DISEASES

DISEASES

1. ACUTE HEADACHE

   • SYMPTOMS
     • Sudden Onset: Thunderclap headache (maximal intensity within seconds or minutes). Associated Symptoms: Fever, neck stiffness, vision changes. Neurologic symptoms: mental status changes, motor/sensory deficits, loss of consciousness. Exertion-induced headache (cough, sexual activity).
       • Specific Red Flags: Age > 40 years. History of hypertension or HIV infection. Pregnancy-related (pre-eclampsia, cerebral sinus thrombosis). Progressive, unusual pattern change in headache.
   • PHYSICAL EXAMINATION
     • Vital Signs: Assess for hypertension or fever. Neurologic Exam: Look for focal deficits (motor/sensory), mental status changes. Test for meningeal signs (Kernig’s and Brudzinski’s signs).
       • Funduscopic Examination: Check for papilledema, retinal hemorrhages, and cotton wool spots (signs of increased intracranial pressure). Look for eye issues (ophthalmoplegia, afferent pupillary defects). Temporal Artery Palpation: In patients over 60, for signs of temporal arteritis. Other Findings: Assess for signs of Horner's syndrome (ipsilateral ptosis, miosis).
   • DIFFERENCIAL DIAGNOSIS
     • Vascular: Subarachnoid hemorrhage, intracranial hemorrhage, arterial dissection, cerebral venous thrombosis. Infections: Meningitis, encephalitis, brain abscess. Intracranial Masses: Tumors, metastasis. Hypertension-Related: Malignant hypertension, pre-eclampsia. Other Causes: Carbon monoxide poisoning, methemoglobinemia, post-traumatic headache, migraine, and sinusitis
   • DIAGNOSTIC STUDIES
     • Neuroimaging: CT scan (noncontrast) for suspected intracranial hemorrhage, masses, or hypertension. MRI with contrast if specific pathologies are suspected (e.g., tumors, abscesses, HIV-related conditions). Lumbar Puncture: If fever or meningeal signs are present (CSF analysis for infection or increased intracranial pressure).
       • Other Tests: ESR (for temporal arteritis), urinalysis (malignant hypertension), sinus CT (bacterial sinusitis or venous sinus thrombosis). Ottawa Subarachnoid Hemorrhage Rule: For patients with certain risk factors (e.g., age >40, exertion-related onset, thunderclap headache). Tests for specific pathogens in immunocompromised patients (e.g., HIV, cryptococcal antigen).
   • WHEN TO REFER AND WHEN TO ADMIT
     • WHEN TO REFER Frequent or Severe Migraines: Not responsive to standard therapy, atypical features, or chronic daily headaches. Atypical Presentations: Unexplained or persistent headaches despite initial treatments. Unclear Diagnosis: When the workup for secondary causes is inconclusive or when a serious pathology is suspected.
       • WHEN TO ADMIT Recurrent or Severe Pain: Need for repeated doses of parenteral pain medication. Unresolved or Complex Workup: To expedite neuroimaging or other necessary procedures. Progressive Symptoms: Monitoring for worsening condition or need for neurology consultation. Life-Threatening Conditions: Subarachnoid hemorrhage, meningitis, or intracranial masses.
   • TREATMENT
     • For Migraines: Acute Relief: Ketorolac, triptans, dihydroergotamine, lasmiditan, or ubrogepant. Intravenous Medications: Prochlorperazine plus diphenhydramine, or IV hydromorphone if needed. Avoid Opioids: Parenteral morphine and hydromorphone should be avoided for acute migraine pain. For Cluster Headaches: High-flow oxygen therapy, galcanezumab (episodic cluster headache).
       • For Post-Traumatic Headaches: Metoclopramide plus diphenhydramine for symptomatic relief. Steroids: Consider corticosteroids to prevent rebound migraines post-treatment. General Acute Management: IV fluids, antiemetics, and pain relief as indicated.

2. FEVER & HYPERTHERMIA

   • SYMPTOMS
     • Fever: Elevated body temperature with cytokine-mediated rise in the hypothalamic set point. Commonly related to infections, particularly in elderly patients. Fever patterns are of limited diagnostic value, except in cases like malaria, borreliosis, and some lymphomas.
       • Hyperthermia: Excessive heat production or reduced heat loss not mediated by cytokines (e.g., heat stroke, thyroid storm). Body temperature can exceed 41.1°C, leading to protein denaturation and brain damage.
   • PHYSICAL EXAMINATION
     • General Evaluation: Check temperature using appropriate methods (rectal more accurate than oral in specific conditions like ICU or mouth breathers).
       • Associated Findings: Rashes, eosinophilia, or joint pain can guide differential diagnosis (e.g., DRESS syndrome).
         • Special Cases: Elderly patients may show hypothermia rather than fever; pregnant women with fever are at risk for complications.
   • DIAGNOSTIC STUDIES
     • Procalcitonin & CRP Levels: Useful in ICU settings to differentiate between central fever (brain injury) and infection.
       • qSOFA Score: Helps assess sepsis risk in fever patients. Procalcitonin-guided management is beneficial in high qSOFA scores.
   • DIFFERENTIAL DIAGNOSIS
     • Fever: Consider infection, drug reaction (DRESS), or inflammatory diseases. Also, consider rare causes like malignant catatonia, neuroleptic malignant syndrome, or serotonin syndrome.
       • Hyperthermia: Consider thyroid storm, heat stroke, or neuroleptic malignant syndrome.
   • WHEN TO REFER AND WHEN TO ADMIT
     • When to Refer: Febrile neutropenia with high risk (based on MASCC score or qSOFA). Fever unresponsive to standard management with complications or systemic involvement.
       • When to Admit: Signs of Sepsis: Abnormal vital signs or evidence of end-organ dysfunction. Fever >41°C: Immediate control measures for hyperthermia. Severe Cases: Heat stroke, malignant hyperthermia, neuroleptic malignant syndrome, serotonin syndrome.
   • TREATMENT
     • Fever: Antipyretics: Aspirin or acetaminophen, 325–650 mg every 4 hours. Empiric Antibiotics: For febrile neutropenic patients or those with hemodynamic instability. Prophylactic Antibiotics: Recommended for patients with neutrophils <100/mcL.
       • Hyperthermia: Immediate heat removal (e.g., ice baths) and treatment of the underlying cause. Discontinue causative agents like neuroleptics or serotonin-elevating drugs.

3. LOWER EXTREMITY EDEMA

   • SYNPTHOMS
     • Unilateral Edema: Causes: DVT (most life-threatening), varicose veins, postphlebitic syndrome, musculoskeletal disorders (e.g., Baker cyst rupture), May-Thurner syndrome
     • Bilateral Edema: Causes: Venous insufficiency, heart failure (HF), cirrhosis, kidney disease Symptoms: "Heavy legs," itching, skin changes (chronic venous insufficiency), medication side effects, prolonged flights
   • PHYSICAL EXAMINATION
     • Assess for: HF, cirrhosis, pulmonary hypertension Signs: Skin changes, leg swelling (>3 cm difference), ulcers (venous vs arterial), Kaposi-Stemmer sign for lymphedema
   • DIAGNOSTIC STUDIES
     • Tests: Ultrasound (rule out DVT), Wells prediction rule, D-dimer, duplex ultrasonography (venous incompetence), ankle-brachial index, serum albumin, lymphoscintigraphy (lymphedema)
   • WHEN TO REFER AND WHEN TO ADMIT
     • When to Refer: Chronic ulcers, nephrotic syndrome, severe arterial insufficiency
       • When to Admit: High-risk DVT, acute severe swelling (compartment syndrome), severe edema impairing mobility
   • TREATMENT
     • General: Avoid diuretics (venous insufficiency), leg elevation, compression therapy, ambulatory exercise Medications: ACE inhibitors/ARBs for calcium channel blocker-related edema Compression: 20–30 mm Hg (mild), 30–40 mm Hg (moderate-severe), compression stockings, lymphatic drainage

4. INVOLUNTARY WEIGHT LOSS

   • SYMPTOMS
     • 5% weight loss over 6-12 months Decreased appetite GI changes (bowel habits, malabsorption) Fatigue, fever, night sweats Depression, dementia, social isolation
   • PHYSICAL EXAMINATION
     • Assess for signs of malnutrition (muscle wasting, dehydration) Check for GI abnormalities (e.g., abdominal pain, distension) Signs of cancer (lymphadenopathy, organ enlargement) Check for dental issues (missing teeth, oral pain)
   • DIFFERENCIAL DIAGNOSIS
     • Malignancy (cancer-related weight loss) GI disorders (malabsorption, swallowing issues) Heart failure (cardiac cachexia) Endocrine disorders (hyperthyroidism, adrenal insufficiency) Psychiatric disorders (depression, anorexia nervosa) Social factors (alcohol use disorder, social isolation)
   • WHEN TO REFER AND WHEN TO ADMIT
     • When to Refer: Malabsorption syndromes Persistent nutritional deficiencies despite supplementation Eating disorders (e.g., anorexia, bulimia)
       • When to Admit: Severe protein-energy malnutrition (e.g., kwashiorkor, marasmus) Vitamin deficiency syndromes Cachexia related to advanced psychiatric disorders or cancer
   • DIAGNOSTIC STUDIES
     • Diagnostic Studies: CBC, liver tests, kidney panel TSH, HIV tests Fecal occult blood test Chest X-ray (CXR) Cancer screening (e.g., mammography, colonoscopy, PSA) GI tests (e.g., endoscopy, malabsorption) Whole-body CT (if warranted)
   • TREATMENT
     • Treat underlying causes (e.g., cancer, GI disorders) Caloric supplementation (oral, nasojejunal, percutaneous tube) Appetite stimulants (corticosteroids, progestational agents) Exercise (prevents muscle wasting, especially in heart failure) Nutritional support for cancer cachexia

5. FATIGUE & SYSTEMIC INTOLERANCE DISEASE

   • SYMPTOMS
     • Fatigue: Generalized weakness (difficulty starting activities) Easy fatigability (difficulty completing activities) Mental fatigue (difficulty concentrating or with memory)
       • Systemic Exertion Intolerance Disease (SEID): Fatigue of new or definite onset, not alleviated by rest Postexertional malaise: Worsening after physical exertion Unrefreshing sleep: Sleep that doesn’t restore energy Cognitive impairment (difficulty concentrating) or orthostatic intolerance (lightheadedness, dizziness)
   • PHYSICAL EXAMINATION
     • General Exam: Often normal, but may show signs of depression or other underlying conditions. Orthostatic Hypotension: May be present in SEID. Post-exertional malaise: Worsens with physical activity. Other findings: Look for signs of associated conditions (thyroid issues, infections, cardiovascular disease, etc.).
   • DIFFERENCIAL DIAGNOSIS
     • Infections: Mononucleosis, hepatitis, endocarditis, sinusitis. Endocrine disorders: Hyper/hypothyroidism, hyperparathyroidism. Cardiovascular disorders: Heart failure, postural hypotension. Neurological conditions: Multiple sclerosis, Parkinson’s, cerebral vascular accident. Psychiatric disorders: Depression, insomnia, anxiety. Other: Anemia, cancer, autoimmune disorders, chronic diseases (e.g., COPD, IBS), side effects of medications.
   • DIAGNOSTIC STUDIES
     • Initial Tests: CBC, ESR, liver function tests, kidney function tests, thyroid function tests, urinalysis. Screening: Tuberculin skin test, psychiatric questionnaires (for depression, anxiety).
       • Additional Tests: Serum cortisol, ANA (for autoimmune disorders), Lyme serology (if indicated). HIV antibody (especially in at-risk populations). No significant findings in Epstein-Barr virus antibodies. Other: Postural hypotension and abnormalities in blood pressure may be noted.
   • WHEN TO REFER AND WHEN TO ADMIT
     • WHEN TO REFER Infections: If infections are not responding to standard treatment. Thyroid disorders: Difficult-to-control hyper- or hypothyroidism. Psychiatric illnesses: Severe psychological issues (depression, anxiety). Cancer: If malignancy is suspected or diagnosed. Fatigue syndromes: Persistent, unexplained fatigue that doesn't fit other diagnoses.
       • WHEN TO ADMIT Failure to thrive: Inability to maintain adequate health or nutrition. Severe fatigue: Impairing activities of daily living. Other conditions: Acute complications from associated conditions like infections or organ failure.
   • TREATMENT
     • Fatigue: Exercise: Resistance and aerobic exercise for chronic conditions (e.g., HF, COPD, cancer). CPAP: For obstructive sleep apnea. Medications: Methylphenidate (psychostimulant), modafinil for fatigue from HIV or depression. Cognitive-behavioral therapy (CBT): Especially for conditions like breast cancer survivors, and fatigue management. Vitamin D: For deficiencies (e.g., in kidney transplant patients).
       • Systemic Exertion Intolerance Disease (SEID): Fludrocortisone: For postural hypotension. Rintatolimod: Immunomodulator with limited evidence. Low-dose naltrexone: Anecdotal reports of benefit. Primary treatments: Cognitive-behavioral therapy (CBT) and graded exercise. Multidisciplinary care: Treat affective disorders and implement a structured CBT program.

6. DISURYA

   • SYMPTOMS
     • Cystitis is commonly diagnosed in women with dysuria, urgency, and frequency, along with fever or back pain. In women, multiple irritative symptoms (dysuria, urgency, frequency) and fever increase the likelihood of cystitis. Elderly patients may not exhibit classic symptoms due to cognitive impairment. Vulvovaginitis should be considered if there are symptoms like vaginal discharge, irritation, or itching.
       • Hematuria in women with voiding symptoms can indicate hemorrhagic cystitis, bladder cancer, or upper tract disease. Acute pyelonephritis can be suspected when symptoms include fever, back pain, nausea, or vomiting, and should be managed promptly to prevent complications.
   • PJHYSICAL EXAMINATION
     • Fever, tachycardia, and hypotension suggest urosepsis and may require hospitalization. In women, a focused physical exam can check for costovertebral angle tenderness, which can indicate pyelonephritis. A pelvic exam is warranted if symptoms suggest vulvovaginitis or cervicitis. For vaginal discharge or other gynecologic concerns, examination can reveal underlying infections like vaginitis or STIs.
   • DIFFERENCIAL DIAGNOSIS
     • Acute cystitis and acute pyelonephritis are the most common causes of dysuria. Vaginitis (Candida, bacterial vaginosis, Trichomonas, herpes simplex) can also lead to dysuria. Urethritis and cervicitis from Chlamydia or gonorrhea should be ruled out. Interstitial cystitis/painful bladder syndrome can present with similar symptoms. Pelvic congestion syndrome (dilated pelvic veins) may cause dysuria and pelvic pain.
   • DIAGNOSTIC STUDIES
     • Urinalysis (UA): Useful in diagnosing uncomplicated cystitis, especially if symptoms align with typical UTI patterns. Positive tests for leukocytes, nitrites, or blood on a dipstick can confirm cystitis. Negative tests in symptomatic patients don't rule out UTI. Urine Culture: Should be considered for patients with upper urinary tract symptoms, or when a negative dipstick test is present in symptomatic individuals. A positive culture with uropathogenic organisms confirms the diagnosis.
       • Renal Imaging: For severe flank/back pain, consider renal ultrasound or CT to check for perinephric abscess, nephrolithiasis, or hydronephrosis.
   • WHEN TO REFER AND WHEN TO ADMIT
     • Refer: For anatomic abnormalities causing recurrent urinary infections. Infections associated with nephrolithiasis or persistent interstitial cystitis/painful bladder syndrome.
       • Admit: In cases of severe pain that impair ambulation or urination (e.g., herpes simplex genitalis). Urinary retention or obstruction causing dysuria. Pyelonephritis with ureteral obstruction. Urosepsis or severe systemic symptoms requiring hospitalization.
   • TREATMENT
     • Antibiotics: The choice depends on the underlying cause, often guided by local resistance patterns. For uncomplicated cystitis, common choices include nitrofurantoin, fosfomycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. For complicated UTI or recurrent UTIs, longer courses of antibiotics may be required.
       • Symptomatic Relief: Phenazopyridine can provide relief from dysuria but should only be used short-term (no more than 2 days). NSAIDs can help with pain but are less effective than antibiotics.