
TPN Total parenteral nutrition
PRL Prolactin TSH
PSC
TTP
PSGN Post streptococcal glomerulonephritis TXA2 Thromboxane A2
130
UC Ulcerative colitis
UCTD Undifferentiated connective tissue disease
UGIB Upper gastrointestinal bleeding
ULN Upper limit of normal
UMN Upper motor neuron
URI
VHD Valvular heart disease
VSD Ventricular septal defect
VT
vWD
VZV
w/o
WG
Appendix 131

Approach Internal Med

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Differential diagnostic algorithm in internal medicine

Differential diagnostic algorithm

Virus Bacteria Mycobacteria Other

HIV Steptococcus TB Toxoplasma

Lolcation Drainage Etiology

Right supraclavicular node lungs, esophagus

Epitrochlear Ulnar aspect of forearm and hand

Massive Moderate Small

- Chronic Myeloid Leukemia

Hepatosplenomegaly -Connective tissue diseases

Prolonged fever and classic FUO

Prolonged fever and Classic FUO

Malignancy CNT dz Miscellaneous

Localized abscess Vascular infection Systemic infection

Diverticulitis Liver abscess Perinephric abscess

Virus Bacteria Microbacteria Tropical infection Other

Infectious Salmonellosis Tuberculosis Fungus

Connective tissue disease Malignancy Other

Drug fever Thermoregulatory disorder Miscellaneous

Antibiotic Central cause arthtitis

Fever with jaundice

Hepatobiliary infection Systemic infection Sepsis with

Fever with Splenomegaly

Virus Bacteria Microbacteria Tropical infection Sepsis with

Acute (< 6 weeks) Chronic (> 6 weeks)

Mono Oligo Poly Mono Oligo Poly

Infection Migratory pattern Infection Infection SpA

Low back pain

Mechanical LBP (97%) Non-mechanical Referred pain(2%)

Traumatic Fx Perinephric abscess

Neoplasm Infection Inflammatory arthritis

CNT dz Arterial occlusion Drug Other

Primary headache Secondary headache

Paracranial Intracranial Systemic

Systemic Infection Non-Infection

Eye Ear Nose Other Hypertension Substance Homeostasis disorder

Otitis media Toothache HT crisis

Ocular inflam Fasting

Brain abscess Vascular Non-vascular

Hemorrhage Vascular Arteritis

Neoplasm High CSF pressure Low CSF pressure

Benign Post dural puncture

Without loss of consciousness Loss of consciousness

Sweating and nausea Common

Tongue biting, lateral Occasional

Seizure like symptoms

Recurrent unprovoked seizure

New onset seizure

Neurologic disorder Systemic disorder

Stroke Head trauma Vascular Infection Brain

Metabolic Medication Drug abuse and toxin Other

AED poor compliance Alcohol intoxication

Genetic Structural/metabolic Unknown cause

1. Idiopathic generalized epilepsy

2. Benign childhood with centrotemperal seizure

Mesial temporal Localized lesional Hemispheric Other

Cavernoma Post traumatic

Abnormal level of consciousness Abnormal cognitive function

Abnormal level of consciousness

Exclude condition mimic coma

Persistent vegetative state

Without focal With signs of With focal

Infection Vascular Other

SAH due to Carcinomatous