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 Buerger’s disease Medium : PAN Kawasaki’s disease Large : Takayasu aortitis Giant cell arteritis Isolated CNS vasculitis Cogan’s sundrome All size vv. : Bechet’s 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 CH-MA CH-PA Cystal Septic Trauma Hemarth PVN

ARF DGI Palindromic CNT dz. Early Ch-PA

Crystal Septic Inflam OA

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 Alport’s 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 < 7 d 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 Still’s 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, Anveil’s 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, Anveil’s test, pain ��� limit ��� spine flexion Other clues Pain on spine flexion post ligamentous structure, Ant compression Fx

11. Magic number HT in the young < 35 yr. Stroke in the young < 45 yr. Pakinsonism in the young < 55 yr.

Early dementia < 60 yr.