Differential Diagnostic by P'nut

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 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
Reflex Orthostatic Cardiac

syncope hypotension syncope
Vasovagal Situational Carotid sinus Non-cardiac Cardiac

syncope
Emotion Aortic dissection

Pain PHT
Fear defecation
Phobia visceral pain
Drug - Autonomic Volume 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
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
Congenital heart Pericardial E: Exercise
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
Essential HT
Still most common
Consider secondary HT
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
so lig
Pleural effusion
1 or
-
lymphoma :
Hems to -
logic
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
Palpation: CVS
Auscultation: Decr Decr CHF
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
- Intrinsic Factor and Bilirubin - 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

Liver cirrhosis
- Viral:
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
winnow ( Voslltisnmds
wnjsqlzariteso . )
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:
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 Infarct Ischemic colitis
Salmonella
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
Bacteria Salmonella
Organic
TB
Infection
Parasite
Step 2
HIV Isospora Belli
HIV vs non HIV
parvum
Non-HIV
Kaposi
Step 3 Drug Protease inhibitor

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
Fat Flatus Feces Fluid Fatal growth Fetus

(Ascites) Abd
Ileus Constipation
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
obstruction
Stone
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:
LN
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
urine output xu
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
Intravascular
Doxorubicin
hemolysb
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 Precoccious Hypogonadism Hyperandrogenism Hyperthyroidism

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 Normal ormal
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 epsrrovirus 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
disease
Fanconi anemia
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

Extrinsic Platelet d/o Intrinsic Platelet d/o
von disease
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

DIC Bleed Clot
TT
FVII inhibitor
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
Venous stasis Vascular injury Hypercoagulable state

“Thrombophilia”
Varicose vein
Venous vascular
anomalies Congenital Acquire
disease
Antithrombin
Orthopaedic
Factor V Leiden
Prothrombin 2010A
Active Hematologic Medication Autoimmune Miscellaneous

Malignancy disease
Hormone Antiphospholipid
Myeloproliferative Estrogen
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

firm
HIV rcurrehtinf
→ .
Steptococcus TB oiostwaeepiookm 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 spohdylosis 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
diffuse cortical ,
bilzt .
thalamus
Without focal With signs of With focal brainstem

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 CT @ Systemic d/o • cardiac
abnormality
-
Structural
Infection Trauma Vascular Other -
Myocardial
Imru
Encephalitis Brain concussion Status epilepticus
-
Coronary tix Thrombolytic

-
Al Capa
syndrome
Eclampsia MI iuris
:
L LCH Ten @
oonnm
TTP Kawasaki
Arrhythmic
-
Intoxication Electrolyte Endocrine Metabolic Severe Other

sepsis
7100 this }2
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

Differential Diagnostic by P'nut

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Differential diagnostic algorithm in internal medicine

Differential diagnostic algorithm

9.9 Visual disorder

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

1.1 Chest pain

Great vessel Pulmonary GI Musculoskeletal Skin

Aortic dissection Pleura Esophagus Costochondritis

High output state Metabolic Drug & Med

Premature beat Irregular Tachyarrhythmia Bradyarrhythmia

Reflex Orthostatic Cardiac

Vasovagal Situational Carotid sinus Non-cardiac Cardiac

Emotion Aortic dissection

Congestive heart failure

Etiology Precipitating factor

Mnemonic “DIE HEART”

DCM: HCM: RCM: ARVC: Unclassified

Alcohol Athletic train Scleroderma Inflammation?

Familial Nutrition/ Inflammation Deposition Miscellaneous

Nutritional Metabolic Toxic

CVS Renal Endocrine Miscellaneous

Coarctation of aorta Adrenal OSA

Von hippel lindau

Renovascular HT Abnormal kidney Glomerulonephritis

- Virus: Adeno Trauma Non-Trauma

Tumor CNT Metabolic Drug & toxin CVS

Airway Parenchyma Pleura Vascular

COPD Infection Pneumothorax PE

Cardio Metabolic Neuromuscular Psychi

Lying -> Dyspnea Sitting -> Dyspnea

Orthopnea Trepopnea orthodeoxia

Cardio GI ENT Drug Other

CHF Allergic rhinitis ACEI mass

Duration of cough Acute Subacute Chronic

Airway Parenchyma Vascular Miscellaneous

Peripheral cyanosis Central cyanosis

Spare mucous membrane

Cold exposure Low O2 sat Hb abnormal

RS Low FiO2 Cardio

Cyanotic heart Dz “5T+2E”

Cardio Pulmonary GI Miscellaneous

- Neoplasm Cirrhosis - Endocrine

Exudate Transudate Cirrhosis

Malignancy Infection CNT Drug GI Other

thoracis Pancreatitis - OB-GYN:

Congestive heart failure

Connective tissue disease

Hemolytic jaundice Hepatocellular jaundice Obstructive jaundice

Isolated hyperbilirubinemia Hepatocellular injury Hepatic d/o with

Direct Indirect - Diffuse infiltration

Dubin - Increase production

- Decrease Uptake Bactrim

Acute liver injury Chronic liver injury

Extrinsic compression Muscle

Progressive Intermittent Variable

Intracranial and Pericranial Extracranial

Brain Vestibular Eye

GI GU Metabolic Drug & toxin

Diaphragm Mediastinum CNS Metabolic Drug & toxin

Upper Gastrointestinal bleeding

Variceal bleeding Non-Variceal bleeding

Ulcer/erosive Traumatic/Post Surg Tumor Vascular malformation

Lower Gastrointestinal bleeding

Diverticular disease Angiodysplasia Colitis Neoplasm