Symptomology

Symptomology & Clinical Approach

Symptom-based approach to diagnosis and management

Respiratory

Dyspnea (Acute)

History Taking

  • •Onset: Sudden (PE, Pneumothorax) vs Gradual (CHF, Pneumonia)
  • •Triggers: Exertion, lying flat (Orthopnea), allergen exposure
  • •Associated: Chest pain, fever, cough, hemoptysis, leg swelling
  • •History: COPD/Asthma, Cardiac disease, DVT risk factors

Differential Diagnosis

Pulmonary: Asthma/COPD exacerbation, Pneumonia, PE, Pneumothorax
Cardiac: Acute Heart Failure (CHF), MI, Arrhythmia, Tamponade
Other: Anemia, Anaphylaxis, Metabolic acidosis (Kussmaul), Anxiety

Investigations

  • •Bedside: SpO2, Vitals, Lung ultrasound
  • •Labs: CBC, BMP, BNP (Heart failure), D-dimer (PE rule out), Troponin
  • •Imaging: CXR (Pneumonia, edema, PTX), CT PE (if high suspicion)
  • •Other: ECG (Ischemia, arrhythmia)

Management

  • 1.1. ABCs: Airway patency? Breathing effort? Circulation?
  • 2.2. Oxygen: Nasal cannula → Venturi/Non-rebreather → HFNC → BiPAP → Intubation
  • 3.3. Wheezing: Albuterol + Ipratropium nebs, Steroids (Prednisone 40mg)
  • 4.4. Crackles/Edema: Furosemide 40mg IV (or 2x home dose), Nitrates if HTN
  • 5.5. Infection: Antibiotics (Ceftriaxone + Azithro) if pneumonia suspected

Monitoring

Oxygen saturation (Keep >90-92%, >88% in COPD) • Respiratory rate and work of breathing (Accessory muscle use) • Mental status (Hypercapnia check) • Blood pressure (Shock index)

Cough (Chronic >8 weeks)

History Taking

  • •Productive vs Dry
  • •Timing: Nocturnal (Asthma, GERD), Post-prandial (GERD)
  • •Triggers: Cold air, exercise, scents
  • •Meds: ACE inhibitors?
  • •Red flags: Hemoptysis, weight loss, smoking history

Differential Diagnosis

Upper Airway Cough Syndrome (Post-nasal drip)
Asthma / Cough-variant asthma
GERD
ACE Inhibitor induced
Chronic Bronchitis / COPD
Malignancy / TB / ILD

Investigations

  • •CXR (Rule out cancer, TB, ILD)
  • •Spirometry (PFTs) with bronchodilator response
  • •Trial of therapy (PPI for GERD, Nasal steroids for UACS)
  • •CT Chest if CXR normal but red flags present

Management

  • 1.1. Stop ACE inhibitor (switch to ARB)
  • 2.2. UACS: Intranasal steroid (Fluticasone) + Antihistamine
  • 3.3. Asthma: Inhaled Corticosteroid (ICS) + LABA
  • 4.4. GERD: PPI (Omeprazole 40mg daily) + Lifestyle changes
  • 5.5. Smoking cessation

Monitoring

Response to empiric therapy (allow 2-4 weeks) • New symptoms (Hemoptysis)

Respiratory / Chest

Hemoptysis

History Taking

  • •Amount: Streaking vs Massive (>600mL/24h or >100mL/hr = Life-threatening)
  • •True hemoptysis (Cough) vs Hematemesis (Vomit) vs Epistaxis (Nose)
  • •Associated: Weight loss/Night sweats (TB, Cancer), Dyspnea (PE), Pleuritic pain
  • •Risk factors: Smoking, TB exposure, Anticoagulation, Prior PE/DVT
  • •History: COPD, Bronchiectasis, Prior cancer

Differential Diagnosis

Pulmonary: Bronchitis (Most common), Bronchiectasis, Lung cancer, TB, Pneumonia, Lung abscess
Vascular: Pulmonary Embolism, Pulmonary AVM, Mitral stenosis (Elevated LA pressure)
Autoimmune: Goodpasture's syndrome, Granulomatosis with polyangiitis (Wegener's), SLE (Diffuse alveolar hemorrhage)
Iatrogenic: Anticoagulation, Post-bronchoscopy
Other: Foreign body, Coagulopathy

Investigations

  • •CXR: Mass, Infiltrate, Cavitary lesion
  • •CT Chest (With contrast): Mass, PE, Bronchiectasis, AVM
  • •Sputum: AFB (TB), Cytology (Cancer), Culture
  • •Labs: CBC, Coagulation, BMP, UA (Goodpasture's - Pulmonary-renal syndrome)
  • •Bronchoscopy: Localize bleeding source, Biopsy mass
  • •Consider: Anti-GBM Ab, ANCA, CT Angiography

Management

  • 1.1. Massive hemoptysis: Position bleeding side DOWN, Intubation (Large ETT), ICU
  • 2.2. Stabilize: IV access, Type and cross, Correct coagulopathy (Reverse anticoagulation)
  • 3.3. Bronchoscopy: Localize and potentially control bleeding (Cold saline lavage, Epinephrine, Balloon tamponade)
  • 4.4. Bronchial artery embolization: First-line for massive hemoptysis (IR consult)
  • 5.5. Treat underlying: Anti-TB therapy, Cancer staging, Antibiotics for infection

Monitoring

Airway patency • Volume of hemoptysis • Hemodynamic stability • Oxygen saturation

Stridor (Adult)

History Taking

  • •Onset: Acute (Anaphylaxis, Foreign body, Epiglottitis) vs Chronic (Tumor, Subglottic stenosis)
  • •Phase: Inspiratory (Supraglottic/Glottic) vs Biphasic (Subglottic) vs Expiratory (Lower airway)
  • •Associated: Drooling (Epiglottitis), Voice change (Laryngeal), Recent intubation (Subglottic stenosis)
  • •History: Allergies (Anaphylaxis), Surgery/Intubation, Smoking, Radiation

Differential Diagnosis

Acute: Anaphylaxis, Foreign body, Angioedema (ACE-I), Epiglottitis, Croup (Pediatric)
Subacute: Peritonsillar abscess, Retropharyngeal abscess, Ludwig's angina
Chronic: Laryngeal cancer, Vocal cord paralysis, Subglottic stenosis (Post-intubation), Tracheomalacia
Functional: Paradoxical vocal fold motion (Vocal cord dysfunction)

Investigations

  • •Direct visualization: Flexible nasolaryngoscopy (Gold standard)
  • •CT Neck with contrast: Abscess, Mass
  • •Lateral neck X-ray: Thumbprint sign (Epiglottitis), Retropharyngeal widening
  • •Tryptase level: If anaphylaxis (Elevated)

Management

  • 1.1. Anaphylaxis: IM Epinephrine 0.3-0.5mg STAT, Airway management, IV fluids
  • 2.2. Angioedema (ACE-I): Stop ACE-I permanently, Epinephrine if severe, Consider icatibant for hereditary
  • 3.3. Epiglottitis: SECURE AIRWAY first (OR/Anesthesia), IV antibiotics (Ceftriaxone + Vancomycin)
  • 4.4. Foreign body: Rigid bronchoscopy/Laryngoscopy for removal
  • 5.5. Abscess: CT-guided drainage or Surgical I&D + Antibiotics

Monitoring

Airway patency (Prepare for emergent airway) • Oxygen saturation • Work of breathing

Neurological

Seizure (First-time)

History Taking

  • •Description: Generalized (Loss of consciousness, Tonic-clonic) vs Focal (Aware, Motor/Sensory)
  • •Prodrome: Aura (Visual, Olfactory, Déjà vu)
  • •Post-ictal: Confusion, Todd's paralysis (Focal weakness after seizure)
  • •Triggers: Sleep deprivation, Alcohol withdrawal, Flashing lights
  • •Red flags: Fever (Meningitis), Headache (ICH, Tumor), Trauma, Pregnancy (Eclampsia)

Differential Diagnosis

Provoked: Hypoglycemia, Hyponatremia, Alcohol/Benzo withdrawal, Medication (Bupropion, Tramadol)
Structural: Tumor, Stroke, Trauma, AVM
Infectious: Meningitis, Encephalitis, Brain abscess
Idiopathic: Epilepsy
Mimics: Syncope, Psychogenic non-epileptic seizures (PNES)

Investigations

  • •Labs: Glucose, Sodium, Calcium, Magnesium, Toxicology screen, Prolactin (elevated post-ictal)
  • •CT Head non-contrast (STAT if first seizure or focal deficit)
  • •MRI Brain (Better for structural lesions)
  • •EEG (After acute phase, looking for epileptiform activity)
  • •LP if fever/meningismus

Management

  • 1.1. Acute: ABCs, Protect airway, Turn on side, Do NOT restrain
  • 2.2. Status Epilepticus (>5min): Benzodiazepines (Lorazepam 4mg IV or Midazolam 10mg IM)
  • 3.3. Treat underlying cause (D50 for hypoglycemia, 3% Saline for hyponatremia)
  • 4.4. Anti-epileptics: Usually NOT started after single unprovoked seizure (30% recurrence)
  • 5.5. Start AED if: 2+ seizures, EEG abnormality, or structural lesion (Levetiracetam 500mg BID)

Monitoring

Recurrent seizures • Level of consciousness • Driving restrictions (varies by jurisdiction)

Weakness (Acute)

History Taking

  • •Distribution: Unilateral (Stroke, Bell's palsy) vs Bilateral, Proximal vs Distal
  • •Onset: Sudden (Stroke) vs Progressive (GBS, Myasthenia)
  • •Associated: Numbness (CNS), Diplopia (Myasthenia, Stroke), Dysphagia
  • •Pattern: Ascending (GBS), Descending (Botulism)
  • •Timing: Worse with activity (Myasthenia), Worse in morning (Polymyalgia)

Differential Diagnosis

CNS: Stroke, Spinal cord compression, MS
Peripheral Nerve: Guillain-Barré Syndrome (GBS), Neuropathy
NMJ: Myasthenia Gravis, Lambert-Eaton, Botulism
Muscle: Polymyositis, Rhabdomyolysis, Hypokalemia
Systemic: Severe anemia, Hypothyroid, Sepsis

Investigations

  • •Urgent: CT/MRI Brain/Spine if CNS suspected
  • •Labs: CK (Rhabdomyolysis), TSH, Potassium, ESR/CRP
  • •EMG/NCS: Differentiate neuropathy vs myopathy vs NMJ
  • •Lumbar Puncture: GBS (Elevated protein, normal cells)
  • •Acetylcholine receptor antibodies (Myasthenia)

Management

  • 1.1. Stroke: Thrombolytics (tPA) if <4.5h, Thrombectomy if large vessel
  • 2.2. GBS: IVIG or Plasmapheresis, ICU monitoring (respiratory failure risk)
  • 3.3. Myasthenia: Pyridostigmine, Steroids, IVIG/PLEX for crisis
  • 4.4. Spinal Cord Compression: Urgent MRI + Neurosurgery consult, Dexamethasone 10mg IV
  • 5.5. Correct electrolytes (Potassium, Magnesium)

Monitoring

Respiratory function (NIF/FVC in GBS) • Progression of weakness • Bulbar symptoms (Dysphagia, Aspiration risk)

Numbness/Paresthesias

History Taking

  • •Distribution: Glove-and-stocking (Peripheral neuropathy), Dermatomal (Radiculopathy), Hemibody (Stroke)
  • •Onset: Acute (Stroke, GBS) vs Chronic (DM neuropathy, B12 def)
  • •Associated: Weakness, Pain (Radiculopathy), Balance issues
  • •Risk factors: Diabetes, Alcohol, B12 deficiency
  • •Positional? Worse at night? (Carpal tunnel)

Differential Diagnosis

Central: Stroke, MS, Spinal cord lesion
Peripheral Neuropathy: Diabetic, Alcohol, B12 deficiency, Uremia, Chemotherapy
Mononeuropathy: Carpal tunnel, Ulnar neuropathy, Peroneal neuropathy
Radiculopathy: Cervical (C5-T1), Lumbar (L4-S1)
Other: Hyperventilation (Perioral), Hypocalcemia

Investigations

  • •If acute/central: MRI Brain/Spine
  • •If chronic/peripheral: EMG/NCS, B12, TSH, HbA1c, RPR (Syphilis)
  • •Consider: ANA (Vasculitis), Lyme serology, Heavy metals
  • •Phalen's/Tinel's test (Carpal tunnel)
  • •Straight leg raise (Radiculopathy)

Management

  • 1.1. Treat underlying cause (B12 supplementation, Glucose control)
  • 2.2. Neuropathic pain: Gabapentin 300-900mg TID or Duloxetine 60mg daily
  • 3.3. Carpal tunnel: Wrist splint at night, Steroid injection, Surgery if severe
  • 4.4. Radiculopathy: NSAIDs, PT, Epidural steroid injection
  • 5.5. MS: Neurology referral for disease-modifying therapy

Monitoring

Progression • Development of weakness • Falls risk

Confusion/Altered Mental Status

History Taking

  • •Onset: Acute (Delirium) vs Chronic (Dementia)
  • •Fluctuating? (Delirium characteristic)
  • •Associated: Fever (Infection), Headache (Meningitis, ICH), Focal deficits (Stroke)
  • •Medications: New meds, Anticholinergics, Opioids, Benzos
  • •Baseline cognition?

Differential Diagnosis

Delirium causes (DIMTOP): Drugs, Infection, Metabolic, Trauma, Oxygen (Hypoxia), Perfusion (Stroke/MI)
Infectious: UTI (elderly), Pneumonia, Meningitis, Encephalitis
Metabolic: Hypoglycemia, Hyponatremia, Hypercalcemia, Uremia, Hepatic encephalopathy
Neurologic: Stroke, ICH, Seizure (post-ictal)
Toxicologic: Alcohol intoxication/withdrawal, Drug overdose
Psychiatric: Psychosis

Investigations

  • •Vitals: Check glucose immediately (finger stick)
  • •Labs: CBC, CMP (Na, Ca, BUN/Cr, Glucose), UA, Ammonia (if liver disease)
  • •Imaging: CT Head (Stroke, bleed, Mass)
  • •Toxicology: Urine drug screen, Alcohol level
  • •Consider: Lumbar puncture (if fever/meningismus), Thiamine level (Wernicke's)

Management

  • 1.1. Treat underlying cause (Antibiotics, Correct electrolytes, Stop offending drugs)
  • 2.2. Supportive: Reorientation, Avoid restraints, Normalize sleep-wake cycle
  • 3.3. Wernicke's encephalopathy: Thiamine 500mg IV TID x3d (BEFORE glucose)
  • 4.4. Agitation: Minimize sedation (Haloperidol 0.5-2mg if needed, NOT in Parkinson's)
  • 5.5. Avoid anticholinergics (Diphenhydramine) - worsens delirium

Monitoring

CAM-ICU (Confusion Assessment Method) • Safety (Fall risk, Wandering) • Agitation level

ENT / Neuro

Tinnitus

History Taking

  • •Unilateral vs Bilateral (Unilateral is red flag for acoustic neuroma)
  • •Pulsatile vs Non-pulsatile (Pulsatile = Vascular etiology)
  • •Associated: Hearing loss, vertigo (Meniere's), fullness
  • •Meds: Aspirin, NSAIDs, Loop diuretics, Aminoglycosides

Differential Diagnosis

Subjective (Common): Presbycusis, Noise trauma, Meniere's, Wax impaction
Objective (Rare): AV Malformation, Carotid stenosis, Glomus tumor
Neurologic: Acoustic Neuroma (Vestibular Schwannoma)
Systemic: Anemia, Hyperthyroidism

Investigations

  • •Otoscopy: Cerumen, fluid, TM perforation, reddish mass (Glomus)
  • •Audiometry: Asymmetric hearing loss?
  • •MRI IAC (Internal Auditory Canal): If unilateral + hearing loss
  • •CT Angio / MRA: If pulsatile

Management

  • 1.1. Treat underlying: Remove wax, stop ototoxic meds
  • 2.2. Hearing aids (masks tinnitus)
  • 3.3. CBT / Sound therapy (White noise machine)
  • 4.4. Treat anxiety/depression
  • 5.5. Vascular causes: Refer to Vascular Surgery/ENT

Monitoring

Progression of hearing loss • Development of vertigo or focal neuro deficits

Vertigo (Acute)

History Taking

  • •True vertigo (room spinning) vs Lightheadedness vs Disequilibrium
  • •Timing: Seconds (BPPV), Minutes-Hours (Meniere's), Days (Vestibular Neuritis)
  • •Triggers: Head movement (BPPV), Hearing loss/tinnitus (Meniere's)
  • •Neuro symptoms: Diplopia, dysarthria, ataxia (Central cause - STROKE)

Differential Diagnosis

Peripheral (Benign): BPPV, Vestibular Neuritis, Labyrinthitis, Meniere's Disease
Central (Dangerous): Cerebellar Stroke/Hemorrhage, Vertebrobasilar TIA, MS
Other: Orthostatic Hypotension, Arrhythmia, Medication

Investigations

  • •Dix-Hallpike Maneuver (BPPV diagnosis)
  • •HINTS Exam (Head Impulse, Nystagmus, Test of Skew) - If abnormal → MRI
  • •Audiogram (Hearing loss in Meniere's)
  • •MRI Brain (If central cause suspected)

Management

  • 1.1. BPPV: Epley Maneuver (Canalith repositioning)
  • 2.2. Vestibular Neuritis: Meclizine 25mg TID, Valium (short term)
  • 3.3. Meniere's: Low salt diet, Diuretics, Betahistine
  • 4.4. Central causes: Urgent MRI + Neuro consult
  • 5.5. Avoid vestibular suppressants >3 days (delays compensation)

Monitoring

Focal neurologic signs • Recurrence pattern

Sore Throat

History Taking

  • •Fever? (Bacterial vs Viral)
  • •Difficulty swallowing/Drooling (Peritonsillar abscess, Epiglottitis)
  • •Exposure: Sick contacts, Sexual history (GC/Chlamydia)
  • •Rash: Scarlet fever (Strep), EBV (Ampicillin rash)

Differential Diagnosis

Viral: EBV (Mono), CMV, Adenovirus, HSV, COVID-19
Bacterial: Group A Strep (GAS), Gonorrhea, Diphtheria (rare)
Serious: Peritonsillar Abscess, Retropharyngeal Abscess, Epiglottitis, Lemierre's Syndrome

Investigations

  • •Rapid Strep Test + Throat Culture
  • •Monospot / EBV Titers (if splenomegaly, atypical lymphocytes)
  • •Soft Tissue Neck X-ray or CT (if abscess suspected)

Management

  • 1.1. GAS Pharyngitis: Penicillin V 500mg TID x10d or Amoxicillin
  • 2.2. Supportive: NSAIDs, Salt water gargles, Fluids
  • 3.3. EBV: Rest, avoid contact sports (Splenic rupture risk x4-6wks)
  • 4.4. Peritonsillar Abscess: I&D + Augmentin + ENT consult
  • 5.5. Epiglottitis: SECURE AIRWAY (ENT/Anesthesia), Antibiotics

Monitoring

Airway patency (Stridor, Drooling) • Development of rheumatic fever (untreated Strep)

Musculoskeletal

Joint Pain (Monoarticular)

History Taking

  • •Acute (<6wks) vs Chronic (>6wks)
  • •Trauma? (Fracture, Ligament tear, Meniscus)
  • •Joint involved: Knee, Hip, Shoulder (common), 1st MTP (Gout)
  • •Associated: Fever (Septic arthritis), Skin changes, Morning stiffness
  • •Risk factors: Immunosuppression, IVDU, Recent procedure

Differential Diagnosis

Infectious: Septic Arthritis (EMERGENCY), Lyme, Gonococcal
Crystal: Gout (Uric acid), Pseudogout (CPPD)
Traumatic: Fracture, Meniscal tear, Ligament injury
Inflammatory: Reactive arthritis, Psoriatic
Degenerative: Osteoarthritis

Investigations

  • •Arthrocentesis (MANDATORY if acute + effusion): Send for:
  • • - Cell count/diff (>50k WBC = Septic, >2k with crystals = Gout/Pseudogout)
  • • - Gram stain & Culture
  • • - Crystal analysis (Polarized microscopy)
  • •Labs: CBC, ESR/CRP, Uric acid, Blood cultures (if fever)
  • •Imaging: X-ray (Fracture, OA), MRI (Soft tissue)

Management

  • 1.1. Septic Arthritis: URGENT Orthopedic consult + IV Antibiotics (Vanc + Ceftriaxone)
  • 2.2. Gout: NSAIDs (Indomethacin 50mg TID) or Colchicine 1.2mg then 0.6mg 1h later
  • 3.3. Pseudogout: NSAIDs, Colchicine, or Intra-articular steroid
  • 4.4. OA: Acetaminophen, NSAIDs, Physical therapy, Weight loss
  • 5.5. Rest, Ice, Elevation, Immobilization PRN

Monitoring

Response to antibiotics (if septic) • Joint function • Recurrence

Back Pain (Low Back)

History Taking

  • •Red Flags: Age >50 or <20, Trauma, Cancer history, Fever, Neurologic deficit, Saddle anesthesia, Bowel/Bladder dysfunction
  • •Radiculopathy? Pain down leg (Sciatica = L5/S1)
  • •Morning stiffness >30min improves with activity (Inflammatory - Ankylosing Spondylitis)
  • •Exacerbation: Bending, Lifting, Prolonged sitting

Differential Diagnosis

Mechanical (90%): Muscle strain, Disc herniation, Degenerative disc disease, Spinal stenosis
Serious (Red Flags): Cauda Equina Syndrome, Epidural Abscess, Malignancy, Vertebral Fracture, AAA
Inflammatory: Ankylosing Spondylitis, Inflammatory Bowel Disease
Referred: Kidney stone, Pancreatitis, Aortic dissection

Investigations

  • •Imaging NOT needed if no red flags and <6 weeks duration
  • •If red flags: MRI Lumbar spine (Cauda equina, Abscess, Tumor)
  • •X-ray: Fracture, Spondylolisthesis (rarely changes management)
  • •Labs: ESR/CRP (Infection/Inflammation), CBC

Management

  • 1.1. Reassurance: 90% resolve in 6 weeks
  • 2.2. Stay active: Bed rest NOT recommended
  • 3.3. NSAIDs: Ibuprofen 600mg TID or Naproxen 500mg BID
  • 4.4. Muscle relaxants: Cyclobenzaprine 5-10mg THS (short term <2wks)
  • 5.5. Physical Therapy: Core strengthening, Stretching
  • 6.6. EMERGENCY: Cauda Equina → Urgent MRI + Neurosurgery consult

Monitoring

Progressive neurologic deficit • Bladder/Bowel function • Pain severity and functional status

Shoulder Pain

History Taking

  • •Onset: Acute (Trauma, Dislocation) vs Chronic (Impingement, OA)
  • •Location: Anterior (Biceps tendon), Lateral (Rotator cuff), Superior (AC joint)
  • •Pain with overhead activities? (Impingement, Rotator cuff)
  • •Night pain? (Rotator cuff tear)
  • •Limited ROM? Active vs Passive (Frozen shoulder = both limited)

Differential Diagnosis

Rotator Cuff: Impingement, Tendinopathy, Tear (Supraspinatus most common)
Instability: Dislocation, Labral tear
Glenohumeral: OA, Frozen shoulder (Adhesive capsulitis)
AC Joint: Separation, Arthritis
Referred: Cervical radiculopathy, Cardiac (MI), Diaphragmatic irritation

Investigations

  • •Physical Exam: Hawkins-Kennedy (Impingement), Drop arm (RC tear), Apprehension (Instability)
  • •X-ray: Dislocation, Fracture, AC separation, Calcific tendinitis
  • •MRI: Rotator cuff tear, Labral tear
  • •Ultrasound: Dynamic assessment of rotator cuff

Management

  • 1.1. Impingement: NSAIDs, Physical therapy (Strengthening), Subacromial steroid injection
  • 2.2. Rotator cuff tear: PT first, Surgery if full-thickness + symptoms persist
  • 3.3. Frozen shoulder: NSAIDs, PT (Aggressive stretching), Intra-articular steroid
  • 4.4. Dislocation: Reduction, Immobilization, Orthopedic follow-up
  • 5.5. Avoid provocative activities, Ice

Monitoring

ROM progression • Strength improvement • Response to therapy

Cardiovascular

Palpitations

History Taking

  • •Character: Regular (SVT) vs Irregular (AFib), Fluttering vs Pounding
  • •Duration: Seconds (PACs/PVCs) vs Sustained (SVT, AFib)
  • •Associated: Syncope (VT), Chest pain, Dyspnea
  • •Triggers: Caffeine, Stress, Exercise
  • •Meds: Beta-agonists, Stimulants, Thyroid replacement

Differential Diagnosis

Benign: PACs, PVCs, Sinus Tachycardia
Arrhythmias: AFib/Flutter, SVT (AVNRT, AVRT), VT
Metabolic: Hyperthyroidism, Hypoglycemia, Pheochromocytoma
Structural: Valvular disease, Cardiomyopathy

Investigations

  • •12-lead ECG during episode (Gold standard)
  • •Holter Monitor (24-48h) or Event Monitor (30 days)
  • •Labs: TSH, CBC (Anemia), BMP (Electrolytes), Troponin
  • •Echo: If structural disease suspected

Management

  • 1.1. Treat underlying (Beta-blocker for Hyperthyroid)
  • 2.2. SVT: Vagal maneuvers → Adenosine
  • 3.3. AFib: Rate control (Metoprolol) + Anticoagulation (CHADS-VASc)
  • 4.4. VT: Cardioversion if unstable, Amiodarone if stable
  • 5.5. Reassurance for benign PACs/PVCs

Monitoring

Frequency and triggers • Syncope or pre-syncope

Syncope

History Taking

  • •Prodrome: Lightheaded/Vision change (Vasovagal) vs None (Cardiac)
  • •Position: Standing (Orthostatic) vs Exertional (Cardiac - dangerous!)
  • •Recovery: Immediate (Vasovagal) vs Prolonged/Confused (Seizure)
  • •Triggers: Pain, Fear, Urination/Defecation (Vasovagal)
  • •Red Flags: Exertional, No warning, Family hx sudden death, Palpitations

Differential Diagnosis

Reflex (Benign): Vasovagal, Situational (Cough, Micturition)
Orthostatic: Volume depletion, Medications, Autonomic dysfunction
Cardiac (Dangerous): Arrhythmia (VT, Complete Heart Block, Long QT), Structural (AS, HOCM, PE)
Neurologic: Seizure, Stroke/TIA, Vertebrobasilar insufficiency

Investigations

  • •ECG: QTc prolongation, Pre-excitation (WPW), Q waves (Prior MI), Epsilon wave (ARVC)
  • •Orthostatic Vitals: Drop >20 systolic or >10 diastolic
  • •Echo: AS, HOCM
  • •Tilt Table Test: Vasovagal confirmation
  • •EP Study: If high suspicion of arrhythmia

Management

  • 1.1. Vasovagal: Reassurance, Hydration, Compression stockings, Counter-pressure maneuvers
  • 2.2. Orthostatic: Discontinue offending meds, Volume expansion, Fludrocortisone
  • 3.3. Cardiac: Treat arrhythmia, Pacemaker if bradycardia, ICD if VT risk
  • 4.4. AS/HOCM: Cardiology referral ± Surgery
  • 5.5. Driving restrictions if cardiac cause (varies by region)

Monitoring

Recurrence (High risk if cardiac cause) • Injury from fall

Vascular / Extremities

Leg Pain (Acute Unilateral)

History Taking

  • •Onset: Sudden (Arterial embolism) vs Gradual (DVT, Cellulitis)
  • •Character: Cramping (Claudication, DVT) vs Burning/Aching (Venous), Severe rest pain (Critical limb ischemia)
  • •Associated: Swelling (DVT, Cellulitis), Color change (Pale = Arterial, Red/Warm = Venous/Infection), Skin changes
  • •Risk factors (DVT): Immobilization, Surgery, Cancer, OCPs, Pregnancy, Prior VTE
  • •Risk factors (PAD): Smoking, DM, HTN, Hyperlipidemia

Differential Diagnosis

Venous: DVT, Superficial thrombophlebitis, Chronic venous insufficiency
Arterial: Acute limb ischemia (6 Ps), Peripheral artery disease (Claudication), Popliteal artery entrapment
Infectious: Cellulitis, Necrotizing fasciitis (EMERGENCY)
Musculoskeletal: Compartment syndrome, Baker's cyst rupture, Muscle strain
Other: Lymphedema, Sciatica

Investigations

  • •DVT: Duplex Ultrasound (Compression US), D-dimer (Only if low Wells score)
  • •Arterial: ABI (Ankle-Brachial Index - <0.9 = PAD), CTA/MRA, Doppler US
  • •Infection: CBC, CRP, Blood cultures, Imaging if deep infection suspected
  • •Compartment syndrome: Compartment pressure measurement (>30mmHg diagnostic)

Management

  • 1.1. DVT: Anticoagulation - Rivaroxaban 15mg BID x21d then 20mg daily, or LMWH bridge to Warfarin
  • 2.2. Acute Limb Ischemia: EMERGENCY - Heparin bolus, Vascular surgery consult, Embolectomy/Thrombolysis within 6h
  • 3.3. Cellulitis: Cephalexin 500mg QID or IV Cefazolin (Severe). Add Vanc if MRSA risk
  • 4.4. Necrotizing Fasciitis: SURGICAL EMERGENCY - Debridement, Broad-spectrum antibiotics (Vanc + Zosyn + Clinda)
  • 5.5. Compartment Syndrome: EMERGENCY Fasciotomy

Monitoring

Limb perfusion (Pulses, Cap refill, Sensation, Motor) • Compartment pressures if at risk • Signs of PE (if DVT)

Dermatology

Rash (Acute)

History Taking

  • •Distribution: Localized vs Generalized, Sun-exposed areas
  • •Morphology: Macular, Papular, Vesicular, Pustular, Petechial
  • •Associated: Fever (Meningococcemia, SJS), Pruritus (Allergic)
  • •Triggers: New medication (Drug rash), Sick contacts, Tick bite
  • •Mucosal involvement? (SJS/TEN, Erythema multiforme)

Differential Diagnosis

Infectious: Viral exanthem (Measles, Rubella), Meningococcemia, Rocky Mountain Spotted Fever, Lyme
Allergic: Drug reaction, Contact dermatitis, Urticaria
Autoimmune: SLE (Malar rash), Dermatomyositis (Heliotrope, Gottron's)
Serious: Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), DRESS
Other: Psoriasis, Eczema, Scabies

Investigations

  • •Physical: Full body exam, Mucosal membranes, Nikolsky sign (SJS/TEN)
  • •Labs: CBC (Eosinophilia in DRESS), CMP, Viral serologies
  • •Skin biopsy if unclear diagnosis
  • •Consider: Lyme serology, RMSF titers

Management

  • 1.1. Drug reaction: STOP offending agent immediately
  • 2.2. SJS/TEN: Burn unit admission, Supportive care, IV fluids, Consider IVIG
  • 3.3. Urticaria: Antihistamines (Cetirizine 10mg daily), Steroids if severe
  • 4.4. Contact dermatitis: Topical steroids (Triamcinolone 0.1%)
  • 5.5. Viral exanthem: Supportive care

Monitoring

Progression to mucosal involvement • Systemic symptoms (Fever, Hypotension) • Body surface area involved

Pruritus (Generalized)

History Taking

  • •Rash present? (Primary skin disease) vs No rash (Systemic cause)
  • •Timing: Worse at night (Scabies, Hodgkin's), After shower (Aquagenic, Polycythemia Vera)
  • •Associated: Jaundice (Cholestasis), Uremia, Weight loss
  • •New meds: Opioids, Aspirin
  • •Family history: Atopy

Differential Diagnosis

With Rash: Atopic dermatitis, Psoriasis, Scabies, Lichen planus, Urticaria
Without Rash (Systemic): Cholestasis, CKD/Uremia, Hyperthyroidism, Polycythemia Vera, Lymphoma
Neuropathic: Post-herpetic, Brachioradial pruritus
Psychogenic: Anxiety, Depression, Delusions of parasitosis

Investigations

  • •Labs: CBC (Polycythemia), CMP (Renal), LFTs (Cholestasis), TSH
  • •Consider: HIV test, Hepatitis panel, Chest X-ray (Lymphoma)
  • •Skin scraping: If scabies suspected
  • •Biopsy: If unclear

Management

  • 1.1. Treat underlying cause (Ursodeoxycholic acid for cholestasis)
  • 2.2. Topical: Emollients (Frequent moisturizing), Menthol/Camphor
  • 3.3. Oral antihistamines: Hydroxyzine 25-50mg QHS, Cetirizine 10mg daily
  • 4.4. Gabapentin 300-900mg for neuropathic itch
  • 5.5. UV phototherapy for chronic cases

Monitoring

Development of jaundice • Excoriations/Secondary infection • Sleep disturbance

Hematology

Anemia (Symptomatic)

History Taking

  • •Onset: Acute (GI bleed, Hemolysis) vs Chronic (Iron def, CKD)
  • •Symptoms: Fatigue, Dyspnea on exertion, Lightheadedness, Chest pain (if severe)
  • •Bleeding: Melena, Hematochezia, Menorrhagia, Hematuria
  • •Diet: Iron intake, B12 source (Vegans at risk)
  • •Past: History of anemia, Family history (Thalassemia, Sickle cell)

Differential Diagnosis

Microcytic (MCV<80): Iron deficiency, Thalassemia, Anemia of chronic disease
Normocytic (80-100): Acute blood loss, Hemolysis, Anemia of chronic disease, CKD
Macrocytic (MCV>100): B12/Folate deficiency, Alcohol, Hypothyroid, MDS
Hemolytic: Autoimmune, G6PD deficiency, TTP, HUS, Mechanical (valve)

Investigations

  • •Initial: CBC with differential, Reticulocyte count, Peripheral smear
  • •Iron studies: Ferritin (best for iron def), TIBC, Transferrin saturation
  • •Hemolysis markers: LDH, Haptoglobin, Indirect bilirubin, Direct Coombs
  • •B12/Folate levels, TSH
  • •Endoscopy: If iron def without obvious source (occult GI bleed)

Management

  • 1.1. Acute severe (Hgb<7, symptomatic): Blood transfusion (1 unit = +1 g/dL Hgb)
  • 2.2. Iron deficiency: Oral iron 325mg (65mg elemental) daily on empty stomach + Vitamin C
  • 3.3. B12 deficiency: Cyanocobalamin 1000mcg IM weekly x4-8wks, then monthly
  • 4.4. Folate deficiency: Folic acid 1-5mg daily
  • 5.5. Treat underlying cause (Stop NSAIDs, Treat IBD, etc)

Monitoring

Hemodynamic stability • Response to iron/B12 supplementation • Reticulocyte count (should rise with treatment)

Bleeding/Easy Bruising

History Taking

  • •Location: Petechiae/Purpura (Platelet), Hemarthrosis (Factor def - Hemophilia)
  • •Onset: Lifelong (Inherited) vs Recent (Acquired)
  • •Pattern: Immediate (Platelet/Vascular) vs Delayed (Factor def)
  • •Associated: Gingival bleeding, Epistaxis, Menorrhagia
  • •Medications: Anticoagulants, Antiplatelet, NSAIDs, SSRIs

Differential Diagnosis

Platelet: Immune Thrombocytopenia (ITP), TTP, HUS, Chemotherapy, Cirrhosis
Coagulation: Hemophilia A/B, Von Willebrand Disease, DIC, Vitamin K deficiency, Anticoagulation
Vascular: Vasculitis, Scurvy (Vitamin C def), Ehlers-Danlos
Medication-induced

Investigations

  • •CBC with platelet count
  • •PT/INR (Extrinsic pathway - Warfarin, Liver disease)
  • •PTT (Intrinsic pathway - Heparin, Hemophilia)
  • •Fibrinogen, D-dimer (DIC)
  • •Peripheral smear: Schistocytes (TTP/HUS)
  • •Consider: vWF studies, Factor assays

Management

  • 1.1. ITP: Steroids (Prednisone 1mg/kg), IVIG if severe (<20k platelets + bleeding)
  • 2.2. TTP: Plasma exchange (URGENT), Rituximab
  • 3.3. Hemophilia: Factor replacement (Factor VIII or IX)
  • 4.4. Vitamin K deficiency: Vitamin K 10mg IV (INR elevated from Warfarin/Malnutrition)
  • 5.5. DIC: Treat underlying cause, Supportive (FFP, Platelets, Cryo)

Monitoring

Active bleeding sites • Hemoglobin trend • Response to treatment

Endocrine

Polyuria/Polydipsia

History Taking

  • •Urine volume: >3L/day = Polyuria
  • •Onset: Acute (DI, DKA) vs Chronic (DM, Primary polydipsia)
  • •Nocturia? (DI, DM, CHF)
  • •Associated: Weight loss (DM), Hypernatremia (DI), Hypokalemia (Primary aldosteronism)
  • •Medications: Diuretics, Lithium (causes Nephrogenic DI)

Differential Diagnosis

Hyperglycemia: Diabetes Mellitus (Type 1 or 2), DKA
Diabetes Insipidus: Central (Pituitary - Tumor, Trauma) vs Nephrogenic (Lithium, Hypercalcemia)
Primary Polydipsia: Psychiatric, Excessive water intake
Hypercalcemia: Malignancy, Hyperparathyroidism
Hypokalemia: Causing nephrogenic DI
Other: CKD, Diuretics

Investigations

  • •Labs: Glucose, HbA1c, Sodium, Calcium, Potassium, BUN/Cr
  • •Urine: Osmolality, Specific gravity (Low in DI)
  • •Serum osmolality
  • •Water deprivation test: Differentiates DI from primary polydipsia
  • •Desmopressin trial: Nephrogenic vs Central DI
  • •MRI Pituitary if Central DI suspected

Management

  • 1.1. Diabetes Mellitus: Insulin (Type 1) or Oral hypoglycemics (Type 2)
  • 2.2. Central DI: Desmopressin (DDAVP) 0.1-0.4mg daily
  • 3.3. Nephrogenic DI: Treat cause (Stop Lithium), Thiazide diuretics + Low sodium diet
  • 4.4. Primary Polydipsia: Psychiatric evaluation, Fluid restriction
  • 5.5. Monitor for dehydration and electrolyte abnormalities

Monitoring

Fluid balance (Intake/Output) • Serum sodium (Risk of hypernatremia) • Weight

Heat/Cold Intolerance

History Taking

  • •Heat intolerance + Weight loss + Palpitations = Hyperthyroidism
  • •Cold intolerance + Weight gain + Fatigue = Hypothyroidism
  • •Associated: Tremor, Anxiety (Hyper), Constipation, Dry skin (Hypo)
  • •Neck swelling? (Goiter)
  • •Eye changes? (Graves' ophthalmopathy)

Differential Diagnosis

Hyperthyroidism: Graves' disease, Toxic adenoma, Thyroiditis (Subacute, Postpartum), Iodine-induced
Hypothyroidism: Hashimoto's thyroiditis, Post-ablation, Iodine deficiency, Central (Pituitary)
Other: Menopause (Hot flashes), Anxiety, Pheochromocytoma

Investigations

  • •TSH: Low (Hyperthyroid), High (Hypothyroid) - BEST screening test
  • •Free T4 and T3
  • •Thyroid antibodies: Anti-TPO (Hashimoto's), TSI (Graves')
  • •Radioactive iodine uptake scan: High (Graves'), Low (Thyroiditis)
  • •Thyroid ultrasound: Nodules

Management

  • 1.1. Hyperthyroidism: Beta-blocker (Propranolol 20-40mg TID) for symptoms, Methimazole 15-30mg daily
  • 2.2. Graves': Radioactive iodine ablation or Thyroidectomy
  • 3.3. Thyroid storm: Propranolol, PTU/Methimazole, Hydrocortisone, Cooling
  • 4.4. Hypothyroidism: Levothyroxine 1.6 mcg/kg/day (typically 50-100mcg)
  • 5.5. Myxedema coma: ICU, IV Levothyroxine, Hydrocortisone

Monitoring

Symptoms resolution • TSH levels (Check 6-8 weeks after dose change) • Cardiac symptoms (AFib risk in hyperthyroid)

Psychiatric

Anxiety (Acute/Panic Attack)

History Taking

  • •Symptoms: Palpitations, Sweating, Trembling, SOB, Chest pain, Nausea, Dizziness
  • •Duration: Peak within 10 minutes, Resolve in 30 minutes (Panic attack)
  • •Triggers: Specific phobias, Social situations, or Spontaneous
  • •Frequency: Recurrent panic = Panic disorder
  • •Rule out medical causes first!

Differential Diagnosis

Cardiac: MI, Arrhythmia, PE
Endocrine: Hyperthyroidism, Pheochromocytoma, Hypoglycemia
Pulmonary: Asthma, PE, Pneumothorax
Psychiatric: Panic disorder, Generalized anxiety disorder (GAD), PTSD
Substance: Caffeine, Stimulants, Alcohol/Benzo withdrawal

Investigations

  • •ECG: Rule out MI, arrhythmia
  • •Labs: TSH, Glucose, CBC
  • •Consider: D-dimer (PE), Troponin, Tox screen
  • •Screening: GAD-7 (Generalized Anxiety Disorder scale)

Management

  • 1.1. Acute: Reassurance, Breathing exercises (Not hyperventilation into bag)
  • 2.2. Short-term: Benzodiazepines (Lorazepam 0.5-1mg PRN - caution: dependence)
  • 3.3. Long-term: SSRIs (Sertraline 50mg daily, Escitalopram 10mg)
  • 4.4. Cognitive Behavioral Therapy (CBT) - First line!
  • 5.5. Lifestyle: Exercise, Sleep hygiene, Reduce caffeine/alcohol

Monitoring

Frequency of attacks • Functional impairment • Depression screening (High comorbidity)

Insomnia

History Taking

  • •Type: Sleep onset (Anxiety) vs Maintenance (Depression, OSA) vs Early morning awakening (Depression)
  • •Duration: Acute (<3mo) vs Chronic (>3mo)
  • •Sleep hygiene: Screen time, Caffeine, Exercise timing, Bedroom environment
  • •Associated: Depression, Anxiety, Chronic pain, Restless legs
  • •Snoring/Witnessed apneas? (OSA)

Differential Diagnosis

Primary: Psychophysiologic insomnia
Psychiatric: Depression, Anxiety, Bipolar (decreased need for sleep)
Medical: OSA, Chronic pain, GERD, Hyperthyroidism, Nocturia
Medications: Stimulants, Steroids, Beta-agonists, SSRIs
Substances: Caffeine, Alcohol (disrupts REM)

Investigations

  • •Screening: PHQ-9 (Depression), GAD-7 (Anxiety), STOP-BANG (OSA)
  • •Sleep diary: 2 weeks
  • •Labs: TSH if indicated
  • •Polysomnography (Sleep study): If OSA suspected

Management

  • 1.1. Sleep Hygiene (First line): Consistent schedule, Dark/cool room, No screens 1h before bed
  • 2.2. CBT-I (Cognitive Behavioral Therapy for Insomnia): Stimulus control, Sleep restriction
  • 3.3. Melatonin 3-5mg 1h before bed (Safe, no dependence)
  • 4.4. Short-term: Zolpidem 5-10mg, Trazodone 25-50mg, Doxepin 3-6mg
  • 5.5. Treat underlying: OSA (CPAP), Depression (SSRI), Pain

Monitoring

Sleep quality and duration • Daytime functioning • Mood

Depression (Major Depressive Disorder)

History Taking

  • •Core symptoms: Depressed mood, Anhedonia (Loss of interest/pleasure) - Need ≥1
  • •Duration: >2 weeks, Most days, Most of the day
  • •Associated: Sleep changes, Appetite/Weight change, Fatigue, Worthlessness/Guilt, Poor concentration, Psychomotor changes
  • •Suicidality: ALWAYS assess (Ideation, Plan, Intent, Means)
  • •Psychotic features? (MDD with psychosis)

Differential Diagnosis

Psychiatric: Bipolar depression, Dysthymia (Persistent depressive disorder), Adjustment disorder
Medical: Hypothyroidism, Anemia, Vitamin D deficiency, Cancer
Neurologic: Parkinson's, Dementia, Stroke
Substance: Alcohol, Substance use disorder

Investigations

  • •Screening: PHQ-9 (Score >10 = Moderate-severe depression)
  • •Labs: TSH, CBC, B12, Vitamin D, CMP
  • •Toxicology if substance use suspected
  • •Risk assessment: Columbia Suicide Severity Rating Scale (C-SSRS)

Management

  • 1.1. Mild-Moderate: Psychotherapy (CBT, IPT) +/- Medication
  • 2.2. Moderate-Severe: SSRI (Sertraline 50mg, Escitalopram 10mg, Fluoxetine 20mg) + Therapy
  • 3.3. Alternative: SNRI (Venlafaxine, Duloxetine), Bupropion (Good if fatigue/low energy)
  • 4.4. Severe/Psychotic: Antidepressant + Antipsychotic, Consider ECT
  • 5.5. Safety: Hospitalization if acute suicide risk
  • 6.6. Response takes 4-6 weeks, Continue 6-12 months after remission

Monitoring

Suicide risk (Highest in first weeks of treatment) • PHQ-9 scores (Track response) • Side effects of medications • Activation/Mania (If undiagnosed Bipolar)

Ophthalmology

Red Eye

History Taking

  • •Unilateral vs Bilateral (Bilateral suggests viral or allergic)
  • •Pain: Severe deep pain (Uveitis, Glaucoma) vs Gritty/Foreign body (Conjunctivitis)
  • •Vision changes: Blurred (Keratitis, Uveitis, Glaucoma) vs Normal (Conjunctivitis)
  • •Discharge: Purulent (Bacterial), Watery (Viral/Allergic), None (Uveitis)
  • •Contact lens use? (Keratitis - Pseudomonas!)
  • •Photophobia? (Uveitis, Keratitis)

Differential Diagnosis

Conjunctivitis: Viral (Most common, Adenovirus), Bacterial (Purulent), Allergic (Bilateral, Itchy)
Keratitis: Bacterial (Contact lens, Pseudomonas), HSV (Dendritic ulcer), Fungal
Uveitis/Iritis: Autoimmune (AS, Sarcoid, IBD), Infection (HSV, Syphilis, TB)
Acute Angle-Closure Glaucoma: EMERGENCY - Mid-dilated pupil, Rock-hard eye
Subconjunctival Hemorrhage: Benign, No treatment needed
Scleritis/Episcleritis: Autoimmune (RA, Granulomatosis with polyangiitis)

Investigations

  • •Visual acuity (ALWAYS test first)
  • •Slit-lamp exam: Cells/Flare (Uveitis), Dendritic ulcer (HSV), Corneal opacity
  • •Intraocular pressure: Elevated (>21mmHg) in Glaucoma
  • •Fluorescein staining: Corneal abrasion, Dendritic ulcer
  • •If uveitis: HLA-B27, RPR, ACE level, CXR, TB testing

Management

  • 1.1. Bacterial conjunctivitis: Erythromycin ointment or Fluoroquinolone drops (Moxifloxacin)
  • 2.2. Viral conjunctivitis: Supportive, Cold compresses, Artificial tears (Self-limited 1-2wks)
  • 3.3. Allergic: Antihistamine/Mast cell stabilizer drops (Olopatadine), Avoid allergens
  • 4.4. HSV keratitis: Oral Valacyclovir + Trifluridine drops (NO STEROIDS - worsens!)
  • 5.5. Uveitis: Topical steroids + Cycloplegics (Ophthalmology referral)
  • 6.6. Acute Angle-Closure Glaucoma: EMERGENCY - Timolol drops, Pilocarpine, Acetazolamide IV → Laser iridotomy

Monitoring

Vision changes • Worsening pain or photophobia • Response to treatment

Acute Vision Loss

History Taking

  • •Onset: Sudden painless (Retinal artery/vein occlusion, Retinal detachment) vs Painful (Optic neuritis, Glaucoma)
  • •Duration: Transient (Amaurosis fugax - TIA) vs Persistent
  • •Unilateral vs Bilateral (Bilateral = Stroke, Giant Cell Arteritis)
  • •Visual field: Curtain/Veil (Retinal detachment), Central scotoma (Optic neuritis, Macular)
  • •Associated: Flashes/Floaters (Retinal detachment), Headache (GCA, Stroke), Eye pain (Optic neuritis)

Differential Diagnosis

Vascular: Central Retinal Artery Occlusion (CRAO), Central Retinal Vein Occlusion (CRVO), Amaurosis Fugax
Retinal: Retinal Detachment, Vitreous Hemorrhage (Diabetic)
Optic Nerve: Optic Neuritis (MS), Ischemic Optic Neuropathy (GCA/Non-arteritic)
Cortical: Occipital Stroke, Migraine with aura
Other: Acute Glaucoma, Endophthalmitis (post-surgical), Methanol poisoning

Investigations

  • •Visual acuity and Visual field testing
  • •Fundoscopy: Cherry-red spot (CRAO), Disc edema (Optic neuritis, NAION), Flame hemorrhages (CRVO)
  • •ESR/CRP: If GCA suspected (ESR often >50)
  • •MRI Brain/Orbits: Optic neuritis (MS), Stroke
  • •CT Head: Stroke, Mass lesion
  • •Carotid ultrasound: If amaurosis fugax (Embolic source)

Management

  • 1.1. CRAO: EMERGENCY - Ocular massage, Lower IOP (Timolol, Anterior chamber paracentesis), tPA within 4.5h
  • 2.2. GCA: High-dose steroids IMMEDIATELY (Prednisolone 60-80mg or Methylpred 1g IV) - Prevent bilateral blindness
  • 3.3. Retinal Detachment: URGENT Ophthalmology referral for surgical repair
  • 4.4. Optic Neuritis: IV Methylprednisolone 1g x3d → Oral taper, MRI for MS evaluation
  • 5.5. Amaurosis Fugax: Stroke workup (Carotid US, Echo, MRA), Antiplatelet therapy

Monitoring

Serial visual acuity • Fellow eye involvement (GCA can affect both) • Neurological status

Obstetrics / Gynecology

Vaginal Bleeding (First Trimester)

History Taking

  • •Amount: Spotting vs Heavy bleeding (Soaking pads)
  • •Pain: Cramping (Threatened/Inevitable abortion), Unilateral (Ectopic pregnancy)
  • •LMP: Gestational age estimation
  • •Previous: Prior ectopic, Miscarriage history, IVF
  • •Risk factors: IUD, PID history, Tubal surgery (Ectopic risk)

Differential Diagnosis

Viable pregnancy: Implantation bleeding, Subchorionic hemorrhage
Miscarriage: Threatened (Closed os), Inevitable (Open os), Incomplete, Complete, Missed
Ectopic Pregnancy: LIFE-THREATENING - Tubal (95%), Abdominal, Cervical
Molar Pregnancy: Complete or Partial hydatidiform mole
Cervical: Cervicitis, Polyp, Cancer

Investigations

  • •Beta-hCG: Quantitative (Double q48h in viable pregnancy), Serial levels
  • •Transvaginal Ultrasound: Intrauterine pregnancy? Ectopic? Fetal heartbeat?
  • •CBC: Hemoglobin (Assess blood loss)
  • •Blood type and Rh: RhoGAM if Rh-negative
  • •Progesterone: Low level concerning for non-viable pregnancy

Management

  • 1.1. Ectopic (Unstable): EMERGENCY surgery (Salpingectomy or Salpingostomy)
  • 2.2. Ectopic (Stable, <3.5cm, no FHR): Methotrexate IM
  • 3.3. Threatened abortion: Pelvic rest, Follow-up US, Reassurance
  • 4.4. Incomplete: Expectant management, Misoprostol, or D&C
  • 5.5. RhoGAM 300mcg IM if Rh-negative (Within 72h of bleeding)

Monitoring

Hemodynamic stability • Serial beta-hCG (q48h) • Repeat ultrasound if indeterminate

Pelvic Pain (Acute)

History Taking

  • •Timing: Mid-cycle (Mittelschmerz, Ruptured cyst), Menstrual (Dysmenorrhea, Endometriosis)
  • •Location: Unilateral (Ovarian), Bilateral/Central (PID, Uterine)
  • •Associated: Fever/Discharge (PID), Amenorrhea (Ectopic), Urinary symptoms
  • •Sexual history: STI exposure, New partner
  • •LMP: Rule out pregnancy first!

Differential Diagnosis

Gynecologic: Ovarian cyst rupture/torsion, PID, Endometriosis, Ectopic pregnancy, Fibroid degeneration
GI: Appendicitis, Diverticulitis, IBD, Constipation
Urologic: UTI, Kidney stone, Interstitial cystitis
Musculoskeletal: Pelvic floor dysfunction

Investigations

  • •Beta-hCG: ALWAYS in reproductive age females
  • •UA: UTI, Kidney stone
  • •CBC/CRP: Infection, Inflammation
  • •Pelvic Ultrasound: Ovarian cyst, Torsion (Absent Doppler flow), Ectopic
  • •NAAT: GC/Chlamydia if PID suspected
  • •CT Abdomen/Pelvis: If non-gyn pathology suspected

Management

  • 1.1. Ovarian Torsion: SURGICAL EMERGENCY - Detorsion ± Oophorectomy
  • 2.2. PID: Ceftriaxone 500mg IM + Doxycycline 100mg BID x14d + Metronidazole 500mg BID x14d
  • 3.3. Ruptured ovarian cyst: Usually conservative (NSAIDs, Monitor Hgb), Surgery if hemodynamically unstable
  • 4.4. Endometriosis: NSAIDs, Hormonal therapy (OCPs, GnRH agonists), Laparoscopy for refractory
  • 5.5. Dysmenorrhea: NSAIDs (Start before menses), OCPs, Consider IUD (Mirena)

Monitoring

Hemodynamic stability • Fever curve • Pain progression

Abnormal Uterine Bleeding

History Taking

  • •Pattern: Heavy (Menorrhagia), Irregular (Metrorrhagia), Post-menopausal (Cancer until proven otherwise)
  • •Duration: >7 days per cycle, >80mL blood loss
  • •Associated: Weight changes (Thyroid, PCOS), Hirsutism (PCOS), Easy bruising (Coagulopathy)
  • •Medications: Anticoagulants, Hormonal contraceptives
  • •Age: Adolescent (Anovulatory), Reproductive (Structural), Post-menopausal (Malignancy)

Differential Diagnosis

Structural (PALM): Polyp, Adenomyosis, Leiomyoma (Fibroid), Malignancy/Hyperplasia
Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction (PCOS, Thyroid), Endometrial, Iatrogenic, Not classified
Post-menopausal: Endometrial atrophy (Most common), Endometrial cancer, Polyps, HRT

Investigations

  • •Beta-hCG: Rule out pregnancy
  • •CBC: Assess for anemia
  • •TSH, Prolactin: Endocrine causes
  • •Coagulation: PT/INR, PTT, vWF (If adolescent or heavy since menarche)
  • •Pelvic Ultrasound: Fibroids, Polyps, Endometrial thickness
  • •Endometrial biopsy: If >45yo, Post-menopausal, or risk factors for endometrial cancer
  • •Saline infusion sonography or Hysteroscopy: Intracavitary lesions

Management

  • 1.1. Acute heavy bleeding: IV Estrogen (Premarin), Tranexamic acid 1g TID, D&C if unstable
  • 2.2. Hormonal: Combined OCPs, Progestin-only pills, Mirena IUD (First-line for chronic)
  • 3.3. Fibroids: GnRH agonists (Pre-surgical shrinkage), Myomectomy, UAE, Hysterectomy
  • 4.4. Polyps: Hysteroscopic polypectomy
  • 5.5. Iron supplementation for anemia (Ferrous sulfate 325mg daily)

Monitoring

Hemoglobin levels • Endometrial thickness • Response to hormonal therapy

Pediatric

Fever in Infants (<3 months)

History Taking

  • •Temperature: ≥38°C (100.4°F) rectal = Fever
  • •Age matters: <28 days (Highest risk), 29-60 days, 61-90 days
  • •Birth history: Premature, NICU stay, Maternal GBS status
  • •Associated: Irritability, Lethargy, Poor feeding, Rash
  • •Immunization status, Sick contacts

Differential Diagnosis

Bacterial: UTI (Most common serious bacterial infection), Meningitis, Bacteremia, Pneumonia, Osteomyelitis
Viral: RSV, Enterovirus, Influenza, HSV (Disseminated neonatal)
Other: Kawasaki disease, Metabolic disorder

Investigations

  • •Full sepsis workup for <28 days: CBC, Blood culture, UA/Urine culture, CSF (LP), CXR if respiratory symptoms
  • •29-60 days: Rochester/Philadelphia/Boston criteria to guide workup
  • •Inflammatory markers: CRP, Procalcitonin (Better for bacterial)
  • •Viral panel: RSV, Influenza, Enterovirus
  • •HSV PCR: If vesicles, seizures, LFT abnormalities, or ill-appearing neonate

Management

  • 1.1. <28 days: Admit, IV Ampicillin + Gentamicin (or Cefotaxime) pending cultures
  • 2.2. Add Acyclovir if HSV suspected (10mg/kg IV q8h)
  • 3.3. 29-60 days (Well-appearing): Risk stratify - Low risk may be observed with close follow-up
  • 4.4. 29-60 days (Ill-appearing): Admit, IV antibiotics
  • 5.5. UTI: Cephalexin (Outpatient) or Ceftriaxone (Inpatient), VCUG after first febrile UTI <2yo

Monitoring

Clinical appearance (Well vs Ill-appearing) • Feeding tolerance • Temperature trend

Wheezing in Children

History Taking

  • •Age: <2 years (Bronchiolitis), >2 years (Asthma more likely)
  • •First episode vs Recurrent (≥3 episodes = likely asthma)
  • •URI prodrome? (Bronchiolitis typically follows URI)
  • •Triggers: Cold air, Exercise, Allergens, URI
  • •Family history: Atopy, Asthma, Eczema
  • •Sudden onset without URI? (Foreign body aspiration!)

Differential Diagnosis

Bronchiolitis: RSV (Most common), Rhinovirus, Most common in <2yo
Asthma: Recurrent wheezing, Atopic history, Reversible with bronchodilators
Foreign Body Aspiration: Sudden onset, Unilateral wheeze, Choking history
Croup: Barking cough, Stridor (NOT wheeze), Steeple sign on X-ray
Other: Pneumonia, GERD, Vascular ring, Tracheomalacia

Investigations

  • •Clinical diagnosis usually sufficient
  • •SpO2: Guide need for supplemental oxygen
  • •CXR: If atypical presentation, First wheeze, Unilateral (Foreign body - air trapping)
  • •RSV/Viral testing: For isolation purposes (Not to guide treatment)
  • •Spirometry: In older children (>5yo) for asthma diagnosis

Management

  • 1.1. Bronchiolitis: Supportive ONLY - Suctioning, Oxygen if SpO2 <90%, Hydration. NO albuterol, NO steroids
  • 2.2. Asthma (Acute): Albuterol MDI (4-8 puffs) or Nebulizer, Oral prednisolone 1-2mg/kg (max 60mg)
  • 3.3. Asthma (Severe): Continuous nebulized albuterol, IV Magnesium sulfate 25-50mg/kg
  • 4.4. Foreign Body: Rigid bronchoscopy for removal
  • 5.5. Asthma (Chronic): Step-up therapy - ICS (Fluticasone), Add LABA if uncontrolled

Monitoring

Respiratory rate and effort (Retractions, Grunting, Nasal flaring) • Oxygen saturation • Feeding tolerance (Cannot feed = severe) • Apnea (Especially in premature infants with bronchiolitis)

Rash with Fever (Pediatric)

History Taking

  • •Rash timing: With fever (Viral exanthem) vs After fever breaks (Roseola)
  • •Morphology: Vesicular (Varicella, Hand-Foot-Mouth), Maculopapular (Measles), Petechial (Meningococcemia!)
  • •Distribution: Starts face then spreads (Measles), Palms/Soles (RMSF, Hand-Foot-Mouth, Syphilis)
  • •Immunization status (Measles, Varicella)
  • •Ill contacts, Travel history

Differential Diagnosis

Viral: Roseola (HHV-6), Measles, Rubella, Varicella, Hand-Foot-Mouth (Coxsackie), Fifth Disease (Parvo B19)
Bacterial: Scarlet Fever (GAS), Meningococcemia (Petechial → Purpura EMERGENCY), Staphylococcal Scalded Skin
Kawasaki Disease: Fever >5d, Conjunctivitis, Strawberry tongue, Rash, Extremity changes, Lymphadenopathy
Drug reaction: Serum sickness-like, DRESS
Henoch-Schönlein Purpura: Palpable purpura on buttocks/legs, Arthritis, Abdominal pain, Renal

Investigations

  • •Clinical diagnosis for most viral exanthems
  • •Blood culture + CBC: If meningococcemia suspected (Do NOT delay antibiotics!)
  • •Throat culture/Rapid strep: Scarlet fever
  • •ESR/CRP, Echo: Kawasaki disease
  • •UA: HSP (Hematuria/Proteinuria)
  • •Parvovirus B19 IgM: If Fifth disease in pregnant contact

Management

  • 1.1. Most viral exanthems: Supportive care, Antipyretics
  • 2.2. Meningococcemia: EMERGENCY - IV Ceftriaxone immediately, ICU, Prophylaxis for contacts (Rifampin/Cipro)
  • 3.3. Kawasaki: IVIG 2g/kg + High-dose Aspirin → Low-dose Aspirin (Prevent coronary aneurysms)
  • 4.4. Scarlet Fever: Penicillin V or Amoxicillin x10 days
  • 5.5. Varicella: Acyclovir if immunocompromised or >12yo, Supportive for healthy children

Monitoring

Petechial progression (Meningococcemia can progress rapidly) • Mucosal involvement (Kawasaki, SJS) • Renal function (HSP)

Renal / Electrolytes

Oliguria / Acute Kidney Injury

History Taking

  • •Urine output: <0.5 mL/kg/hr = Oliguria, <100 mL/day = Anuria
  • •Recent: Medications (NSAIDs, ACE-I, Aminoglycosides, Contrast), Surgery, Hypotension
  • •Volume status: Vomiting, Diarrhea, Bleeding (Prerenal)
  • •Urinary symptoms: Difficulty voiding (Obstruction - BPH, Stone)
  • •History: CKD, DM, HTN, Heart failure, Liver disease

Differential Diagnosis

Prerenal (60-70%): Hypovolemia (Dehydration, Hemorrhage), Decreased cardiac output (CHF, Cardiogenic shock), Vasodilation (Sepsis), Renal artery stenosis
Intrinsic (25-30%): ATN (Ischemic, Nephrotoxic), AIN (Drug-induced), Glomerulonephritis, Rhabdomyolysis
Postrenal (5-10%): BPH, Kidney stones, Tumor compression, Neurogenic bladder

Investigations

  • •UA with microscopy: Muddy brown casts (ATN), WBC casts (AIN), RBC casts (GN), Eosinophils (AIN)
  • •BMP: Creatinine trend, BUN/Cr ratio (>20:1 = Prerenal)
  • •FENa: <1% (Prerenal), >2% (ATN), FEUrea if on diuretics
  • •Renal ultrasound: Hydronephrosis (Obstruction), Kidney size
  • •Consider: CK (Rhabdomyolysis), Complement levels (GN), ANCA/Anti-GBM
  • •Bladder scan: Post-void residual (Retention)

Management

  • 1.1. Prerenal: IV fluid resuscitation (NS or LR), Treat underlying cause, Stop nephrotoxins
  • 2.2. Obstruction: Foley catheter (Urinary retention), Nephrostomy/Stent (Ureteral)
  • 3.3. ATN: Supportive, Avoid further nephrotoxins, Adjust medication doses
  • 4.4. Rhabdomyolysis: Aggressive IV NS (200-300mL/hr target UO 200-300mL/hr)
  • 5.5. Hyperkalemia: Calcium gluconate → Insulin/Glucose → Kayexalate → Dialysis if refractory
  • 6.6. Dialysis indications (AEIOU): Acidosis, Electrolytes (K+), Ingestion (Toxins), Overload, Uremia (Pericarditis, Encephalopathy)

Monitoring

Strict I&O, Daily weights • BMP (Potassium! - Hyperkalemia risk) • Volume status assessment • Urine output trend

Hyponatremia

History Taking

  • •Severity: Mild (130-135), Moderate (125-130), Severe (<125)
  • •Symptoms: Asymptomatic (Chronic) vs Headache, Nausea, Confusion, Seizures (Acute/Severe)
  • •Volume status: Edema (CHF, Cirrhosis, Nephrotic), Dry (Vomiting, Diarrhea, Diuretics), Euvolemic (SIADH)
  • •Medications: Thiazides, SSRIs, Carbamazepine, Desmopressin
  • •Medical history: CHF, Cirrhosis, CKD, Hypothyroid, Adrenal insufficiency

Differential Diagnosis

Hypovolemic: GI losses (Vomiting, Diarrhea), Diuretics (Thiazides!), Cerebral salt wasting, Adrenal insufficiency
Euvolemic: SIADH (Malignancy, CNS disease, Drugs, Pulmonary), Hypothyroidism, Cortisol deficiency, Psychogenic polydipsia
Hypervolemic: CHF, Cirrhosis, Nephrotic Syndrome, CKD
Pseudohyponatremia: Hyperlipidemia, Hyperproteinemia
Redistributive: Hyperglycemia (Corrected Na = Na + 1.6 per 100 glucose >100)

Investigations

  • •Serum osmolality: Low (<280) = True hyponatremia
  • •Urine osmolality: >100 (Impaired water excretion = SIADH, Volume depletion) vs <100 (Polydipsia)
  • •Urine sodium: <20 (Hypovolemic, Edematous states) vs >40 (SIADH, Diuretics, Renal salt wasting)
  • •TSH, Cortisol: Rule out hypothyroid and adrenal insufficiency
  • •BMP, LFTs, BNP: Assess for CHF, Cirrhosis

Management

  • 1.1. Severe/Symptomatic (Seizures): 3% Hypertonic saline 100-150mL bolus over 10-20min, Repeat x2 if needed
  • 2.2. SIADH: Fluid restriction (1-1.5L/day), Salt tabs, Tolvaptan (if refractory)
  • 3.3. Hypovolemic: NS (0.9%) fluid resuscitation
  • 4.4. Hypervolemic: Fluid/Salt restriction, Loop diuretics
  • 5.5. CRITICAL: If Na corrects >10-12 mEq in 24h → Give D5W or DDAVP to slow correction (Prevent osmotic demyelination syndrome)

Monitoring

Na correction rate: <10-12 mEq/L in 24h (Risk of osmotic demyelination if too fast!) • Neurologic status (Seizures, AMS) • Strict I&O • Check Na q2-4h during active correction

GI / GU

Nausea & Vomiting

History Taking

  • •Timing: Post-prandial (Obstruction, Gastroparesis), Morning (Pregnancy, ICP)
  • •Content: Bilious (Small bowel), Feculent (Distal obstruction), Blood (GI bleed)
  • •Associated: Headache (Migraine, Meningitis), Abdominal pain, Diarrhea
  • •Meds: Opioids, Chemotherapy, Antibiotics

Differential Diagnosis

GI: Gastroenteritis, GERD, PUD, Obstruction, Pancreatitis, Appendicitis
Systemic: Pregnancy, DKA, Uremia, Hypercalcemia, Adrenal insufficiency
Neuro: Migraine, Increased ICP, Meningitis, Labyrinthitis
Cardiac: Inferior MI

Investigations

  • •Labs: BMP (Electrolytes), Glucose, Lipase, Beta-hCG, UA
  • •Imaging: Abdominal X-ray (Obstruction), CT if surgical abdomen suspected
  • •ECG: Rule out MI

Management

  • 1.1. Rehydration: PO (if tolerating) or IV fluids
  • 2.2. Antiemetics: Ondansetron 4-8mg (Serotonin blocker), Metoclopramide 10mg (Prokinetic), Promethazine 12.5-25mg
  • 3.3. Treat underlying cause
  • 4.4. NPO if obstruction/ileus
  • 5.5. NG tube if severe obstruction

Monitoring

Hydration status (Urine output, Mucous membranes) • Electrolyte abnormalities

Dysuria

History Taking

  • •Location: External (Vulvovaginitis, HSV) vs Internal (UTI)
  • •Frequency/Urgency? (Cystitis)
  • •Hematuria? (Hemorrhagic cystitis, Stones)
  • •Discharge? (STI: GC, Chlamydia, Trich)
  • •Sexual history, Contraception

Differential Diagnosis

Infectious: UTI (Cystitis, Pyelonephritis), STI (GC, Chlamydia), Vaginitis, Prostatitis
Structural: Urolithiasis, BPH
Other: Interstitial Cystitis, Chemical irritant

Investigations

  • •UA with Micro: Leukocyte esterase, Nitrites, WBCs, Bacteria
  • •Urine Culture (if recurrent, complicated, or pyelonephritis)
  • •NAAT (GC/Chlamydia) if STI suspected
  • •CT Urogram if stones suspected

Management

  • 1.1. Uncomplicated Cystitis: Nitrofurantoin 100mg BID x5d or Bactrim DS BID x3d
  • 2.2. Pyelonephritis: Cipro 500mg BID x7d (outpatient) or Ceftriaxone 1g IV (inpatient)
  • 3.3. STI: Ceftriaxone 500mg IM + Doxycycline 100mg BID x7d
  • 4.4. Phenazopyridine (Pyridium) for symptom relief (caution: turns urine orange)
  • 5.5. Hydration

Monitoring

Fever development (Pyelonephritis) • Symptom resolution on treatment

General

Fatigue

History Taking

  • •Duration (>6mo = Chronic Fatigue Syndrome possibility)
  • •Sleep quality (Sleep apnea?)
  • •Mood (Depression/Anxiety)
  • •Weight change, Cold intolerance (Thyroid)
  • •Exertional dyspnea (Anemia, Heart failure)

Differential Diagnosis

Psychiatric: Depression, Anxiety, Somatization
Endocrine: Hypothyroidism, Diabetes, Adrenal insufficiency
Hematologic: Anemia (Iron def, B12)
Infectious: EBV, HIV, Hepatitis, TB
Sleep: OSA, Insomnia
Medications: Beta-blockers, Antihistamines, Benzos

Investigations

  • •Initial: CBC, CMP, TSH, Ferritin
  • •Secondary: B12, Folate, HIV, Hepatitis panel, Cortisol
  • •Screening: PHQ-9 (Depression), STOP-BANG (Sleep apnea)

Management

  • 1.1. Treat specific cause (Iron for anemia, CPAP for OSA)
  • 2.2. Sleep hygiene optimization
  • 3.3. Graded Exercise Therapy
  • 4.4. Antidepressants if depression component
  • 5.5. De-prescribe sedating medications

Monitoring

Functional status impact • Weight changes

Weight Loss (Unintentional)

History Taking

  • •Amount and timeframe (>5% in 6mo = Significant)
  • •Appetite: Increased (Hyperthyroid, DM) vs Decreased (Cancer, Depression)
  • •Associated: Night sweats (TB, Lymphoma), Diarrhea (Malabsorption), Polyuria (DM)
  • •Symptoms: Dysphagia, Abdominal pain, Change in bowel habits
  • •Social: Food insecurity, Depression, Dementia

Differential Diagnosis

Malignancy: GI cancers, Lymphoma, Lung cancer
Endocrine: Hyperthyroidism, Diabetes (uncontrolled), Adrenal insufficiency
GI: Malabsorption (Celiac, IBD, Pancreatitis), Peptic Ulcer
Infectious: HIV, TB, Chronic infections
Psychiatric: Depression, Anorexia Nervosa
Medications: Metformin, SSRIs, Stimulants

Investigations

  • •Labs: CBC, CMP, TSH, HbA1c, HIV, ESR/CRP
  • •Stool: Fecal occult blood, Calprotectin (IBD), Fat (Malabsorption)
  • •Imaging: CT Chest/Abdomen/Pelvis (Malignancy search)
  • •Endoscopy: If GI symptoms (EGD/Colonoscopy)
  • •Age-appropriate cancer screening

Management

  • 1.1. Treat underlying cause
  • 2.2. Nutritional support: High-calorie diet, Nutritional supplements
  • 3.3. Appetite stimulants if appropriate (Megestrol, Mirtazapine)
  • 4.4. Address social determinants (Food access, Home support)
  • 5.5. Oncology/GI referral if indicated

Monitoring

Serial weights • Nutritional status (Albumin, Prealbumin) • Development of new symptoms

Chest Pain

History Taking

  • •Onset: Sudden (PE, MI, Aortic Dissection) vs Gradual
  • •Character: Pressure/Squeezing (ACS), Tearing (Dissection), Sharp/Pleuritic (PE, Pericarditis)
  • •Radiation: Jaw/Arm (ACS), Back (Dissection, Pancreatitis)
  • •Exertional? Relieved by rest/NTG? (Stable Angina)
  • •Risk Factors: Smoking, HTN, DM, HLD, Family Hx

Differential Diagnosis

Life-Threatening: ACS (MI/Unstable Angina), Aortic Dissection, Pulmonary Embolism, Tension Pneumothorax, Esophageal Rupture (Boerhaave)
Cardiac: Pericarditis, Myocarditis, Stable Angina
Pulmonary: Pneumonia, Pleuritis
GI: GERD, Esophageal Spasm, Peptic Ulcer, Pancreatitis
Musculoskeletal: Costochondritis, Trauma

Investigations

  • •ECG: ST elevation/depression, T wave inversion (ACS), S1Q3T3 (PE), Diffuse ST elevation (Pericarditis)
  • •Labs: Troponin (serial), D-dimer (low risk PE), CBC, CMP, Lipase
  • •Imaging: CXR (Widened mediastinum, PTX, Pneumonia), CT Angio (PE, Dissection)

Management

  • 1.1. MONA-B for ACS suspected (Morphine, Oxygen, Nitrates, Aspirin, Beta-blocker)
  • 2.2. Anticoagulation if PE confirmed (Heparin/DOAC)
  • 3.3. GI Cocktail (Maalox/Lidocaine) helps distinguish GERD (caution: can soothe MI pain too)
  • 4.4. NSAIDs/Colchicine for Pericarditis
  • 5.5. Urgent Surgery/Consult for Dissection

Monitoring

Continuous Cardiac Monitoring (Telemetry) • Serial Troponins/ECGs • Vital signs (BP asymmetry in dissection)

Fever (Acute)

History Taking

  • •Duration: <48h (Viral) vs Prolonged (TB, Endocarditis, Malignancy)
  • •Pattern: Continuous vs Intermittent vs Tertian/Quartan (Malaria)
  • •Associated: Cough/SOB (Pneumonia), Dysuria (UTI), Rash, Sick contacts
  • •Travel: Malaria, Dengue, Typhoid
  • •Immunocompromised? HIV, Chemo, Transplant

Differential Diagnosis

Infectious: Pneumonia, UTI, Meningitis, Cellulitis, Sepsis, COVID-19, Influenza
Inflammatory: Drug fever, Connective tissue disease (SLE, Still's)
Neoplastic: Lymphoma, Leukemia, RCC
Other: PE, MI (Inflammatory response)

Investigations

  • •Initial: CBC, CMP, UA, Blood cultures x2 (before antibiotics), CXR
  • •If prolonged: ESR/CRP, HIV, Hepatitis panel, PPD/IGRA, CT Chest/Abdomen
  • •Special: Echocardiogram (Endocarditis), Lumbar Puncture (Meningitis)

Management

  • 1.1. Sepsis Protocol: IV fluids, Broad-spectrum antibiotics (Vanc + Zosyn)
  • 2.2. Source Control: Drain abscess, Remove infected catheter
  • 3.3. Antipyretics: Acetaminophen 1g q6h, Ibuprofen 600mg q6h
  • 4.4. Fever of Unknown Origin (FUO): >3 weeks, no diagnosis after 1 week workup → ID consult
  • 5.5. Neutropenic Fever (ANC<500): MEDICAL EMERGENCY → Cefepime 2g q8h

Monitoring

Response to empiric antibiotics • Development of septic shock (Hypotension, Organ dysfunction)

Edema (Lower Extremity)

History Taking

  • •Unilateral vs Bilateral (Unilateral = DVT/Cellulitis, Bilateral = Systemic)
  • •Onset: Acute (DVT) vs Chronic (CHF, Venous insufficiency)
  • •Pitting vs Non-pitting (Lymphedema, Myxedema)
  • •Associated: Dyspnea (CHF), Proteinuria (Nephrotic), Ascites (Cirrhosis)
  • •Medications: CCB (Amlodipine), NSAIDs, Steroids

Differential Diagnosis

Cardiac: CHF
Hepatic: Cirrhosis with portal hypertension
Renal: Nephrotic Syndrome, CKD
Venous: DVT, Chronic Venous Insufficiency
Other: Lymphedema, Medications, Hypoalbuminemia (Malnutrition)

Investigations

  • •Labs: BNP (CHF), Albumin, Creatinine, UA (Proteinuria), LFTs
  • •Imaging: Doppler Ultrasound (DVT), Echocardiogram (Assess EF)
  • •Consider: Liver ultrasound (Cirrhosis, ascites)

Management

  • 1.1. CHF: Diuresis (Furosemide 40mg daily), Fluid/Salt restriction
  • 2.2. DVT: Anticoagulation (Rivaroxaban 15mg BID or Enoxaparin)
  • 3.3. Nephrotic: Treat underlying (ACE-I, Steroids if needed)
  • 4.4. Medication-induced: Discontinue/Switch offending agent
  • 5.5. Compression stockings for Venous insufficiency

Monitoring

Daily weights • Jugular venous distension (JVD) • Urine output

Abdominal Pain (Acute)

History Taking

  • •Location: RUQ (Biliary/Hepatic), RLQ (Appy/Gyn), LLQ (Diverticulitis), Epigastric (PUD/Pancreatitis)
  • •Migration? (Periumbilical to RLQ = Appendicitis)
  • •Radiation: Back (Pancreatitis/Aorta), Scapula (Cholecystitis), Groin (Renal Colic)
  • •Associated: Nausea/Vomiting, Fever, Change in bowel habits, Hematochezia/Melena

Differential Diagnosis

RUQ: Cholecystitis, Cholangitis, Hepatitis
RLQ: Appendicitis, Ectopic Pregnancy, Ovarian Torsion/Cyst
LLQ: Diverticulitis, Kidney Stone
Epigastric: Pancreatitis, PUD, Gastritis, MI (Inferior)
Diffuse: Perforation, Ischemic Bowel, Obstruction, DKA, Gastroenteritis

Investigations

  • •Labs: CBC, CMP (LFTs), Lipase, UA, Beta-hCG (Females)
  • •Imaging:
  • • - RUQ Ultrasound (Gallbladder/Liver)
  • • - CT Abdomen/Pelvis (Appendicitis, Diverticulitis, Obstruction)
  • • - X-ray (Free air/Obstruction - low sensitivity)

Management

  • 1.1. NPO, IV Fluids
  • 2.2. Pain Control (IV Morphine/Fentanyl - does not mask peritoneal signs)
  • 3.3. Antiemetics (Zofran)
  • 4.4. Antibiotics if infection suspected (Zosyn/Flagyl+Cipro)
  • 5.5. Surgical Consult for 'Acute Abdomen' (Rigid, guarding, rebound)

Monitoring

Serial abdominal exams (Peritonitis?) • Hemodynamics (Sepsis/Bleed) • Urine output

Headache

History Taking

  • •Onset: Sudden 'Thunderclap' (SAH) vs Gradual
  • •Features: Unilateral/Pulsating (Migraine), Band-like (Tension), Periorbital/Lacrimation (Cluster)
  • •Red Flags (SNOOP): Systemic signs (fever), Neoplasm history, Onset sudden, Older age (>50 new onset), Pattern change/Papilledema/Pregnancy

Differential Diagnosis

Primary: Migraine, Tension, Cluster
Secondary (Dangerous): Subarachnoid Hemorrhage (SAH), Meningitis, Tumor, Temporal Arteritis (GCA), Venous Sinus Thrombosis, Stroke/Dissection
Other: Medication Overuse, Sinusitis, Glaucoma

Investigations

  • •Physical: Neuro exam, Fundoscopy (Papilledema), Temporal artery palpation
  • •Labs: ESR/CRP (Temporal Arteritis)
  • •Imaging: CT Head non-contrast (Acute blood), MRI Brain (Tumor, Posterior fossa)
  • •Procedures: Lumbar Puncture (Meningitis, SAH if CT negative)

Management

  • 1.1. Migraine Cocktail: Fluids + NSAID (Toradol) + Antiemetic (Reglan/Compazine) + Diphenhydramine
  • 2.2. Cluster: 100% Oxygen
  • 3.3. Tension: NSAIDs, Acetaminophen, Caffeine
  • 4.4. Temporal Arteritis: High dose steroids immediately
  • 5.5. Meningitis: Empiric Antibiotics + Steroids

Monitoring

Neurologic status • Visual changes • Response to abortive therapy

Diarrhea (Acute)

History Taking

  • •Duration: <2 weeks (Acute), 2-4 weeks (Persistent), >4 weeks (Chronic)
  • •Volume: Large (Small bowel/Secretory) vs Small frequent (Colonic/Inflammatory)
  • •Character: Watery (Viral, Toxin) vs Bloody (Inflammatory - Shigella, E. coli O157)
  • •Associated: Fever (Bacterial), Vomiting (Viral, Toxin), Abdominal pain
  • •Exposures: Sick contacts, Travel, Antibiotics (C. diff), Raw food

Differential Diagnosis

Infectious: Viral (Norovirus, Rotavirus), Bacterial (Campylobacter, Salmonella, Shigella, E. coli), C. difficile
Toxin-mediated: S. aureus, B. cereus (Preformed toxin - Rapid onset <6h)
Parasitic: Giardia, Cryptosporidium, Entamoeba
Non-infectious: Medications, Food intolerance, IBS, IBD

Investigations

  • •Usually clinical diagnosis - Supportive care
  • •Stool culture/PCR: If bloody, severe, immunocompromised, or persistent
  • •C. diff toxin: If recent antibiotics or hospitalization
  • •Stool O&P: If travel to endemic area or >7 days
  • •Labs: BMP (Electrolytes, AKI), CBC (Leukocytosis)

Management

  • 1.1. Hydration: Oral rehydration solution (ORS) preferred, IV if severe
  • 2.2. Diet: BRAT diet (Bananas, Rice, Applesauce, Toast) as tolerated
  • 3.3. Antimotility: Loperamide 4mg then 2mg after each stool (Avoid if bloody/high fever)
  • 4.4. Antibiotics: Usually NOT needed unless:
  • 5. - C. diff: Vancomycin 125mg QID or Fidaxomicin
  • 6. - Traveler's diarrhea: Azithromycin 1g single dose or Cipro 500mg BID x3d
  • 7. - Shigella/Campylobacter (severe): Azithromycin
  • 8.5. Probiotics may reduce duration

Monitoring

Hydration status (Vitals, Urine output, Skin turgor) • Electrolytes • Development of HUS (if E. coli O157 - Do NOT give antibiotics)

Constipation

History Taking

  • •Definition: <3 BM/week or straining/hard stools >25% of time
  • •Onset: Acute (Obstruction, Ileus) vs Chronic (Functional, IBS-C)
  • •Red flags: Weight loss, Blood in stool, Family history of colon cancer, Age >50 new onset
  • •Associated: Abdominal pain, Bloating, Nausea
  • •Medications: Opioids, Anticholinergics, Iron, Calcium channel blockers

Differential Diagnosis

Primary: Functional constipation, IBS-C, Slow transit, Dyssynergic defecation
Metabolic: Hypothyroidism, Hypercalcemia, Hypokalemia, Diabetes
Neurologic: Parkinson's, MS, Spinal cord injury
Obstruction: Colon cancer, Stricture, Volvulus
Medications: Opioids (Most common iatrogenic cause)

Investigations

  • •If red flags: Colonoscopy (Rule out cancer)
  • •Labs: TSH, Calcium, Glucose
  • •Abdominal X-ray: If obstruction suspected (Dilated loops, Air-fluid levels)
  • •Anorectal manometry: If dyssynergic defecation suspected
  • •Colonic transit study: If slow transit suspected

Management

  • 1.1. Lifestyle: Increase fiber (25-35g/day), Fluids (2L/day), Exercise
  • 2.2. Bulk-forming: Psyllium (Metamucil) 1 tsp TID with water
  • 3.3. Osmotic: Polyethylene glycol (MiraLAX) 17g daily, Lactulose 15-30ml daily
  • 4.4. Stimulant: Senna 2 tabs QHS, Bisacodyl 10mg (Use short-term)
  • 5.5. Opioid-induced: Peripheral opioid antagonist (Methylnaltrexone), Scheduled laxatives
  • 6.6. Refractory: Biofeedback therapy, Rarely surgery

Monitoring

Bowel movement frequency • Complications: Fecal impaction, Hemorrhoids • Response to treatment

Jaundice

History Taking

  • •Timing: Acute (Hepatitis, Biliary obstruction) vs Chronic (Cirrhosis)
  • •Associated: Dark urine (Conjugated bili), Clay stools (Biliary obstruction), Pruritus (Cholestasis)
  • •RUQ pain? (Choledocholithiasis, Cholangitis)
  • •Risk factors: Alcohol, Drugs (Acetaminophen), Transfusions, IVDU, Travel
  • •Family history: Gilbert's syndrome, Hemolytic anemias

Differential Diagnosis

Pre-hepatic (Unconjugated): Hemolysis, Gilbert's syndrome
Hepatic (Mixed): Viral Hepatitis (A, B, C), Alcoholic hepatitis, Drug-induced (Acetaminophen, Antibiotics), Cirrhosis, Autoimmune hepatitis
Post-hepatic (Conjugated): Choledocholithiasis, Cholangitis, Pancreatic cancer, Biliary stricture, Primary biliary cholangitis, Primary sclerosing cholangitis

Investigations

  • •Labs: Total/Direct bilirubin, AST/ALT, Alkaline phosphatase, Albumin, PT/INR
  • •Pattern: Hepatocellular (AST/ALT >> ALP) vs Cholestatic (ALP >> AST/ALT)
  • •Viral serologies: Hep A IgM, HBsAg, Anti-HCV, Consider Hep E
  • •Ultrasound RUQ: Dilated ducts (Obstruction), Gallstones, Liver texture
  • •MRCP or ERCP: If biliary obstruction
  • •Hemolysis workup: CBC, Retic count, Haptoglobin, Coombs test

Management

  • 1.1. Choledocholithiasis: ERCP with stone extraction + Sphincterotomy
  • 2.2. Cholangitis (Charcot's triad: Fever, Jaundice, RUQ pain): Broad-spectrum antibiotics + URGENT ERCP
  • 3.3. Viral Hepatitis A/E: Supportive care (Usually resolves)
  • 4.4. Hepatitis B/C: Antiviral therapy (Tenofovir, Entecavir for B; DAAs for C)
  • 5.5. Acetaminophen toxicity: N-acetylcysteine (NAC)
  • 6.6. Alcoholic hepatitis: Prednisolone 40mg daily (if severe), Abstinence
  • 7.7. Pruritus: Cholestyramine 4g BID-QID

Monitoring

Coagulopathy (PT/INR - Synthetic function) • Encephalopathy • Liver enzymes trend

Hematuria

History Taking

  • •Timing: Painless (Malignancy, Glomerulonephritis) vs Painful (Stones, UTI)
  • •Initial vs Terminal vs Throughout (Bladder origin = Throughout)
  • •Associated: Dysuria (UTI), Flank pain (Stone, Pyelonephritis), Weight loss (Cancer)
  • •Gross vs Microscopic (>3 RBC/hpf)
  • •Risk factors: Smoking (Bladder cancer), Recent URI (Post-infectious GN)

Differential Diagnosis

Glomerular: Post-infectious GN, IgA nephropathy, Lupus nephritis, Goodpasture's, ANCA vasculitis
Non-glomerular: Kidney stone, UTI/Pyelonephritis, Bladder cancer, Prostate cancer/BPH, Trauma
Pseudohematuria: Menstruation, Myoglobinuria (Rhabdomyolysis), Foods (Beets), Meds (Rifampin)

Investigations

  • •UA with Microscopy: RBC casts (Glomerular), WBCs/Bacteria (Infection), Dysmorphic RBCs
  • •Urine culture
  • •Labs: Creatinine, BUN, CBC, PT/INR (if on anticoagulation)
  • •Imaging: CT Urogram (Stones, Masses), Renal ultrasound
  • •Cystoscopy: If >35yo, smoking, or risk factors for bladder cancer
  • •If glomerular: Complement levels, ANA, ANCA, Anti-GBM

Management

  • 1.1. UTI: Antibiotics (Nitrofurantoin, Bactrim)
  • 2.2. Kidney stone: Hydration, NSAIDs, Tamsulosin (if <10mm), Urology if large or obstructing
  • 3.3. Glomerulonephritis: Nephrology referral, Immunosuppression (Steroids +/- Cyclophosphamide)
  • 4.4. Bladder cancer: Transurethral resection (TURBT), Intravesical chemo/BCG
  • 5.5. Anticoagulation: Continue if therapeutic, Investigate cause of bleeding

Monitoring

Renal function • Persistence of hematuria • Blood pressure (Glomerular disease)

Created by Safana Abdullah

For educational purposes only. Always consult a medical professional for diagnosis and treatment.

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