Approach in Miscellaneous

Te & Chin
1. Multiple organ involvement 2. Single organ involvement 3. Vasculopathy-vasculitis 4. Arthritis 5. Localized edema 6. Generalized edema 7. Glomerular disease 8. Fever / FUO / Prolong fever 9. Weight loss 10. Low back pain 11. Magic number 1. Multiple organ involvement (7) Metabolic derangement : Na / K / Ca / Glucose Endocrine and Metabolism END Single gland : TH / PTH / PIT / AD / GON / P Multiple gland : MEN / PGA Metabolism Infection Systemic : L / R / Dg / Malaria / Enteric f Disseminated : Meloiod / TB-NTM / F / Parasite-Strongyloid / Tissue Septic emboli / : Infective endocarditis Or endarteritis CNTdz. : SLE / RA / SSc / DM-PM / Sj / SNSA etc. Infiltrative dz. : Amyloidosis / Sarcoidosis Vasculopathy Embolic : Cardiac / Artery to artery except PFO Vessel Ext-luminal : compression VV. wall : Vasculitis / Infiltrative / Irregular Int-luminal : cell and plasma components (thrombophilia) Malignancy Direct effect Hematologic malignancy organ involvement Solid tumor Distant metastasis Indirect effect Paraneoplastic syndrome

2. Single organ involvement : Approach by structure Heart Pericardium / Myocardium / Endocardium Lung Airway / Parenchyma / Vascular / Pleura / Chest wall Kidney Glomerular / TI / Renal vv. (artery & vein) NS / GI Anatomic localization / Nature of disease 3. Multiple organ involvement compatible with vasculopathy Exclude embolic disease TE / Cholesterol / Tumor / Septic emboli DDX by structure Extraluminal / Vessels wall / Intraluminal DDX Vessel wall disease Infiltrative Irregular surface Vasculitis Clinical features of vasculitis FUO / WL / fatigue + constitutional symptom Clinical indicate vv. size involvement Secondary vasculitis to be R/O (MAIN) Classified size of vv. involvement Small : Eye / K / Pulm / Sk-LCV / Ut / Purpura Medium : Jt. / MI / Ttis / N. / Sk-LVR / Gg / EN Large : Pulse / Bruit / Claud / HT / Blindness DDX Specific Dz. Small : HSP / CGb / Urticarial vasculitis Small-Med : ANCA associated Immune cpx. : SLE / RA / IBD / PSC Buergers disease Medium : PAN Kawasakis disease Large : Takayasu aortitis Giant cell arteritis Isolated CNS vasculitis Cogans sundrome All size vv. : Bechets disease DDX. APS

Clinical clues PAN

predominate n. associated with HBV 10-30% not involve pulmonary vv. WG predominate Lung + Sinus-NP + K CSS asthma + eosinophilia Eosinophil infiltrate on bx. MPA predominate K + Lung TK Age < 40 yr. + asym pulse + claud Segmental irregular vv. wall + Post-stenotic dilatation Subclavian > Common carotid > AA GCA Jaw claudication / Scalp necrosis associated with PMR 50% HSP Age < 20 yr. IgA deposit Skin + GI + K + Jt. Investigation to confirm diagnosis Small and small to medium size : biopsy Granulomatous inflammation all except MPA / PAN C/I for biopsy in PAN Angiogram + AutoAb Large : Angiogram Treatment 4. Arthritis cut point 6 wk. AC-MA AC-PA Cystal ARF Septic DGI Trauma Palindromic Hemarth CNT dz. PVN Early Ch-PA CH-MA Crystal Septic Inflam OA CH-PA RA Crystal SNSA / SLE Infection CA-HOA PN

5. Localized edema Skin : Cellulitis SC. : Necrotizing fasciitis M. : Local myositis (Trichinella) / Hematoma Tumor A. : AAO V. : DVT Lymp : Lympatic obstruction Bone : Tumor / Fracture

6. Generalized Edema Heart failure : Rt sided or CHF Kidney : Nephritis / RF Hypoalbuminemia : Liver / Malnutrition / Nephrotic Edematous phase SSC Angioedema Hypothyroidism (Cushing) 7. Clinical syndrome of Glomerular disease (3) Asymptomatic Hematuria Transient / Persistent Glomerular / Non-Glomerular Glomerular (5) IgA nephropathy Thin basement membrane Alports syndrome IgM nephropathy MPGN Proteinuria Transient / Persistent Glomerular / Non-Glomerular Persistent (3) Glomerular Tubular Overflow (3) MM / Myeloid Lk / Mburia Glomerulonephritis Acute GN (4) 70% Immune complex 30% Pauci-immune 1% AntiGBM Post infectious IgA nephropathy MPGN / FSGS RPGN (3) DDX pseudo-RPGN 45% Immune complex Renal limited MPGN / PIGN / IgA / MbN Systemic involvement ECGb / HSP / SLE-LN / IE

45% Pauci-immune ANCA + Idiopathic crescentric GN 10% Anti-GBM Chronic GN Nephrotic syndrome Primary (5) Minimal change disease can FSGS !!! IgM nephropathy FSGS Membranous nephropathy MPGN Conclusion FSGS / MPGN can present with all manifestation Glom dz. Secondary cause of Glomerular dz. M : NSAIDs A : LN I : HIV / HBV / HCV N : Hematologic / Solid O : DM / Deposition dz. If known underlying dz. WG : FSGS RPGN NSAIDs : FSGS / MCD / MbN Lithium : as NSAIDs HIVAN : FSGS / MCD Lymphoma : MCD / MPGN Solid tumor : MbN Obesity : FSGS HBV : Predominate MbN HCV : Predominate MPGN Predominate nephritis R/O secondary LN !!! Primary IgA / PIGN + 2 Predominate nephritic R/O secondary DN !!! Primary MbN / MCD / IgM / TBM + 2

8. Fever / FUO / Prolong fever Normal Core BT 37.0 + 0.8 / diurnal variation 0.6-1.1 Maximum BT 4-6 pm. The best Rectal T / Oral-Tympanic + 0.5 / Axilla + 1 Fever BT > 38.0 from change hypothalamic set point Hyperthermia : increase heat production not change set point Terms <7d Acute febrile illness 7-14 d. Subacute fever > 14 d. Prolong fever > 21 d. FUO uncertain Dx. After 3 d. study Approach Infection / Non infection Non infection Autoimmune disease CNT dz. + JRA IBD / Adult Stills dz. Cancer Hematologic Solid Infiltrative disease Metabolic and Endocrine dz. Hyperthyroidism Adrenal insufficiency Drugs Infection Host ex. HIV & OIs / Non-HIV Localized or Systemic organ involvement Skin & Soft tissue infection Cellulitis / Necrotizing fasciitis / Lymphadenitis Infection of Animal bites CNS Menigitis / Encephalitis / Brain abscess RTI URTI Rhinitis / Common cold Sinusitis / OM / Sore throat / Pharyngitis / Deep neck Tracheobronchitis LRTI Pneumonia / Empyema thoracis

CVS Myo-Pericarditis / IE / Enarteritis / Mycotic aneurysm GI Infective diarrhea / Peritonitis-SBP / Visceral abscess HB Viral Hepatitis : A-E / Liver abscess Acute cholecystitis / Acute Cholangitis UTI LUTI : Cystitis UUTI : Pyelonephritis OB-GYN Peuperal / Cervicitis / Vaginitis / PID AIR Septic arthritis / Osteomyelitis Systemic organ involvement Systemic infection Viral : Flu / Dengue / Chikunkunya Leptospirosis Ricketsiosis Malaria Enteric fever Disseminated infection TB-NTM Melioidosis Fungus Septic emboli Bacterial endocarditis Pathogen and treatment 9. Weight loss Exclude dehydration Poor Intake Eating / Deglutition Apatite : Hormone / Cytokine / Peptide Psychiatric dz. ex. depression / stress Maldigestion / Malabsorption Overutilization Hypercatabolic state Heavy exercise Idiopathic

10. Low Back pain Local pain pain near affected part Pain referred to the back: Abd, Pelvic viscera o Unaffected by posture o abd or pelvic pain

character

o Local pain at spine o Common = Pancreatitis, AAA, Pyelonephritis o Lower throracic & Upper lumbar region Upper abd o Mid lumbar region (L2-4) Lower abd o Sacral region Pelvic organ o Pain groin, labia, testicles Iliopsoas region ( lesion) DDx: retroperitoneal hge sudden pain + on coumadin Mass Abscess: o Acute staph, Gram neg (host) o Subac: TB NTM melioid o route of spread Pain of spine origin: o back refer buttock or leg o dermatome (sclerotome) radiculopathy o o Pain on percussion o limited hip flexion pain on spine flexion o Lateral bending lesion stretch lesion pain & limit motion Radicular pain o Sharp & radiate to leg dermatome o Precipitated by: cough, sneeze, abd m contraction, stretch posture o Specific posture pain = Sciatic n. (L5-S1 root) Femoral n. pain o SLR test pain o Crossed SLR less Sn Sp Dx Herniate disk o Reverse SLR full extend knee then extend hip stretch femoral n o Muscle spasm pain

o spine origin o taut paraspinal muscles o Dull pain o Asymmetry paraspinal m o Limited forward bending Hip pain o mimic lumbar spine pain o Pain on Patrick test, Anveils test Inflammatory back pain o Morning back stiffness o Nocturnal pain o Rest , exercise o Elevated ESR o Young male <40yr o Loss of lumbar lordosis & increased Thoracic kyphosis Cancer pain o Metas: kidney, thyroid, lung, breast, prostate, GI tr o HD, NHL o Character Pain worse at night Unrelieved by rest Constant dull pain Vertebral osteomyelitis o Risk = IVDU o Source of infection = UTI, skin, lungs, BE o Common organism = Staph, TB (Pott) o Character: Pain exacerbated by motion Spine tenderness ESR X-ray: disk sp , erosion of adjacent vertebrae Spinal epidural abscess o Backpain movement or palpation o Sign of nerve root injury/ SC compression

Lumbar adhesive arachnoiditis o Fibrosis inflammation subarachnoid space n. root adhesions o Back pain radiculopathy o Causes of arachnoiditis Multiple lumbar operations Chr spinal infections SC injury Intrathecal hge Intrathecal injection of GC or Anas agents, foreign body Myelography (rare) Cauda equine syndrome (CES) o Definition = injury of multiple n roots spinal canal o Low back pain + weakness, leg areflexia, saddle anesthesia, loss of bladder fn o conus medullaris synd & acute transverse myelitis, GBS o Cause of CES: disk herniated, Vertebral Fx, Hematoma spinal canal, Tu o Rx = surgical decompression, RT in Metas

Fractures o Traumatic o Atraumatic Osteoporosis: HyperPTH, GC, MM, Hyperthyroid Osteomalacia Neoplasm: Metas Infection: Osteomyelitis Approach Back pain Back pain w/ alarm favor Functional back pain musculoligamentous disease, degeneration Wt loss Malignancy, infection, +/- inflammation Night pain inflammation, infection, Tu Pain worse at rest inflammation, infection, Tu Fever infection Spine tenderness Inflam, infec, Tu, Fx Progressive neuro deficit complication: cord or nerve root compression (including Cauda equina syndrome) type of back pain Radicular pain Herniate disk Infection Paravertebral abscess Metastatic Tumor (Kidney, Thyroid, lung, breast, prostate, GI) Lumbar adhesive arachnoiditis Spine pain as above & level Referred pain vertebral level Lower T & Upper L upper abd Mid Lumbar (L2-4) Lower abd Sacral pelvic organ Groin, labia, testicles Iliopsoas Muscle spasm pain underlying spine pain Inflammatory back pain AS, other SpA Other adjacent pain: Hip pain pain on Patrick test, Anveils test, pain limit spine flexion Other clues Pain on spine flexion post ligamentous structure, Ant compression Fx

11. Magic number HT in the young Stroke in the young Pakinsonism in the young Early dementia

< 35 yr. < 45 yr. < 55 yr. < 60 yr.