Medical Symptoms and Treatment

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Back ache or pain
Behavioral disturbances
Behavioral problem
Bitterness
Black stools
Bleeding gums
Bleeding in brain
Bleeding tendency
Blindness
Blister ( Pocket or fluid)
Bloating
Blood in stool
Blood in urine ( Hematuria)
Blod in vomit
Blood shot eyes
Bloody diarrhea
Bloody nose ( epistaxis)
Blue skin tone
Blurry vision
Blurry vision and eye pain
Blody aches
Boil ( Furuncle)
Bradycardia ( Slow heart rate )
Bruising
Bulging abdomen

1. Back ache or pain

COMMON CAUSES

a. Low back pain ( lumbago )

Description of Low back pain (lumbago)
Low back pain is pain in the lower (lumbar) area of the spine and is defined as chronic if the symptoms
last longer than three months. Over time gravity and normal use can result in the gradual degeneration
of the spine. A variety of spinal structures are affected by this steady gravitational pull and their
degeneration is thought to cause low back pain. Strains and other injuries to the bones, ligaments,
muscles and intervertebral disks in the spine are commonly diagnosed along with arthirits all of which
lead to low back pain. Low back pain is the most common cause of disability in Americans younger than
45.
Symptoms of Low back pain (lumbago)
Symptoms include back pain, pain radiating down the leg, decreased flexibility, pain with movement,
and occasionally numbness and weakness.
Tests for Low back pain (lumbago)
Workup
A history and physical will be performed. Imaging tests and possibly blood samples may be performed
depending on the severity and extent of symptoms.
Tests
CT Scan, MRI, Urinalysis (UA) and X-ray
Additional tests that may be required
Myelogram, CBC
Specialists
Family Practice, Internal Medicine, Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation
(physiatry) and Spine Surgery
Treatment of Low back pain (lumbago)
Therapy depends on the extent of the disease and symptoms. Treatment may include: pain medications,
muscle relaxants, non-steroidal anti-inflammatory medications (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), acetaminophen (Tylenol), exercise and physical therapy. Epidural steroid
injections and/or surgery may be considered for persistent pain. Numbness, weakness, or loss of bowel
or bladder control may require emergent surgery.

b. Herniated disc (slipped disc, ruptured disc)

Description of Herniated disc (slipped disc, ruptured disc)
The spine consists of bones (the vertebra) separated by gelatinous cushions (the discs). The discs are
held in place with ligaments. When these ligaments tear, the discs protrude between the vertebra.
These protruded discs can push on spinal nerves, causing severe pain in the back, arm or leg served by
these nerves. At times the protrusion can cause permanent damage to the nerves and requires
emergent surgical repair.
Symptoms of Herniated disc (slipped disc, ruptured disc)
Symptoms depend on the location of the herniated disc and may include: neck pain, back pain, pain
radiating into the arms or legs, numbness, tingling, extremity weakness, loss of bowel or bladder
control.
Tests for Herniated disc (slipped disc, ruptured disc)
Workup
A history and physical exam will be performed. MRI or CT scanning may be recommended to confirm the
diagnosis.
Tests
MRI
Additional tests that may be required
CT myelogram
Specialists
Family Practice, Internal Medicine, Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation
(physiatry), Spine Surgery and Vascular and Interventional Radiology

Treatment of Herniated disc (slipped disc, ruptured disc)
Therapy depends on the extent of the herniation and the symptoms experienced. Some people with
herniated discs improve with the passage of time. Treatment may include: physical therapy, rest
balanced with exercise and stretching, pain medications, nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), acetaminophen (Tylenol),
steroids, muscle relaxants, epidural steroid injections, and/or surgery. Acupuncture, massage or other
alternative therapies also seem helpful in some cases.

c. Muscle strain ( pulled muscle)

Description of Muscle strain (pulled muscle)
A strain is a stretched or torn muscle. Any muscle may be involved. For a short time the injured muscle
will have decreased strength or function. Bleeding into the tissue can occur causing bruising. Sometimes
a strain (muscle injury) can be difficult to tell apart from a sprain (a sprain is an over-stretched or torn
ligament.)
Symptoms of Muscle strain (pulled muscle)
Pain and difficulty moving the injured muscle, discolored and bruised skin, swelling.
Tests for Muscle strain (pulled muscle)
Workup
A history and physical exam will be performed. A X-ray may be done to rule out fracture. A MRI may be
used to identify a torn muscle or injury to a ligament or tendon. MRI is not necessary in most cases
because the diagnosis may be obvious.
Tests
MRI and X-ray
Specialists
Family Practice, Internal Medicine, Pediatric Sports Medicine, Pediatrics, Physical Medicine and
Rehabilitation (physiatry) and Sports Medicine
Treatment of Muscle strain (pulled muscle)
Treatment includes: rest, ice, pressure (ace wrap if needed), elevation, and nonsteroidal antiinflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), pain medications
such as acetaminophen (Tylenol). Severe muscle tears or those with associated injury to tendons or
ligaments may require surgery.

d. Lumbar spondylosis (spine arthritis)
Description of Lumbar spondylosis (spine arthritis)
Lumbar spondylosis is the degeneration of the lower back. This arthritis usually occurs because of the
age-related degenerative disease that develops in the joints and disks of the spine. All patients
experience some wear and tear of the lower back joints as they age, but some have more severe
damage causing significant pain and loss of function. As the arthritis develops there can be the
development of bone spurs, or osteophytes. The rough edges of these bone spurs can irritate the nearby

nerves, ligaments and muscles causing pain. Spondylosis of the spine is one of the most common causes
of pain in the elderly.
Symptoms of Lumbar spondylosis (spine arthritis)
Low back pain, pain and stiffness with activity, numbness and / or weakness.
Tests for Lumbar spondylosis (spine arthritis)
Workup
A history and physical exam will be performed. An X-ray, CT scan and/or MRI may be performed to
identify the extent of the degeneration of the spine.
Tests
CT Scan, MRI and X-ray
Specialists
Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation (physiatry) and Spine Surgery
Treatment of Lumbar spondylosis (spine arthritis)
Therapy depends on the extent of the disease and symptoms. Treatment includes: pain medications,
muscle relaxants, nonsteroidal anti-inflammatory medications (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), acetaminophen (Tylenol), exercise and physical therapy. Surgery is considered for
persistent pain, loss of sensation, or weakness.

e. Sciatica (Lower back nerve irritation)
Description of Sciatica (lower back nerve irritation)
Pain in the lower back and hip radiating down the back of the thigh into the leg. The pain usually
increases with flexion at the hip. Patients also experience numbness and occasionally weakness in the
leg. The disorder can be caused by irritation of the sciatic nerve (irritants may be released from a
ruptured disc in the back), by a pulled muscle injury, or by a bulging (herniated) lumbar disk compressing
a nerve root, most commonly the L5 or S1 root.
Symptoms of Sciatica (lower back nerve irritation)
Dull ache in back, burning sensation in back, pain that radiates down the leg, pain that increases with leg
movement, numbness and tingling in the leg, weakness in the leg.
Tests for Sciatica (lower back nerve irritation)

Workup
A history and physical exam will be performed. An MRI may be done to identify other causes of the
symptoms.
Tests
MRI
Specialists
Family Practice, Internal Medicine, Neurosurgery, Pain Medicine, Pediatrics, Spine Surgery and Vascular
and Interventional Radiology
Treatment of Sciatica (lower back nerve irritation)
Therapy is aimed at maximizing mobility and independence. The following treatments may be
prescribed: medications, physical therapy, epidural steroid injection, and/or surgery. Medications may
include: nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol), gabapentin (Neurontin),
phenytoin, carbamazepine, tricyclic antidepressants, and/or steroids.

ADDITIONAL CAUSES

a. Thoracic spine stenosis
Description of Thoracic spine stenosis
Spinal stenosis of the thoracic spine is narrowing of the spinal canal of the upper back. The narrowing
can cause compression of the spinal cord and nerves exiting the spine. The canal becomes narrowed by
arthritis and degeneration of the bones and ligaments, by a herniated disc, or from a tumor. It is more
common in patients older than 60, but may occur at any age. Thoracic spine stenosis is less common
than lumbar or cervical spinal stenosis
Symptoms of Thoracic spine stenosis
Upper back pain, that may radiate around the chest and legs; numbness, weakness, and pain that
worsens with upper back movement. More severe stenosis may cause problems with balance and
coordination. Individuals who loose bowel or bladder function should seek immediate medical
attention.
Tests for Thoracic spine stenosis

Workup
A history and physical exam will be performed. An x-ray and CT scan can be performed to reveal bone
alignment and degenerative changes. An MRI may reveal the narrowing of the spinal canal and damage
to the nerves.
Tests
CT Scan, MRI and X-ray
Specialists
Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation (physiatry) and Spine Surgery
Treatment of Thoracic spine stenosis
Therapy depends on the extent of the disease. Medication used include: non-steroidal antiinflammatory drugs (ibuprofen/Motrin or naproxen/Naprosyn), acetaminophen/Tylenol, a short trial of
oral corticosteroids (prednisone), and/or narcotic pain relievers. Epidural steroid injections and physical
therapy are also used to control the symptoms as well. Surgery is considered for persistent symptoms or
if nerve compression is significant.

b. Back trauma (injury)
Description of Back trauma (injury)
Trauma to the back may involve injury to the soft tissue (skin, muscles and ligaments) and bony injuries
involving fractures, dislocations, and occasionally spinal cord injuries.
Symptoms of Back trauma (injury)
Pain, swelling, difficulty with range of motion, neurologic abnormalities such as loss of sensation and leg
weakness.
Tests for Back trauma (injury)
Workup
A history and physical exam will be performed. An imaging study may be necessary to characterize the
injury.
Tests
CT Scan, MRI and X-ray
Specialists

Neurosurgery, Orthopedic Surgery, Physical Medicine and Rehabilitation (physiatry), Spine Surgery and
Sports Medicine
Treatment of Back trauma (injury)
Therapy is directed at decreasing the pain and addressing the underlying cause of the pain. Treatment
may include: nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn or Aleve), muscle relaxants, acetaminophen (Tylenol), stronger pain medications,
and/or surgery.

c. Degenerative disc disease
Description of Degenerative disc disease
Degenerative disk disease is the progressive deterioration of the soft tissue between the bones of the
spine. Over time, the the disk between the bones of the spine hardens, resulting in pain, decreased
movement and possible compression of the nerves as they leave the spinal cord. This disease is
extremely common and symptoms are worsened by obesity, and lack of exercise.
Symptoms of Degenerative disc disease
Symptoms depend on the area of the neck or back affected and may include neck and back pain, muscle
weakness, numbness, and decreased movement. At times the pain can be referred to the parts of the
body supplied by the nerves in the neck or back such as the hands, arms, shoulders, legs and feet.
Tests for Degenerative disc disease
Workup
A history and physical exam will be performed. Imaging and at times blood tests will be performed to
confirm the diagnosis.
Tests
CT Scan, MRI and X-ray
Additional tests that may be required
Rheumatoid factor, antinuclear antibody, ESR, C-reactive protein, Chem-12, CBC
Specialists
Family Practice, Internal Medicine, Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation
(physiatry) and Spine Surgery
Treatment of Degenerative disc disease

Treatment may vary depending on the severity of disease. Initial therapy may be directed at weight loss,
exercise and physical therapy. Medications such as anti-inflammatories and muscle relaxants are often
used. Other treatment options include steroid injections around the disk and surgery.

d. Ankylosing spondylitis (Spine arthritis)
Description of Ankylosing spondylitis (severe spine arthritis)
A type of arthritis that affects the spine. Symptoms include pain and stiffness from the neck to the lower
back. The spine's bones (vertebrae) may fuse together, resulting in a rigid spine. These changes may be
mild or severe. Ankylosing spondylitis is also a systemic rheumatic disease, meaning it can affect other
tissues throughout the body including the eyes, heart, lungs, and kidneys. The disorder is more common
in males in the 20 to 40 year age range.
Symptoms of Ankylosing spondylitis (severe spine arthritis)
Neck pain, back pain, stiffness, fatigue, forward curvature of the spine, eye pain and redness, heart
arrhythmias, kidney failure.
Tests for Ankylosing spondylitis (severe spine arthritis)
Workup
A history and physical exam will be performed. Additional blood tests and X-rays may be taken.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Urinalysis (UA) and X-ray
Additional tests that may be required
HLA-B27
Specialists
Pediatric Rheumatology and Rheumatology
Treatment of Ankylosing spondylitis (severe spine arthritis)
Treatment may include: nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn or Aleve), acetaminophen (Tylenol), exercise, sulfasalazine, methotrexate,
etanercept (Enbrel), infliximab (Remicade), and/or adalimumab (Humira).

e. Thoracic spondylosis (spine arthritis)

Description of Thoracic spondylosis (spine arthritis)
Thoracic spondylosis is the degeneration of the mid to upper spine. This arthritis usually occurs because
of the age-related degenerative disease that develops in the joints and disks of the spine. All patients
experience some wear and tear of the upper back joints as they age, but some have more severe
damage causing significant pain and loss of function. As the arthritis develops there can be the
development of bone spurs, or osteophytes. The rough edges of these bone spurs can irritate the nearby
nerves, ligaments and muscles causing pain. Spondylosis of the spine is one of the most common causes
of pain in the elderly.
Symptoms of Thoracic spondylosis (spine arthritis)
Mid to upper back pain, pain and stiffness with activity, numbness and / or weakness.
Tests for Thoracic spondylosis (spine arthritis)
Workup
A history and physical exam will be performed. An X-ray, CT scan and/or MRI may be performed to
identify the extent of the degeneration of the spine.
Tests
CT Scan, MRI and X-ray
Specialists
Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation (physiatry) and Spine Surgery
Treatment of Thoracic spondylosis (spine arthritis)
Therapy depends on the extent of the disease and symptoms. Treatment may include: pain medications,
muscle relaxants, nonsteroidal anti-inflammatory medications (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), acetaminophen (Tylenol), exercise and physical therapy. Surgery is considered for
persistent pain, loss of sensation, or weakness.

f.

Arthritis (joint inflammation)

Description of Arthritis (joint inflammation)
Inflammation of a single joint or multiple joints. There are many causes including infection, and
inflammatory conditions such as: osteoarthritis, gout, pseudogout, rheumatoid arthritis, lupus,
ankylosing spondylitis, and psoriasis.
Symptoms of Arthritis (joint inflammation)

Joint pain, joint swelling, redness, increased warmth, decreased motion.
Tests for Arthritis (joint inflammation)
Workup
A history and physical exam will be performed. Blood tests and/or analysis of joint fluid will be done to
determine cause of arthritis. Imaging studies may also be beneficial.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, MRI and X-ray
Additional tests that may be required
Rheumatoid factor, ANA (Antinuclear antibody), ESR (erythrocyte sedimentation rate), Analysis of joint
fluid
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pediatric Rheumatology, Pediatrics and
Rheumatology
Treatment of Arthritis (joint inflammation)
Determined by the type of arthritis. If the joint is infected, the main treatment is antibiotics and removal
of joint fluid. For other types of arthritis, treatment may include but may include: nonsteroidal antiinflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn or Aleve),
acetaminophen (Tylenol), sulfasalazine, corticosteroids (prednisone), methotrexate, etanercept (Enbrel),
infliximab (Remicade), and/or adalimumab (Humira). For more information contact the National
Institute of Arthritis and Musculoskeletal and Skin Information Clearinghouse at:
http://www.niams.nih.gov or (877) 226-4267

(877) 226-4267 Arthritis Foundation: (800)283-7800

(800)283-7800 Arthritis National Research Foundation: (800)588-2873

(800)588-2873

g. Fibromyalgia (chronic pain disorder)
Description of Fibromyalgia (chronic pain disorder)
Characterized by chronic, widespread pain and tenderness in multiple areas of the body. It can be
associated with impaired sleep, fatigue and poor concentration. The disorder is common among women
between the ages of 20 and 50.
Symptoms of Fibromyalgia (chronic pain disorder)
Pain, achy joints, muscle pain and cramping, weakness, fatigue, non-restorative sleep.

Tests for Fibromyalgia (chronic pain disorder)
Workup
A history and physical exam will be performed. Imaging studies and blood tests may be recommended
to identify another cause of pain. Test results tend to be normal in people with fibromyalgia.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), Lipase,
MRI and Urinalysis (UA)
Additional tests that may be required
Rheumatologic studies to rule out other causes of joint and muscle pain
Specialists
Family Practice, Internal Medicine and Rheumatology
Treatment of Fibromyalgia (chronic pain disorder)
Treatment may include f reduction, exercise, and psychotherapy in addition to medications. Medications
include: pain medications, antidepressants, and anti-seizure medications (anti-convulsants). For more
information contact: Fibromyalgia Network: (800)853-2929

(800)853-2929

h. Ligament sprain (connection between two bones)
Description of Ligament sprain (connection between two bones)
Ligaments are strong, fibrous bands of tissue that hold bones together near joints. This provides
stability. Trauma or over use can stretch a ligament or cause microscopic tears, producing a sprain.
Ligament sprains can cause enough swelling and pain that it makes use of the joint difficult or
impossible.
Symptoms of Ligament sprain (connection between two bones)
Pain, swelling, mild redness, bruising, tenderness, decreased motion, a feeling of instability.
Tests for Ligament sprain (connection between two bones)
Workup
A history and physical exam will be performed. An x-ray may be helpful to rule out a fracture. An MRI
can identify the injured ligament and assess the extent of damage.

Tests
MRI and X-ray
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pediatric Sports Medicine, Pediatrics, Podiatry,
Sports Medicine and Sports Medicine Surgery
Treatment of Ligament sprain (connection between two bones)
Most mild sprains heal on their own with just rest. Treatment includes: immobilization, ice, elevation
and nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn) and pain medications such as acetaminophen (Tylenol). Physical therapy and
therapeutic ultrasound may be helpful. For severe sprains that do not improve with other treatments,
more prolonged immobilization and/or surgery may be required.

i.

Discitis (spinal disk inflammation) *CRITICAL

Description of Discitis (spinal disk inflammation)
Conditions in which the intervertebral disc is infected or inflamed. The intervertebral discs are the
cushioning structures between the bones of the back. Discitis can develop through bacteria in the blood
being delivered to the disc space, or from inflammation caused by an autoimmune disorder. Infections
can also spread from adjacent infections and occasionally from diagnostic testing or surgery.
Symptoms of Discitis (spinal disk inflammation)
Fever, back pain, back stiffness, weakness, numbness, tingling in the extremities.
Tests for Discitis (spinal disk inflammation)
Workup
A history and physical exam will be performed, X-rays, CT scan and/or MRI may be performed. MRI is the
most accurate method of detection. White blood cell count and ESR (erythrocyte sedimentation rate)
may be measured and monitored.
Tests
Complete blood count (CBC), CT Scan, MRI and X-ray
Additional tests that may be required
ESR (erythrocyte sedimentation rate)

Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Discitis (spinal disk inflammation)
Antibiotics, especially those to cover staphylococcal infections are administered. If the disease is due to
an autoimmune disorder, anti-inflammatory or immune suppressing medications may be provided.

j.

Enthesopathy

Description of Muscle and ligament inflammation (enthesopathy)
Enthesopathy is an inflammatory condition involving the attachment of ligaments, tendons and fascia to
bone. It may develop as a result of inflammatory diseases such as ankylosing spondylitis, rheumatoid
arthritis, psoriatic arthritis, and enteropathic arthritis. It is generally considered a process rather than a
condition. Any joint in the body can experience enthesopathy. Males and females are affected equally.
Individuals diagnosed with inflammatory conditions are at greatest risk for development of
enthesopathy.
Symptoms of Muscle and ligament inflammation (enthesopathy)
Symptoms include joint pain, joint swelling, redness or fever.
Tests for Muscle and ligament inflammation (enthesopathy)
Workup
Symptoms include joint pain, joint swelling, redness or fever.
Tests
Complete blood count (CBC), ESR, Joint fluid analysis, MRI, Uric acid and X-ray
Additional tests that may be required
C-reactive protein, Anti-nuclear antibody, Rheumatoid factor, Human leukocyte antigen B27 (HLA-B27)
Specialists
Family Practice, Internal Medicine, Neurosurgery, Orthopedic Surgery, Physical Medicine and
Rehabilitation (physiatry), Rheumatology and Spine Surgery
Treatment of Muscle and ligament inflammation (enthesopathy)

Therapy depends on the extent of the disease and symptoms. Treatment may include: pain medications,
muscle relaxants, nonsteroidal anti-inflammatory medications (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), acetaminophen (Tylenol), exercise and physical therapy.

k. Crohn's disease (Intestinal inflammation) *CRITICAL
Description of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
A recurrent inflammatory disease affecting the gastrointestinal tract. Sections of the intestinal tract
most commonly affected include the lower part of the small intestine (ileum) and the large intestine
(colon); however, any part of the digestive tract, from mouth to rectum, may be involved. It is an
autoimmune disease and is most common in people between the ages of 15 and 35. Other risk factors
are a family history of Crohn's disease, Jewish ancestry and smoking.
Symptoms of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Crampy abdominal pain, nausea, vomiting, loss of appetite, watery or bloody diarrhea, fever, joint pain,
painful bowel movements, weight loss , fatigue, black stools (melena), and skin, eye or joint
inflammation (arthritis)
Tests for Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Workup
A history and physical exam will be performed. Other tests to confirm the diagnosis and identify
complications may be performed, including a barium enema or upper GI series, colonoscopy, CT scan or
MRI. Stool tests may be recommended to check for blood or other causes of symptoms, such as
infection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, MRI and X-ray
Additional tests that may be required
Upper GI series, colonoscopy
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Aminosalicylates (5-ASAs) help control inflammation, and can be given rectally or orally. Corticosteroids
(prednisone and methylprednisolone) are used to treat moderate to severe Crohn's disease. They may
be taken by mouth or inserted into the rectum. Azathioprine and 6-mercaptopurine are

immunomodulators and they help reduce the need for corticosteroids and can help heal some fistulas.
Antibiotics may be used for abscesses or fistulas. Infliximab (Remicade), adalimumab (Humira),
certolizumab (Cimzia), and natalizumab (Tysabri) are powerful anti-inflammatory immune modulators
(called "biologics") that are used for severe cases that don't respond to other treatments. Surgery may
be needed for fistulas or active disease that does not respond to medications. For more information
contact the National Digestive Diseases Information Clearinghouse at:
http://www.digestive.niddk.nih.gov or (800)891-5389
(800)891-5389. Further information is
available at the Crohn's and Colitis Foundation of America at: http://ccfa.org

l.

Muscle spasm (charley horse)

Description of Muscle spasm (charley horse)
A muscle spasm also known as a Charley horse typically occurs after vigorous exercise. The affected
muscle contracts involuntarily and will not relax. It can occur in any muscle of the body but typically
involves the legs, arms and neck. Other causes include dehydration and changes in a patient's body
chemistry with abnormal levels of minerals. Low blood levels of potassium, magnesium and calcium are
the most frequent causes of a Charley horse, but sometimes no cause can be found. More rarely muscle
spasms can occur if the nerve supplying the muscle is injured or irritated.
Symptoms of Muscle spasm (charley horse)
Uncontrolled muscle contraction, pain in the muscles involved, inability to relax the muscle, loss of
function of the muscle during the contraction, muscle twitching.
Tests for Muscle spasm (charley horse)
Workup
A history and physical will be done. Generally no other tests are done. If the healthcare provider
suspects alterations in the body chemistry a blood test may be done. If an irritated nerve is suspected a
MRI of the neck or back may be performed.
Tests
MRI
Additional tests that may be required
Potassium and calcium levels
Specialists
Family Practice, Internal Medicine and Pediatrics

Treatment of Muscle spasm (charley horse)
Typically stretching and massaging the muscle will allow the muscle to relax. Rest and better
conditioning before repeating the exercise can prevent a repeat episode. If dehydration is present
drinking fluids will prevent recurrence. Sports drinks are typically better for dehydration since they
replenish some of the missing minerals in the body. If the spasms continue to occur or are severe the
healthcare provider may evaluate the blood chemistry or look for an irritated nerve.

m. Pleuritis (inflammation of the lung's lining, pleurisy)
Description of Pleuritis (inflammation of the lung's lining, pleurisy)
The pleura is a thin two-layered membrane that lines the outer surface of the lungs and inside surface of
the ribcage. Pleurisy or pleuritis is an inflammation of the pleura. This inflammation is caused by many
different disorders including: autoimmune diseases (Rheumatoid arthritis, Lupus, Scleroderma,
Sarcoidosis), cancer, kidney failure, certain medications (Dilantin, procainamide, hydralazine), viral
infections, bacterial infections, pulmonary embolism, and trauma.
Symptoms of Pleuritis (inflammation of the lung's lining, pleurisy)
Chest pain, chest pain that increases with deep breathing, coughing, shortness of breath, rapid
breathing (tachypnea).
Tests for Pleuritis (inflammation of the lung's lining, pleurisy)
Workup
A history and physical exam will be performed. A rubbing sound may be heard with a stethoscope. Chest
X-ray can be helpful.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG) and Troponin
Specialists
Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Pleuritis (inflammation of the lung's lining, pleurisy)
Treatment depends on what is causing the pleurisy and may include: nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), pain medications such as
acetaminophen (Tylenol), antibiotics, autoimmune medications, and/or chemotherapy. For additional

information contact the National Heart, Lung and Blood Institute Health Information Center at:
http://www.nhlbi.nih.gov or call (301)592-8573

(301)592-8573.

n. Nephrolithiasis (Kidney stone)
Description of Kidney stone (nephrolithiasis)
Kidney stones are small, solid particles that form in one or both kidneys. The majority of kidney stones
contain calcium oxalate. Other types of stones contain uric acid, struvite, and cystine. They generally do
not cause problems until they enter the tube connecting the kidney to the bladder (ureter) causing
obstruction of the urine flow from the kidney to the bladder. The obstruction causes severe pain. The
following conditions increase the risk of developing kidney stones: obesity, a family history of the
disorder, diets high in protein, previous gastric bypass surgery, and dehydration.
Symptoms of Kidney stone (nephrolithiasis)
Flank, back and or abdominal pain; pain often radiates to the groin: abnormal urine color, blood in the
urine; nausea, vomiting; painful urination; urinary frequency/urgency, urinary hesitancy.
Tests for Kidney stone (nephrolithiasis)
Workup
A history and physical exam will be performed. A urine analysis is done to look for red blood cells. A CT
scan is the standard method of diagnosis. An ultrasound can demonstrate the dilation of the ureter and
kidney, suggesting a blocked ureter.
Tests
CT Scan, Ultrasound and Urinalysis (UA)
Additional tests that may be required
Intravenous pyelogram
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Kidney stone (nephrolithiasis)
Vigorous oral or intravenous fluids, pain medications and anti-nausea medications are the primary
treatments. Most stones less than 6mm in size will pass on their own. Stones that don't pass on their
own will need to be removed during a cystoscopy or other surgical procedure. For additional

information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390

(800)891-5390.

o. Urinary tract infection (UTI)
Description of Bladder infection (cystitis, UTI, urinary tract infection)
Acute infections of the urinary tract can be separated into upper and lower tract infections. The bladder
is the most common site of all infections (cystitis).It is a lower tract infection. Upper tract infections
involve the ureters and kidneys. Kidney infections (pyelonephritis) can be very serious with high fever,
vomiting, and severe pain. Because of the shorter urethras in women they are more prone to develop
urinary tract infections than men. Most urinary tract infections are caused by bacteria. Catheterization
of the bladder increases the risk of the infection. In patents with a weakened immune system (diabetics,
patients receiving chemotherapy, HIV/AIDS, elderly) prompt treatment is needed because of the
increased chance of a life threatening infection developing.
Symptoms of Bladder infection (cystitis, UTI, urinary tract infection)
Cloudy urine, blood in the urine (hematuria), foul or strong urine odor, frequent or urgent need to
urinate, need to urinate at night (nocturia), pain or burning with urination (dysuria), pressure below the
umbilicus of the abdomen. Upper tract infections cause flank pain, fever, loss of appetite, nausea and
vomiting. Elderly patients can experience significant confusion.
Tests for Bladder infection (cystitis, UTI, urinary tract infection)
Workup
A history and physical exam will be performed. A urine analysis (UA) and culture will establish the
diagnosis and identify the organism.
Tests
Urinalysis (UA) and Urine Culture
Additional tests that may be required
Urine culture
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Bladder infection (cystitis, UTI, urinary tract infection)

Therapy depends on whether the person has a simple lower tract infection vs. an upper tract infection
and the severity of illness. Treatment includes: antibiotics, medications to decrease the burning
(phenazopyridine/Pyridium), and/or pain medications. A urinalysis is sometimes recommended after
treatment to ensure the infection has gone away.

p. Lumbar spinal stenosis (back spinal stenosis)
Description of Lumbar spinal stenosis (spinal cord compression)
The most common cause of lumbar spinal stenosis is degenerative arthritis. As one ages the bones, discs
and ligaments can begin to wear out resulting in loss of cartilage, extra bone formation (osteophytes),
and loss of height of the discs. These processes cause a reduction in the normal spaces for the nerves to
travel resulting in compression of the nerves and the symptoms of pain, weakness and numbness. Other
causes include bone diseases such as Paget's, tumors and injury.
Symptoms of Lumbar spinal stenosis (spinal cord compression)
Low back pain, weakness, numbness, loss of bowel or bladder control, and/or muscle cramping.
Tests for Lumbar spinal stenosis (spinal cord compression)
Workup
A history and physical exam will be done. If there is severe narrowing the provider may find numbness,
weakness, or problems with the reflexes. A CT scan can detect the narrowing and an MRI can reveal
damage to the nerves from compression.
Tests
CT Scan, MRI and X-ray
Specialists
Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation (physiatry) and Spine Surgery
Treatment of Lumbar spinal stenosis (spinal cord compression)
The course of therapy depends on the severity of the narrowing and the symptoms. Medical treatment
is usually tried first and consists of antidepressants (amitriptyline/Elavil), anti-seizure medications
(gabapentin/Neurontin, pregabalin/Lyrica), non-steroidal anti-inflammatory medications
(ibuprofen/Motrin, naproxen/Naprosyn) and opiates (hydrocodone/Vicodin, oxycodone/Percocet).
Epidural steroid injections can be helpful in reducing inflammation and determining if surgery may be
helpful. Surgery may be indicated for patients that do not improve with the above treatments. Typically
surgery consists of enlarging the narrowed areas and is called a laminectomy.

q. Peripheral neuropathy (Nerve dysfunction)
Description of Peripheral neuropathy (nerve damage)
The brain communicates with the spinal cord. The spinal cord transmits signals to the body through the
peripheral nerves. Damage can occur to these nerves. This results in numbness, weakness, and/or pain.
Causes include: diabetes, alcohol, vitamin B12 deficiency, hypothyroid, lead poisoning, kidney failure,
chemotherapy. Sometimes a cause of peripheral neuropathy is not found.
Symptoms of Peripheral neuropathy (nerve damage)
The nerves that are most affected by peripheral neuropathy are the longest nerves in the body. This
means the worst symptoms are usually in the feet. Sensation changes include: burning, pain that
increases with touching the skin, tingling or numbness, or an inability to determine position. Numbness
in the feet can lead to calluses and foot ulcers.
Tests for Peripheral neuropathy (nerve damage)
Workup
A history and physical exam will be performed. If the problem is not obvious, tests to diagnose the
neuropathy may include: "EMG" (electromyogram, electroneurogram) which test nerve function. This
test is not usually necessary to diagnose peripheral neuropathy. Blood tests to screen for medical
conditions, such as diabetes and vitamin deficiency, should be done.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and MRI
Additional tests that may be required
EMG, Nerve conduction study, Nerve biopsy
Specialists
Family Practice, Internal Medicine, Neurology, Pediatric Neurology and Pediatrics
Treatment of Peripheral neuropathy (nerve damage)
The cause of neuropathy needs to be treated to minimize progression of nerve damage. Symptoms can
be improved with medications (gabapentin/Neurontin, carbamazepine/Tegretol, lamotrigine/Lamictal,
amitriptyline/Elavil, nortriptyline/Pamelor)

r.

Bone metastases (cancer)

Description of Bone metastases (cancer spread to bone)

Cancer that spreads to the bones. The most commonly affected sites are the spine, pelvis, skull and ribs.
These cancers spread from the original site of the cancer (primary cancer) to the bones by traveling
through the blood or lymphatic channels. The most common cancers that spread to the bones are
prostate cancer, breast cancer, and lung cancer.
Symptoms of Bone metastases (cancer spread to bone)
Bone pain, spontaneous fractures (pathologic fractures), weakness.
Tests for Bone metastases (cancer spread to bone)
Workup
A history and physical exam will be performed. Blood tests and imaging will be done to determine the
extent of the metastases.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, MRI and X-ray
Additional tests that may be required
Bone scan
Specialists
Blood and Cancer Care (hematology and oncology) and Pediatric Hematology and Oncology
Treatment of Bone metastases (cancer spread to bone)
Depends on extent of the cancer spread, but may include chemotherapy, radiation therapy, and surgical
repair of fractures. For more information contact the American Cancer Society: (800)227-2345
(800)227-2345

s. Scoliosis (crooked spine)
Description of Scoliosis (crooked spine)
A curvature of the spine in any axis that causes pain, disability, and occasionally respiratory problems.
The cause of the disorder is generally not known although it can run in families. Scoliosis is usually
diagnosed in childhood. Treatment depends on the severity of the curvature and any other symptoms
being experienced.
Symptoms of Scoliosis (crooked spine)
Pain, curved back, immobility, weakness or numbness if severe.

Tests for Scoliosis (crooked spine)
Workup
A history and physical exam will be performed to determine the degree of curvature. A MRI and/or
scoliometer measurements may be done.
Additional tests that may be required
Scoliometer measurements
Do I Need This Test?
Don’t screen adolescents for scoliosis. There is no good evidence that screening asymptomatic
adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The
potential harms of screening and treating adolescents include unnecessary follow-up visits and
evaluations due to false positive test results and psychological adverse effects.
How this was created and why it is important

The American Academy of Family Physicians and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pain Medicine, Pediatric Orthopedic Surgery,
Pediatrics and Physical Medicine and Rehabilitation (physiatry)
Treatment of Scoliosis (crooked spine)
Treatment includes observation, back brace, physical therapy, and surgery to correct the curvature.

t.

Osteoarthritis (bone inflammation)

Description of Osteoarthritis (bone inflammation)
One or more painful joints resulting from degeneration of cartilage in the joints. When cartilage thins,
bone just beneath the cartilage thickens to absorb more impact. On x-ray, there is less "space" between
bones (actually, less cartilage which does not show up on x-ray). Thickening of bone at the edge of a
joint can create ridges of bone. When a ridge of bone is seen on a 2-dimentional x-ray it is called a "bone
spur." Osteoarthritis commonly occurs more in fingers, thumb and wrist, knees, hips and spine. It is
more common after age 45.
Symptoms of Osteoarthritis (bone inflammation)
Deep aching joint pain that gets worse after exercise, pain relieved by rest, grating of the joint with
motion, joint pain in rainy weather, joint swelling, limited movement, morning stiffness.
Tests for Osteoarthritis (bone inflammation)
Workup
A history and physical exam will be performed. An X-ray can demonstrate thinned cartilage, thickened
bone, ridges of bone that appear as "bone spurs." At times a CT scan and/or MRI is performed for more
information.
Tests
CT Scan, MRI and X-ray
Do I Need This Test?
Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
Both glucosamine and chondroitin sulfate do not provide relief for patients with symptomatic
osteoarthritis of the knee.
How this was created and why it is important

The American Academy of Orthopaedic Surgeons and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests

and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists
Family Practice, Internal Medicine, Joint Replacement Surgery, Orthopedic Surgery, Pediatrics, Podiatry
and Rheumatology
Treatment of Osteoarthritis (bone inflammation)
The goals of treatment are to decrease pain and maintain function. Treatment includes: exercise, pain
medications such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory medications/NSAIDs
(ibuprofen/Motrin or Advil, naproxen/Naprosyn), braces (especially for knee arthritis), joint injections,
and physical therapy. Osteoarthritis gets worse over time. When it is severe joint replacement surgery
can improve function and relieve pain.

u. Cellulitis (skin infection)
Description of Cellulitis (skin infection)
A skin infection usually caused by bacteria. Bacteria can enter into the skin either through a cut or insect
bite and spread to deeper tissues causing an infection. If it is not treated with antibiotics, the infection
can spread to the blood or lymph nodes. The most common bacteria are staphylococcus and
streptococcus species. A particular staphylococcus species called Methicillin-resistant Staphylococcus
aureus (MRSA) is becoming a more common cause. People with depressed immune systems as with
diabetes, cancer, HIV, chronic steroid use, and auto- immune diseases are more likely to develop
cellulitis.
Symptoms of Cellulitis (skin infection)
The affected skin becomes painful, red, warm to the touch, and swollen. If the surrounding lymph
channels become infected red streaks up the arm or leg will be seen. These red streaks are called
lymphangitis. Patients may also experience fever and fatigue.
Tests for Cellulitis (skin infection)
Workup
A history and physical exam will be performed. Blood counts and blood cultures may also be performed.
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics

Treatment of Cellulitis (skin infection)
Cleaning and bandaging of any lacerations or abrasions will be done. Removal of the stinger will be
performed if the infection is from an insect bite. Antibiotics are routinely recommended for cellulitis and
may be administered orally or intravenously, depending on the severity of the infection. Common
antibiotics include: cephalexin/Keflex, dicloxacillin/Dynapen, clindamycin/Cleocin, or
clarithromycin/Biaxin. If MRSA is suspected the following antibiotics may be used: trimethoprim and
sulfamethoxazole/Bactrim, vancomycin/Vancocin, daptomycin/Cubicin, tigecycline/Tygacil, or
linezolid/Zyvox.

v. Neuralgia (nerve pain)
Description of Neuralgia (nerve pain)
Neuralgia is a term that refers to pain caused by irritation or damage to a nerve. It is described as sharp
and burning and can be very severe. The pain is usually in the area of the skin supplied by the nerve and
the symptoms can become worse with simply touching the area of skin involved. Common neuralgias
are trigeminal neuralgia, neuralgia from shingles and radiating nerve pain from the lumbar or cervical
spine.
Symptoms of Neuralgia (nerve pain)
Symptoms include pain described as sharp, stabbing, and electrical shocks. The symptoms are
experienced in the area of the skin supplied by the nerve. The symptoms can get worse with movement
or by touching the affected area. Some patients experience numbness and more rarely muscle
weakness.
Tests for Neuralgia (nerve pain)
Workup
A complete history and physical will be performed. Laboratory and imaging tests will often be
performed to determine the cause of the neuralgia.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electomyography (EMG) and MRI
Additional tests that may be required
Magnesium level
Specialists
Family Practice, Internal Medicine, Neurology and Pain Medicine

Treatment of Neuralgia (nerve pain)
Treatment is varied and is directed at the specific cause of neuralgia and the extent of symptoms.

w. Sickle cell disease *CRITICAL
Description of Sickle cell disease (disease of red blood cells)
A disorder that causes abnormal red blood cells, and these cells can clog blood vessels. Sickle cell
disease is the most common of the inherited blood disorders, and is seen primarily in black Americans
and black Africans. A sickle cell crisis causes pain because blood vessels become blocked and the
defective red blood cells can damage organs in the body. The most commonly affected organs include:
lungs, liver, bone, muscles, brain, spleen, penis, eyes, and kidneys. Patients also experience chronic
anemia.
Symptoms of Sickle cell disease (disease of red blood cells)
Abdominal pain, chest pain, flank pain, bone pain, breathlessness, delayed growth and puberty, fatigue,
fever, jaundice, rapid heart rate, susceptibility to infections, ulcers on the lower legs (in adolescents and
adults), anemia.
Tests for Sickle cell disease (disease of red blood cells)
Workup
A history and physical exam will be performed. Tests will be performed to diagnose and monitor the
disease.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Hemoglobin electrophoresis, sickle cell test
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Sickle cell disease (disease of red blood cells)
The goal of therapy is to control symptoms, and to limit the frequency of crises. Hydroxyurea (Hydrea) is
used to reduce the acute episodes of pain but is not effective in all patients. An acute episode is treated
with the following: intravenous fluids, supplemental oxygen, pain medications, antibiotics (if infection is

found), and/or blood transfusions. For additional information contact the National Heart, Lung and
Blood Institute Health Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573
(301)592-8573. For more information contact: Sickle Cell Disease Association of America: (800)421-8453
(800)421-8453

x. Pyelonephritis (kidney infection) *CRITICAL
Description of Pyelonephritis (kidney infection)
A bacterial infection involving the kidneys. It is more common in females, although it affects both
genders and all ages. Kidney infections in males are more likely if the bladder does not drain easily (one
cause of this problem is a large prostate.) Bladder infections are common in women, and the typical
cause of a kidney infection in a female is migration of bacteria from the bladder infection. The infection
travels up the tube (ureter) that drains into the bladder from the kidneys.
Symptoms of Pyelonephritis (kidney infection)
Flank pain, back pain, occasionally abdominal pain, fever, chills, warm skin, vomiting, nausea, fatigue,
painful urination, urinary frequency, urinary urgency, need to urinate at night (nocturia), cloudy urine,
blood in the urine, foul or strong urine odor, confusion.
Tests for Pyelonephritis (kidney infection)
Workup
A history and physical exam will be performed. Blood tests will be done to check on the function of the
kidneys, to check for spread of bacteria into the blood. A urine test can identify the infection and culture
of the urine can reveal the type of bacteria that is involved. If a kidney stone is suspected a CT scan will
be done.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan
and Urinalysis (UA)
Additional tests that may be required
Urine culture
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics

Treatment of Pyelonephritis (kidney infection)
Intravenous fluids, pain medications, anti-nausea medications and antibiotics are the mainstay of
therapy. Patients with severe infections or with depressed immune systems will be admitted to the
hospital. A co-existing blockage of a ureter from a kidney stone is a surgical emergency requiring
removal of the blockage to prevent a life threatening infection.

y. Contusion (Bruise)
Description of Contusion (bruise)
Bruises that develop when small blood vessels under the skin tear or rupture, most often from blunt
injury or a crush injury. Blood leaks into tissues under the skin and causes the black-and-blue color.
Symptoms of Contusion (bruise)
Pain, swelling, bluish discoloration, tenderness. Over time, the skin may turn from red, blue or purple to
green, yellow, or brown.
Tests for Contusion (bruise)
Workup
A history and physical exam will be performed. X-rays are used to rule out underlying fractures. When
appropriate compartment pressures are measured to rule out compartment syndrome. Additional
testing of the blood may be recommended if bruising is excessive or occurs without trauma.
Tests
X-ray
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Contusion (bruise)
Treatment includes: ruling out other injuries, elevating and icing to reduce swelling, and immobilization
with a splint to speed healing. For minor bruising, no treatment may be necessary.

z. Lymphoma (lymph node cancer)
Description of Lymphoma (lymph node cancer)

A cancer of the lymphocytes and the lymphatic system. There are two main types: Hodgkin's and NonHodgkin's. Non-Hodgkin's is 5 times more common. The disease occurs when the lymphocytes of the
immune system grow out of control becoming cancerous. The overgrowth of the lymphocytes causes
swelling of the lymph nodes. The cancerous lymphocytes can spread to other parts of the body
(metastasize).
Symptoms of Lymphoma (lymph node cancer)
Swollen lymph nodes, fatigue, weight loss, fever, night sweats.
Tests for Lymphoma (lymph node cancer)
Workup
A history and physical exam will be performed. Blood tests and imaging tests such as abdominal and
chest CT scans to determine the extent of the disease will be performed. The diagnosis is established by
performing a lymph node or bone marrow biopsy.
Tests
Bone marrow biopsy, Complete blood count (CBC), CT Scan, Lymph node biopsy and PET scan
Specialists
Blood and Cancer Care (hematology and oncology) and Pediatric Hematology and Oncology
Treatment of Lymphoma (lymph node cancer)
Therapy depends on the type of lymphoma. Treatment includes: chemotherapy, radiation therapy,
biologic therapy (using monoclonal antibodies) such as rituximab/Rituxan, and bone marrow transplant.
American Cancer Society: (800)227-2345
4572

(800)227-2345 Leukemia and Lymphoma Society: (800)955-

(800)955-4572

aa. Thoracic outlet syndrome
Description of Thoracic outlet syndrome (nerve, blood vessel compression)
The thoracic outlet is the region where neurovascular structures exit the chest. It is composed of the
first rib, the subclavian artery and vein, the brachial plexus and the upper part of the lung. Any
enlargement or movement in these structures can cause compression of the nerve or blood vessels.
Occasionally patients will have an extra rib that causes the syndrome. This compression causes the
symptoms experienced in the neck and arm. It occurs more often in women between ages 35 and 55.
Reviewed by Harvard Medical School

Symptoms of Thoracic outlet syndrome (nerve, blood vessel compression)
Pain, numbness, and tingling in the last three fingers and inner forearm. Pain and tingling in the neck
and shoulders. Bluish discoloration of the hand, weakness of the muscles in the hand. Symptoms can
become worse with lifting the arm above the head.
Tests for Thoracic outlet syndrome (nerve, blood vessel compression)
Workup
A history and physical exam will be performed. Tests to establish the diagnosis may include: X-ray (to
reveal an extra rib), MRI, nerve conduction velocity study, and electromyography (EMG).
Tests
MRI and X-ray
Additional tests that may be required
Nerve conduction velocity study, electromyography (EMG)
Specialists
Cardiothoracic Surgery
Treatment of Thoracic outlet syndrome (nerve, blood vessel compression)
Therapy depends on the severity of the illness, and the specific cause of the disorder. Treatment may
include: physical therapy, behavioral modifications, losing weight, nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn or Aleve), and/or pain medications
such as acetaminophen (Tylenol). Surgery may be necessary for persistent or severe symptoms.

bb. Bladder infection (Cystitis)
Ne postoji opis na sajtu !

cc. Chronic pain
Description of Chronic pain
Chronic pain is often due to an identifiable cause, such as degenerative arthritis in the lower back or
nerve disease. However, it may also develop for no apparent reason. Despite thorough exams and tests,
a doctor may be unable to find a specific physical cause.
Symptoms of Chronic pain

Long-lasting pain that persists despite treatment. Depression and anxiety commonly accompany chronic
pain.
Tests for Chronic pain
Workup
A history and physical exam will be performed. Tests to rule out a reversible cause of the pain are
usually recommended. This may include blood tests and imaging studies.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, MRI, Urinalysis
(UA) and X-ray
Specialists
Family Practice, Internal Medicine, Pain Medicine, Pediatrics and Physical Medicine and Rehabilitation
(physiatry)
Treatment of Chronic pain
Treatment includes: pain medications, antidepressant medications, and psychological treatment. Nondrug treatments for pain include: massage, acupuncture, relaxation training, and electrical nerve
stimulation (called TENS). If effective, nerve stimulators may be surgically implanted in appropriate
patients.

dd. Spondylolisthesis (slipped back bone)
Description of Spondylolisthesis (slipped back bone)
A condition in which one vertebra becomes offset in its position over another. The main cause is
degeneration of the discs in the spine. Other causes include congenital anomalies, trauma, tumors and
bone diseases, and surgical procedures. Although this disorder most commonly occurs in the low back, it
can occur in any part of the spine.
Symptoms of Spondylolisthesis (slipped back bone)
Abnormal spine curvature (lordosis), lower back pain, localized tenderness over the spine, pain in
buttocks, tight hamstrings, stiffness in back, tingling, weakness.
Tests for Spondylolisthesis (slipped back bone)
Workup

A history and physical exam will be performed. Imaging studies (X-ray, CT or MRI) will be done to
establish the diagnosis.
Tests
CT Scan, MRI and X-ray
Specialists
Family Practice, Internal Medicine, Neurosurgery, Pain Medicine, Physical Medicine and Rehabilitation
(physiatry) and Spine Surgery
Treatment of Spondylolisthesis (slipped back bone)
Therapy varies depending on the severity of the spondylolisthesis, and the symptoms being
experienced. Treatment includes: no treatment, physical therapy, bracing, and/or surgery.

ee. Abdominal aortic aneurysm (Dilation) *CRITICAL
Description of Abdominal aortic aneurysm (enlarged major blood vessel)
A weakened portion of the abdominal aorta that expands. The abdominal aorta is the large artery in the
abdomen that carries blood to the abdomen and legs. This weakened section can continue to expand,
dissect, or rupture. A rupture of the aneurysm is a life threatening condition, leading to rapid blood loss
and if left untreated death. A dissection of the aorta is a separation of the layers of the aorta and can
occlude blood vessels to the abdominal organs (intestines, kidneys, etc.) and legs.
Symptoms of Abdominal aortic aneurysm (enlarged major blood vessel)
An abdominal aortic aneurysm can cause abdominal pain, back pain, vomiting, weakness, fainting or
death. Some patients may not have symptoms especially if the aneurysm is small.
Tests for Abdominal aortic aneurysm (enlarged major blood vessel)
Workup
A history and physical exam will be performed. An abdominal aortic aneurysm can be diagnosed by
ultrasound or CT scan. A CT scan is the only way the doctor can determine if the aneurysm is bleeding.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Troponin and Ultrasound
Specialists

Cardiovascular Surgery, General Surgery and Vascular Surgery
Treatment of Abdominal aortic aneurysm (enlarged major blood vessel)
An abdominal aortic aneurysm can be repaired surgically, or with a special catheter and an intraabdominal sheath. Some aneurysms, usually less than 5 centimeters, can be treated with watchful
waiting.

ff. Prostatitis (prostate infection)
Description of Prostatitis (prostate inflammation)
Infection of the prostate gland, and can be either an acute or a chronic condition. The prostate gland is
located under the bladder, where it surrounds the urethra (the bladder's drainage tube). The gland is a
source of fluid for semen. The inflammation can irritate or put pressure on the tube connecting the
bladder to the penis (urethra), resulting in difficultly urinating, and urinary retention. Palpation of the
prostate during a rectal exam revels a very tender prostate. Rarely an abscess can develop. This disorder
is most often seen in 20-40 year old men, in those with a urinary catheter, and with patients having
unprotected sex with multiple partners.
Symptoms of Prostatitis (prostate inflammation)
Chills and fever, lower abdominal discomfort, pain in the area between the genitals and the anus,
burning with urination, difficulty urinating, urinary retention, painful ejaculation, painful bowel
movement, back pain.
Tests for Prostatitis (prostate inflammation)
Workup
A history and physical exam will be performed. Diagnosis is made by feeling the prostate during a rectal
exam and testing for signs of inflammation in the urine. A urine culture can identify the bacteria.
Tests
CT Scan and Urinalysis (UA)
Additional tests that may be required
Urine culture
Specialists
Family Practice, Internal Medicine and Urology
Treatment of Prostatitis (prostate inflammation)

Oral antibiotics are usually effective. The most commonly used are: trimethoprim-sulfamethoxazole
(Bactrim), fluoroquinolones (Floxin, Cipro, Levaquin), and tetracycline derivatives. If a STD is considered
the source, a shot of ceftriaxone followed by oral doxycycline or ofloxacin is recommended. Rarely
intravenous antibiotics are needed. Most patients require more than a month-long time of treatment to
eradicate the infection.

gg. Pulmonary embolism (blood clot in the lungs) *CRITICAL

Description of Pulmonary embolism (blood clot in the lungs)
A blood clot in a pulmonary artery (the circulation of the lung.) Blood clots typically start in a vein in the
leg. A clot builds up stuck to the wall of the vein, and some or all of the clot can break off, pass through
the heart, and then float into a pulmonary artery. These arteries get progressively smaller and the clot
(embolus) eventually lodges into one of these arteries preventing blood flow. These clots make
circulation through the lungs inefficient so the lungs do not work as well. When the clot is very large
(called a saddle embolus) it can result in rapid death. The following increase the risk of blood clots:
recent surgery, previous blood clots, cancer, immobilization, sitting for prolonged periods of time, birth
control pills, surgery and pregnancy.
Symptoms of Pulmonary embolism (blood clot in the lungs)
Cough, shortness of breath, pain in ribs during breathing (pleuritic chest pain), chest pain, rapid
breathing, rapid heart rate, blue discoloration of the skin (cyanosis), weak pulse, confusion.
Tests for Pulmonary embolism (blood clot in the lungs)
Workup
A history and physical exam will be performed. Tests including a chest x-ray, an EKG (electrocardiogram),
and ultrasound of the veins in the leg are done. The diagnosis is confirmed with a CT scan of the chest or
less commonly, a specialized scan called a ventilation and perfusion scan.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin, Ultrasound and X-ray
Additional tests that may be required
PT (Protime), PTT (Partial Thromboplastin Time), CT angiogram (CTA) of the chest, ventilation and
perfusion scan, pulmonary angiogram
Do I Need This Test?

In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive Ddimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic
test. In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative
high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.
How this was created and why it is important

The American College of Physicians and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology, Pediatric Pulmonology and Pulmonology
Treatment of Pulmonary embolism (blood clot in the lungs)
Most of the time, a pulmonary embolus requires a hospital stay for initial treatment. Immediate lifethreatening pulmonary embolisms require dissolving the clot (thrombolysis) with a medication: tissue
plasminogen activator (t-PA), streptokinase, or urokinase. Medications to stabilize the clot and to
prevent further clots are given and include: heparin, enoxaparin (Lovenox), and/or warfarin (Coumadin).
Emergency treatments may include mechanical ventilation to maintain oxygen levels, and pressors to
increase the blood pressure. For additional information contact the National Heart, Lung and Blood
Institute Health Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573
8573. American Lung Association: (800)586-4872
Research Center: (800)222-5864

(800)222-5864

(301)592-

(800)586-4872 National Jewish Medical and

hh. Rheumatoid arthritis
Description of Rheumatoid arthritis (type of chronic joint inflammation)
A kind of arthritis caused by an autoimmune disease. Rheumatoid arthritis causes pain and swelling in
joints, but can also cause a variety of other symptoms. The disorder causes swelling and damage to the
lining of the joints (synovium) producing the joint pain and joint destruction experienced. It occurs
between the ages 20 and 60 and is 3 times more common in women than men.
Symptoms of Rheumatoid arthritis (type of chronic joint inflammation)
Fatigue, morning stiffness (lasting more than 1 hour), widespread muscle aches, loss of appetite,
weakness, deformity of joints (primarily of the hands).
Tests for Rheumatoid arthritis (type of chronic joint inflammation)
Workup
A history and physical exam will be performed. X-rays can be helpful. A specific blood test, anti-CCP
antibody test, can distinguish most cases of rheumatoid arthritis from other types of arthritis. Other
tests that may be helpful include: C-reactive protein, ESR (erythrocyte sedimentation rate), rheumatoid
factor test (positive in about 75% of people with symptoms), and joint fluid analysis.
Additional tests that may be required
C-reactive protein, ESR (erythrocyte sedimentation rate) , rheumatoid factor test, synovial fluid analysis
Specialists
Family Practice, Internal Medicine, Pediatrics and Rheumatology
Treatment of Rheumatoid arthritis (type of chronic joint inflammation)
This is a life-long illness. Treatment is directed at controlling the symptoms and slowing down the joint
damage. Treatment includes: medications, physical therapy, and exercise. The medications used include:
nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn),
steroids, disease-modifying antirheumatic drugs (hydroxychloroquine/Plaquenil, the gold compound
auranofin/Ridaura, sulfasalazine/Azulfidine, minocycline/Dynacin, methotrexate/Rheumatrex),
immunosuppressant's (leflunomide/Arava, azathioprine/Imuran, cyclosporine/Neoral,
cyclophosphamide/Cytoxan, rituximab/Rituxan), TNF-alpha inhibitors (etanercept/Enbrel,
infliximab/Remicade, adalimumab/Humira), and other immune modulators. Surgery may be required for
severe joint destruction. Arthritis Foundation: (800)283-7800

(800)283-7800

ii. Vertebral fracture (back or neck fracture) *CRITICAL

Description of Vertebral fracture (broken back or neck bone)
The vertebrae are the bones in the neck and back. Fractures are broken bones. The severity of a
vertebral fracture depends on the location and whether or not the fracture affects the spinal cord. The
most common fracture is a compression fracture of the lower thoracic and lumbar spine. These
commonly occur in elderly patients and can be the result of minor trauma such as sitting down too hard.
Vertebral fractures can be true emergencies if the spinal cord is injured. Symptoms of weakness,
numbness and/or loss of bowel or bladder control require an immediate evaluation.
Symptoms of Vertebral fracture (broken back or neck bone)
Back pain that may become chronic, shortened height, hunchback (kyphosis), numbness, weakness, loss
of bowel or bladder control.
Tests for Vertebral fracture (broken back or neck bone)
Workup
A history and physical exam will be performed. An x-ray, CT scan or MRI will usually be done to identify
the fracture.
Tests
CT Scan, MRI and X-ray
Specialists
Neurosurgery, Pediatric Neurosurgery and Spine Surgery
Treatment of Vertebral fracture (broken back or neck bone)
Treatment depends on the location of the fracture, the size of the fracture and whether or not the
spinal cord is injured. Some fractures require only pain medications and observation. Other treatment
options include: kyphoplasty (injection of material into the vertebra to repair the bone), physical
therapy, and surgical fixation.

jj. Unstable angina *CRITICAL
Description of Unstable angina (pre heart attack chest pain)
Chest pain that is caused by insufficient blood supply through the coronary arteries that feed oxygen
and nutrients to the heart. Stable angina is pain that occurs with a fixed amount of exercise. Unstable
angina is pain that now occurs with less exertion or at rest. The disorder is very serious since it is a
warning sign of an imminent heart attack. This is a medical emergency. Untreated it can lead to rapid
death.

Symptoms of Unstable angina (pre heart attack chest pain)
Chest pain (the pain can also be in the shoulder, back, arm, jaw or abdomen), chest pain that occurs at
rest or with less exertion, shortness of breath, sweating, feeling faint, nausea, vomiting. The chest pain
may be described as tightness, squeezing, crushing, burning, choking, or aching.
Tests for Unstable angina (pre heart attack chest pain)
Workup
A history and physical exam will be performed. Initial testing includes an electrocardiogram (EKG) and
blood test for troponin (a heart muscle protein released into the blood if heart muscle damage has
occurred). A coronary angiogram can identify the site of coronary artery blockage. A high resolution
chest CT scan can also demonstrate blockages. CT scans can also rule out other diseases that can
clinically mimic unstable angina. An echocardiogram may be done to see well the heart is pumping
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Troponin
and X-ray
Additional tests that may be required
Creatine phosphokinase (CPK), troponin, coronary angiography, echocardiography, standard stress,
radionucleotide stress test, high resolution chest CT scan
Do I Need This Test?
Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for
uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI). Stent
placement in a noninfarct artery during primary PCI for STEMI in a hemodynamically stable patient may
lead to increased mortality and complications. While potentially beneficial in patients with
hemodynamic compromise, intervention beyond the culprit lesion during primary PCI has not
demonstrated benefit in clinical trials to date.
How this was created and why it is important

The American College of Cardiology and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures

based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Cardiology and Cardiothoracic Surgery
Treatment of Unstable angina (pre heart attack chest pain)
Therapy is directed at relieving the pain by increasing the blood supply to the heart and preventing
blood clot formation inside the coronary arteries. Anti-platelet drugs, such as aspirin and
clopidogrel/Plavix, and nitroglycerin are given immediately. Coronary (heart) artery blockages are
reduced by the following: balloon angioplasty, stent placement, surgical bypass, and/or blood thinners.
Other medications also given usually include a high dose statin to lower cholesterol, a beta blocker to
slow heart rate and an angiotensin enzyme inhibitor (ACEI) that helps the heart remodel appropriately.
For more information contact the American Heart Association: (800)242-8721

(800)242-8721

kk. Osteomyelitis (bone infection) *CRITICAL
Description of Osteomyelitis (bone infection)
An infection in a bone. It is particularly common for bone infection to occur in the spine (vertebra), in
the foot or heel, or next to an artificial joint if the joint becomes infected. Osteomyelitis of the spine
usually occurs after another serious infection has spread to the blood, bringing bacteria into the bone.
Osteomyelitis of the foot or heel usually occurs with spread of infection from a foot ulcer (open skin
sore).
Symptoms of Osteomyelitis (bone infection)
Pain, fever, drainage of pus through the skin, skin ulcer (open sore).
Tests for Osteomyelitis (bone infection)
Workup
A history and physical exam will be performed. X-rays and MRI can show bone infection. A bone biopsy
and culture is typically done. This requires surgery.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), MRI and X-ray
Additional tests that may be required
Bone scan, blood cultures, needle aspiration, bone lesion biopsy

Specialists
Infectious Disease Medicine, Orthopedic Surgery, Pediatric Infectious Disease Medicine, Pediatric
Orthopedic Surgery and Podiatry
Treatment of Osteomyelitis (bone infection)
Intravenous antibiotics will be given, followed by oral antibiotics; Surgery may be needed to remove
dead bone tissue. If an artificial joint becomes infected the hardware may need to be removed. Bone
infection requires many weeks of intravenous antibiotic treatment (6 weeks or longer) and often
requires a long hospital stay.

ll. Cholelithiasis (Gallstones, gall stones)
Description of Cholelithiasis (gallstones)
Gallstones enter the bile ducts and block the passage of bile. The gallbladder is located in the right upper
abdomen and stores bile pigments that are secreted by the liver and ultimately meant to be released
into the gastrointestinal tract. Gallstones are found most commonly in the gallbladder, but can also be
found in the bile ducts of the liver. Although both sexes are affected, women are affected more often
with 20% of those over 40 having gallstones.
Symptoms of Cholelithiasis (gallstones)
Abdominal pain (right upper abdomen), vomiting, fever, yellowing eyes or skin.
Tests for Cholelithiasis (gallstones)
Workup
A history and physical exam will be performed. Abdominal ultrasound is the most common method used
to make the diagnosis. Gallstones can also be seen with CT scan and MRI. Lab tests are also done to
identify any liver or pancreas injury.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, MRI and
Ultrasound
Additional tests that may be required
HIDA scan
Specialists
Family Practice, Gastroenterology, General Surgery and Internal Medicine

Treatment of Cholelithiasis (gallstones)
No treatment may be recommended if the stones are not causing symptoms. If the stones cause pain or
problems in the liver or pancreas the gallbladder needs to be surgically removed. For more information
contact the National Digestive Diseases Information Clearinghouse at http://digestive.niddk.nih.gov

mm.

Transverse myelitis (spinal cord inflammation) *CRITICAL

Description of Transverse myelitis (spinal cord inflammation)
A neurological disorder caused by severe inflammation of the spinal cord. The condition involves an
entire cross section of the spinal cord preventing the brain from communicating with the body below
the level of the inflammation. Symptoms are only experienced below this area while no symptoms
above the level are experienced. Symptoms are related to movement and sensory difficulties. The
disorder occurs in both adults and children, and typically begins with a rapid development of symptoms
over the course of several hours to weeks. The condition can follow a viral infection or result from an
autoimmune disease flare-up.
Symptoms of Transverse myelitis (spinal cord inflammation)
Symptoms may include lower back pain, weakness in the legs or both the arms and legs, decreased
sensation below the level of inflammation, muscle spasms, bowel and/or bladder dysfunction.
Tests for Transverse myelitis (spinal cord inflammation)
Workup
A history and physical exam will be performed. Tests to identify the location of the spinal cord
inflammation, and isolate the cause of the disorder will be done.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and MRI
Additional tests that may be required
NMO-IgG blood test, lumbar puncture (spinal tap)
Specialists
Neurology and Pediatric Neurology
Treatment of Transverse myelitis (spinal cord inflammation)

Treatment includes: intravenous corticosteroids, plasma exchange therapy, pain medications, physical
therapy and/or occupational therapy. If the symptoms are severe mechanical ventilation to support
respirations may be necessary.

nn. Pancreatitis (pancreas inflammation) *CRITICAL
Description of Pancreatitis (pancreas inflammation)
Inflammation of the pancreas. Normally digestive enzymes from the pancreas are only allowed to flow
into areas of the digestive tract that are protected by mucus. Inflammation of the pancreas can expose
unprotected pancreas tissues to digestive enzymes, so pancreatitis can cause serious damage and
scarring of the pancreas, and inflammation can spread. Pancreatitis has many causes with alcohol and
gallstones being the most common.
Symptoms of Pancreatitis (pancreas inflammation)
Abdominal pain, back pain, vomiting, anxiety, chills, clammy skin, fatty stools, fever, jaundice (yellow
skin), nausea, sweating, weakness, weight loss.
Tests for Pancreatitis (pancreas inflammation)
Workup
A history and physical exam will be performed. Blood tests look for changes in blood levels of pancreas
enzymes (amylase or lipase). An abdominal CT scan and/or ultrasound may be helpful.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Lipase, Ultrasound and X-ray
Additional tests that may be required
Amylase
Specialists
Gastroenterology
Treatment of Pancreatitis (pancreas inflammation)
Usually pancreatitis requires a hospital stay. Eating is stopped for several days so the pancreas does not
make as much digestive enzyme. A nasogastric tube (tube from the nose to the stomach) can help
nausea by allowing removal of stomach juices. Intravenous fluids are almost always needed. Pain
medications and nausea medications are helpful. If the problem was caused by a gallstone, surgery to
remove the gallbladder can prevent recurrence. For more information contact the National Digestive

Diseases Information Clearinghouse at http://digestive.niddk.nih.gov or call (800)891-5389
(800)891-5389

oo. Costochondritis (chest wall inflammation)
Description of Costochondritis (chest wall inflammation)
An inflammatory condition that affects the cartilaginous portions of the ribs and causes chest pain. It
affects one or more ribs, most commonly the second or third ribs, especially where these ribs meet the
breastbone (sternum). The pain that is produced is sharp and often intensified by change of position of
the ribs, such as lying down, bending over, coughing or sneezing. Symptoms may be confused with that
of coronary artery disease or a heart attack.
Symptoms of Costochondritis (chest wall inflammation)
Chest pain, shortness of breath, chest pain that increases with use of chest wall muscles, chest wall
tenderness.
Tests for Costochondritis (chest wall inflammation)
Workup
A history and physical exam will be performed. Tests are generally done to rule out other more serious
causes of chest pain such as: heart attack, blood clot, aortic dissection, or lung collapse.
Tests
CT Scan, D-Dimer, Electrocardiogram (EKG), Troponin and X-ray
Specialists
Emergency Medicine, Family Practice, Internal Medicine and Pediatrics
Treatment of Costochondritis (chest wall inflammation)
Treatment includes nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn) and pain medications, acetaminophen (Tylenol). In severe cases, a cortisone
injection may be helpful.

pp. Lung cancer (tumor)
Description of Lung cancer (tumor)

An abnormal growth of cells in the lung. The cancer can arise primarily from lung cells or by traveling
from a distant tumor (metastasis). It occurs in adults of both sexes, usually between ages 40 and 70.
Lung cancer causes more deaths than any other form of cancer. The incidence is steady or falling in
recent years in direct relation to the incidence of cigarette smoking. The cancer cells destroy lung tissue
and damage the surrounding organs. There are two main types of lung cancer: small cell lung cancer and
non-small cell lung cancer.
Symptoms of Lung cancer (tumor)
Persistent cough, coughing up blood, shortness of breath, wheezing, chest pain, loss of appetite,
unexplained weight loss, fatigue. Initially, there may be no symptoms.
Tests for Lung cancer (tumor)
Workup
A history and physical exam will be performed. Imaging tests are done to identify the cancer. The cancer
type is identified by performing a biopsy, or by evaluating the sputum for cancer cells.
Additional tests that may be required
Sputum cytology, Positron Emission Tomagraphy (PET) scan, Bronchoscopy
Specialists
Blood and Cancer Care (hematology and oncology), Pediatric Hematology and Oncology, Pediatric
Pulmonology, Pulmonology and Thoracic Surgery
Treatment of Lung cancer (tumor)
Treatment depends on the specific type of lung cancer, and on the extent of the disease. Each type is
treated differently. Chemotherapy, radiation, and/or surgery may be needed. American Cancer Society:
(800)227-2345

(800)227-2345 Smoking cessation information at (877)448-7848

(877)448-7848

Reviewed by Harvard Medical School

qq. Reflex sympathetic dystrophy
Description of Reflex sympathetic dystrophy (complex pain syndrome)
Also called Type 1 complex regional pain syndrome. A disorder that causes chronic pain, tenderness,
sweating and swelling of the affected area. The arms and legs are most often involved. The exact cause
of this disorder is not known but is thought to involve damage to the nerves resulting in the symptoms
experienced. Complex regional pain syndrome usually occurs after an injury or surgery to the area.
There are two types: Type 1 involves an injury or insult to the affected area but no injury to the nerve

can be identified; In Type 2 an injury to the nerve has occurred. Most people suffer from Type 1 and this
type used to be called Reflex Sympathetic Dystrophy.
Symptoms of Reflex sympathetic dystrophy (complex pain syndrome)
In the affected area the patient experiences pain, burning pain, redness, swelling, changes in hair
growth, sensitivity to cold or heat, brittle nails, stiff joints.
Tests for Reflex sympathetic dystrophy (complex pain syndrome)
Workup
A history and physical exam will be performed. Lab and imaging tests are performed to rule out other
causes of the symptoms. Nerve tests such as electromyography and nerve conduction studies also can
be performed to further evaluate the nerve tissue.
Specialists
Family Practice, Internal Medicine, Neurology, Pain Medicine, Pediatric Neurology and Pediatrics
Treatment of Reflex sympathetic dystrophy (complex pain syndrome)
Treatment depends on the extent of the disease and may consist of physical therapy, medications to
control pain, nerve blocks or trigger point injections.

rr. Cholecystitis (infected gallbladder) *CRITICAL
Description of Cholecystitis (infected gallbladder)
A blockage of bile flow can cause bacterial infections of the gallbladder (cholecystitis) or the ducts
(cholangitis). The bile ducts carry bile from the liver to the gall bladder and then to the small intestine.
The most common cause of bile blockage is gallstones. Another cause of cholecystitis is a nonfunctioning gallbladder. Cholecystitis from a non-functioning gallbladder is called acalculous
cholecystitis. This disease can be very serious and lead to death if left untreated.
Symptoms of Cholecystitis (infected gallbladder)
Abdominal pain (upper right abdomen), vomiting, fever, yellowing skin.
Tests for Cholecystitis (infected gallbladder)
Workup
A history and physical exam will be performed. An ultrasound will be done to identify the gallstones and
establish the diagnosis. A CT scan and MRI can also be used. If no gallstones are seen a HIDA scan can
detect a non-functioning gallbladder that can also cause cholecystitis.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, MRI and
Ultrasound
Additional tests that may be required
HIDA scan
Specialists
General Surgery
Treatment of Cholecystitis (infected gallbladder)
Treatment may include: intravenous antibiotics and surgical removal of gallbladder (cholecystectomy).
For more information contact the National Digestive Diseases Information Clearinghouse at:
http://digestive.niddk.nih.gov or (800)891-5389

(800)891-5389

ss. Osteoporosis
Description of Osteoporosis (extremely thin bone)
A disorder where the bones become weak, making it easier for them to break. Fractures can occur with
even mild stress such as sitting down too hard, coughing, or bending over. The most common areas of
fracture are in the back (spine), wrist and hip. Anyone can develop osteoporosis, but it is more common
in older women. The body constantly makes new bone and breaks down old bone. As one gets older
more bone gets broken down than gets made, causing a loss of bone mass with advancing age. Other
conditions can worsen this disorder including: poor nutrition, smoking, being thin, chemotherapy,
radiation treatment, medications such as steroids, decreased physical activity, alcohol consumption,
being of Caucasian ancestry, and drinking cola drinks. Osteoporosis runs in families,
Symptoms of Osteoporosis (extremely thin bone)
Early in the disease no symptoms are experienced. As the bones become weaker fractures occur causing
pain usually in the back, hips, and wrist. Loss of height of the back bones (vertebrae) causes a stooped
posture.
Tests for Osteoporosis (extremely thin bone)
Workup
A history and physical will be done. The disorder is diagnosed by measuring a patient's bone density. The
most commonly used test is dual energy x-ray absorptiometry (DXA).

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Dual energy x-ray absorptiometry
(DXA) and Thyroid stimulating hormaone
Additional tests that may be required
MRI, CT scan, Ultrasound
Do I Need This Test?
Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than
65 or men younger than 70 with no risk factors. DEXA is not cost effective in younger, low-risk patients,
but is cost effective in older patients.
How this was created and why it is important

The American Academy of Family Physicians and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists
Diabetes, Endocrinology and Metabolism, Family Practice, Geriatric Medicine, Internal Medicine and
Obstetrics and Gynecology
Treatment of Osteoporosis (extremely thin bone)
A patient's maximum bone mass is established at about age 30. Treatment is aimed at reducing the loss
of bone and it is never too late to start therapy. Patients with a family history of osteoporosis should see
a doctor sooner and consider earlier treatment. Medications used include a group of drugs called
bisphosphonates. The most common bisphosphonates are alendronate (Fosamax), ibandronate
(Boniva), risedronate (Actonel),and zoledronic acid (Reclast). Other medications that may be used are
raloxifene (Evista), calcitonin, and teriparatide (Forteo). Estrogen therapy is sometimes used but can be

associated with other complications such as blood clots, cancer, and heart disease. Physical therapy can
help maintain bone strength and prevent falls.

tt. Pneumonia (lung infection) *CRITICAL
Description of Pneumonia (lung infection)
Infection in the lung. The air cells can fill with fluid (pus) causing shortness of breath and breathing
problems. Pneumonia can be severe and is a common cause of death. Certain risk factors, such as
smoking, excessive alcohol use, diabetes, depressed immune systems, and poor nutrition increase the
risk of developing pneumonia. The pneumococcal vaccination (Pneumovax) protects against the most
common cause of bacterial pneumonia.
Symptoms of Pneumonia (lung infection)
Cough with greenish or yellow sputum, bloody sputum, fever with shaking chills, sharp or stabbing chest
pain, chest pain worsened by deep breathing or coughing, rapid, shallow breathing, shortness of breath,
weak pulse.
Tests for Pneumonia (lung infection)
Workup
A history and physical exam will be performed. An X-ray can confirm the diagnosis. Blood tests, sputum
cultures, and blood cultures can identify the cause and severity of the infection. Occasionally a CT scan is
performed as well especially if an associated pleural effusion is present.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and X-ray
Additional tests that may be required
Blood cultures, Sputum cultures, Arterial blood gas (ABG)
Specialists
Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Pneumonia (lung infection)
Antibiotics (azithromycin, clarithromycin, erythromycin, levofloxacin, ceftriaxone, doxycycline).
Pneumonia treatment may require a stay in the hospital for intravenous antibiotics. Supplemental
oxygen may be needed until the pneumonia improves. Severe cases can require mechanical ventilation.
For additional information contact the National Heart, Lung and Blood Institute Health Information

Center at: http://www.nhlbi.nih.gov or call (301)592-8573
Association: (800)586-4872
5864

(301)592-8573. American Lung

(800)586-4872 National Jewish Medical and Research Center: (800)222-

(800)222-5864

uu. Spinal abscess (collection of spinal pus) *CRITICAL
Description of Spinal abscess (collection of spinal pus)
A collection of infectious material adjacent to the spine. The most common causes are a complication of
surgery, spread from an infection in the blood, infection spread from a nearby infection, or from an
injury that penetrates the back allowing bacteria to enter. This is a rare disorder but is more common in
intravenous drug users and patients with a weakened immune system.
Symptoms of Spinal abscess (collection of spinal pus)
Back or neck pain, weakness, numbness, fever, skin redness.
Tests for Spinal abscess (collection of spinal pus)
Workup
A history and physical exam will be performed. Other tests will be done to establish the diagnosis. A MRI
is the most useful test to identify this disorder.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and MRI
Additional tests that may be required
Blood culture, culture of abscess fluid
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Spinal abscess (collection of spinal pus)
Intravenous antibiotics, Surgery to drain the infection may be necessary.

vv. Shingles (herpes zoster)
Description of Shingles (herpes zoster)

A viral infection caused by varicella (reactivated chickenpox virus). After recovery from chickenpox,
some virus particles continue to survive for decades. This surviving virus lives in clusters of nerve cells
called nerve roots where it is protected from your immune system . The virus re-emerges many years
later causing painful lesions that look like pimples. They typically appear on only one side of the body
and are localized to one area. Stress, old age and other infections can cause the re-emergence of the
virus. Also called herpes zoster.
Symptoms of Shingles (herpes zoster)
Initial symptoms consist of tingling and burning of the skin, followed by pain which can be intense. Later
a rash develops consisting of bumps, blisters , pimples, crusting. The rash is typically only on one side of
the body, and in one area. Unfortunately some patients can have persistent symptoms even after the
rash has resolved. This is called post herpetic neuralgia.
Tests for Shingles (herpes zoster)
Workup
A history and physical exam will be performed. If needed, a culture of blister fluid can be used to identify
the virus.
Additional tests that may be required
Viral antigen test, viral culture
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine and Pediatrics
Treatment of Shingles (herpes zoster)
Treatment involves antiviral medications (acyclovir/Zovirax, famciclovir/Famvir, valacyclovir/Valtrex),
pain medications, and occasionally steroids. Treatment is more effective the sooner it is started.

ww.

Rib fracture (broken bone)

Description of Rib fracture (broken bone)
Commonly occurs after blunt trauma to the chest. They are more common in the elderly or in those with
weak bones, and in this group can occur with coughing. The underlying lung can be injured causing a
collapsed lung (pneumothorax) or bruise of the lung (contusion). Multiple rib fractures can prevent
normal respiration and be life threatening.
Symptoms of Rib fracture (broken bone)

Chest pain, localized chest pain with breathing, chest tenderness, air in the soft tissue of the chest,
shortness of breath.
Tests for Rib fracture (broken bone)
Workup
A history and physical exam will be performed. The diagnosis is made with X-rays.
Tests
CT Scan and X-ray
Specialists
Trauma Surgery
Treatment of Rib fracture (broken bone)
Treatment is for pain relief. Treatment includes: nonsteroidal anti-inflammatory medications/NSAIDs
(ibuprofen/Motrin or Advil, naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol),
and incentive spirometry (breathing exercises to ensure deep breaths are being taken).

xx. Pilonidal cyst ( Buttocks cyst)
Description of Pilonidal cyst (fluid filled sac on tailbone)
A cyst below the tailbone (coccyx) usually containing skin or hair cells. These cysts can become infected
and develop into an abscess causing swelling and pain. It is believed they occur when a hair cell grows
inward. They are more common in men.
Symptoms of Pilonidal cyst (fluid filled sac on tailbone)
Pain and swelling below the tailbone, skin redness, tenderness, increased warmth, drainage of pus from
the skin, hardening of the skin over the swelling, rarely fever.
Tests for Pilonidal cyst (fluid filled sac on tailbone)
Workup
A history and physical exam will be performed.
Specialists
Colon and Rectal Surgery, Family Practice, Internal Medicine, Pediatric Surgery and Pediatrics
Treatment of Pilonidal cyst (fluid filled sac on tailbone)

Incision and drainage is necessary if an abscess has developed. Antibiotics are not required unless there
is a surrounding skin infection (cellulitis). Repeated occurrences may require a surgical removal of the
cyst.

yy. Rotator cuff syndrome (shoulder injury)
Description of Rotator cuff syndrome (shoulder injury)
The rotator cuff is a band of tendons which compose a portion of the shoulder joint. The rotator cuff is
composed of tendons of the supraspinatus, infraspinatus, teres minor and subscapularis muscles.
Rotator cuff syndrome is a spectrum of diseases ranging from shoulder impingement, to inflammation
(tendonitis or bursitis) to a partial or complete tear (rotator cuff tear).
Symptoms of Rotator cuff syndrome (shoulder injury)
Shoulder pain which may radiate down to the elbow. Pain with reaching, lifting, and overhead activities.
Tenderness may be experienced through the front, side and back of the shoulder. Most individuals with
rotator cuff pain will experience increased pain at night while sleeping.
Tests for Rotator cuff syndrome (shoulder injury)
Workup
A history and physical exam will be performed. In most cases this is all that is needed for making a
diagnosis. Shoulder x-rays can check for other causes of pain, such as fracture. A MRI is useful in severe
cases, when your doctor suspects a rotator cuff tear..
Tests
MRI and X-ray
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pediatric Orthopedic Surgery, Pediatrics, Sports
Medicine and Sports Medicine Surgery
Treatment of Rotator cuff syndrome (shoulder injury)
Treatment depends on the extent of injury but may include: nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), injection of the shoulder, physical
therapy, and (in the case of a rotator cuff tear) surgery.

zz. Colonic diverticulitis (large intestine inflammation of diverticula) *CRITICAL

Description of Colonic diverticulitis (inflammation of pouches in the large intestine)
A diverticulum is an outpouching of the colon that develop as one ages. Diverticulitis occurs when the
opening of these pouches become blocked and get inflamed or infected. The pain is in the lower
abdomen and more likely on the left. If severe, the diverticulum can perforate and lead to a life
threatening infection.
Symptoms of Colonic diverticulitis (inflammation of pouches in the large intestine)
Lower abdominal pain (more common on the left), diarrhea, fever, nausea, vomiting, low blood
pressure.
Tests for Colonic diverticulitis (inflammation of pouches in the large intestine)
Workup
A history and physical exam will be performed. Blood tests and a CT scan or MRI may be performed to
define the disease and determine the extent of the involvement. A CT scan is especially useful in
identifying a perforation and/or abscess.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, MRI, Urinalysis (UA) and
X-ray
Specialists
Family Practice, Gastroenterology and Internal Medicine
Treatment of Colonic diverticulitis (inflammation of pouches in the large intestine)
If not severe, diverticulitis can be treated with oral antibiotics, More serious cases require intravenous
antibiotics and bowel rest. Abscesses require drainage either percutaneously or surgically. If the
infection is severe the affected colon may need to be removed surgically.

aaa.

Pancreatitis, chronic (Pancreas inflammation) *CRITICAL

Description of Pancreas inflammation (pancreatitis, chronic)
Repeated inflammation of the pancreas causes scarring and destruction of the pancreas. Normally, the
pancreas makes digestive enzymes and the hormone insulin. When the pancreas is damaged, lack of
digestive enzymes can cause diarrhea and weight loss due to poor digestion. Lack of insulin can cause
diabetes. Chronic pancreatitis can cause constant pain in the abdomen. The most cause of chronic
pancreatitis is heavy alcohol consumption.
Symptoms of Pancreas inflammation (pancreatitis, chronic)

Abdominal pain, back pain, diarrhea, fatty stools (steatorrhea), fever, nausea, weakness, weight loss,
vomiting, diabetes (symptoms from high blood sugar such as frequent urinating or blurred vision).
Tests for Pancreas inflammation (pancreatitis, chronic)
Workup
A history and physical exam will be performed. X-Ray may show calcium deposits in the pancreas. An
abdominal CT scan can show a shrunken and scarred pancreas. Blood tests may or may not be abnormal
when pancreatitis is chronic or repeated.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Lipase, Ultrasound and X-ray
Additional tests that may be required
Amylase
Specialists
Family Practice, Gastroenterology and Internal Medicine
Treatment of Pancreas inflammation (pancreatitis, chronic)
In a flare-up of pain, a hospital stay may be needed. Avoiding alcohol is very important. Several days
without food may be needed for a flare to improve. Diarrhea may improve with pills that supplement
digestive enzymes. Diabetes from pancreatitis requires treatment with insulin. If a scarred area of
pancreas has caused a painful collection of fluid (called a "pseudocyst,") this may require drainage.
Drainage can occur in the following ways: through the skin, through the stomach wall using an
endoscope, and surgically. For more information contact the National Digestive Diseases Information
Clearinghouse at: http://digestive.niddk.nih.gov

bbb.

Appendicitis *CRITICAL

Description of Appendicitis
Inflammation of the appendix. The appendix is a small pouch extending from the cecum, the first part of
the large intestine. In appendicitis the opening of the pouch becomes blocked with fecal material
(appendicolith) causing swelling of the appendix and allowing bacteria to grow in this area. The
appendix has no function and can rupture if the appendicitis is untreated.
Symptoms of Appendicitis

Nausea, vomiting, abdominal pain. The pain typically starts in the center of the abdomen then moves to
the right lower side. Less frequently the pain is in other areas of the abdomen and even on the left side.
Tests for Appendicitis
Workup
A history and physical exam will be performed. A blood test and an imaging test (CT or Ultrasound) may
be necessary in ambiguous cases.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and Ultrasound
Specialists
General Surgery and Pediatric Surgery
Treatment of Appendicitis
The usual treatment is surgical removal of the appendix. Antibiotics may be given as well.

ccc. Obesity
Description of Obesity
Defined as an increase in total body fat, or at least a 20% increase in one's ideal body weight. Obesity
has increased in frequency in the last 20 years and it is estimated 33% of Americans are obese. One
calculation of obesity is the body mass index or BMI. To calculate the BMI a patient takes their weight in
pounds and multiplies it by 705, then divides this number by their height in inches, then divides this
number again by their height in inches. The US Department of Health and Human Services provides a
BMI calculator at http://www.nhlbisupport.com/bmi/. A normal BMI = 18.5-24.9; overweight = 25.029.9; obese = 30 or greater; and morbidly obese = 40 or greater. Obesity is the second leading cause of
preventable death (after smoking), and is associated with type 2 diabetes, elevated cholesterol, heart
disease, arthritis, gallstones, obstructive sleep apnea, and cancer. There are many causes of obesity
from genetic to environmental factors, and certain conditions including Cushing's syndrome,
hypothyroidism and medications, such as steroids, can cause obesity. In the great majority of cases no
secondary cause is determined.
Symptoms of Obesity
Most of the symptoms of obesity come from the diseases obesity causes such as arthritis, heart disease,
gallstones, sleep apnea, and poor self-esteem. These symptoms include: back pain, hip pain, knee pain,
ankle pain, neck pain, chest pain, breathing problems, sadness, depression, snoring, rashes in the folds
of the skin, and excessive sweating.

Tests for Obesity
Workup
A history and physical exam will be done. Other tests may be performed to determine the cause of the
excess body fat. A BMI will be calculated.
Tests
Thyroid function test
Additional tests that may be required
Fasting glucose, cholesterol, triglycerides
Specialists
Bariatric Medicine, Bariatric Surgery, Diabetes, Endocrinology and Metabolism, Family Practice, Internal
Medicine and Pediatrics
Treatment of Obesity
Treatment is aimed at decreasing the intake of calories while still maintaining a healthy diet, and
increasing exercise. Successful programs for weight loss should be started and followed under the care
of a physician and/or a nutritionist. Behavioral modification therapy and social support can help achieve
positive results. Medications can be used and include orlistat and diethylpropion. Bariatric surgery such
as gastric bypass and lap band procedures have been found to be effective. They are usually reserved for
those patients with BMIs greater than 40, or for those with a BMI between 35-40 and with a co-existing
obesity related medical problem such as diabetes.

ddd.

Fracture (broken bone)

Description of Fracture (broken bone)
A fracture is a break in a bone. Fractures can be simple or complex in multiple pieces (comminuted). The
fracture can bleed into the surrounding tissue resulting in bruising and in severe cases a limb
threatening condition, compartment syndrome. The fracture can also injure adjacent nerves, tendons or
blood vessels.
Symptoms of Fracture (broken bone)
Pain, swelling, deformity, numbness. A snapping sound may be noted at the time of injury.
Tests for Fracture (broken bone)
Workup

A history and physical exam will be performed. If a fracture is strongly suspected and not seen on X-ray,
a CT scan may be recommended.
Tests
X-ray
Specialists
Orthopedic Surgery
Treatment of Fracture (broken bone)
If the broken bones are not properly aligned, a reduction to restore the normal positioning will be
performed. This can be accomplished without surgery (though with sedation) during a "closed
reduction" but certain complicated fractures require surgical reduction. A splint or cast is then applied.
Medications for pain including nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin
or Advil, naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol) or codeine may be
prescribed.

2. Behavioral disturbances

COMMON CAUSES

a. Personality disorder
Description of Personality disorder (unhealthy patterns of thinking and behavior)
This term describes a lifelong pattern of behavior that interferes with normal social interaction and
function. There are a variety of named personality disorder types. Examples are "borderline personality"
and "antisocial personality." Psychiatrists have made lists of very specific criteria that are used to
diagnose a person with personality disorder. A personality disorder results in trouble with relationships,
work and the law. Individuals suffering with these conditions feel their behavior is normal and only a few
ever seek psychiatric help.
Symptoms of Personality disorder (unhealthy patterns of thinking and behavior)

Symptoms vary widely depending on the specific type of personality disorder but may include: frequent
mood swings, stormy relationships, social isolation, angry outbursts, suspicion and mistrust of others,
difficulty making friends, a need for instant gratification, poor impulse control, alcohol or substance
abuse.
Tests for Personality disorder (unhealthy patterns of thinking and behavior)
Workup
A history and physical exam will be performed. The diagnosis is based on a psychological evaluation and
the history and severity of the symptoms.
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Personality disorder (unhealthy patterns of thinking and behavior)
Treatment consists of medications, psychotherapy, and/or hospitalizations. Medications that are used
include: antidepressants, anti-anxiety medications, mood stabilizers, and anti-psychotics.

b. Anxiety disorder
Description of Anxiety disorder (generalized anxiety disorder, GAD)
A psychological disorder in which anxiety is so severe they prevent a person from performing their
normal daily activities. Anxiety is a sense of fear or apprehension accompanied by some or all of the
following signs: muscle tension, restlessness, palpitations, rapid breathing, jitteriness, suspicion,
confusion, decreased concentration, or fear of losing control. This reaction may occur as result of a real
or perceived danger or stressor. It might also occur without any clear reason. An episode may be brief or
long lasting. The symptoms may go away and return repeatedly. The exact cause of this disorder is not
known but it is felt to be a combination of genetic and environmental factors.
Symptoms of Anxiety disorder (generalized anxiety disorder, GAD)
Fear, apprehension, muscle tension, restlessness, palpitations, rapid breathing, jitteriness, hyper
vigilance, confusion, decreased concentration, fear of losing control.
Tests for Anxiety disorder (generalized anxiety disorder, GAD)
Workup
A history and physical exam will be performed both to make the diagnosis and to help find the triggers
and potentially an underlying cause.
Additional tests that may be required

if necessary, BHCG, Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and
Urinalysis (UA), blood alcohol, drug screen test
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Anxiety disorder (generalized anxiety disorder, GAD)
Therapy depends on the severity of symptoms. Treatment may include: benzodiazepines
(diazepam/Valium, lorazepam/Ativan), antidepressant medications, psychological counseling, and/or
psychological treatment such as cognitive-behavioral therapy.

c. Bipolar affective disorder (Bipolar depression)
Description of Bipolar disorder (manic depressive disorder)
A mental illness characterized by mood instability that can be serious and disabling. Bipolar disorder is
also known as manic-depression or manic-depressive illness. Patients with this disorder suffer from
extreme sadness (depression) coupled with periods of excessive energy and impulsive behavior. A
milder form of this disorder is called cyclothymia. Bipolar disorder can be very serious and lead to
suicidal thoughts and actions.
Symptoms of Bipolar disorder (manic depressive disorder)
Depression, hopelessness, suicidal thoughts, suicide attempts, insomnia, fatigue, excitability,
restlessness, excessive energy, impulsive actions, reckless behaviors.
Tests for Bipolar disorder (manic depressive disorder)
Workup
A history and physical exam will be performed. A psychiatric consultation is generally done to confirm
the diagnosis.
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Bipolar disorder (manic depressive disorder)
Therapy depends on the severity of the symptoms. Treatment includes: psychological counseling,
lithium, antidepressant medications, mood stabilizer medications, and/or antipsychotic medications.
Patients having suicidal thoughts require immediate medical attention.

d. Post-traumatic stress disorder (PTSD)
Description of Post-traumatic stress disorder (PTSD)
PTSD occurs in people that have experienced or witnessed extremely distressing events such as natural
disasters, murder, rape, war, imprisonment, torture, and accidents. Rather than recovering from the
event patients frequently re-experience or re-live the trauma and associated symptoms. The symptoms
may begin right after the event or may develop months or years later. The recurrence of symptoms can
be very debilitating.
Symptoms of Post-traumatic stress disorder (PTSD)
Flashback episodes, recurrent distressing memories of the event, repeated dreams of the event, physical
reactions to situations that remind one of the traumatic event, feelings of detachment, inability to
remember important aspects of the trauma, lack of interest in normal activities, staying away from
places or people, difficulty concentrating, exaggerated response to being startled, excess awareness
(hyper vigilance), irritability or outbursts of anger, sleeping difficulties.
Tests for Post-traumatic stress disorder (PTSD)
Workup
A history and physical exam will be performed. The diagnosis is established with the history of the
symptoms and previous life events.
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Post-traumatic stress disorder (PTSD)
Conditions such as substance abuse or depression may need to be treated before directly treating the
symptoms of PTSD. Behavioral therapy is used to help control symptoms. Medical therapy may include
antidepressants (selective serotonin reuptake inhibitors) and antianxiety medications.

e. Drug reaction
Description of Drug reaction
Drug reactions can result in many different symptoms but rash, fatigue and gastrointestinal reactions
are among the most common. In severe cases, the reactions can result in airway swelling and very low
blood pressure, occasionally resulting in death.
Symptoms of Drug reaction
Rash, fatigue, nausea, vomiting, diarrhea, fever, swelling, breathing problems, low blood pressure.

Tests for Drug reaction
Workup
A history and physical exam will be performed.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Drug reaction
Removal of the offending drug. Treatment of any symptoms may include: intravenous fluids, oxygen,
anti-nausea medications, antihistamines, steroids, and/or epinephrine.

ADDITIONAL CAUSES

a. Depression (excessive sadness) *CRITICAL
Description of Depression (excessive sadness)
A mental state or chronic psychiatric disorder characterized by excessive feelings of sadness, loneliness,
despair, helplessness, low self-esteem, and self-reproach. Depression is different than normal sadness
because it prevents the person from functioning normally in their daily life. Other signs of depression
include a lack of energy or initiative (psychomotor retardation), agitation, withdrawal from social
contact, insomnia, decreased appetite and/or a vegetative state. The symptoms can become severe
enough to cause self harm or suicide. Any patient having thoughts their life is not worth living needs to
get immediate medical help.
Symptoms of Depression (excessive sadness)
Patients suffering from the following symptoms may have depression: excessive sadness, problems
falling asleep, sleeping too much, problems concentrating, uncontrollable negative thoughts, no
appetite, short temper, feeling helpless, increase in drinking alcohol, increase reckless behavior,
increased fatigue, thoughts life isn't worth living.
Tests for Depression (excessive sadness)
Workup

A history and physical exam will be performed. Additional tests may include: thyroid function tests,
electrolytes, or a brain CT scan.
Tests
Comprehensive metabolic panel (CMP), CT Scan and Thyroid function test
Specialists
Family Practice, Geriatric Psychiatry, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics
and Psychiatry
Treatment of Depression (excessive sadness)
Antidepressants and/or psychotherapy are the mainstays of treatment. Psychiatric hospitalizations may
be needed for severe symptoms and for those with suicidal thoughts. For patients who fail to respond to
medications and psychotherapy electroconvulsive treatment (ECT) may be an option. Any patient who
feels life is not worth living needs to seek medical care immediately. Help is available for patients 24
hours a day at the National Suicide Prevention Lifeline: 1-800-273-TALK
8255

1-800-273-TALK (1-800-273-

1-800-273-8255); TTY: 1-800-799-4TTY (4889).

b. Altered mental status (confusion) *CRITICAL
Description of Altered mental status (confusion)
A change in awareness of a person's surroundings and/or impaired mental functioning. Also known as
altered mental status. Treatable causes include: infection, adverse drug reaction, very high or very low
blood sugar, low oxygen level, a blood electrolyte imbalance.
Symptoms of Altered mental status (confusion)
Altered thinking, difficulty concentrating, strange behavior, excessive sleepiness, decreased arousal.
Tests for Altered mental status (confusion)
Workup
A history and physical exam will be performed. Blood tests may include: a complete blood count, sugar
level, electrolytes, liver and kidney function tests, cultures of blood and urine to look for infection.
Usually a CT scan or MRI of the brain is done.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, DDimer, Electrocardiogram (EKG), MRI, Troponin, Urinalysis (UA) and X-ray

Additional tests that may be required
Toxicology screen, ethanol level, aspirin level
Specialists
Internal Medicine, Neurology and Pediatric Neurology
Treatment of Altered mental status (confusion)
The goal of therapy is to first support vital body functions. This often includes intravenous fluids and
oxygen if needed. At the same time, treatment is started to reverse identified offending problems.
Protection from self-harm is also important.

c. Attention deficit hyperactivity disorder (ADHD)
Description of Attention deficit hyperactivity disorder (ADHD)
A problem with inattentiveness, over-activity, and/or impulsivity. Children may struggle with low selfesteem, troubled relationships and poor performance in school. The symptoms must be out of the
normal range for the child's age and development. The disorder affects millions of children and can
persist into adulthood. ADHD, also sometimes referred to as just plain attention deficit disorder (ADD).
Symptoms of Attention deficit hyperactivity disorder (ADHD)
To establish the diagnosis children should have at least 6 attention symptoms or 6 activity and
impulsivity symptoms that are unusual for age and development. Inattention symptoms include:
inability to give close attention to details or makes careless mistakes in schoolwork; difficulty sustaining
attention in tasks or play; does not seem to listen during a one-on-one conversation; does not follow
through on instructions and fails to finish schoolwork, chores, or duties in the workplace; difficulty
organizing tasks and activities; avoids or dislikes tasks that require sustained mental effort (such as
schoolwork); often loses toys, assignments, pencils, books, or tools needed for tasks or activities; easily
distracted; often forgetful in daily activities. Hyperactivity symptoms: fidgets with hands or feet or
squirms in seat; leaves seat when remaining seated is expected; runs about or climbs in inappropriate
situations; difficulty playing quietly; often "on the go"; acts as if "driven by a motor"; talks excessively.
Impulsivity symptoms: blurts out answers before questions have been completed; difficulty waiting for
his or her turn; interrupts or intrudes on others (butts into conversations or games).
Tests for Attention deficit hyperactivity disorder (ADHD)
Workup
A history and physical exam will be performed. There is no specific test for ADHD. The child should have
a clinical evaluation if ADHD is suspected. The evaluation may include parent and teacher questionnaires
(Connors, Burks), IQ testing, and psychological testing.

Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Attention deficit hyperactivity disorder (ADHD)
Treatment involves behavioral therapy and medications. Behavioral treatment includes: psychotherapy,
behavioral therapy, social therapy, family therapy, and support groups. Medications include:
methylphenidate (Ritalin, Concerta, Daytrana), dextroamphetamine-amphetamine (Adderall),
dextroamphetamine (Dexedrine), atomoxetine (Strattera), antidepressants and clonidine.

a. Schizophrenia (Psychiatric disease) *CRITICAL
Description of Schizophrenia (chronic impaired reality perception)
A psychiatric disease characterized by a distorted interpretation of reality resulting in hallucinations,
delusions, and disordered thinking and behavior. Contrary to belief it does not mean a split personality.
Untreated, the disease can cause severe emotional, behavioral, health, and legal and financial problems.
Lifelong treatment is needed, and can enable many patients to live normal productive lives. This is a
serious mental disorder with about 10% of patients committing suicide. The disease usually first appears
in the teenage years.
Reviewed by Harvard Medical School
Symptoms of Schizophrenia (chronic impaired reality perception)
Symptoms typically begin gradually and worsen with time and include: trouble sleeping, trouble
concentrating, withdrawing from family and friends, bizarre motor behavior in which there is less
reaction to the environment (catatonic behavior), false beliefs or thoughts (delusions), hearing voices,
seeing things (hallucinations), thoughts race between unrelated topics (disordered thinking).
Tests for Schizophrenia (chronic impaired reality perception)
Workup
A history and physical exam will be performed. Substance abuse (drug use) can cause similar symptoms.
Tests may be done to rule out other causes of the symptoms such as thyroid disease, electrolyte
problems, drug abuse, and adverse drug interactions.
Tests
Comprehensive metabolic panel (CMP)
Additional tests that may be required
Thyroid studies, urine and/or serum toxicology screen

Do I Need This Test?
Don’t routinely prescribe two or more antipsychotic medications concurrently. Research shows that use
of two or more antipsychotic medications occurs in 4 to 35% of outpatients and 30 to 50% of inpatients.
However, evidence for the efficacy and safety of using multiple antipsychotic medications is limited, and
risk for drug interactions, noncompliance and medication errors is increased. Generally, the use of two
or more antipsychotic medications concurrently should be avoided except in cases of three failed trials
of monotherapy, which included one failed trial of Clozapine where possible, or where a second
antipsychotic medication is added with a plan to cross-taper to monotherapy.
How this was created and why it is important

The American Psychiatric Association and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Pediatric and Adolescent Psychiatry and Psychiatry
Treatment of Schizophrenia (chronic impaired reality perception)
Treatment depends on the severity of symptoms but may include: antipsychotic medications
(haloperidol/Haldol, clozapine/Clozaril, risperidone/Risperdal, olanzapine/Zyprexa, quetiapine/Seroquel,
ziprasidone/Geodon, aripiprazole/Abilify, paliperidone/Invega), psychiatric and psychologic counseling,
and/or hospitalizations.

b. Obsessive compulsive disorder (OCD)
Description of Obsessive compulsive disorder (OCD, anxiety disorder)

A type of anxiety defined by obsessions (recurrent, intrusive thoughts) and compulsions (repetitive,
ritualistic behaviors). It usually begins in childhood or adolescence, and is somewhat common during
and following pregnancy. OCD symptoms fluctuate throughout life, but rarely go completely away.
Symptoms of Obsessive compulsive disorder (OCD, anxiety disorder)
Obsessions and compulsions can take many forms, examples are: excessive hand washing or refusing to
step on cracks in the sidewalk. The symptoms cause distress or interfere with everyday life. Patients
usually recognize the behavior is excessive and unreasonable.
Tests for Obsessive compulsive disorder (OCD, anxiety disorder)
Workup
A history and physical exam will be performed. In children a temporary type of OCD may follow a strep
throat infection. Questionnaires, such as the Yale-Brown Obsessive Compulsive Scale, can help diagnose
OCD and track the progress of treatment.
Additional tests that may be required
Yale-Brown Obsessive Compulsive Scale
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Obsessive compulsive disorder (OCD, anxiety disorder)
OCD is treated using medications and therapy. Medications used include: serotonin reuptake inhibitors
(citalopram/Celexa, fluoxetine/Prozac, fluvoxamine/Luvox, paroxetine/Paxil, sertraline/Zoloft); or a
tricyclic antidepressant (clomipramine/Anafranil).

c. Major depressive disorder (severe depression) *CRITICAL
Description of Major depressive disorder (severe depression)
A disorder causing severe and persistent low mood. Other common symptoms include profound
sadness, a sense of despair and a loss of pleasure for previously enjoyable activities. The diagnosis is
made when mood changes and other symptoms of depression persist for at least 2 weeks. Major
depression carries a risk of suicide if not appropriately treated. The cause of major depression is not
known. An episode of depression can be triggered by a stressful life event, such as the death of a loved
one. But in many cases, depression does not appear to be related to a specific event. Major depression
may occur just once in a person's life or may return repeatedly.
Symptoms of Major depressive disorder (severe depression)

Trouble sleeping or excessive sleeping, a dramatic change in appetite, often with weight gain or loss,
fatigue and lack of energy, feelings of worthlessness, self-hate, inappropriate guilt, extreme difficulty
concentrating, agitation, restlessness, irritability, inactivity and withdrawal from usual activities, a loss of
interest or pleasure in activities that were once enjoyed (such as sex), feelings of hopelessness and
helplessness, thoughts of death or suicide.
Tests for Major depressive disorder (severe depression)
Workup
A history and physical exam will be performed. Tests may be done to rule out another medical problem
that might be contributing to the symptoms, such as an under active thyroid.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
TSH (Thyroid Stimulating Hormone)
Specialists
Geriatric Psychiatry, Pediatric and Adolescent Psychiatry and Psychiatry
Reviewed by Harvard Medical School
Treatment of Major depressive disorder (severe depression)
Depression is most effectively treated with medications and/or talk therapy. Medications include
selective serotonin re-uptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase
inhibitors. At the start of drug therapy, there may be increased suicidal thoughts that must be taken
seriously and monitored closely. Psychiatric hospitalization may be needed for severe symptoms and for
those with suicidal thoughts. For patients who fail to respond to medications and psychotherapy
electroconvulsive treatment (ECT) may be an option. Any patient who feels life is not worth living needs
to seek medical care immediately. Help is available for patients 24 hours a day at the National Suicide
Prevention Lifeline: 1-800-273-TALK
800-799-4TTY (4889).

1-800-273-TALK (1-800-273-8255

1-800-273-8255); TTY: 1-

d. Schizoaffective disorder
Description of Schizoaffective disorder (features of schizophrenia and mood disorder)
A psychiatric diagnosis having characteristics of schizophrenia and affective disorder (depression).
Patients experience psychosis, such as hallucinations or delusions, and symptoms of elevated or

depressed mood. Untreated, patients become disenfranchised and are unable to hold jobs or perform
their normal daily responsibilities.
Symptoms of Schizoaffective disorder (features of schizophrenia and mood disorder)
Symptoms vary widely but include: very good or bad mood, abnormal thoughts, changes in appetite and
energy, belief that someone on TV or radio is speaking directly to them, believe secret messages are
hidden in common objects, disorganized speech that is not logical, false beliefs (delusions), feeling that
everyone or one person or agency is out to get them (paranoia), irritability, poor temper control, lack of
concern with hygiene, sleeping problems, seeing or hearing things (hallucinations), trouble
concentrating.
Tests for Schizoaffective disorder (features of schizophrenia and mood disorder)
Workup
A history and physical exam will be performed. Tests may be done to rule out other causes of the
symptoms such as thyroid disease, electrolyte problems, drug abuse, and adverse drug interactions.
Tests
Comprehensive metabolic panel (CMP)
Additional tests that may be required
Thyroid studies, urine and/or serum toxicology screen
Do I Need This Test?
Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial
evaluation and appropriate ongoing monitoring. Metabolic, neuromuscular and cardiovascular side
effects are common in patients receiving antipsychotic medications for any indication, so thorough
initial evaluation to ensure that their use is clinically warranted, and ongoing monitoring to ensure that
side effects are identified, are essential. “Appropriate initial evaluation” includes the following: (a)
thorough assessment of possible underlying causes of target symptoms including general medical,
psychiatric, environmental or psychosocial problems; (b) consideration of general medical conditions;
and (c) assessment of family history of general medical conditions, especially of metabolic and
cardiovascular disorders. “Appropriate ongoing monitoring” includes re-evaluation and documentation
of dose, efficacy and adverse effects; and targeted assessment, including assessment of movement
disorder or neurological symptoms; weight, waist circumference and/or BMI; blood pressure; heart rate;
blood glucose level; and lipid profile at periodic intervals.
How this was created and why it is important

The American Psychiatric Association and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Pediatric and Adolescent Psychiatry and Psychiatry
Treatment of Schizoaffective disorder (features of schizophrenia and mood disorder)
Therapy can vary depending on the severity of symptoms. The primary treatments are psychotherapy
and medications. Medications used include: antipsychotics to treat psychosis, medications for mood
stabilization, and anti-depressants.

e. Dysthymia
Description of Dysthymia (neurotic depression)
Dysthymia is a form of depression that is less severe than major depression but usually lasts longer. It is
characterized by a depressed mood for most of the day and for at least two years in adults and one year
in children. Symptoms usually begin slowly in adolescence or early adult life. Dysthymia does tend to run
in families. People with dysthymia have a greater than average chance of developing major depression.
Symptoms of Dysthymia (neurotic depression)
Symptoms vary with the severity of the disease. They may include weight loss or gain, excessive sleeping
or trouble sleeping, irritability, decreased pleasure and a loss of energy. Dysthymic people also often
have difficulty with interpersonal relationships, poor self esteem and a lack of personal identity.
Tests for Dysthymia (neurotic depression)

Workup
A complete history and physical will be performed. The provider may order certain lab tests to exclude
other causes of depression.
Tests
Complete blood count (CBC) and TSH
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Dysthymia (neurotic depression)
Treatment may vary depending on the severity of disease. A combination of psychotherapy and
medications are frequently used. The most common anti-depressant medications used are fluoxetine
(Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). In some cases, your doctor may
decide to add a mood stabilizer or anti-anxiety medication.

f.

Adjustment disorder (Depression anxiety)

Description of Adjustment disorder (poor adjustment to life stressor)
A response to stress that results in significant emotional or behavioral symptoms and impairment of
function in daily life. The disorder typically causes symptoms of depression, anxiety or both. In severe
cases patients may have suicidal thoughts. The symptoms begin within 3 months of a stressful life event.
Symptoms of Adjustment disorder (poor adjustment to life stressor)
Depression, anxiety, desperation, trouble sleeping, nervousness, and agitation.
Tests for Adjustment disorder (poor adjustment to life stressor)
Workup
A history and physical exam will be performed.
Specialists
Family Practice, Geriatric Psychiatry, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics
and Psychiatry
Treatment of Adjustment disorder (poor adjustment to life stressor)
Treatment options include talk therapy and/or medications. Medications used include antidepressants
and anti-anxiety medications.

g. Alcohol (ethanol) intoxication
Description of Alcohol (ethanol) intoxication
An alteration in thinking, behavior and/or consciousness caused by the consumption of alcohol
(ethanol). Can result in impulsive and uninhibited behavior. Alcohol affects people differently. The same
amount can have only minimal effects on one person, and severely depress the breathing of another.
Symptoms of Alcohol (ethanol) intoxication
Confusion, slurred speech, vomiting, breathing problems, incoordination, emotional instability, coma,
death.
Tests for Alcohol (ethanol) intoxication
Workup
A history and physical exam will be performed along with other tests which may include: ethanol
(alcohol) level, liver function tests, and electrolytes.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Lipase
Additional tests that may be required
Ethanol level
Specialists
Family Practice and Internal Medicine
Treatment of Alcohol (ethanol) intoxication
Therapy is aimed at supporting vital signs and preventing self-harm. Treatment may include: intravenous
fluids, breathing and vital sign support, medications for vomiting, sedatives (benzodiazepines) and
antipsychotics. Alcohol and Drug Helpline: (800) 821-4357
(888)821-4357

h. Cerebellar syndrome
Description of Cerebellar syndrome (loss of coordination)

(800) 821-4357 Al-Anon (888)821-4357

This disorder describes a collection of symptoms that result from diseases of the cerebellum. The
cerebellum is located at the base of the skull and controls coordination, balance, and equilibrium.
Symptoms of Cerebellar syndrome (loss of coordination)
Incoordination, clumsy gait, tremors, visual problems, speech problems.
Tests for Cerebellar syndrome (loss of coordination)
Workup
A history and physical exam will be performed. A CT scan or MRI will be taken to determine the cause of
the syndrome.
Tests
CT Scan and MRI
Specialists
Neurology and Pediatric Neurology
Treatment of Cerebellar syndrome (loss of coordination)
Depends on the cause of the syndrome.

i.

Hypoglycemia (low blood glucose) *CRITICAL

Description of Hypoglycemia (low blood sugar)
A condition of low glucose (sugar) in the blood. Causes of hypoglycemia include : 1) taking too much
insulin or oral diabetic medications; 2) not eating or drinking enough; 3) liver disease; 4) an insulin
producing tumor of the pancreas; 5) drinking excessive alcohol. Sometimes no cause is found. If severe
and untreated it can lead to stroke and death.
Symptoms of Hypoglycemia (low blood sugar)
Hunger, irritability, confusion, seizures, unconsciousness, sweating, death.
Tests for Hypoglycemia (low blood sugar)
Workup
A history and physical exam will be performed. Blood glucose measurement and other blood tests will
be checked to determine the cause of the low glucose.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Urinalysis (UA)
Specialists
Diabetes, Endocrinology and Metabolism, Endocrinology, Family Practice, Internal Medicine, Pediatric
Endocrinology and Pediatrics
Treatment of Hypoglycemia (low blood sugar)
Treatment options include improving nutrition, oral or intravenous glucose, or glucagon. The cause of
the low blood sugar needs to be identified and treated to prevent recurrence.

j.

Hepatic encephalopathy (liver failure confusion) *CRITICAL

Description of Hepatic encephalopathy (confusion from liver failure)
Confusion, agitation, and abnormal arm and leg movements caused by liver failure (cirrhosis). The
disease is caused by the buildup of toxic substances that are normally cleared by the liver, such as
ammonia. The disorder is triggered by dehydration, eating too much protein, bleeding from the
intestinal tract, infections, kidney failure, low oxygen levels, shunt placement or surgery.
Symptoms of Hepatic encephalopathy (confusion from liver failure)
Symptoms occur gradually and include confusion, change in behavior, personality changes, agitation,
sleeping problems, abnormal movements of the arms and legs, seizures, slurred speech, and coma.
Tests for Hepatic encephalopathy (confusion from liver failure)
Workup
A history and physical exam will be done. A brain CT scan and/or MRI may be performed to rule out
other causes of the symptoms. Blood tests including an ammonia level will also be done.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Hepatic encephalopathy (confusion from liver failure)
Therapy is aimed at treating the triggering event as well as the hepatic encephalopathy. Patients should
avoid eating high protein foods. Treatment includes causing diarrhea with medications such as lactulose

and giving antibiotics orally such as neomycin. These treatments remove ammonia from the large
intestine, and from the body.

k. Medication reaction *CRITICAL
Description of Medication reaction
Any allergic reaction or symptom that is caused by a medication. The reactions can be mild such as
nausea. They can be life threatening such anaphylaxis—low blood pressure, fainting and collapse. Small
children and the elderly are most susceptible to medication reactions. A medication reaction should be
considered as a possible cause for a sudden change in behavior or new symptom in children and the
elderly. Over the counter medications can also cause serious side effects. Even medications that initially
were tolerated without a problem can result in serious reactions. Some medication reactions are caused
by taking too much of the drug requiring a decrease in a patient's dose. For specific reactions review the
adverse reaction section of the medication being taken.
Symptoms of Medication reaction
Symptoms depend on the medication being taken. Mild to moderate symptoms include nausea,
vomiting, abdominal pain, diarrhea, headache, easy bruising. More serious symptoms include breathing
problems, low blood pressure, fainting, facial swelling, intestinal bleeding, or low blood sugar (glucose).
Tests for Medication reaction
Workup
A history and physical exam will be done. Further tests will depend on the symptoms being experienced.
The provider may remove the medication and observe to see if the symptoms go away. If available a
drug level may be performed to measure the amount of medication in the body.
Specialists
Family Practice, Internal Medicine, Medical Toxicology and Pediatrics
Treatment of Medication reaction
Treatment depends on the reaction and the medication being taken. Patients should always discuss with
their healthcare provider before abruptly stopping a medication since some drugs require a gradual
reduction to prevent serious side effects.

l.

Alcoholism

Description of Alcoholism

A physical and mental dependence on alcohol, sometimes resulting in chronic disease and the loss of
interpersonal, family and work relationships. Continued daily use can result in permanent damage to the
liver (cirrhosis). Other long term effects include: anemia, internal bleeding, impaired thinking, confusion,
coma, multiple cancers, and premature death.
Symptoms of Alcoholism
Weakness, impaired thinking, poor decision making, depression, separation from family.
Tests for Alcoholism
Workup
A history and physical exam will be performed along with other tests which may include: a complete
blood count, liver function tests, blood sugar, and electrolytes.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Lipase
Additional tests that may be required
Ethanol level
Specialists
Family Practice, Internal Medicine and Psychiatry
Treatment of Alcoholism
Treatment includes individual and/or group counseling (such as AA), talk therapy ,and/or medications.
Alcohol and Drug Helpline: (800)821-4357

(800)821-4357 Al-Anon (888)425-2666

(888)425-2666

Reviewed by Harvard Medical School

m. Dementia (impaired cognitive function)
Description of Dementia (decline in mental ability)
A loss of normal brain function, such as memory, language, abstract thinking and analysis. It can occur
from many different types of diseases. The two main causes are Alzheimer's disease and vascular
dementia. The disease is progressive. Certain medications and alcohol can worsen the symptoms.
Symptoms of Dementia (decline in mental ability)

Confusion, loss of memory, delusions, hallucinations, gait problems, speech problems, insomnia,
irritability, depression.
Tests for Dementia (decline in mental ability)
Workup
A history and physical exam will be performed, Imaging studies (CT scan or MRI) will be done to rule out
structural defects that could be causing the disorder. Blood test will be done that could identify a
reversible cause of the symptoms.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and MRI
Do I Need This Test?
Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
People with dementia often exhibit aggression, resistance to care and other challenging or disruptive
behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited
benefit and can cause serious harm, including stroke and premature death. Use of these drugs should be
limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat
to themselves or others. Identifying and addressing causes of behavior change can make drug treatment
unnecessary.
How this was created and why it is important

The American Geriatrics Society and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Family Practice, Geriatric Medicine, Geriatric Psychiatry, Internal Medicine and Neurology
Treatment of Dementia (decline in mental ability)

All medications that could be worsening the symptoms should be reviewed and changed or stopped
with your doctor's approval. Other medical treatment depends on the severity of the disease and may
include: serotonin-affecting drugs (trazodone, buspirone), dopamine blockers (haloperidol, Risperdal,
olanzapine, clozapine), cholinesterase inhibitors (donepezil /Aricept), rivastigmine/Exelon), mood
stabilizers (fluoxetine, imipramine, citalopram) and/or stimulants such as methylphenidate to increase
activity and spontaneity. Some patients may require long term 24 hour care as the disease progresses.

n. Respiratory failure (breathing failure) *CRITICAL
Description of Respiratory failure (breathing failure, ARDS)
Respiratory failure results in inadequate oxygen delivery to the body and can lead to rapid death. The
body's respiratory system is composed of the chest cavity and diaphragm, the lungs, the air tubes
(trachea and bronchi) and the upper airway (mouth and throat). A disorder in any structure or a
combination of these structures can cause a failure of the respiratory system.
Symptoms of Respiratory failure (breathing failure, ARDS)
Confusion, easy fatigue, lethargy, shortness of breath, sleepiness, blue discoloration of the skin
(cyanosis), coma.
Tests for Respiratory failure (breathing failure, ARDS)
Workup
A history and physical exam will be performed. Tests that to identify the cause and the extent of the
respiratory failure will be done, starting with a chest x-ray.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Arterial blood gas (ABG), pulmonary function test, BNP
Specialists
Pediatric Pulmonology and Pulmonology
Treatment of Respiratory failure (breathing failure, ARDS)
Treatment is aimed at reversing the cause of the respiratory failure and maximizing the oxygen delivery
to the body. Treatment includes: supplemental oxygen, continuous positive airway pressure (CPAP), and
mechanical ventilation.

o. Alcohol withdrawal syndrome *CRITICAL
Description of Alcohol withdrawal syndrome (mild)
After suddenly stopping alcohol consumption patients can have a wide range of symptoms ranging from
tremors and sweating, to seizures, hallucinations, and death. This disorder is more likely to occur in
patients who have been drinking daily for weeks to months. The symptoms can begin a few hours to a
day after drinking has stopped, and can last for as long as 1-2 weeks.
Symptoms of Alcohol withdrawal syndrome (mild)
Tremors, sweating, high blood pressure, racing heart, fever, confusion, hallucinations.
Tests for Alcohol withdrawal syndrome (mild)
Workup
A history and physical exam will be performed along with other tests which usually include: a complete
blood count, liver function tests, electrolytes, lipase, and a brain CT scan.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and Urinalysis (UA)
Additional tests that may be required
Ethanol level
Specialists
Addiction Medicine, Family Practice, Internal Medicine and Medical Toxicology
Treatment of Alcohol withdrawal syndrome (mild)
The mainstay of therapy is sedation, supporting the vital signs, and preventing self-harm. Treatment
always includes: intravenous fluids and benzodiazepines (lorazepam/Ativan, chlordiazepoxide (Librium),
diazepam/Valium).In some cases, anti-psychotic medications are needed. Thiamine (vitamin B1) and
other vitamins are also given intravenously. Alcohol and Drug Helpline: (800) 821-4357
4357 Al-Anon (888)425-2666

(888)425-2666

p. Phobias (irrational fear)
Description of Phobias (irrational fear)

(800) 821-

A persistent, irrational or exaggerated fear of a particular object, situation, activity, setting or even a
bodily function. Patients usually recognize that the fear is inappropriate to the situation, but cannot
control their emotions or response. Avoidance of the agent or object can affect their social and work
life.
Symptoms of Phobias (irrational fear)
Exposure to the feared object provokes an anxiety reaction, the anxiety and discomfort is out of
proportion to the real threat of the feared object. Other symptoms include: excessive sweating, rapid
heart rate, hyperventilation, depression.
Tests for Phobias (irrational fear)
Workup
A history and physical exam will be performed. No specific tests are needed.
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Phobias (irrational fear)
The goal of treatment is to help the person function effectively. Treatment options include: systematic
desensitization, graded real-life exposure, anti-anxiety medications, and antidepressant medications.
Group therapy can also be helpful.

q. Seizure (epilepsy) *CRITICAL
Description of Seizure (abnormal brain electrical activity)
There are many different types of seizures. The most common is called a generalized seizure. It has also
been called a tonic-clonic or grand mal seizure. Other types of seizures include petit mal seizures, partial
(focal) seizures, febrile seizures and alcohol withdrawal seizures. A person may have a single seizure or
repetitive seizures. People with recurrent seizures or at risk for recurrent seizures have epilepsy. A
seizure results from an abnormal electrical discharge in the brain. Seizures can occur for many reasons,
such as a head injury, an infection, a metabolic problem (for example, low blood sugar), a tumor, or drug
use. Often the exact reason for seizures is not found.
Symptoms of Seizure (abnormal brain electrical activity)
Symptoms vary depending on the type of seizure. There is a period of decreased consciousness that
might only appear as a short staring spell (petit mal seizure). Or the loss of consciousness may be
associated with uncontrollable shaking of the arms and legs, loss of control of urine and stool, followed
by a period of confusion.

Tests for Seizure (abnormal brain electrical activity)
Workup
A history and physical will be performed. The tests performed depend on the circumstances of the
seizure. If this is a new seizure, a diagnostic evaluation will be done including blood tests and usually a
head CT scan or brain MRI. An electroencephalogram (EEG) will often show characteristic brain wave
patterns consistent with a seizure disorder. For people with epilepsy that take anti-seizure medications,
blood tests for drug levels may be measured to help achieve seizure control.
Tests
Blood alcohol level, Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan,
Electroencephalogram (EEG), Lumbar puncture, MRI and Urine tox screen
Specialists
Family Practice, Internal Medicine, Neurology, Pediatric Neurology and Pediatrics
Treatment of Seizure (abnormal brain electrical activity)
Treatment depends on the circumstances of the seizure. If the seizure does not stop on its own antiseizure medications will be emergently given since a prolonged seizure can cause brain damage. A blood
glucose level should be immediately checked and corrected if low. If the patient's anti-seizure
medication level is low, he/she will be given more. If an infection is suspected antibiotics or anti-viral
medications may be administered.

r.

Borderline personality disorder

Description of Borderline personality disorder
A psychiatric disorder characterized by feelings of emptiness, poor self image, unstable relationships and
impulsive behavior. Symptoms usually begin by early adulthood. People with this disorder often have a
mood disorder, eating disorder or substance abuse problem as well. The disorder is diagnosed three
times more often in women than men.
Symptoms of Borderline personality disorder
Symptoms include unstable self-image, impulsiveness, suicidal gestures, fear of abandonment and
difficulty controlling anger. Some individuals experience paranoia and, in some cases, psychotic
symptoms.
Tests for Borderline personality disorder
Workup

A history and physical exam will be performed. Lab tests are performed to rule out other conditions. The
diagnosis is based on a clinical assessment.
Tests
TSH and Urine or serum toxicology screen
Specialists
Family Practice, Internal Medicine and Psychiatry
Treatment of Borderline personality disorder
Treatment may vary depending on the severity of disease. Psychotherapy is an essential component of
the treatment of this disorder. There is no medication specific to borderline personality disorder.
However, medications are frequently added as symptoms emerge. Anti-depressant medications such as
fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa) are frequently added
to treat depressive symptoms. In some cases, your doctor may decide to add a mood stabilizer such as
lithium (Lithobid and other brand names) or topiramate (Topamax). Finally, in cases with psychotic
symptoms, your doctor may add a drug like risperidone (Risperdal) or olanzapine (Zyprexa).

s. Diabetic ketoacidosis (DKA, a complication of poorly controlled diabetes) *CRITICAL
Description of Diabetic ketoacidosis (DKA, a complication of poorly controlled diabetes)
Occurs when there is not enough circulating insulin. This lack of insulin causes elevated glucose levels in
the blood and forces the body to breakdown body fats for energy. This results in a buildup of ketones.
The increased ketones increases the acidity of the blood and when severe can result in coma and death.
This disorder is also called DKA and is most often associated with diabetes type 1. The most common
causes of DKA are not taking the correct amounts of insulin and a secondary stress to the body such as
infections, surgery and trauma.
Symptoms of Diabetic ketoacidosis (DKA, a complication of poorly controlled diabetes)
Fatigue, frequent urination, increased thirst, fruity breath odor, confusion, coma, muscle stiffness or
aching, nausea, vomiting, rapid breathing, shortness of breath.
Tests for Diabetic ketoacidosis (DKA, a complication of poorly controlled diabetes)
Workup
A history and physical exam will be performed. Blood tests, urine tests and X-rays are done to determine
why the glucose is elevated since an infection can cause dramatic increase in glucose. The severity of
diabetic ketoacidosis is evaluated by measuring the acid and base and electrolyte status of the blood.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Serum ketones, arterial blood gas
Specialists
Diabetes, Endocrinology and Metabolism, Internal Medicine and Pediatric Endocrinology
Treatment of Diabetic ketoacidosis (DKA, a complication of poorly controlled diabetes)
Intravenous fluids and insulin are the mainstays of therapy. Correction of metabolic abnormalities such
as low sodium or potassium is necessary as well. Treatment of the cause of the DKA must also be
reversed.

t.

Cerebral vascular accident (stroke) *CRITICAL

Description of Cerebral vascular accident (stroke)
A sudden interruption of blood flow to a portion of the brain causing injury. Some strokes are associated
with bleeding into the damaged area. Most strokes are caused by a blocked artery in the brain from
hardening of the arteries (atherosclerosis) or from a blood clot that travels from another area
(embolus). The symptoms experienced depend on the artery blocked. Survival and the best outcome
depend on seeking medical care immediately. Also known as a stroke.
Symptoms of Cerebral vascular accident (stroke)
Weakness of an arm, leg, side of the face, or any part of the body. Numbness, decreased sensation,
vision changes, slurred speech, inability to speak, inability to understand speech, difficulty reading or
writing, swallowing difficulty, drooling, loss of memory, vertigo (spinning sensation), loss of balance or
coordination, personality changes, mood changes (depression, apathy), drowsiness, lethargy, or loss of
consciousness, uncontrollable eye movements, double vision, nausea, vomiting.
Tests for Cerebral vascular accident (stroke)
Workup
A history and physical exam will be performed. Tests to identify the location and cause of the stroke will
be performed.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
MRI, Ultrasound and X-ray
Additional tests that may be required
Head and Neck CTA, carotid ultrasound, echocardiogram, PT (Protime), PTT (Partial Thromboplastin
Time)
Specialists
Neurology, Pediatric Neurology and Vascular and Interventional Radiology
Treatment of Cerebral vascular accident (stroke)
A stroke is a medical emergency. Therapy depends on the size of the stroke, its location in the brain, the
medications the patient is taking, how long the symptoms have been present and other associated
diseases. Treatment may include: blood pressure medication, anti-platelet medications (aspirin,
clopidogrel/Plavix), anticoagulants (heparin, enoxaparin, warfarin), thrombolysis (tissue plasminogen
activator/t-PA), intravascular thrombolysis, physical therapy, speech therapy, and/or occupational
therapy. Blood pressure and cholesterol medications are usually recommended to prevent a recurrence.

u. Panic disorder
Description of Panic disorder
Anxiety episodes that are experienced as physical symptoms. The physical symptoms are frightening but
they are not dangerous. It can be difficult to recognize that the symptoms are from anxiety, and a
medical evaluation to check for other explanations for the symptoms is appropriate. Up to 2% of the
population have panic disorder (panic attacks). Episodes typically last from 2 to 10 minutes, but can be
as long as 1-2 hours. Some people with panic attacks avoid locations or activities that have seemed to
trigger previous attacks—this habit of avoiding triggers is called "agoraphobia" and this behavior can be
extreme enough to interfere with usual life.
Symptoms of Panic disorder
Chest pain, dizziness or faintness, fear of dying, fear of losing control, feeling of choking, feelings of
detachment, feelings of unreality, nausea or upset stomach, numbness or tingling, palpitations or
pounding heart, shortness of breath, sweating, chills, hot flashes, trembling.
Tests for Panic disorder
Workup
A history and physical exam will be performed. Tests to rule out other causes of the symptoms may be
done. These tests may include an electrocardiogram (ECG) and blood tests.

Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, DDimer, Electrocardiogram (EKG), Lipase, Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Urine and/or serum toxicology screen
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Panic disorder
Antidepressants (such as fluoxetine/Prozac, sertraline/Zoloft, paroxetine/Paxil, fluvoxamine /Luvox,
citalopram/Celexa, escitalopram/Lexapro) are the most effective treatments. These medicines prevent
panic attacks and reduce severity of attacks. During individual episodes anxiety medicines called
benzodiazepines (lorazepam/Ativan, alprazolam/Xanax) may be prescribed. These medications can lead
to addiction if they are used frequently so frequent repeated use is not recommended. Working with a
therapist Is an important part of treatment.

v. Meningioma (brain tumor)
Description of Meningioma (brain tumor)
The meninges are the covering of the brain. Abnormal growth of these cells causes a tumor called a
meningioma. These tumors are generally slow growing and do not spread beyond the brain. Symptoms
depend on the size and location of the tumor. Some tumors are found incidentally when a CT scan is
done for another reason. This disorder is very rare in children but increases with age.
Symptoms of Meningioma (brain tumor)
Most often no symptoms. Possible symptoms include headaches, seizures, weakness in one part of the
body, numbness, confusion, gait problems, change in personality.
Tests for Meningioma (brain tumor)
Workup
A history and physical exam will be performed. A CT scan or MRI identifies the meningioma. Biopsies are
rarely performed since meningiomas have a characteristic appearance on CT or MRI. If the appearance is
atypical, a biopsy can confirm the diagnosis.
Tests

CT Scan and MRI
Additional tests that may be required
Brain biopsy
Specialists
Neurology and Neurosurgery
Treatment of Meningioma (brain tumor)
Therapy depends on the size of the tumor, the location of the tumor, and the symptoms. Small
meningiomas that don't cause symptoms can be observed, with repeat brain imaging in the future.
Larger meningiomas and/or ones that cause symptoms can be treated with surgery or radiation therapy.
See the American Cancer Society: (800) 227-2345
Association: (800) 886-2282

(800) 227-2345 and/or the American Brain Tumor

(800) 886-2282 for more information.

Reviewed by Harvard Medical School

w. Stress
Description of Stress
The physical, mental and emotional reactions resulting from changes and demands in one's life. The
reaction can cause a mild to severe depressed mood or be a motivator. Long term stress can cause sleep
disorders and lack of energy.
Symptoms of Stress
Fatigue, depressed mood, poor sleep pattern, anxiety.
Tests for Stress
Workup
A history and physical exam will be performed. No additional tests are needed.
Specialists
Family Practice, Internal Medicine, Pediatrics and Psychiatry
Treatment of Stress
Behavioral modifications to help deal with the stress. Occasional antidepressants and anti-anxiety
medications are needed on a short term basis.

x. Prescription drug abuse
Description of Prescription drug abuse
A type of drug abuse characterized by the improper use of prescription drugs. The most commonly
abused drugs are sedatives, stimulants and pain medications. It is estimated that up to 15% of high
school seniors have illicitly taken prescription drugs. The most commonly abused drugs are oxycodone
LA (OxyContin), oxycodone (Percocet) and hydrocodone (Vicodin).
Symptoms of Prescription drug abuse
Symptoms depend on the drug being abused. Narcotics and sedatives: confusion, constipation, poor
judgment, bizarre behavior, excessive sleepiness, decreased respiratory effort, fatigue. Stimulants: fast
heart rate, agitation, sweating, bizarre behavior, hallucinations, high blood pressure, insomnia.
Tests for Prescription drug abuse
Workup
A history and physical exam will be performed. Airway and breathing are the first functions that are
checked. Urine drug tests can detect many prescription medicines for several days after they have been
ingested.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), Urinalysis
(UA) and X-ray
Additional tests that may be required
Urine or serum toxicology screen
Specialists
Addiction Medicine, Addiction Psychiatry, Family Practice, Internal Medicine, Pediatric and Adolescent
Psychiatry and Pediatrics
Treatment of Prescription drug abuse
Overdose can be life-threatening. A hospital stay may be needed. Intubation and breathing support by a
ventilator may be needed. Some medicines can be "reversed" with an antidote: Narcan (naloxone) may
be used for narcotic overdose. Flumazenil (Romazicon) may be used for certain cases of sedative
overdose. Participation in a long-term counseling or detox program may be necessary for addiction
treatment. For more information and help call your local poison center at 1-800-222-1222
222-1222.

1-800-

y. Alzheimer's disease (dementia)
Description of Alzheimer's disease (dementia)
The most common form of dementia. Dementia is a brain disorder that affects memory. In its more
severe stages, it prevents patients from performing their daily activities, recognizing their family and
friends, and from understanding speech or speaking. It is a devastating disease that becomes worse with
time and can progress rapidly in some individuals. While treatment is limited the medications used are
most effective when they are started as soon as possible. In addition, early identification enables
families to prepare for the progression of the symptoms and arrange appropriate intervention. The
disorder is more common in older patients although it is not part of normal aging. The likelihood of
acquiring the disorder is also increased with a family history of Alzheimer's, long standing hypertension
and previous head trauma.
Symptoms of Alzheimer's disease (dementia)
The beginning of symptoms is usually gradual and progressively worsen. In some the symptoms become
worse rapidly. Symptoms include memory problems, inability to perform routine tasks, problems
remembering people, change in personality, problems speaking, and behavior changes.
Tests for Alzheimer's disease (dementia)
Workup
A history and physical will be done. Tests will be done to rule out other causes of the symptoms such as
a stroke, infection, brain tumor or metabolic problem.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and MRI
Do I Need This Test?
Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral
assisted feeding. Careful hand-feeding for patients with severe dementia is at least as good as tubefeeding for the outcomes of death, aspiration pneumonia, functional status and patient comfort. Food is
the preferred nutrient. Tube-feeding is associated with agitation, increased use of physical and chemical
restraints and worsening pressure ulcers.
How this was created and why it is important

The American Geriatrics Society and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Family Practice, Geriatric Medicine, Internal Medicine and Neurology
Treatment of Alzheimer's disease (dementia)
Unfortunately there are no medications that have been shown to slow the progression of the disease.
Some medications can improve the daily functioning of the patient. These include: donepezil (Aricept),
rivastigmine (Exelon), galantamine (Reminyl) and memantine (Namenda). Simplifying the patient's daily
routine can be helpful. As the disease progresses it is important to provide support for the patient and
families through caregivers and support groups.

z. Malignant hyperthermia (high temperature) *CRITICAL
Description of Malignant hyperthermia (rare temperature abnormality)
An inherited disorder in which patients can have serious adverse reactions to certain anesthetic drugs.
The disorder is characterized by a sudden and dangerous elevation of the body temperature usually
after receiving anesthetic gas or the paralytic drug succinylcholine. This disorder is autosomal dominant
meaning that only one parent must have the disease to pass the disorder on to their children. The
disease can be very serious causing permanent injury to the kidneys and result in death.
Symptoms of Malignant hyperthermia (rare temperature abnormality)
Rapid rise in temperature to 105 degrees F or higher, muscle rigidity and stiffness, dark brown urine,
muscle ache.
Tests for Malignant hyperthermia (rare temperature abnormality)
Workup
A history and physical exam will be performed. Tests to identify the defective gene can be performed. A
family history of similar problems may be discovered. Other tests to determine damage done by the
high fever will be done.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Urinalysis (UA) and X-ray
Additional tests that may be required
Genetic testing to look for defects in the RYR1 gene, Muscle biopsy, Myoglobin in the urine
Specialists
Anesthesiology and Critical Care Medicine
Treatment of Malignant hyperthermia (rare temperature abnormality)
Treatment includes: a cooling blanket and intravenous fluids to help reduce fever. Dantrolene is a
muscle relaxant and has been shown to decrease the mortality of malignant hyperthermia. For
additional information contact the Malignant Hyperthermia Association of the United States at
http://www.mhaus.org or call (800) 644-9737

(800) 644-9737 (for emergencies only).

aa. Narcotic (morphine, heroin) abuse
Description of Narcotic (morphine, heroin) abuse
Narcotic abuse can involve illegal opiates such as heroin or from the abuse of prescription medications
such as opiates (pain medication: hydrocodone, oxycodone, morphine). Overuse of prescription pain
medications can often be referred to "prescription medication abuse". Taking narcotics for an extended
period of time may require increased doses to alleviate pain. Abruptly stopping the medication will
cause withdrawal symptoms-this is narcotic dependence. Addiction is elevated narcotic abuse that
becomes compulsive and self-destructive. Complications of intravenous narcotic abuse include
infections, such as HIV, hepatitis and organ failure. Abuse of any narcotic can lead to loss of job and
alienation from loved ones.
Symptoms of Narcotic (morphine, heroin) abuse
Needing increasing doses of narcotics, taking narcotics for other reasons besides pain, experiencing
social and work problems associated with the drug, experiencing withdrawal when not taking narcotics.
Tests for Narcotic (morphine, heroin) abuse
Workup
A history and physical exam will be performed. Tests to determine damage done by the narcotic abuse
may be performed.
Tests

BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), Urinalysis
(UA) and X-ray
Additional tests that may be required
Urine or serum toxicology screen
Specialists
Addiction Medicine, Addiction Psychiatry, Family Practice, Internal Medicine, Pediatric and Adolescent
Psychiatry, Pediatrics and Psychiatry
Treatment of Narcotic (morphine, heroin) abuse
Clonidine and anti-nausea medications can help relieve withdrawal symptoms as the narcotic dose is
reduced. A narcotic antagonist naltrexone may be added. Switching the patient to methadone, then
starting a program with methadone maintenance is often recommended. For more information and help
call your local poison center at 1-800-222-1222

1-800-222-1222.

bb. Benzodiazepine (Valium) overdose *CRITICAL
Description of Benzodiazepine (Valium) overdose
Benzodiazepines (Valium, Xanax, Ativan) are tranquilizers and are commonly prescribed for anxiety,
panic attacks, and as muscle relaxants. An overdose can cause coma, severe respiratory depression and
death. The symptoms of intoxication are accentuated by the co-ingestion of narcotic pain medications
and/or alcohol.
Symptoms of Benzodiazepine (Valium) overdose
Confusion, coma, incoordination, sleepiness, slurred speech, decreased respiratory effort.
Tests for Benzodiazepine (Valium) overdose
Workup
A history and physical exam will be performed. Lab and radiology tests will be done to rule out other
causes of the symptoms.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan,
Electrocardiogram (EKG), Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required

Urine and serum toxicology screen
Specialists
Medical Toxicology
Treatment of Benzodiazepine (Valium) overdose
The respiratory and circulatory symptoms are aggressively treated. Specific therapy may include
mechanical ventilation and intravenous fluids. A reversal agent, flumazenil (Romazicon), is available but
must be used with caution since it can induce seizures in patients taking benzodiazepines chronically.
For more information and help call your local poison center at 1-800-222-1222

1-800-222-1222.

cc. Anemia (low red blood cell count)
Description of Anemia (low red blood cell count)
A condition that develops when the blood lacks enough red blood cells. These cells are the main
transporters of oxygen to organs. There are three main causes of anemia: blood loss, destruction of
blood cells in the body, or abnormal production of red blood cells. Disorders causing anemia include iron
deficiency, B12 deficiency, folate deficiency, sickle cell anemia, cancer, aplastic anemia and
myelodysplastic syndrome.
Symptoms of Anemia (low red blood cell count)
Weakness, fatigue, pale skin, shortness of breath, lightheadedness, fainting.
Tests for Anemia (low red blood cell count)
Workup
A history and physical exam will be performed, along with additional blood tests. A bone marrow biopsy
may need to be performed to determine cause.
Tests
Complete blood count (CBC)
Additional tests that may be required
Bone marrow biopsy. Iron, B12 and other blood tests
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics

Treatment of Anemia (low red blood cell count)
Therapy is aimed at reversing cause of the bleeding or deficiency, and treating the low red blood cell
count. Treatment may include: iron, B12, folic acid and/or blood transfusions. For additional information
contact the National Heart, Lung and Blood Institute Health Information Center at:
http://www.nhlbi.nih.gov or call (301)592-8573

(301)592-8573.

dd. Cocaine abuse *CRITICAL
Description of Cocaine abuse
Cocaine is a commonly abused drug because of its euphoric effects and addictive properties. The drug
stimulates the brain and heart and if too much is used serious side effects can occur such as an irregular
heart rate (arrhythmia), stroke, seizure and death. Drinking alcohol while taking cocaine can increase the
chance of death. There are multiple forms of cocaine and it can be injected into a vein, inhaled through
the nose or smoked.
Symptoms of Cocaine abuse
Agitation, confusion, chest pain, shortness of breath, fainting, weakness, slurred speech, coma, low
blood pressure or high blood pressure, fever, seizure.
Tests for Cocaine abuse
Workup
A history and physical exam will be performed. Additional tests include: blood tests, EKG, and imaging
studies to rule out any cardiovascular or central nervous system damage. Work-up is dependent on the
presenting symptoms.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Troponin
Additional tests that may be required
Urine tox screen
Specialists
Addiction Medicine, Addiction Psychiatry, Family Practice, Internal Medicine, Pediatric and Adolescent
Psychiatry, Pediatrics and Psychiatry
Treatment of Cocaine abuse

Treatment is dependent on the presenting symptoms. The primary goals of treatment are to protect the
patient from the stimulant effects of cocaine and to avoid treatment-related sedation. If the patient has
a fever, active cooling measures are needed to prevent cardiovascular collapse. Counseling and other
treatments may be helpful to break the addiction to cocaine. For more information and help call your
local poison center at 1-800-222-1222

1-800-222-1222.

ee. Epidural hematoma (bleeding outside of the brain or spinal cord) *CRITICAL
Description of Epidural hematoma (bleeding around brain or spine)
A blood clot which forms between the skull and the outermost linings of the brain called the dura. The
bleeding often comes from an injured artery after a skull fracture or other head trauma. The bleeding
can occur rapidly leading to brain injury and death. Occasionally patients experience a lucid period
where their initial symptoms improve before they become rapidly ill and unconscious.
Symptoms of Epidural hematoma (bleeding around brain or spine)
Headache, vomiting, confusion, seizure, coma, weakness, death. Occasionally a lucid period occurs
where the patient's symptoms improve before rapid deterioration occurs.
Tests for Epidural hematoma (bleeding around brain or spine)
Workup
A history and physical exam will be performed. A head CT or MRI scan demonstrates the epidural blood.
Blood tests to evaluate blood clotting may be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
Protime, partial thromboplastin time
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Epidural hematoma (bleeding around brain or spine)
If significant symptoms are present, urgent drainage of the blood may be necessary. Medications to
prevent seizures may be administered and any blood clotting abnormalities are reversed. If the brain
swelling is severe medications to reduce the swelling (mannitol) may be administered.

ff. Meningitis (brain spin infection) *CRITICAL
Description of Meningitis (spinal fluid infection)
An infection or inflammation of the meninges. The meninges cover the brain and spinal cord. A fluid
called cerebrospinal fluid (CSF) is contained within the meninges in an area named the subarachnoid
space. Infections of the CSF are the most common cause of meningitis and these infections can be
caused by viruses, bacteria, or fungi. Viruses are the most common cause of this disorder and in general
are not as serious as the other causes. If left untreated meningitis can lead to loss of hearing, brain
damage and death. This disease can arise from an infection of the blood, or from an adjacent infection
such as an infection of the ear, sinuses or nose.
Symptoms of Meningitis (spinal fluid infection)
Fever and chills, severe headache that worsens when exposed to bright lights (photophobia), confusion,
nausea and vomiting, seizures, rash, and stiff neck (meningismus). In babies the symptoms may be fever,
irritability, poor feeding, increase in sleeping, rash, seizures, bulging fontanel (soft spot on top of the
head), and breathing problems.
Tests for Meningitis (spinal fluid infection)
Workup
A history and physical exam will be performed. The doctor will do a lumbar puncture (spinal tap) to
obtain a CSF sample for examination under the microscope. The presence of white blood cells confirms
the diagnosis. Other tests, such as cultures for infectious causes, will be done on the CSF sample as
needed. A CT scan of the brain may also be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Urinalysis (UA)
Additional tests that may be required
Lumbar puncture, CSF (cerebrospinal fluid) culture, Antibody testing of the CSF (cerebrospinal fluid)
Specialists
Infectious Disease Medicine, Neurology, Pediatric Infectious Disease Medicine and Pediatric Neurology
Treatment of Meningitis (spinal fluid infection)
To prevent permanent brain damage treatment with intravenous antibiotics should be started as soon
as possible for meningitis caused by bacteria. An antiviral medication (acyclovir) will also be given if
herpes virus infection is suspected. In some cases, intravenous corticosteroids are given prior to
antibiotics.

gg. Hyponatremia (low blood sodium) *CRITICAL
BDescription of Hyponatremia (low blood sodium)
Low sodium levels in the blood. Sodium is important for maintaining blood pressure, and for the normal
functioning of nerves and muscles. A sudden reduction in the blood sodium level or a severely low blood
sodium level can cause lethal brain swelling. Causes of low sodium are: vomiting and diarrhea, burns,
congestive heart failure, drugs that increase urine output (diuretics), kidney disease, cirrhosis, and
syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Symptoms of Hyponatremia (low blood sodium)
Confusion, lethargy, seizure, muscle weakness, muscle spasms, vomiting, headache.
Tests for Hyponatremia (low blood sodium)
Workup
A history and physical exam will be performed. Tests to determine and monitor blood sodium levels and
to identify the cause of the disorder will be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG),
Urinalysis (UA) and X-ray
Additional tests that may be required
Serum osmolality, urine osmolality, urine sodium
Specialists
Diabetes, Endocrinology and Metabolism, Family Practice, Internal Medicine, Nephrology, Pediatric
Nephrology and Pediatrics
Treatment of Hyponatremia (low blood sodium)
The goal of therapy is to correct the sodium level and reverse the cause of the low sodium. Treatment
includes: intravenous fluids with sodium, restriction of fluids with low sodium levels, and/or changing
the patient's medications.

hh. Somatization Disorder
Description of Somatization Disorder

Somatization disorder is the development of and preoccupation with physical symptoms that cannot be
fully explained based on medical testing. The symptoms develop over years and can lead to impairment
in normal daily functioning. The symptoms are varied and involve many different areas of the body. The
person with somatization disorder has real symptoms and is simply not "faking it." It is thought that the
symptoms may be the result of abnormal brain function or emotional regulation. Individuals with the
disorder often have depression and anxiety as well.
Symptoms of Somatization Disorder
Symptoms are varied and can involve multiple areas of the body. Symptoms may include pain in various
body parts (example: chest, abdomen, musculoskeletal pain) vomiting, diarrhea, sexual dysfunction,
painful periods, numbness, weakness or seizures.
Tests for Somatization Disorder
Workup
A history and physical will be performed. There are no specific tests to diagnose somatization disorder.
Blood and imaging tests may be performed to exclude other potential diagnoses based on presenting
symptoms such as multiple sclerosis, fibromyalgia, chronic fatigue syndrome and irritable bowel
syndrome.
Tests
Antinuclear antibody (ANA), Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT
Scan, ESR, MRI, Troponin, Ultrasound and Urinalysis (UA)
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Psychiatry
Treatment of Somatization Disorder
Treatment may involve referral to a psychiatric professional after all treatable medical causes of the
symptoms have been excluded. Psychotherapy and cognitive behavioral therapy have been shown to
improve symptoms.

ii. Marijuana abuse
Description of Marijuana abuse
The most common illegal drug used in the US. The drug is primarily smoked but can be ingested as well.
Its intoxicating effects include relaxation, sleepiness, and mild euphoria. Marijuana can cause
undesirable side effects, which increase with higher doses.

Symptoms of Marijuana abuse
Relaxation, sleepiness, mild euphoria, dry mouth, red eyes, impaired perception and motor skills,
decreased short-term memory, paranoia, mood swings, and hallucinations.
Tests for Marijuana abuse
Workup
A history and physical exam will be performed.
Additional tests that may be required
Urine or serum toxicology screen
Specialists
Addiction Medicine, Addiction Psychiatry, Family Practice, Internal Medicine, Pediatric and Adolescent
Psychiatry, Pediatrics and Psychiatry
Treatment of Marijuana abuse
Treatment includes supportive therapy. Sedation may be necessary. For more information and help call
your local poison center at

1-800-222-1222.

jj. Multiple sclerosis (MS)
Description of Multiple sclerosis (MS)
An autoimmune disorder of the central nervous system (brain and spinal cord). Nerve cells normally are
surrounded by an insulating sheath made of a fatty substance called myelin that helps to transmit nerve
impulses. In MS, this myelin sheath is inflamed or damaged. This disrupts or slows nerve impulses and
causes nerves to malfunction. Scarring (sclerosis) occurs in the white matter of the brain and spinal cord.
. These areas of myelin damage and scarring are called MS plaques. The disease periodically flares up
with episodes of increased symptoms. The disease can be mild, and non-progressive disease, can slowly
get worse, or get worse rapidly. It is slightly more common in women between the ages of 20 to 40.
Symptoms of Multiple sclerosis (MS)
Symptoms vary widely. They may come and go or remain permanently. Symptoms include impaired
vision, numbness, weakness, decreased coordination, poor balance, halting speech, muscle spasms
(especially in the legs), muscle spasticity, impaired bladder function.
Tests for Multiple sclerosis (MS)

Workup
A history and physical exam will be performed. Diagnosis is made by ruling out other conditions. Tests
that are used to confirm multiple sclerosis include: Head MRI scan, spine MRI, lumbar puncture (spinal
tap), cerebrospinal fluid tests including CSF (cerebrospinal fluid) oligoclonal banding.
Tests
CT Scan and MRI
Additional tests that may be required
Lumbar puncture (spinal tap), cerebrospinal fluid tests including CSF oligoclonal banding
Specialists
Neurology, Pediatric Neurology and Physical Medicine and Rehabilitation (physiatry)
Treatment of Multiple sclerosis (MS)
There is no definitive cure, but new treatments can help slow the progression of the disease.
Medications that alter the immune response include: immune modulators such as interferon (Avonex,
Betaseron, or Rebif), monoclonal antibodies (Tysabri), and glatiramer acetate (Copaxone). Short courses
of a corticosteroid (prednisone) can decrease the severity of attacks. Medicines to reduce muscle
spasms include baclofen (Lioresal), tizanidine (Zanaflex), or a benzodiazepine such as diazepam (Valium).
For more information contact: Multiple Sclerosis Association of America:
Sclerosis Foundation

(800)532-7667 Multiple

(888)673-6287

kk. Drug overuse *CRITICAL
Description of Drug overuse
Drug overuse is the misuse of prescription medications. This disorder can happen intentionally or
accidentally.
Symptoms of Drug overuse
Symptoms depend on the drug being overused..
Tests for Drug overuse
Workup

A history and physical exam will be performed. Urine and/or serum toxicology testing may also be
performed.
Tests
Urinalysis (UA)
Additional tests that may be required
Urine or serum toxicology screen
Specialists
Addiction Medicine, Addiction Psychiatry, Family Practice, Internal Medicine, Pediatric and Adolescent
Psychiatry, Pediatrics and Psychiatry
Treatment of Drug overuse
Treatment requires removing the drug of use and, in some cases treating the effects of the excessive
medication exposure. Withdrawal symptoms may also require treatment. Psychological therapy and
counseling are necessary to prevent any recurrence of use. Consider calling the National Poison Control
Phone Number for further information or assistance:
3784

1-800-222-1222. Drug Help:

(800) 488-

ll. Subdural hematoma (bleeding on brain) *CRITICAL
Description of Subdural hematoma (bleeding on brain)
The brain is surrounded by three linings, and the outermost is the dura mater. Head trauma can result in
bleeding in the space between the dura and the brain. The bleeding normally occurs from injured veins
in the dura. As the bleeding continues it causes pressure on the brain resulting in the symptoms and
damage to the brain. Bleeding can be recognized immediately, an acute subdural, or many weeks after
the initial injury, a chronic subdural. Symptoms can vary from complete paralysis and coma to mild
alterations in behavior. This disorder is most commonly found between the ages of 50-70 and any
disorder that prevents normal blood clotting increases the risk of this disorder.
Symptoms of Subdural hematoma (bleeding on brain)
Recent head injury, headache, loss of consciousness after head injury, weakness, numbness, can't speak,
slurred speech, nausea and vomiting, lethargy, seizures, confusion, change in behavior.
Tests for Subdural hematoma (bleeding on brain)
Workup

A history and physical exam will be performed. Tests done to identify the bleeding and any factors
contributing to the bleeding will be done. A head CT is the most common imaging test.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and MRI
Additional tests that may be required
PT (Protime), PTT (Partial Thromboplastin Time)
Specialists
Neurosurgery
Treatment of Subdural hematoma (bleeding on brain)
A subdural hematoma might require emergency treatment. Therapy depends on the size of the
bleeding, the location of the injury, the length of time it has been present and the patient's other
medical problems. Small subdural hematomas are allowed to heal on their own. Treatment may include:
surgery, diuretics to reduce swelling, reversal of any bleeding abnormalities, and/or antiseizure
medications.

mm.

Hydrocephalus (fluid on the brain) *CRITICAL

Description of Hydrocephalus (brain fluid build-up)
Hydrocephalus is an abnormal build-up of cerebrospinal fluid in the ventricles, most often associated
with high pressure inside and around the brain. The ventricles are cavities inside the brain. CSF circulates
from the ventricles, out through small holes into the area around the brain and spinal cord. New CSF is
constantly being made inside the ventricles and reabsorbed through the surfaces around the brain. The
CSF communicates between the ventricles through communication channels. Hydrocephalus can occur
through blockage of these channels (Obstructive Hydrocephalus) or by decreased reabsorption of the
CSF (Normal Pressure Hydrocephalus).
Symptoms of Hydrocephalus (brain fluid build-up)
The symptoms experienced depend on the cause of the hydrocephalus and how quickly it occurs. In
infants one may see a bulging of the fontanelle (the soft part of the skull on top of the head), an
abnormally large head, poor development, irritability, poor feeding, vomiting, seizures, and muscle
spasms. In older children and adults with obstructive hydrocephalus: headaches, blurred and/or double
vision, nausea, vomiting, difficulty concentrating, change in behavior. In older people with normal
pressure hydrocephalus: memory loss and confusion, problems walking, incoordination, urinary
incontinence.

Tests for Hydrocephalus (brain fluid build-up)
Workup
A history and physical exam will be performed. A head CT scan and brain MRI are the best imaging study
to identify hydrocephalus. The ventricles are usually enlarged. If the patient is an infant and the head
size appears too large, a brain ultrasound may be done as a screening tool.
Tests
CT Scan and MRI
Specialists
Neurology and Pediatric Neurosurgery
Treatment of Hydrocephalus (brain fluid build-up)
The goals of therapy are to diagnose and treat the reason for the hydrocephalus and reduce the
pressure in and around the brain. The most common procedure is a shunt that is surgically placed to
drain fluid away from the ventricles.

nn. Environmental exposure (Cold hypothermia) *CRITICAL
Description of Hypothermia (extreme cold exposure)
Exposure to cold can cause a dangerously low body temperature (hypothermia). The very old, very
young, those with chronic illnesses, and the intoxicated are most susceptible. Becoming wet causes a
particularly rapid drop in body temperature. Death can result from cardiovascular collapse.
Symptoms of Hypothermia (extreme cold exposure)
Shivering, confusion, slow heart rate, low blood pressure, weakness.
Tests for Hypothermia (extreme cold exposure)
Workup
A history and physical exam will be performed. Blood tests will be done to determine damage from the
hypothermia. An EKG may be performed to look for cardiac abnormalities resulting from hypothermia.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG),
Urinalysis (UA) and X-ray
Specialists

Emergency Medicine
Treatment of Hypothermia (extreme cold exposure)
Rewarming and removing the wet clothes are essential. The method of warming depends on how low
the temperature is and what symptoms are present. Treatment may include: passive warming with
external warming devices, or active warming by the injection of pre-warmed fluids, providing warmed
oxygen or by warming the blood directly (using a procedure called "arteriovenous heated
countercurrent exchange."

oo. Lewy body dementia *CRITICAL
Description of Lewy body dementia (common type of dementia)
A disorder that causes dementia. Dementia is a loss of normal brain function that affects daily activities.
Lewy Body dementia is the second most common cause of dementia second only to Alzheimer's disease.
This disorder has cognitive deficiencies similar to those in Alzheimer's and movement problems similar
to those Parkinson's disease. This can make confirming the diagnosis difficult early in the patient's
course. Some patients develop the memory problems first while others suffer the movement symptoms
first. Most patients also demonstrate hallucinations, difficulties sleeping and troubles with behavior. The
disease name originates from the characteristic microscopic Lewy bodies found in the brain at autopsy.
Symptoms of Lewy body dementia (common type of dementia)
Seeing colors, shapes, people and animals that do not exist. Memory problems, confusion, short
attention span, shuffling gait, rigid muscles, tremors, delusions, problems sleeping, falling asleep during
the day, and disorganized speech.
Tests for Lewy body dementia (common type of dementia)
Workup
A history and physical exam will be done. The diagnosis is made by evaluating the patient's symptoms.
The Lewy bodies found at autopsy cannot be seen with a CT scan or MRI although these tests are
frequently performed to rule out other causes of the symptoms.
Tests
CT Scan and MRI
Specialists
Geriatric Medicine, Internal Medicine and Neurology
Treatment of Lewy body dementia (common type of dementia)

There is no cure for this disease. Medicines called cholinesterase inhibitors and a medicine called
memantine may provide some improvement in memory and movement problems, and even reduce the
confusion and hallucinations. Changing a patient's environment to reduce the frequency and effects of
the symptoms is important. Environmental changes include reducing clutter and distractions, and
simplifying tasks of the patient. One third to one half of patients treated with antipsychotic medications
will have serious and sometimes irreversible side effects.

pp. Hypothyroidism (low thyroid hormone)
Description of Hypothyroidism (low thyroid hormone)
A condition of low thyroid hormone. The thyroid gland is located in the front of the neck. Thyroid
hormone helps control metabolism. Low thyroid hormone is caused by abnormalities of the thyroid
gland, pituitary gland, or hypothalamus. For people who take thyroid hormone medication,
hypothyroidism may be due to an insufficient dose. Low thyroid hormone can affect all bodily functions
and if severe may cause coma (myxedema) and death.
Symptoms of Hypothyroidism (low thyroid hormone)
Cold intolerance, fatigue, abnormal menstrual cycles, unexplained weight gain, depression, thin and
brittle hair, hoarseness, thickening skin, leg swelling, confusion, lethargy, coma.
Tests for Hypothyroidism (low thyroid hormone)
Workup
A history and physical exam will be performed. Tests will be performed to determine the cause of the
low thyroid hormone.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG)
and Urinalysis (UA)
Additional tests that may be required
Thyroid stimulating hormone (TSH), T4, T3
Specialists
Diabetes, Endocrinology and Metabolism, Family Practice, Internal Medicine, Pediatric Endocrinology
and Pediatrics
Treatment of Hypothyroidism (low thyroid hormone)

The goal of therapy is to reverse the cause of hypothyroidism and to return the thyroid hormone levels
to normal. Oral thyroid hormone is usually effective but severe hypothyroidism may require intravenous
treatment. Myxedema coma, the most dangerous form of the disease, requires immediate treatment,
including intravenous thyroid replacement, steroids, and other supportive measures. For more
information contact the National Endocrine and Metabolic Diseases Information Service at
http://www.endocrine.niddk.nih.gov or call

(888)828-0904.

qq. Porphyria
Description of Porphyria (rare disorder of skin, nervous system)
A group of diseases caused by an abnormal accumulation of porphyrins in the body. The disorder affects
the nervous system and skin and is inherited. The nervous system type is called acute porphyria and the
skin type is cutaneous porphyria. There is no cure for the disease but the symptoms can be controlled.
Porphyrins come from the metabolism of heme. Heme is present in many places in the body but most of
it comes from the hemoglobin found in red blood cells. Symptoms can be triggered by exposure to
certain medications, excessive dieting, sun exposure, smoking, infections, drinking alcohol or hormones.
If left untreated the disease can be very serious causing breathing problems, kidney failure, skin damage
and liver problems.
Symptoms of Porphyria (rare disorder of skin, nervous system)
Acute porphyria symptoms include nausea, vomiting, diarrhea, dehydration, muscle pain, abdominal
pain, anxiety, problems sleeping, excessive sweating, hallucinations, seizures, confusion, paranoia, red
urine, and personality changes. Cutaneous porphyria causes symptoms when exposed to sunlight and
these include blisters, itching, skin swelling, skin redness and red urine.
Tests for Porphyria (rare disorder of skin, nervous system)
Workup
A history and physical exam will be done. The urine may be tested for porphobilinogen (PBG), urine
porphyrins, and delta-Aminolevulinic Acid (ALA). Blood and stool may also be tested for porphyrins to
help establish the diagnosis.
Additional tests that may be required
Porphobilinogen (PBG), urine porphyrins, delta-Aminolevulinic Acid (ALA)
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics

Treatment of Porphyria (rare disorder of skin, nervous system)
There is no cure for porphyria. The treatment of acute porphyria is aimed at removing anything
triggering the symptoms such as stopping certain medications, stopping alcohol use and treating
infections. The other goal of therapy is to reduce the symptoms and these treatments include: pain
medications, intravenous fluids, intravenous sugars, and hematin. Severe cases causing liver failure
(cirrhosis) may require a liver transplant. Cutaneous porphyria treatment includes: avoiding sunlight,
drawing blood to reduce the amount of iron in the body, malaria medications, and beta-carotene.

rr. Blood loss *CRITICAL
Description of Blood loss
Blood loss leads to anemia. The most common cause of blood loss is bleeding into the intestinal tract.
Symptoms of Blood loss
Weakness, fatigue, pallor, fainting, shortness of breath.
Tests for Blood loss
Workup
A history and physical exam will be performed. A complete blood count will be done to determine the
extent of bleeding. Other tests are performed to identify the site of bleeding.
Tests
Complete blood count (CBC)
Additional tests that may be required
Endoscopy, Colonoscopy, Tagged red blood cell study
Specialists
General Surgery
Treatment of Blood loss
Treatment includes finding and stopping ongoing blood loss. Transfusion of blood is sometimes needed
if the blood loss is severe.

ss. Intracranial hemorrhage (bleeding in brain) *CRITICAL

Description of Intracranial hemorrhage (bleeding in brain)
Bleeding into the brain. It often occurs in people with uncontrolled high blood pressure. Other causes
include trauma, aneurysms, blood clotting disorders, or brain tumors (either primary or from
metastasis).
Symptoms of Intracranial hemorrhage (bleeding in brain)
Headache, nausea, vomiting, change in alertness (level of consciousness), vision changes, sensation
changes, difficulty speaking, slurred speech, difficulty swallowing, difficulty writing or reading,
movement changes, incoordination, loss of balance, seizure.
Tests for Intracranial hemorrhage (bleeding in brain)
Workup
A history and physical exam will be performed. Imaging studies, such as CT scan or MRI of the brain, are
typically performed to establish the diagnosis.
Tests
CT Scan
Additional tests that may be required
PT (prothrombin time), PTT (partial thromboplastin time), cerebral angiogram, Head CTA
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Intracranial hemorrhage (bleeding in brain)
Treatment depends on the location, cause, and extent of the hemorrhage. Surgery may be necessary
and is more likely if the bleeding is in the cerebellum. The cause of the bleeding must be reversed, if
possible, to prevent recurrence and may include: surgery to repair or remove structures causing the
bleed (such as a cerebral aneurysm or arteriovenous malformation) and/or medicines to control blood
pressure and bleeding problems. A diuretic (mannitol) may be administered to reduce brain swelling,
and anticonvulsants are sometimes given to prevent seizures.

tt. Hypoxia (lack of oxygen) *CRITICAL
Description of Hypoxia (lack of oxygen)
A condition of low oxygen concentration in the blood. Adequate oxygen levels require a proper
functioning of the airways, lungs and heart. Any defect in this chain can cause low oxygen. Low oxygen

may be caused by: infection (sepsis), lung infection (such as pneumonia), blood clots in lung, heart
failure, airway obstruction, the effects of drugs or medications, and head injury.
Symptoms of Hypoxia (lack of oxygen)
Shortness of breath, confusion, cyanosis (blue discoloration), anxiety, fatigue.
Tests for Hypoxia (lack of oxygen)
Workup
A history and physical exam will be performed. Tests will be done to determine the cause of the low
oxygen level and its severity. For example, a chest x-ray, oxygen saturation level and/or an arterial blood
gas may be measured.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Blood cultures, urine culture
Specialists
Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Hypoxia (lack of oxygen)
The most immediate priorities are to reverse the cause of hypoxia and to administer enough oxygen to
increase blood levels out of a dangerous range. Oxygen may be provided with a nasal cannula, face
mask, or a ventilator if severe.

uu. Carbon monoxide poisoning *CRITICAL
Description of Carbon monoxide poisoning (odorless, poisonous gas)
Carbon monoxide poisoning can be a life threatening problem. The disorder occurs when one breathes
too much carbon monoxide. Carbon monoxide is a gas produced by burning any type of fuel-gas, oil,
kerosene, wood, or charcoal. Faulty house heaters, holes in mufflers, and building fires are common
causes of exposure. This poisoning is especially dangerous for pregnant women since the unborn baby is
very susceptible to the damaging effects of carbon monoxide. Carbon monoxide prevents a patient's
cells from using oxygen normally causing significant cardiac and nervous system problems.
Symptoms of Carbon monoxide poisoning (odorless, poisonous gas)

Nausea, vomiting, headaches, flu-like symptoms, chest pain, confusion, seizures, coma, death.
Tests for Carbon monoxide poisoning (odorless, poisonous gas)
Workup
A history and physical exam will be performed. A carboxyhemoglobin level will be taken to determine
level of toxicity. Other blood tests might be done to determine extent of damage.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Troponin
Additional tests that may be required
Carboxyhemoglobin level
Specialists
Medical Toxicology
Treatment of Carbon monoxide poisoning (odorless, poisonous gas)
Treatment should not be delayed. High flow oxygen, and medications to treat symptoms. Hyperbaric
oxygen treatment may be indicated for people with significant exposures. A medical toxicologist should
be consulted to determine the need for hyperbaric oxygen treatment. For more information and help
call your local poison center at

1-800-222-1222.

vv. Dehydration *CRITICAL
Description of Dehydration
Occurs when the body is deprived of its normal supply of water or excessive water is lost. There is a
delicate balance in the body between water and dissolved substances. This condition is most lifethreatening in newborns, infants and persons over 60. Dehydration occurs when the body loses more
fluids then it takes in. The loss of fluid can come from vomiting, diarrhea, sweating, or urination. Severe
dehydration can lead to renal failure, and cardiovascular collapse.
Symptoms of Dehydration
Headache, dry or sticky mouth, low or no urine output, dark yellow urine, not producing tears, sunken
eyes, confusion, low blood pressure, dizziness, lethargy, coma.
Tests for Dehydration

Workup
A history and physical exam will be performed. Blood tests will be done to measure kidney function and
the severity of the dehydration. Tests to determine the cause of the dehydration will also be performed
and may include: blood cultures, urine culture, toxicology screen, X-rays, or CT scans.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Urinalysis (UA) and X-ray
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Dehydration
Depends on the cause and severity of the dehydration. If not severe, oral rehydration will be performed.
More serious cases will require intravenous fluids. The cause of the dehydration will be addressed as
well.

3. BEHAVIORAL PROBLEM

a. Adjustment disorder (poor adjustment to life stressor)
Description of Adjustment disorder (poor adjustment to life stressor)
A response to stress that results in significant emotional or behavioral symptoms and impairment of
function in daily life. The disorder typically causes symptoms of depression, anxiety or both. In severe
cases patients may have suicidal thoughts. The symptoms begin within 3 months of a stressful life event.
Symptoms of Adjustment disorder (poor adjustment to life stressor)
Depression, anxiety, desperation, trouble sleeping, nervousness, and agitation.
Tests for Adjustment disorder (poor adjustment to life stressor)
Workup
A history and physical exam will be performed.

Specialists
Family Practice, Geriatric Psychiatry, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics
and Psychiatry
Treatment of Adjustment disorder (poor adjustment to life stressor)
Treatment options include talk therapy and/or medications. Medications used include antidepressants
and anti-anxiety medications.

ï‚·

b. Alzheimer's disease (dementia)
DEMENCIJA JE VEC OPISANA U RANIJEM TEKSTU, SADA SE PONAVLJA
c. Anorexia (eating disorder)

Description of Anorexia (eating disorder)
Patients have a distorted self-perception of their body, think they are overweight, and have an irrational
fear of becoming obese. This disorder can be very serious and patients can become dangerously
underweight and malnourished. Anorexia is also called anorexia nervosa and is most often seen in
women in their teenage and early adult years.

Symptoms of Anorexia (eating disorder)
Unreasonable fear of getting fat, greater than 15% loss of weight, depression, excessive exercise, loss of
menstrual cycle, malnutrition.
Tests for Anorexia (eating disorder)
Workup
A history and physical exam will be performed. Lab tests will be done to rule out consequences of
malnutrition.
Tests
BHCG (pregnancy test), Complete blood count (CBC), Comprehensive metabolic panel (CMP) and
Urinalysis (UA)
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Anorexia (eating disorder)

Therapy is aimed at reversing the immediate damage and psychological evaluation. Treatment includes:
intravenous feeding, intravenous fluids, psychological counseling, and antidepressants.

d. Anxiety disorder (generalized anxiety disorder,GAD)
Description of Anxiety disorder (generalized anxiety disorder, GAD)
A psychological disorder in which anxiety is so severe they prevent a person from performing their
normal daily activities. Anxiety is a sense of fear or apprehension accompanied by some or all of the
following signs: muscle tension, restlessness, palpitations, rapid breathing, jitteriness, suspicion,
confusion, decreased concentration, or fear of losing control. This reaction may occur as result of a real
or perceived danger or stressor. It might also occur without any clear reason. An episode may be brief or
long lasting. The symptoms may go away and return repeatedly. The exact cause of this disorder is not
known but it is felt to be a combination of genetic and environmental factors.
Reviewed by Harvard Medical School
Symptoms of Anxiety disorder (generalized anxiety disorder, GAD)
Fear, apprehension, muscle tension, restlessness, palpitations, rapid breathing, jitteriness, hyper
vigilance, confusion, decreased concentration, fear of losing control.
Tests for Anxiety disorder (generalized anxiety disorder, GAD)
Workup
A history and physical exam will be performed both to make the diagnosis and to help find the triggers
and potentially an underlying cause.
Additional tests that may be required
if necessary, BHCG, Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and
Urinalysis (UA), blood alcohol, drug screen test
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Anxiety disorder (generalized anxiety disorder, GAD)
Therapy depends on the severity of symptoms. Treatment may include: benzodiazepines
(diazepam/Valium, lorazepam/Ativan), antidepressant medications, psychological counseling, and/or
psychological treatment such as cognitive-behavioral therapy.

e. Asperger's syndrome (autism spectrum disorder)
Description of Asperger's syndrome (autism spectrum disorder)
Asperger's syndrome is a developmental disorder that falls into the broader category of autism
spectrum disorders. Some consider it a high functioning form of autism. Persons with this syndrome
display social awkwardness, have limited repetitive patterns of behavior, possess a tendency to focus on
one subject, and often are clumsy. Motor milestones may be delayed. There is no cure but early
intervention can help the child assimilate and better function in society.
Symptoms of Asperger's syndrome (autism spectrum disorder)
Abnormal nonverbal communication: avoidance of eye contact, abnormal facial expressions, unnatural
body postures or gestures. Failure to develop relationships, inability to empathize with other's feelings,
inflexibility about specific routines, unusual repetitive behaviors (repetitive finger flapping, twisting, or
whole body movements), unusually intense preoccupation with narrow subjects such as obsession with
train schedules, phone books, weather, sports statistics, or collections of objects.
Tests for Asperger's syndrome (autism spectrum disorder)
Workup
A history and physical exam will be performed. Physical, behavioral, and mental evaluations are usually
performed to make the diagnosis and rule out other causes. The doctor may involve other specialists
such as a psychiatrist and/or psychologist to confirm the disorder. No specific diagnostic blood or
imaging tests are available.
Specialists
Family Practice, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Asperger's syndrome (autism spectrum disorder)
There is no cure. Children benefit from behavioral and social skills training. Treatment consists of
communication and social skills therapy, cognitive behavior therapy, and medications. Medications are
used to treat specific symptoms such as anxiety, depression and aggression, and include: serotonin reuptake inhibitors (SSRIs), anti-psychotics, and stimulants.

f.

Autism

Description of Autism
A developmental disorder that usually appears in the first 3 years of life. Some children progress
normally until 2 years of age and then begin to show symptoms. The disorder affects the brain's normal
development of social and communication skills. There is no known single cause but genetic and

environmental factors are thought to contribute to the disease. There is no known evidence that links
autism to childhood vaccines. It is believed 0.3 to 0.6% of children in the US are affected.
Symptoms of Autism
Symptoms usually appear by 18 months and most parents notice something is abnormal by 2 years of
age. Children demonstrate problems with: pretend play, social interactions, nonverbal communication,
language development, and poor social skills. Some children develop normally until 2 years of age then
regress.
Tests for Autism
Workup
A history and physical exam will be performed. There is no blood test or radiology test that can confirm
the disorder. The diagnosis is made by ruling out other causes of the behavior and by performing a
screening exam using tools such as: Autism Diagnostic Interview - Revised (ADI-R), Autism Diagnostic
Observation Schedule (ADOS), Childhood Autism rating Scale (CARS), and/or Gilliam Autism Rating Scale.
Specialists
Family Practice, Pediatric and Adolescent Psychiatry, Pediatric Developmental Behavioral Health and
Pediatrics
Treatment of Autism
Treatment is best started early and individualized to the patient. Multiple therapies are used singly or in
combination and include: applied behavior analysis (ABA), medications, occupational therapy, physical
therapy, and speech-language therapy. Medications that may be used include certain types of
antidepressants, antipsychotics, and stimulants.

g. Bulimia nervosa (binge eating, vomiting)
Description of Bulimia nervosa (binge eating, vomiting)
An eating disorder associated with an abnormal perception of body image. Patients may eat large
amounts of food then purge through self-induced vomiting or with the use of laxatives. This disorder
may be associated with anorexia nervosa. Patients with this disorder can suffer from depression and
other psychiatric problems.
Symptoms of Bulimia nervosa (binge eating, vomiting)
Binge eating, self-induced vomiting, inappropriate use of laxatives and/or diuretics, overachieving
behavior.

Tests for Bulimia nervosa (binge eating, vomiting)
Workup
A history and physical exam will be performed. Additional tests include: blood tests to identify metabolic
abnormalities.
Tests
Comprehensive metabolic panel (CMP)
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Bulimia nervosa (binge eating, vomiting)
Therapy depends on the severity of the disorder. Treatment of any metabolic abnormalities (low
sodium, low potassium, dehydration). Psychological treatment may include: behavioral modification
techniques, and counseling. Antidepressants are sometimes used.

h. Drug overuse
*OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA

i.

Marijuana abuse
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA

j.

Panic disorder
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA

k. Social anxiety disorder (social phobia)
Description of Social anxiety disorder (social phobia)
A disorder in which normal social situations cause extreme anxiety and avoidance behavior. In its mild
form, it is known as "stage fright." People with this disorder may go to lengths to avoid these situations
and can have difficulties performing straight forward tasks such as shopping. Patients often feel
embarrassment and know their anxiety reactions are abnormal.
Symptoms of Social anxiety disorder (social phobia)
Patients experience fear and anxiety about the following tasks: speaking in public, meeting new people,
eating in public, writing in public, using public restrooms, attending parties. Patients withdraw from
those around them.

Tests for Social anxiety disorder (social phobia)
Workup
A history and physical exam will be performed. No tests are generally needed.
Specialists
Family Practice, Internal Medicine, Pediatric and Adolescent Psychiatry, Pediatrics and Psychiatry
Treatment of Social anxiety disorder (social phobia)
The goal of treatment is to help the person function more effectively. Even with mild symptoms, social
anxiety can improve with a blood pressure medicine from the drug family "beta blockers." The medicine
prevents the heart from racing and can greatly diminish social anxiety. Other treatment options include:
systematic desensitization, graded real-life exposure, social skills training, role playing and modeling,
anti-anxiety medications and anti-depressants.

4. BITTERNESS
a. Bipolar disorder (manic depressive disorder)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA

b. Depression (excessive sadness)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
c.

Dysthymia (neurotic depression)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA

d. Post-traumatic stress disorder (PTSD)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
e. Schizoaffective disorder (features of schizophrenia, and mood disorder)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
f.

Stress

Description of Stress

The physical, mental and emotional reactions resulting from changes and demands in one's life. The
reaction can cause a mild to severe depressed mood or be a motivator. Long term stress can cause sleep
disorders and lack of energy.
Symptoms of Stress
Fatigue, depressed mood, poor sleep pattern, anxiety.
Tests for Stress
Workup
A history and physical exam will be performed. No additional tests are needed.
Specialists
Family Practice, Internal Medicine, Pediatrics and Psychiatry
Treatment of Stress
Behavioral modifications to help deal with the stress. Occasional antidepressants and anti-anxiety
medications are needed on a short term basis.

5. BLACK STOOLS
a. Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
b. Esophageal varices (dilation of esophageal veins)
Description of Esophageal varices (dilation of esophageal veins)
The esophagus is the tube that connects the mouth to the stomach. Varices are dilated veins most
commonly found near the esophagus or stomach. The most common cause of esophageal varices is
scarring of the liver (cirrhosis) from longstanding alcohol abuse. Cirrhosis causes a back-up of blood in
the esophageal veins which leads to the development of varices. Bleeding esophageal varices can be lifethreatening.
Symptoms of Esophageal varices (dilation of esophageal veins)
Vomiting blood or a material that resembles coffee grounds, chest pain, breathing problems, fainting,
black stools (melena), anemia, fatigue.
Tests for Esophageal varices (dilation of esophageal veins)
Workup

A history and physical exam will be performed. Additional tests may include:
Esophagogastroduodenoscopy (EGD), or esophagram (barium swallow), and blood tests to measure the
red blood cell count and the ability to clot blood.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Esophagogastroduodenoscopy (EGD), esophagram, protime, partial thromboplastin
Specialists
Gastroenterology and Vascular and Interventional Radiology
Treatment of Esophageal varices (dilation of esophageal veins)
For small, non-bleeding varices no treatment may be necessary although close monitoring is
recommended. Certain medications (such as beta-blockers and nitrates) may reduce the risk of bleeding.
For those that are enlarging, bleeding or appear to be at risk for bleeding, ligation or injection of the
varices through the endoscope are the most common initial treatments. A transjugular intrahepatic
portosystemic shunt (TIPS) may be performed to reduce the back-up pressure in the esophageal veins.
In severe cases liver transplant is the only effective treatment.

c. Gastritis (stomach inflammation)
mDescription of Gastritis (stomach inflammation)
An irritation, inflammation, erosion or infection of the stomach lining. It can be acute or chronic.
Gastritis can be present with either a gastric erosion or gastric ulcer. An infection with the bacteria
Helicobacter pylori (H. pylori) can increase the incidence and severity of the disease. The following
conditions increase the risk of this disorder: drinking alcohol, use of nonsteroidal anti-inflammatory
drugs / NSAIDs (ibuprofen, naproxen, aspirin), smoking, and serious illness or stress (such as an infection
or trauma).
Symptoms of Gastritis (stomach inflammation)
Abdominal pain, nausea, vomiting, black stools (melena), bloody stools, burning in chest. Gastritis may
cause no symptoms.
Tests for Gastritis (stomach inflammation)
Workup

A history and physical exam will be performed. Other tests to determine the extent of disease include:
nasogastric tube lavage, rectal exam, EGD (esophagogastroduodenoscopy), and blood tests.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Lipase
Additional tests that may be required
Clotting studies, Type and screen, Gastric culture
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Reviewed by Harvard Medical School
Treatment of Gastritis (stomach inflammation)
Treatment depends on the severity of the illness and includes: proton pump inhibitors
(omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers (cimetidine/Tagamet, ranitidine/Zantac), and
antibiotics if caused by H. pylori. For severe symptoms, bleeding or complications of gastritis,
hospitalization may be recommended.

d. Mallory Weiss syndrome (esophageal tear)
Description of Mallory Weiss syndrome (esophageal tear)
Refers to a superficial tear in the lower part of the esophagus that occurs during forceful vomiting,
prolonged vomiting, or persistent coughing. These tears may cause severe bleeding. Any disorder that
causes vomiting or coughing can cause this disorder.
Symptoms of Mallory Weiss syndrome (esophageal tear)
Vomiting blood, vomiting coffee ground material, bloody stools, black stools (melena), chest pain.
Tests for Mallory Weiss syndrome (esophageal tear)
Workup
A history and physical exam will be performed. Additional tests include: an EGD
(esophagogastroduodenoscopy), tests to measure the blood count and ability to clot blood, X-ray and/or
CT scan to rule out esophageal rupture.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and X-ray
Additional tests that may be required
EGD (esophagogastroduodenoscopy), PT, PTT (Partial Thromboplastin Time)
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Mallory Weiss syndrome (esophageal tear)
The tear and bleeding usually resolve without special treatment. Surgery is rarely required. Proton pump
inhibitors (omeprazole/Prilosec, pantoprazole/Protonix) or H2 blockers (cimetidine/Tagamet,
ranitidine/Zantac) may be given. Blood transfusions may be necessary if the bleeding is severe. Excessive
bleeding or persistent bleeding may require endoscopy or surgery to stop the bleeding.

e. Pepto Bismol or Kaopectate ingestion (bismuth)
Description of Pepto Bismol or Kaopectate ingestion (bismuth)
Black stools can be the result of ingesting bismuth usually in the form of bismuth subsalicylate
commonly known as "pink bismuth". Pink bismuth is the active ingredient in Pepto-Bismol and
Kaopectate. Note iron ingestion can also cause black stools unrelated to bismuth.
Symptoms of Pepto Bismol or Kaopectate ingestion (bismuth)
Black stools
Tests for Pepto Bismol or Kaopectate ingestion (bismuth)
Workup
A history and physical exam will be done. Your doctor may test the black stool for blood using an hemeoccult blood card. This is an office test and the result is known in 30 seconds.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Pepto Bismol or Kaopectate ingestion (bismuth)
No treatment is required. The stool color should return to normal in a few days.

f.

Small bowel lymphoma (intestinal lymph node cancer)

Description of Small bowel lymphoma (intestinal lymph node cancer)
A tumor of the lymph nodes of the small intestine. It most often occurs in the 5th or 6th decade and is
more common in men. It is associated with the following diseases, or conditions: celiac disease, Crohn's
disease, autoimmune disease, HIV, organ transplant patients, and patients on chemotherapy.
Symptoms of Small bowel lymphoma (intestinal lymph node cancer)
Abdominal pain, bowel obstruction, vomiting, weight loss, vomiting blood, bloody stools, black stools
(melena).
Tests for Small bowel lymphoma (intestinal lymph node cancer)
Workup
A history and physical exam will be performed. A CT scan or small bowel series is performed to establish
the diagnosis.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
Small bowel series
Specialists
Blood and Cancer Care (hematology and oncology)
Treatment of Small bowel lymphoma (intestinal lymph node cancer)
Treatment includes surgery, chemotherapy, and/or radiation therapy.

g. Warfarin (Coumadin) use
Description of Warfarin (Coumadin) use
Warfarin inhibits vitamin K dependent coagulation factors. It is used to thin the blood and is prescribed
in the following conditions: heart arrhythmias (atrial fibrillation), stroke, heart stents, deep vein
thrombosis (blood clot), pulmonary embolus (blood clot of the lung), mechanical heart valves, and
hyper-coagulable disorders. The patient's blood is checked periodically to monitor the effectiveness of
the medication. Dietary changes and new medications can alter the effects of the drug causing either
too much or too little anti-coagulation.
Symptoms of Warfarin (Coumadin) use

Too much medication can cause: nosebleeds, bleeding gums, vomiting blood, vomiting coffee grounds,
bloody stools, black stools (melena), easy bruising, dizziness, fainting, confusion.
Tests for Warfarin (Coumadin) use
Workup
Blood tests are performed periodically to measure the Prothrombin Time (PT), which is converted to a
value called the INR (International Normalized Ratio). The target INR range is usually between 2 and 3,
although people with a mechanical heart valve or a hyper-coagulable state may need to run a higher
INR.
Additional tests that may be required
PT (Protime)
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Warfarin (Coumadin) use
The patient's blood is monitored to ensure the PT/INR is therapeutic. Patients with an INR above the
target range are at increased risk of bleeding. Those with an INR below the target range are at risk of
unwanted clotting. In both situations, more frequent monitoring is needed.

6. BLEEDING GUMS
a. Cirrhosis (liver failure and scarring)
Description of Cirrhosis (liver failure and scarring)
A liver disease that persists over a long period of time, resulting in a progressive destruction of the liver.
Normal liver function is essential for many reasons, including its production of blood clotting factors and
its role in detoxifying the blood. In the end stages patients experience excessive bleeding, and can
become confused. There are many causes with alcohol and viral infections being the most common.
Hepatitis B and C are the most common viral infections related to this disorder. Less common causes of
cirrhosis include autoimmune diseases, medications, hemochromatosis and Wilson's disease.
Symptoms of Cirrhosis (liver failure and scarring)
Abdominal pain, abdominal bloating, easy bleeding, vomiting, confusion, yellowing skin, weakness.
Tests for Cirrhosis (liver failure and scarring)

Workup
A history and physical exam will be performed. Blood tests will be performed to determine the cause
and severity of the liver damage. An ultrasound of the liver or other imaging tests may be recommended
as well.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Ultrasound
Additional tests that may be required
Hepatitis profile, protime
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Cirrhosis (liver failure and scarring)
Treatment depends on the cause of the liver failure and the extent of the liver failure but may include:
diuretics for fluid overload, lactulose for confusion, blood products or vitamin K for bleeding, and/or
antibiotics for infection. For more information contact the National Digestive Diseases Information
Clearinghouse at: http://digestive.niddk.nih.gov or

(800) 891-5389 American Liver Foundation

(800)465-4837

b. Gingivitis (inflammation of the gums)
Description of Gingivitis (inflammation of the gums)
The gingiva is the tissue covering the jaw bone and teeth. Food, plaque and bacteria become lodged
between the teeth causing swelling and pain of this tissue causing inflammation of the gums. Gingivitis is
the mildest form of periodontal disease. If the disease progresses it can involve more of the surrounding
tissue becoming periodontitis. If left untreated this disorder can lead to loss of the teeth. Periodontal
disease is the most common cause of tooth loss. Recent studies have demonstrated a correlation
between periodontal disease and heart disease: patients with periodontal disease can have twice the
risk for developing a heart attack or stroke as people without periodontal disease.
Symptoms of Gingivitis (inflammation of the gums)
Halitosis (bad breath), gum pain, loose teeth, gum swelling.
Tests for Gingivitis (inflammation of the gums)

Workup
A history and physical exam will be performed.
Tests
X-ray
Specialists
Dentistry and Dentistry - Pediatric
Treatment of Gingivitis (inflammation of the gums)
Treatment includes: dental treatment for cavities, improved dental hygiene, and mouthwashes. For
severe gum disease surgery may be recommended.

c. Idiopathic thrombocytopenia purpura (ITP, low platelets)
Description of Idiopathic thrombocytopenia purpura (ITP, low platelets)
A disease that causes excessive bleeding secondary to a low number of platelets (thrombocytopenia).
Platelets are essential for normal blood clotting and are made in the bone marrow. Most people have
more than 150,000 platelets per microliter. Serious bleeding is usually seen when the count drops below
10,000. In ITP the body's immune system attacks and destroys the platelets. The disease can occur in
children and adults and usually occurs in children after a viral infection. The disorders resolves in
children but can be long lasting (chronic) in adults.
Symptoms of Idiopathic thrombocytopenia purpura (ITP, low platelets)
Pinpoint red spots under the skin (petechiae). Purplish bruises on the skin, mouth, or vaginal area
(purpura). Bleeding from the nose (epistaxis), from the gums, in the urine (hematuria) or in the bowels.
Large bruises (hematomas) can occur with mild trauma. Excessive vaginal bleeding during menstruation.
Serious life threatening bleeding can occur after minor injuries.
Tests for Idiopathic thrombocytopenia purpura (ITP, low platelets)
Workup
A history and physical exam will be done. A complete blood cell count (CBC) will determine the number
of platelets. The blood cells will be examined under a microscope. A blood test will be performed to look
for antibodies against platelets. A bone marrow biopsy may also be done.
Tests
Complete blood count (CBC)

Additional tests that may be required
bone marrow biopsy, blood smear
Specialists
Blood and Cancer Care (hematology and oncology) and Pediatric Hematology and Oncology
Treatment of Idiopathic thrombocytopenia purpura (ITP, low platelets)
Many patients do not need treatment because the platelet counts remain high enough to prevent any
bleeding. These patients are observed closely and may need periodic transfusions if they undergo
surgery. When the platelet counts become too low and are associated with bleeding complications the
main course of treatment is medical and surgical. Medical treatment consists of steroids and
intravenous immune globulin (IVIG). Surgery involves the removal of the spleen (splenectomy). The
spleen is the main source of platelet destruction.

d. Low platelets (thrombocytopenia)
Description of Low platelets (thrombocytopenia)
Platelets are cells that help the body form blood clots. Low platelets, also called thrombocytopenia, can
occur from insufficient production of platelets, or from increased destruction. Some causes are: immune
thrombocytopenic purpura (ITP), drug-induced immune thrombocytopenia, drug-induced nonimmune
thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), disseminated intravascular
coagulation (DIC), an enlarged spleen, aplastic anemia, cancer and infection.
Symptoms of Low platelets (thrombocytopenia)
Easy bruising, easy bleeding, reddish-purple spots on skin (petechiae).
Tests for Low platelets (thrombocytopenia)
Workup
A history and physical exam will be performed. Tests will be performed to determine the cause of the
low platelets. A bone marrow biopsy may be recommended.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Platelet associated antibodies, Bone marrow biopsy, PT, PTT (Partial Thromboplastin Time) (Partial
Thromboplastin Time)

Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Low platelets (thrombocytopenia)
Treatment depends on the cause of the low platelets. While evaluation and treatment are ongoing,
transfusion of platelets may be helpful for severe bleeding. Unfortunately, transfused platelets do not
last long in the body and are only a temporary treatment.

e. Periodontitis (gum inflammation)
Description of Periodontitis (gum inflammation)
Inflammation of the gums (also called gingivitis). An increasing layer of plaque forms in pockets between
the teeth and the gum. Bacteria infect these areas causing inflammation. With time the inflammation
and infection may lead to loss of the supporting structures of the teeth. Recent studies have
demonstrated a correlation between dental disease and heart disease, and patients with periodontal
disease can have twice the risk for developing a heart attack or stroke.
Symptoms of Periodontitis (gum inflammation)
Swollen gums, pus from the gums, loose teeth, mouth pain, sensitive teeth, painful gums, bad breath.
Tests for Periodontitis (gum inflammation)
Workup
A history and physical exam will be performed. The height of the gums will be measured.
Specialists
Dentistry and Dentistry - Pediatric
Treatment of Periodontitis (gum inflammation)
Antibiotics, scaling, and root planning is performed for moderate disease. Very serious cases require
surgery including bone grafting and flap procedures. There is an association between periodontal
disease and heart disease and having healthy gums will decrease the risk of heart attacks and other
cardiovascular disease.

f.

Warfarin (Coumadin) use
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7. BLEEDING IN BRAIN
a. Brain tumor (cancer of the brain)
Description of Brain tumor (cancer of the brain)
An abnormal growth within the brain and skull. It can be benign or cancerous (malignant). Even benign
tumors can be life threatening depending on their location causing compression and/or elevation of the
pressure in the brain (hydrocephalous). Malignant tumors can arise from cells of the brain, such as
astrocytomas, or from cells transported to the brain through the blood stream or lymphatic system
(metastases).
Symptoms of Brain tumor (cancer of the brain)
Headache, seizure, vomiting, weakness, slurred speech, double vision, confusion.
Tests for Brain tumor (cancer of the brain)
Workup
A history and physical exam will be performed. A head CT or MRI is done to diagnose the tumor. A
biopsy may be required to identify the type of tumor.
Tests
CT Scan and MRI
Additional tests that may be required
Biopsy
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Brain tumor (cancer of the brain)
Treatment depends on the type of cancer but may include surgical resection, chemotherapy, and/or
radiation therapy. American Brain Tumor Association:
Foundation

(800)934-2873 American Cancer Society:

b. Cerebral aneurysm (brain artery dilation)
Description of Cerebral aneurysm (brain artery dilation)

(800)886-2282 National Brain Tumor
(800)227-2345

An abnormal widening or ballooning of an artery in the brain. Most are congenital and do not cause
symptoms until they leak blood or burst and bleed profusely. Rarely the dilation of the vessel can be
large enough to cause symptoms before they leak by pressing on surrounding brain. The most common
initial symptom is a sudden severe headache.
Symptoms of Cerebral aneurysm (brain artery dilation)
The symptoms depend on the amount of bleeding. A small amount of bleeding (sentinel bleed) causes a
sudden severe headache (thunder clap headache), and vomiting. More significant bleeding can cause:
confusion, fainting, weakness, seizures, coma and death. If the aneurysm has not bled but is large
enough to cause symptoms then one may see: progressively worse headache, vomiting, confusion,
change in behavior, weakness, visual problems, seizures.
Tests for Cerebral aneurysm (brain artery dilation)
Workup
A history and physical exam will be performed. If the doctor suspects an aneurysm a head CT or brain
MRI will be done. The addition of contrast may help identify the disorder (CT angiogram or MR
angiogram). Sometimes a lumbar puncture is performed to identify the blood in the cerebrospinal fluid
when an imaging study has been negative and the suspicion is still high for a ruptured aneurysm.
Tests
Complete blood count (CBC), CT Scan and MRI
Additional tests that may be required
Lumbar puncture, CTA, MRA
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Cerebral aneurysm (brain artery dilation)
Therapy depends on the amount of bleeding. Severe bleeding may require: insertion of a breathing
tube, anti-seizure medication, blood pressure medication, and/or surgery. The goal of unruptured
aneurysms that don't cause symptoms depends on the size and location. Observation and periodic
repeat imaging may be advised. Or treatment to prevent rupture or reduce symptoms may include:
surgical clipping or endovascular embolization.

c. Epidural hematoma (bleeding around brain or spin)
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d. Head trauma
Description of Head trauma
Head injuries range from minor trauma to concussions, unconsciousness and death. Traumatic injury to
the brain can cause bleeding on the surface of the brain or within the brain. The brain can be
permanently damaged by this trauma. Coma occurs when the central portion of the brain is unable to
activate or stimulate the rest of the brain to wakefulness or when there is extensive injury to the brain.
Head injuries can also produce fractures of the skull. Depressed skull fractures can cause a piece of bone
to penetrate or deform the brain. Basilar skull fractures involve the base of the skull. They can injure the
nerves that pass through these regions and produce cerebrospinal fluid leaks.
Symptoms of Head trauma
Headache, bleeding from the face or scalp, nose or ear, bruising behind ear, dizziness, visual problems,
ringing in the ears (tinnitus), nausea, vomiting, neurologic abnormalities, confusion, instability, paralysis
of a leg or arm, abnormal breathing, seizures, unconsciousness.
Tests for Head trauma
Workup
A history and physical exam will be performed with particular attention to neurologic abnormalities. A
CT scan and/or MRI may be recommended to rule out fractures, bruising of the brain, and bleeding into
or near the brain.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Urinalysis (UA) and X-ray
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Head trauma
Therapy is determined by the severity of the injury and may include: observation, diuretics (mannitol) to
decrease swelling, anti-seizure medications, anti-nausea medications, mechanical ventilation, and/or
neurosurgery. Steroids are no longer recommended..

e. Hypertensive emergency (severely high blood pressure)
Description of Hypertensive emergency (severely high blood pressure)
Severe elevation of blood pressure with acute damage of an organ system (usually the brain, heart
and/or kidneys) and possibly permanent damage. To reverse the damage the blood pressure should be

lowered aggressively over minutes to hours. Triggers include: not taking blood pressure medications,
abruptly stopping a blood pressure medication, drugs abuse (cocaine, methamphetamine), severe
elevation of thyroid hormone, and taking certain over the counter medications.
Symptoms of Hypertensive emergency (severely high blood pressure)
Chest pain, shortness of breath, headache, confusion, weakness, fatigue, lethargy, decreased urine
output.
Tests for Hypertensive emergency (severely high blood pressure)
Workup
A history and physical exam will be performed with frequent measures of the blood pressure. Tests may
be performed to identify the cause of the severe hypertension and to detect organ damage.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Troponin and X-ray
Specialists
Cardiology and Pediatric Cardiology
Treatment of Hypertensive emergency (severely high blood pressure)
This condition is a medical emergency and requires immediate treatment including intravenous
medications to reduce the blood pressure, cardiac monitoring, and hospitalization. Other treatments
will depend on which organs are affected.

f.

Intracranial hemorrhage (bleeding in brain)
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g. Subarachnoid hemorrhage (brain bleeding)
Description of Subarachnoid hemorrhage (brain bleeding)
The subarachnoid space covers the brain and spinal cord. A subarachnoid hemorrhage (SAH) occurs
when there is bleeding into this space. A subarachnoid hemorrhage can be life threatening. The most
common cause of bleeding is a rupture of an aneurysm. An aneurysm is a focal area of swelling of an
artery in the brain. An aneurysm can be congenital (present from time of birth) and may not cause any
symptoms unless it bleeds. A tendency to form aneurysms can be an inherited trait. Other causes of SAH
include head trauma and arteriovenous malformation (AVM, a tangle of veins and arteries that is a
variation of normal anatomy and is prone to rupture).

Symptoms of Subarachnoid hemorrhage (brain bleeding)
Sudden onset of severe headache, a popping or snapping sensation is sometimes described, the
headache is described as the worst of one's life, vomiting, fainting, weakness, confusion, seizure, coma.
Tests for Subarachnoid hemorrhage (brain bleeding)
Workup
A history and physical exam will be performed. Tests to establish the diagnosis and determine the cause
will be done. If the initial head CT is normal a lumbar puncture (spinal tap) may be performed to rule out
a small bleed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
MRI and X-ray
Additional tests that may be required
Cerebral angiogram, CTA of head, MRA of head, lumbar puncture
Specialists
Neurosurgery and Vascular and Interventional Radiology
Treatment of Subarachnoid hemorrhage (brain bleeding)
The goals of therapy are repair the cause of bleeding, relieve symptoms, and prevent complications.
Specific treatments depend on the cause of the bleeding. For aneurysms surgical clipping and
endovascular clotting off of the aneurysm are the most common procedures. Any associated bleeding
abnormalities will be reversed as well as blood pressure control.

h. Subdural hematoma (bleeding on brain)
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8. Bleeding tendency
a. Hemophilia (inherited bleeding disorder)
Description of Hemophilia (inherited bleeding disorder)
A bleeding disorder that may be caused by one of several blood clotting factor deficiencies. Classic
Hemophilia, or Hemophilia A, is caused by a deficiency of factor VIII. Hemophilia B, (Christmas disease),

occurs with a deficiency of factor IX. These diseases are usually genetic and usually occur only in males.
Due to mutations, new cases can arise in families with no history of the disorder. Hemophilia can cause
dangerous episodes of bleeding.
Symptoms of Hemophilia (inherited bleeding disorder)
Blood in stool, easy bruising, heavy periods, bleeding gums, bleeding in joints.
Tests for Hemophilia (inherited bleeding disorder)
Workup
A history and physical exam will be performed. Factor studies are completed to diagnose the specific
clotting disorder.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Clotting studies, PT (Protime), PTT (Partial thromboplastin time)
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Hemophilia (inherited bleeding disorder)
Therapy is determined by the type of hemophilia, the severity of the clotting deficiency, and the
symptoms being experienced. The goal is to stop the bleeding, and replace the needed blood factor. For
more information contact: National Hemophilia Foundation: (800)424-2634

(800)424-2634

b. Low platelets (thrombocytopenia)
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c. Myelodysplastic syndrome (bone marrow failure)
Description of Myelodysplastic syndrome (bone marrow failure)
A syndrome where the stem cells in the bone marrow fail to develop normally into the white blood cells,
red blood cells and platelets needed for normal bodily function. There is a range of severity with some
patients experiencing serious low red blood cells, excessive bleeding, and an increase in infections. This
disorder can be life threatening and in some cases it can progress to leukemia. The disease is most often

seen in patients greater than 60 and is more common in men. The following conditions increase the risk
of this disorder: previous treatment for cancer, a family history of the disease, smoking, and exposure to
certain chemicals.
Symptoms of Myelodysplastic syndrome (bone marrow failure)
Fatigue, pin point reddish-purple skin blotches, frequent infections, easy bruising, shortness of breath,
pale skin (anemia).
Tests for Myelodysplastic syndrome (bone marrow failure)
Workup
A history and physical exam will be performed. Blood tests will be done to determine the number and
types of blood cells. A bone marrow biopsy will be done to establish the diagnosis, evaluate the stem
cells and look for cancers and genetic defects.
Tests
Complete blood count (CBC)
Additional tests that may be required
Bone marrow biopsy
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice and Internal Medicine
Treatment of Myelodysplastic syndrome (bone marrow failure)
Therapy depends on the severity of disease and the chromosomal defect present but may include:
erythropoietin or darbepoetin to stimulate red blood cell production, azacitidine (Vidaza) and decitabine
(Dacogen) to stimulate stem cell transformation into mature cells, and lenalidomide (Revlimid) in cases
with a specific chromosome abnormality. Other treatment options include: blood transfusion,
chemotherapy and stem cell transplantation.

d. Von Willebrand's disease
Description of Von Willebrand's disease
Von Willebrand's Disease is a bleeding disorder that affects the body's ability to clot. It is most often an
inherited disorder that results from low levels of Von Willebrand's protein. This protein acts as the glue
that holds tiny cells called platelets together during the formation of a clot. Von Willebrand's disease is
relatively common and affects both males and females.

Symptoms of Von Willebrand's disease
Symptoms include easy bruising, prolonged bleeding, and significant bleeding during menstrual periods
in women (menorrhagia).
Tests for Von Willebrand's disease
Workup
A complete history and physical will be performed. Blood tests will be ordered to evaluate the amount
and function of the Von Willebrand's factor in your blood.
Tests
Bleeding time, Complete blood count (CBC), Partial throboplastin time (PTT) and Prothrombin (PT)
Additional tests that may be required
Von Willebrand factor (VWF) antigen, platelet function test (PFA-100), Von Willebrand factor multimers,
factor VIII clotting activity, Ristocetin cofactor activity
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Von Willebrand's disease
Treatment may vary depending on the severity of your disease. Desmopressin (DDAVP) is the most
common treatment and can be administered via a nasal spray. DDAVP is a synthetic hormone that
stimulates the release of more Von Willibrand factor. Other treatment options include contraceptives
for women, clot-stabilizing medications such as aminocaproic acid (Amicar) and transxemic acid
(Cyklokapron), and clotting factor infusions.

e. Warfarin (Coumadin) use
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9. BLINDNESS
a. Amaurosis fugax (momentary vision loss in one eye)
Description of Amaurosis fugax (momentary vision loss in one eye)

A sudden loss of vision in one eye caused by a blockage of blood flow to the retinal artery. The retinal
artery feeds the retina. The retina captures the light in the back of the eye and transmits these images
to the brain. This condition is sometimes followed by a stroke and is considered very serious. The
blockage of the retinal artery is usually due to a piece of plaque that builds up in the carotid arteries in
the neck. The carotid arteries supply blood to the brain. The plaque buildup is caused by atherosclerosis,
and consists of fat deposits and calcium.
Symptoms of Amaurosis fugax (momentary vision loss in one eye)
Sudden loss of vision in one eye. The decreased vision can lasts seconds to hours. The loss of vision can
be complete or is sometimes described as a veil being pulled over the eye. The loss of vision is usually
painless.
Tests for Amaurosis fugax (momentary vision loss in one eye)
Workup
A history and physical exam will be done. The eyes will be examined and the blockage of the retinal
artery can sometimes be seen. A CT scan and/or MRI of the brain will be done. Imaging studies of the
neck such as an ultrasound may also be performed to look for blockages of the carotid artery. Blood
tests are also routinely examined.
Specialists
Ophthalmology, Vascular and Interventional Radiology and Vascular Surgery
Treatment of Amaurosis fugax (momentary vision loss in one eye)
Immediate therapy is aimed at removing the blockage of the retinal artery Since time is very important
immediate medical assistance is needed. Treatment options include surgery, interventional vascular
treatment with clot busting medications, and medications. The medications most commonly prescribed
include: aspirin, clopidogrel, and aspirin and dipyridamole. Treatment after an episode of amaurosis
fugax, to prevent it from recurring, involves various lifestyle changes, medicines and techniques for
reducing the plaque buildup in the carotid arteries.

b. Carotid artery stenosis (neck artery narrowing)
Description of Carotid artery stenosis (neck artery narrowing)
The carotid arteries carry blood from the heart to the brain. Blockages typically occur from
atherosclerosis but congenital abnormalities and trauma can result in narrowing of the arteries
(stenosis). A stroke can occur if the narrowing suddenly becomes blocked with a clot or a piece of
material (called plaque) breaks off and blocks an artery inside the brain.
Reviewed by Harvard Medical School

Symptoms of Carotid artery stenosis (neck artery narrowing)
No symptoms, unless there is insufficient blood flow to part of the brain to allow normal brain function.
If that occurs, symptoms may include weakness, numbness, slurred speech, confusion, incoordination,
or decreased vision. Temporary symptoms are called a transient ischemic attack (TIA). Permanent
symptoms are a stroke.
Tests for Carotid artery stenosis (neck artery narrowing)
Workup
A history and physical exam will be performed. A carotid ultrasound is often the first test. More detail is
gained by obtaining a CT angiogram (CTA), or MR angiogram (MRA).
Tests
Ultrasound
Additional tests that may be required
CTA, MRA
Do I Need This Test?
Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. There is good evidence
that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the
benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death,
stroke and myocardial infarction.
How this was created and why it is important

The American Academy of Family Physicians and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.

Specialists
Vascular Surgery
Treatment of Carotid artery stenosis (neck artery narrowing)
Therapy depends on the severity of the degree of blockage and severity of symptoms. Therapy for mild
to moderate blockages is aimed at reducing further atherosclerosis with lifestyle changes and keeping
blood pressure and cholesterol levels in the normal range. Also aspirin or other anti-platelet drug is
given to prevent clots inside the carotid artery. More severe blockages that cause symptoms may
require stenting of the artery or surgery (endarterectomy).

c. Cataracts (clouding of the eye lens)
Description of Cataracts (clouding of the eye lens)
Clouding of the lens of the eye. Normally, light that enters the eye passes through a clear lens and falls
on the retina, in the back of the eye. When the lens is clouded, this decreases vision. Typically a cataract
occurs slowly and commonly happens as one gets older. Trauma to the eye and congenital abnormalities
can cause the cataract to form more quickly. The following conditions can increase the likelihood of
developing a cataract: smoking, steroid medications, diabetes, high blood pressure, alcoholism,
exposure to sunlight without wearing glasses, obesity, previous eye injury or eye disease, and a family
history of cataracts.
Symptoms of Cataracts (clouding of the eye lens)
The symptoms typically appear slowly and include: decreased vision, cloudy vision, sensitivity to bright
light, problems seeing colors, difficulty seeing at night, or seeing double in one eye.
Tests for Cataracts (clouding of the eye lens)
Workup
A history and physical exam will be done. A visual acuity test will demonstrate deceased vision. The
provider will do a slit lamp exam which magnifies the eye and allows the examiner to look deep into the
eye and see the clouded lens. The pupil of the eye may be dilated as well for better visualization.
Specialists
Ophthalmology
Treatment of Cataracts (clouding of the eye lens)

Surgery is required to remove the cloudy lens and replace it with a replacement lens. Rarely the lens is
removed and a replacement lens cannot be inserted requiring a contact lens or pair of glasses to
improve the eyesight.
d. Cerebral vascular accident (stroke)
Description of Cerebral vascular accident (stroke)
A sudden interruption of blood flow to a portion of the brain causing injury. Some strokes are associated
with bleeding into the damaged area. Most strokes are caused by a blocked artery in the brain from
hardening of the arteries (atherosclerosis) or from a blood clot that travels from another area
(embolus). The symptoms experienced depend on the artery blocked. Survival and the best outcome
depend on seeking medical care immediately. Also known as a stroke.
Symptoms of Cerebral vascular accident (stroke)
Weakness of an arm, leg, side of the face, or any part of the body. Numbness, decreased sensation,
vision changes, slurred speech, inability to speak, inability to understand speech, difficulty reading or
writing, swallowing difficulty, drooling, loss of memory, vertigo (spinning sensation), loss of balance or
coordination, personality changes, mood changes (depression, apathy), drowsiness, lethargy, or loss of
consciousness, uncontrollable eye movements, double vision, nausea, vomiting.
Tests for Cerebral vascular accident (stroke)
Workup
A history and physical exam will be performed. Tests to identify the location and cause of the stroke will
be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
MRI, Ultrasound and X-ray
Additional tests that may be required
Head and Neck CTA, carotid ultrasound, echocardiogram, PT (Protime), PTT (Partial Thromboplastin
Time)
Specialists
Neurology, Pediatric Neurology and Vascular and Interventional Radiology
Reviewed by Harvard Medical School
Treatment of Cerebral vascular accident (stroke)

A stroke is a medical emergency. Therapy depends on the size of the stroke, its location in the brain, the
medications the patient is taking, how long the symptoms have been present and other associated
diseases. Treatment may include: blood pressure medication, anti-platelet medications (aspirin,
clopidogrel/Plavix), anticoagulants (heparin, enoxaparin, warfarin), thrombolysis (tissue plasminogen
activator/t-PA), intravascular thrombolysis, physical therapy, speech therapy, and/or occupational
therapy. Blood pressure and cholesterol medications are usually recommended to prevent a recurrence.
e. Corneal abrasion (scrape on eye)
Description of Corneal abrasion (scrape on eye)
A scratch (abrasion) to the transparent covering of the center of the eye called the cornea. The cornea
allows light to enter the eye, where it strikes the retina and is eventually interpreted by the brain as
vision. Trauma to the eye can cause a scratch (abrasion) to the cornea. If the abrasion does not heal
correctly an infection can develop resulting in permanent scarring and decreased vision. If the abrasion
is caused by metal, a rust ring can develop in the cornea. This rust ring will need to be removed to
prevent scarring of the cornea.
Symptoms of Corneal abrasion (scrape on eye)
Eye pain, eye redness, eye swelling, decreased vision, light sensitivity, increased tearing, foreign body
sensation of the eye.
Tests for Corneal abrasion (scrape on eye)
Workup
A history and physical exam will be completed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology
Treatment of Corneal abrasion (scrape on eye)
Treatment includes antibiotic solution and/or ointment to prevent infection. Eye patching is used for
comfort only since patches have not been shown to speed healing. If the patient's tetanus status is not
up to date a tetanus booster may be given.
f.

Corneal foreign body (object in the eye)

Description of Corneal foreign body (object in the eye)
A foreign object that hits the cornea can cause an injury. The cornea is a transparent covering of the
center of the eye. It allows light to penetrate into the eye, where it strikes the retina and is eventually
interpreted by the brain as vision. The cornea is soft and the foreign object may become lodged in it. If

the foreign object is metal a rust ring can develop around the injury as well. If the foreign body and the
rust ring are not removed a corneal scar can occur resulting in permanent vision loss.
Symptoms of Corneal foreign body (object in the eye)
Redness, foreign body sensation, increased tearing, eye pain, decreased vision, light sensitivity.
Tests for Corneal foreign body (object in the eye)
Workup
A history and physical exam will be performed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology
Treatment of Corneal foreign body (object in the eye)
Removal of the foreign body. If a rust ring has developed it must be removed with an ophthalmic burr to
prevent permanent scarring. Antibiotic drops and/or ointment are used to prevent infection. If the
patient's tetanus status is not up to date a tetanus booster may be given.
g. Detached retina (retinal detachment)
Description of Detached retina (retinal detachment)
The retina is pulled away from the back of the eye (choroid) causing the cells of the retina to lose their
blood supply. The retina is the "film" of the eye that allows light to be detected and is necessary for
proper sight. The longer the retina stays detached the more likely permanent damage and permanent
loss of vision will occur. Early diagnosis and treatment can save the vision of the eye. The most common
causes of this disorder include: trauma, diabetes, and inflammation of the eye and aging of the jelly-like
fluid in front of the retina (the vitreous). Retinal detachment is more common in patients over 40, those
with a family history of the disease, and in extreme near sightedness.
Symptoms of Detached retina (retinal detachment)
Sudden appearance of floaters (spots or strings in the field of vision), sudden flashes of light, loss of
vision (described as a shadow or veil), sudden blurry vision.
Tests for Detached retina (retinal detachment)
Workup
A history and physical exam will be done. The provider can sometimes see the detachment of the retina
with an ophthalmoscope (a special magnifying viewer). Many times the defect in the retina cannot be
seen unless an ophthalmologist uses a special lens called a gonioscope.

Specialists
Ophthalmology
Treatment of Detached retina (retinal detachment)
Treatment within the first 24-48 hours of the sudden symptoms is essential: the longer the retina is
detached the more likely permanent loss of sight will occur. Very simple and small detachments may not
require treatment. However, particularly if the retina also is torn, immediate treatment is required. The
most common treatments use beams of laser light, or freezing (cryopexy). Surgery for the detachment
includes: pneumatic retinopexy, scleral buckling, or vitrectomy
h. Diabetes (high blood sugar)
Description of Diabetes (high blood sugar)
A chronic disease of metabolism distinguished by the body's inability to produce enough insulin, and/or
a resistance to the insulin being made. Insulin is necessary for body cells to transport sugar into the cells
and to process carbohydrates, fat, and protein efficiently. Patients with diabetes have too much glucose
in their circulation causing damage to almost every organ in their body. There are three types of
diabetes: Type 1 is usually found in younger patients and requires insulin, Type 2 develops later in life
and is more commonly associated with obesity, and gestational diabetes is associated with pregnancy.
Symptoms of Diabetes (high blood sugar)
Increased urination, increased drinking of fluids, increased appetite, nausea, fatigue, blurry vision,
numbness or tingling in the feet..
Tests for Diabetes (high blood sugar)
Workup
A history and physical exam will be performed. Glucose measurements are performed randomly and as
a fasting level first thing in the morning. A hemoglobin A1C can measure the average glucose level over
time. With very high glucose levels or high acid levels in the body, serum ketones and an arterial blood
gas may be measured to rule out a serious complication called diabetic ketoacidosis (DKA).
Tests
Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Serum ketones, hemoglobin A1C, arterial blood gas
Specialists

Diabetes, Endocrinology and Metabolism, Family Practice, Internal Medicine, Pediatric Endocrinology
and Pediatrics
Treatment of Diabetes (high blood sugar)
Type 1 diabetes requires supplemental insulin either as an injection or as an intermittent continuous
infusion delivered from an insulin pump. The insulin doses required are dependent on glucose
measurements performed during the day. Type 2 diabetes times can often be controlled with weight
loss, dietary discretion and exercise. Type 2 diabetes often requires oral hypoglycemic medications and
may also require insulin. For more information contact National Diabetes Information Clearinghouse:
http://diabetes.niddk.nih.gov or (800)860-8747
(800)342-2383
i.

(800)860-8747 American Diabetes Association:

(800)342-2383
Farsightedness (hyperopia/hypermetropia)

Description of Farsightedness (hyperopia/hypermetropia)
Farsightedness is the difficulty seeing close objects. It is an inherited disorder in most cases and is
caused by an eye that is too short from front to back.
Symptoms of Farsightedness (hyperopia/hypermetropia)
Symptoms include difficulty seeing objects that are close, headaches and crossed eyes in children.
Tests for Farsightedness (hyperopia/hypermetropia)
Workup
A complete history and physical will be performed. A specific ophthalmologic exam and visual testing
will be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology
Treatment of Farsightedness (hyperopia/hypermetropia)
Treatment usually consists of prescribing glasses or contacts to correct the vision problems. Some cases
can be be corrected by laser surgery (LASIK).
j.

Head trauma

Description of Head trauma
Head injuries range from minor trauma to concussions, unconsciousness and death. Traumatic injury to
the brain can cause bleeding on the surface of the brain or within the brain. The brain can be
permanently damaged by this trauma. Coma occurs when the central portion of the brain is unable to

activate or stimulate the rest of the brain to wakefulness or when there is extensive injury to the brain.
Head injuries can also produce fractures of the skull. Depressed skull fractures can cause a piece of bone
to penetrate or deform the brain. Basilar skull fractures involve the base of the skull. They can injure the
nerves that pass through these regions and produce cerebrospinal fluid leaks.
Symptoms of Head trauma
Headache, bleeding from the face or scalp, nose or ear, bruising behind ear, dizziness, visual problems,
ringing in the ears (tinnitus), nausea, vomiting, neurologic abnormalities, confusion, instability, paralysis
of a leg or arm, abnormal breathing, seizures, unconsciousness.
Tests for Head trauma
Workup
A history and physical exam will be performed with particular attention to neurologic abnormalities. A
CT scan and/or MRI may be recommended to rule out fractures, bruising of the brain, and bleeding into
or near the brain.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Urinalysis (UA) and X-ray
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Head trauma
Therapy is determined by the severity of the injury and may include: observation, diuretics (mannitol) to
decrease swelling, anti-seizure medications, anti-nausea medications, mechanical ventilation, and/or
neurosurgery. Steroids are no longer recommended..
k. Macular degeneration (chronic eye disease)
Description of Macular degeneration (chronic eye disease)
This disorder destroys the central vision of the eye. It is the leading cause of vision loss in patients over
60. The macula is a part of the retina that enables one to see fine detail. Over time the cells of the
macula die causing a gradual and painless loss of eyesight. The cause of macular degeneration is
unknown but the following conditions increase the risk of developing this disorder: family history of the
problem, increasing age, high blood pressure, high cholesterol, smoking, being white, and being female.
Symptoms of Macular degeneration (chronic eye disease)
Gradual loss of eyesight. Needing brighter light to read, increased blurry vision, increased problems
reading, problems recognizing faces, a blind spot in the center of vision.

Tests for Macular degeneration (chronic eye disease)
Workup
A history and physical exam will be done. The central vision is tested using an Amsler grid. The retina is
examined using a magnifier called an ophthalmoscope to see characteristic changes of the macula. An
angiogram of the retina or special pictures of the retina using optical coherence tomography may be
done.
Specialists
Ophthalmology
Treatment of Macular degeneration (chronic eye disease)
The vision loss of this disorder cannot be reversed but it can be slowed down. It is recommended
patients take Vitamin C, Vitamin E, beta carotene, copper and zinc supplements. Patients should stop
smoking. Special magnifying glasses may help patients read. There are more investigational drugs
available for certain subsets of patients with this disorder (Anecortave acetate/Retaane,
pegaptanib/Macugen
l.

Migraine (type of headache)

Description of Migraine (type of headache)
A common, but very particular type of headache. The typical migraine headache is throbbing or
pulsating, and often is associated with nausea and intolerance to light and sound. Many people
experience an aura, usually visual changes, before the headache. The headache is usually intense and
often incapacitating and is frequently accompanied by nausea and vomiting and an intolerance to light
(photophobia). Migraines are believed to be triggered by brain chemicals, but their exact cause of these
headaches is not known. Migraines often first occur during the teenage years and are more common in
women. Patients who have family members with migraines are at increased risk to develop these
headaches.
Symptoms of Migraine (type of headache)
Severe headache (throbbing, pounding, pulsating), nausea, vomiting, sensitivity to light or sound. An
aura may precede the headache consisting of seeing stars or zigzag lines, tunnel vision, or a temporary
blind spot.
Tests for Migraine (type of headache)
Workup
A history and physical exam will be performed. Tests to rule out other causes of the headaches may be
done.

Tests
CT Scan and MRI
Additional tests that may be required
Lumbar puncture
Specialists
Family Practice, Internal Medicine, Neurology, Pain Medicine, Pediatric Neurology and Pediatrics
Treatment of Migraine (type of headache)
Therapy depends on the severity of the headaches. Several different types of medications may be used
including: ergots like dihydroergotamine, ergots with caffeine (Cafergot); and/or triptans like
sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and zolmitriptan
(Zomig). They can be taken orally, nasally or as a self-injection. Medications to help prevent the
frequency and severity of migraines include certain antidepressants, blood pressure medications, and
anti-seizure drugs. For more information contact the American Headache Society: (800)255-2243
(800)255-2243.
m. Presbyopia (aging vision)
Description of Presbyopia (aging vision)
Presbyopia is the difficulty focusing on objects that are close due to a hardening of the lens in the eye.
The lens naturally begins to harden as we age. This hardening begins as early as age ten but symptoms
usually do not begin until age forty.
Symptoms of Presbyopia (aging vision)
Symptoms include difficulty seeing objects that are close, headaches and eye fatigue.
Tests for Presbyopia (aging vision)
Workup
A complete history and physical will be performed. A specific ophthalmologic exam and visual testing
will be performed.
Specialists
Family Practice, Internal Medicine and Ophthalmology
Treatment of Presbyopia (aging vision)

Treatment usually consists of prescribing glasses or contacts to correct the vision problems. Over-thecounter readers may be effective for some individuals.
n. Transient ischemic attack (TIA, reversible stroke)
Description of Transient ischemic attack (TIA, reversible stroke)
A temporary decrease in the blood supply to some part of the brain. The affected part of the brain does
not function properly, producing the symptoms observed. The syndrome looks similar to a stroke except
the symptoms last less than 24 hours and the majority resolve in the first hour. The most common
causes of TIA are atherosclerosis and atrial fibrillation. These patients need a prompt work-up to identify
and treat the cause of the TIA because of the high risk of stroke, especially within the first week after a
TIA.
Symptoms of Transient ischemic attack (TIA, reversible stroke)
Weakness or numbness on one side of the face or body, slurred speech, inability to speak, transient
visual loss in one eye, sensation that the room is moving (vertigo), loss of balance, lack of coordination.
Tests for Transient ischemic attack (TIA, reversible stroke)
Workup
A history and physical exam will be performed. Tests to determine the cause of the symptoms, and
identify any blocked arteries or irregular heart beat will be done. These tests often include a head CT
scan or brain MRI, EKG monitoring and ultrasound exam of the carotid arteries.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG)
and MRI
Additional tests that may be required
Carotid ultrasound, CT angiogram, MR angiogram
Specialists
Neurology
Treatment of Transient ischemic attack (TIA, reversible stroke)
The goal is to prevent the development of a stroke. Specific treatment depends on what is causing the
decreased blood flow to the brain and may include: platelet inhibitors (aspirin, clopidogrel/Plavix,
aspirin/extended-release dipyridamole/Aggrenox), anti-coagulants (heparin, enoxaparin, warfarin),
and/or carotid artery surgery.

10. BLISTER (Pocket of fluid)
a. Burns
Description of Burns
The body's reaction to heat, radiation, electricity or chemicals which causes damage to the skin and
sometimes organs. Electrical and radiation burns may involve tissues underneath the skin, such as the
intestinal tract, nerves, spinal cord, heart and brain. Burns caused by contact involve primarily the skin.
They can be superficial or destroy all layers of the skin. Any burn that causes singed nasal hairs or the
coughing up of darkish sputum requires immediate medical treatment since the respiratory tract may be
injured. Burns involving larger areas of the body can result in a great deal of fluid being lost and result in
life threatening dehydration. Potential injury is greatest with infants, young children and the elderly.
Symptoms of Burns
Injury to the skin causes: pain, redness, blistering, dehydration and a skin infection. Injury to the
respiratory tract causes: cough, singed nasal hairs, shortness of breath, wheezing.
Tests for Burns
Workup
A history and physical exam will be performed. A chest x-ray and blood tests may be done for more
serious burns.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Specialists
Family Practice, Internal Medicine, Pediatrics and Trauma Surgery
Treatment of Burns
Wound care and treatment of pain for minor burns. Simple burns can be treated by running them under
cool water, cleaning with a mild soap, and keeping them covered with a clean bandage. More serious
burns that completely surround an arm or leg can result in decreased blood supply and may require a
emergent surgical procedure (escharotomy). Serious cases that involve larger areas of the body may
require intravenous fluids and observation in the hospital. Babies and the elderly are treated more
aggressively. Burns to the hands and face require specialized treatment to prevent permanent damage
and scarring.
b. Chemical burn
Description of Chemical burn

Chemicals that touch the skin can lead to a reaction on the skin. Some can be absorbed and affect the
body as well. A chemical reaction should be suspected when a reaction occurs after a new exposure to
any chemical. It is often seen immediately, but can be seen after long term use. Consider a chemical
burn in children with a new unexplained skin reaction. Keep all chemicals out of reach of children to
prevent occurrence.
Symptoms of Chemical burn
Skin reactions include: redness, pain, itching, burning, tenderness, hives. If the chemical is absorbed the
following reactions include: abdominal pain, breathing difficulty, bright red or bluish skin and lips,
convulsions (seizures), dizziness, headache, nausea, vomiting, weakness.
Tests for Chemical burn
Workup
A history and physical exam will be performed. Generally no tests are necessary.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Chemical burn
First remove the chemical and clean the skin with water. Try to avoid exposing others while cleaning off
the chemical. Localized skin reactions will require burn care. Treatment depends on the depth of the
burn. Severe and extensive burns may be life threatening and require aggressive cardiac and respiratory
support
c. Herpes simplex infection (viral infection)
Description of Herpes simplex infection (viral infection)
A virus that causes painful blisters on the skin and the mucus membranes. They occur around the
mouth, lips and the genitals. Herpes simplex type 1 (HSV-type 1) commonly causes oral sores like fever
blisters on the mouth or face (oral herpes). HSV-type 2 typically affects the genital area (genital herpes).
Once infected, the blisters may heal but the virus may remain dormant within the nerve cells. When a
patient experiences emotional or physical stress the lesions of HSV can return in one area of the skin.
The virus is very contagious and spreads from physical contact such as kissing or sexual intercourse.
Symptoms of Herpes simplex infection (viral infection)
Painful blisters, red bumps, weeping blisters, recurrence in the same area is common.
Tests for Herpes simplex infection (viral infection)
Workup

A history and physical exam will be performed. A culture of a blister or a direct fluorescent antibody
(DFA) test can be done to establish the diagnosis.
Additional tests that may be required
Viral culture, direct fluorescent antibody (DFA) test
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Herpes simplex infection (viral infection)
Treatment includes: antiviral treatment (acyclovir/Zovirax, famciclovir/Famvir), nonsteroidal antiinflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), and pain
medications such as acetaminophen (Tylenol).
d. Impetigo (bacterial skin infection)
Description of Impetigo (bacterial skin infection)
Impetigo is a common skin infection. It is highly contagious and usually affects infants and children. The
crusty lesions are typically found around the mouth and on the face. The infecting bacteria are mostly of
the streptococcal or staphylococcal species. These bacteria can enter normal skin, but more often
invade skin affected by cuts, insect bites, or a pre-existing rash. The disorder usually resolves on its own,
but treatment with topical or oral antibiotics reduces the complication rate.
Symptoms of Impetigo (bacterial skin infection)
Red and oozing rash. Many times the rash has painless blisters that burst causing crusting. The rash is
mostly found on the face and around the mouth, but can involve any part of the body.
Tests for Impetigo (bacterial skin infection)
Workup
A history and physical exam will be performed. Diagnosis is usually made by examining the skin. At times
a skin biopsy is performed. A culture of the skin lesion usually grows the bacteria streptococcus or
staphylococcus and may be performed to identify methicillin resistant Staphylococcus aureus (MRSA).
MRSA requires a different antibiotic treatment then is usually prescribed for impetigo.
Additional tests that may be required
Skin biopsy
Specialists

Dermatology, Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Dermatology
and Pediatrics
Treatment of Impetigo (bacterial skin infection)
The goal is to cure the infection and prevent recurrence. Treatment consists of good hygiene and
antibiotics. Topical antibiotics include mupirocin (Bactroban). Oral antibiotics include cephalexin
(Keflex), erythromycin, or dicloxacillin. If MRSA is suspected, other antibiotics may be utilized.
e. Overuse syndrome (injury from repetitive activity)
Description of Overuse syndrome (injury from repetitive activity)
Muscle or nerve pain caused by repetitive use of a muscle or by clenching (tight contraction) of a
muscle. Examples of overuse syndromes include: carpal tunnel syndrome, tarsal tunnel syndrome,
tennis elbow, tendonitis, temporomandibular joint (TMJ) syndrome and certain sprains and strains. Also
called cumulative trauma disorder or repetitive strain injury.
Symptoms of Overuse syndrome (injury from repetitive activity)
Pain, tingling of the skin, tenderness, stiffness, decreased range of motion.
Tests for Overuse syndrome (injury from repetitive activity)
Workup
A history and physical exam will be performed. Most of the time overuse syndromes can be identified
without special tests.
Tests
MRI and X-ray
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pediatric Sports Medicine, Pediatrics, Podiatry
and Sports Medicine
Treatment of Overuse syndrome (injury from repetitive activity)
Treatment includes identifying the activity that resulted in symptoms and reducing or modifying this
activity. Nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn) or acetaminophen (Tylenol) can relieve pain. Injection, splinting, bracing, or
physical therapy may be recommended.
f.

Pemphigus (rare skin disorder)

Description of Pemphigus (rare skin disorder)

A disease in which a patient's own immune system attacks (autoimmune disease) their skin and mucous
membranes (mouth and genitals). The outer part of the skin separates from the inner part of the skin in
various places, causing blisters to form. These blisters can cause open sores and lead to skin infections.
Rarely these infections can become serious. The disorder can occur at any age but is more common in
the middle age group. There are three types of pemphigus. Pemphigus vulgaris is the most common
type and affects the skin and mucous membranes. Pemphigus foliaceus only involves the skin.
Paraneoplastic pemphigus involves the skin, and is associated with cancer.
Symptoms of Pemphigus (rare skin disorder)
Blisters on the skin, in the mouth and on the genitals. If a skin infection occurs the patient will
experience skin redness, skin swelling, increased warmth and pain.
Tests for Pemphigus (rare skin disorder)
Workup
A history and physical exam will be done. The Nikolsky sign is a test done in the office where the
provider will apply skin pressure next to a blister. If the skin shears away over the blister this is a positive
Nikolsky sign and suggests the patient has pemphigus. A skin biopsy can confirm the disease.
Specialists
Dermatology, Family Practice, Internal Medicine, Pediatric Dermatology and Pediatrics
Treatment of Pemphigus (rare skin disorder)
Treatment includes steroids and immunosuppressants. Both treatments quiet the overactive immune
system, and prevent the body from attacking itself. If the disease is severe plasmapheresis may be done.
Plasmapheresis is performed by removing the patient's plasma and replacing it with donor plasma.
g. Skin blood vessel damage (Chilblains, pernio)
Description of Skin blood vessel damage (Chilblains, pernio)
Chilblains, also known as pernio, occurs with a combination of cold air and humidity. It most often
happens when hands, feet, ears or nose are suddenly rewarmed after being very cold. The symptoms of
itching, red patches, swelling and blistering, occur from inflammation of the small blood vessels
secondary to the rapid temperature change. The disorder does not cause permanent damage unless an
associated infection occurs. Chilblains can re-occur with repeated exposure to the cold. Chilblains may
occur more often in people with autoimmune diseases.
Symptoms of Skin blood vessel damage (Chilblains, pernio)
Usually affects the fingers, toes, ears and nose. Small itchy red areas on the skin, blistering, burning
sensation, swelling, changes in skin color from red to dark blue, pain. In severe case ulcers can occur.

Tests for Skin blood vessel damage (Chilblains, pernio)
Workup
A history and physical exam will be done. Tests to determine the extent of the damage may be
performed.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Skin blood vessel damage (Chilblains, pernio)
Any damage to the skin should be kept clean and dry and covered with a sterile dressing. Specific
treatment includes steroid creams such as hydrocortisone 1%, and medications to prevent recurrence
such as nifedipine (Adalat, Procardia). Any associated infections will be treated with antibiotics.
h. Sunburn
Description of Sunburn
Damage to the skin caused by too much exposure to the sun. Ultraviolet rays from the sun burn the skin.
Sunburn occurs whenever people engage in outdoor activities without appropriate protection either
with clothing and/or sun blocking agents such as suntan lotions. For best prevention one should use a
lotion with the highest SPF (sun protection factor). A sunburn can also occur from improper use of
tanning beds. A severe sunburn can become sun poisoning which is a potentially life threatening
reaction to the damage.
Symptoms of Sunburn
Skin redness, skin peeling, itching, painful skin, blisters. The symptoms begin 6-48 hours after exposure.
Repeated sunburns result in permanent damage and premature aging of the skin. A sunburn can
become sun poisoning which is very serious and consists of fever, vomiting, fainting, near-fainting, and
confusion.
Tests for Sunburn
Workup
A history and physical exam will be done. Usually no other tests are needed.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Sunburn

The best treatment is prevention by: limiting direct exposure to the sun, wearing clothing that covers
the arms and legs, wide brim hats that shield the neck and face, and applying skin blocking agents.
Select a sun blocking agent with the highest SPF (sun protection factor) as possible, and a water
resistant variety of activities around water will be performed. Once a sunburn occurs avoid any further
exposure to the sun. Cool showers or baths will help with the discomfort. If there are no blisters then
moisturizing creams can be applied. Ibuprofen (Motrin/Advil) or acetaminophen (Tylenol) can be used to
alleviate the pain. Medical treatment should be obtained if there is fever, fainting, vomiting, severe pain,
or confusion.

11. BLOATING
a. Ascites (fluid in the abdomen)
Description of Ascites (fluid in the abdomen)
Excess fluid in the space (the peritoneal cavity) inside the abdomen that is not occupied by abdominal
organs. There are many causes of ascites with the most common being liver failure and cancer. The fluid
build-up can become severe enough to make breathing difficult, because the fluid pushes upward on the
lungs and preventing their normal expansion. The fluid can also become infected leading to spontaneous
bacterial peritonitis, a potentially life threatening condition.
Symptoms of Ascites (fluid in the abdomen)
Abdominal swelling, weight gain, abdominal pain, difficulty breathing.
Tests for Ascites (fluid in the abdomen)
Workup
A history and physical exam will be performed. The provider may take ascites fluid from the abdomen to
analyze it. This is called a paracentesis. A CT scan, ultrasound and/or MRI may be done to help
determine the cause of the fluid.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, MRI and Ultrasound
Additional tests that may be required
Cell count, protein, LDH, Gram stain, culture
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Ascites (fluid in the abdomen)

Therapy is aimed at determining and reversing the cause of the ascites. Simply removing the fluid
(paracentesis) is many times only a temporary solution since the fluid accumulates over time,
sometimes very quickly within days. Medicines that increase urine output called diuretics are frequently
used with the most common being spironolactone (Aldactone) and furosemide (Lasix). Decreasing salt
intake can also sometimes help prevent the fluid from returning.
b. Celiac disease (celiac sprue)
Description of Celiac disease (celiac sprue)
An inherited, autoimmune disease in which the lining of the small intestine is damaged from eating
gluten and other proteins found in wheat, barley, rye, and oats. The disease causes diarrhea,
malabsorption, steatorrhea, nutritional and vitamin deficiencies, and in children can result in failure to
thrive and short stature. This disorder is more common in patients who have Type 1 diabetes,
autoimmune disorders, microscopic colitis, lactose intolerance, Down syndrome, and intestinal cancer.
Avoiding foods with gluten allows the intestine to heal but this can take months or even years for
complete resolution of symptoms.
Symptoms of Celiac disease (celiac sprue)
Abdominal pain, abdominal distension, constipation, decreased appetite, diarrhea, nausea, vomiting,
lactose intolerance, fatty stools, weight loss.
Tests for Celiac disease (celiac sprue)
Workup
A history and physical exam will be performed. Blood tests to detect antibodies in the blood. Endoscopy
and biopsy of small intestine may be necessary.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Endoscopy, biopsy, antibody detection
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Celiac disease (celiac sprue)
Treatment includes avoidance of any gluten in the diet including all foods made from wheat, rye, and
barley. Examples include: breads, cereals, pasta, crackers, cakes, pies, cookies, and gravies. Counseling
by a Nutritionist may be particularly helpful. For more information contact the National Digestive

Diseases Information Clearinghouse at: http://digestive.niddk.nih.gov or (800)891-5389
5389

(800)891-

c. Constipation
Description of Constipation
Difficult, uncomfortable, or infrequent bowel movements. The feces is typically hard and dry.
Constipation is usually harmless, but it can indicate an underlying disorder. When severe constipation
can lead to fecal impaction, and if not relieved can result in intestinal obstruction. The primary causes of
constipation include dehydration, sedentary lifestyle, medications (especially narcotics), stress,
pregnancy, laxative abuse, depression, a diet that is low in fiber, and low thyroid levels.
Symptoms of Constipation
Inability to have a bowel movement, rectal pain, abdominal cramping, nausea, vomiting.
Tests for Constipation
Workup
A history and physical exam will be performed. Generally no tests beyond an examination is needed
although a blood thyroid test may be recommended . Occasionally a CT scan is performed to rule out
other more serious causes.
Tests
CT Scan and X-ray
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Constipation
Treatment includes: medications to increase the water content of stool, laxatives, enemas, and/or
digital disimpaction. Prevention of recurrence is important and involves increasing dietary fiber, exercise
and staying hydrated. Chronic use of stool softeners may be needed. Changing medications that might
be contributing to constipation (such as certain pain medications) may be helpful.
d. Inguinal hernia (groin hernia)
Description of Inguinal hernia (groin hernia)
Occurs when tissue pushes through a weak spot in the groin muscle. This causes a bulge in the groin or
scrotum. The bulge may hurt or burn. The hernia may get larger with straining. If the bulge does not go
away with relaxation it can become lodged in the defect (an "incarcerated hernia"). Intestine can

become trapped in the hernia and lose its blood supply leading to a serious surgical emergency named
strangulation.
Symptoms of Inguinal hernia (groin hernia)
Groin discomfort, groin pain aggravated by bending or lifting, a groin lump or scrotum lump that
increases with straining or cough, a non-tender bulge or lump in children.
Tests for Inguinal hernia (groin hernia)
Workup
A history and physical exam will be performed. The diagnosis can often be established by physical
examination alone; an abdominal ultrasound or abdominal CT scan can confirm the diagnosis.
Tests
CT Scan and Ultrasound
Specialists
General Surgery and Pediatric Surgery
Treatment of Inguinal hernia (groin hernia)
Most hernias can be pushed back into the abdominal cavity. If it cannot be pushed back through the
abdominal wall the hernia may need to be emergently repaired to prevent the intestine from losing its
blood supply and dying (strangulation). Strangulation can lead to peritonitis and this complication can be
life threatening. Inguinal hernias often require surgery; however, some can be followed closely.
e. Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
Description of Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
Recurrent constipation and diarrhea associated with abdominal pain. The colon in irritable bowel
syndrome is normal appearing, but the symptoms are thought to come from abnormal contractions of
the colon. It is not contagious or inherited. Women are affected twice as often as men and the cause of
the disorder is not known.
Symptoms of Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
The symptoms can be mild to severe. Many patients have variable periods of diarrhea, constipation and
normal bowel movements. Other symptoms include abdominal pain, tenderness, distension or fullness,
gas, bloating, nausea and vomiting, loss of appetite, emotional distress, and depression.
Tests for Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
Workup

A history and physical exam will be performed. EGD (esophagogastroduodenoscopy) and/or
colonoscopy may be performed. Tests typically reveal no physiologic abnormalities that can explain the
symptoms.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
EGD (esophagogastroduodenoscopy), colonoscopy
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
Therapy depends on the severity of the symptoms. The following medications may be prescribed:
anticholinergic medications before meals, anti-diarrheal medications, and/or low-dose antidepressants.
Counseling and dietary changes are often recommended. For more information contact the National
Digestive Diseases Information Clearinghouse at: http://digestive.niddk.nih.gov or call (800) 891-5389
(800) 891-5389
f.

Lactose intolerance

Description of Lactose intolerance
Deficiency of lactase- the enzyme made in the small intestine that helps metabolize lactose. Also called
lactase deficiency. Lactose is the primary sugar found in milk products. Not all patients with low levels of
lactase experience symptoms. Patients must have low levels of lactase and have symptoms to be
diagnosed with this disorder. Lactase deficiency can occur with aging, or after a physical stress such as
bowel surgery, infections of the small intestine, or with celiac disease.
Symptoms of Lactose intolerance
Symptoms usually begin 30 minutes to 2 hours after eating a meal containing lactose and include:
diarrhea, nausea, abdominal pain, bloating, gas, and excess fat in stool (steatorrhea). Most patients only
experience mild symptoms but for some they are severe.
Tests for Lactose intolerance
Workup
A history and physical exam will be done. 3 tests can be performed to diagnose lactose intolerance:
lactose tolerance test, hydrogen breath test, and stool acidity test. Only the stool acidity test is
appropriate for infants and small children.

Additional tests that may be required
lactose tolerance test, hydrogen breath test, stool acidity test
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Lactose intolerance
The best treatment is to avoid eating foods high in lactose. The missing enzyme lactase can be taken as a
pill prior to eating a meal high in lactose and some find relief with this remedy.
g. Malabsorption syndrome (abnormal intestinal digestion)
Description of Malabsorption syndrome (abnormal intestinal digestion)
Characterized by poor absorption of nutrients, vitamins and minerals from the intestinal tract into the
bloodstream. Many diseases cause malabsorption, such as celiac disease, certain medications, certain
types of cancer, certain types of surgery, chronic liver disease, chronic pancreatitis, Crohn's disease, and
persistent parasite infections.
Symptoms of Malabsorption syndrome (abnormal intestinal digestion)
Bloating, cramping, gas, chronic diarrhea, foul smelling and greasy stools, weight loss, decreased muscle
mass.
Tests for Malabsorption syndrome (abnormal intestinal digestion)
Workup
A history and physical exam will be performed. Multiple tests to determine the cause of the
malabsorption may be performed including blood tests, stool studies, abdominal CT scan, and
endoscopy.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and Urinalysis (UA)
Additional tests that may be required
D-xylose test, hydrogen breath test, qualitative stool fat test, quantitative stool fat test, schilling test for
vitamin B12, secretin stimulation test, small bowel biopsy, stool culture, culture of small intestine
aspirate
Specialists
Gastroenterology and Pediatric Gastroenterology

Treatment of Malabsorption syndrome (abnormal intestinal digestion)
Treatment will depend upon the specific disease or condition causing the malabsorption. If the cause is
chronic pancreatitis, taking oral pancreatic enzymes may help. In addition, therapy will include efforts to
correct protein, calorie, vitamin and mineral deficiencies. Intravenous fluids, vitamins, and nutrient
replacement may be necessary if oral intake is not sufficient.
h. Paralytic Ileus (intestinal paralysis)
Description of Paralytic Ileus (intestinal paralysis)
A temporary paralysis of a portion of the intestines after an abdominal surgery. The syndrome causes
constipation, abdominal distension, and sometimes vomiting. It usually resolves on its own but may limit
the ability to eat for some days following surgery.
Symptoms of Paralytic Ileus (intestinal paralysis)
Absent bowel sounds, abdominal fullness, gaseous abdominal distention, abdominal pain and cramping,
vomiting, failure to pass gas or stool (constipation), diarrhea.
Tests for Paralytic Ileus (intestinal paralysis)
Workup
A history and physical exam will be performed. Usually the diagnosis is obvious if surgery has just
occurred. Abdominal X-rays may be done to confirm the problem.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, Urinalysis (UA)
and X-ray
Additional tests that may be required
Barium enema, upper GI and small bowel series
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Paralytic Ileus (intestinal paralysis)
A nasogastric (NG) tube from the nose to the stomach can relieve nausea. This problem almost always
improves on its own within a few days.
i.

Urine retention (inability to urinate)

Description of Urine retention (inability to urinate)

The inability to empty the bladder. Urinary retention can be caused by an obstruction in the urinary
tract or by nerve problems that interfere with signals between the brain and the bladder. There are
many causes, and the disorder can occur over a long period of time (chronic) or abruptly (acute). People
with chronic retention are able to urinate but the stream is decreased and many times they cannot
empty the bladder completely. Acute retention is an emergency since the kidneys can fail if the urine is
not able to drain. In men, an enlarged prostate is the most common reason for urinary retention.
Symptoms of Urine retention (inability to urinate)
Lower abdominal pain, flank pain, lower abdominal distension, dribbling of urine, urinary frequency.
Tests for Urine retention (inability to urinate)
Workup
A history and physical exam will be performed. A bladder ultrasound and/or catheter insertion to
measure the amount of urine retained in the bladder after voiding. Blood tests for BUN and creatinine
to assess kidney function.
Tests
CT Scan, Ultrasound and Urinalysis (UA)
Additional tests that may be required
Urodynamic tests, bladder scan, cystoscopy
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Urine retention (inability to urinate)
Therapy is aimed at relieving the obstruction and reversing the cause of the retention. Initial treatment
is insertion of a catheter into the bladder. Antibiotics are given if the urine is infected. Men with an
enlarged prostate may require surgery. For additional information contact the National Kidney and
Urologic Diseases Information Clearinghouse at: http://www.kidney.niddk.nih.gov or call (800)891-5390
(800)891-5390.

12. BLOOD IN STOOL
*Postoji I odabir da li je u pitanju Rectal pain ili Diarrhea koji suzava simptome
COMMON CAUSES
a. Gastrointestinal bleeding ( intestinal bleeding) *CRITICAL

Description of Gastrointestinal bleeding (stomach, intestine bleeding)
The digestive tract begins with the mouth and includes esophagus, stomach, small and large intestine,
and ends at the anus. Bleeding may occur anywhere along this pathway and may be visible in vomit or in
the stool. The bleeding can be slow and persistent causing anemia and black stools (melena) or fast and
extensive resulting in bright red blood in the stool and dizziness. Rapid gastrointestinal bleeding can be a
life threatening illness.
Symptoms of Gastrointestinal bleeding (stomach, intestine bleeding)
Slow bleeding of a small amount of blood may cause no symptoms. When symptoms are present, they
include: vomiting blood, vomiting material with the appearance of coffee grounds, blood in the stool
(melena or bright red blood), weakness, dizziness, fainting, or abdominal pain.
Tests for Gastrointestinal bleeding (stomach, intestine bleeding)
Workup
A history and physical exam will be performed. Other tests to determine the extent of disease include:
nasogastric tube lavage, rectal exam, EGD (esophagogastroduodenoscopy), colonoscopy, and blood
tests.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Lipase and X-ray
Additional tests that may be required
Endoscopy, Clotting studies, Type and screen
Specialists
Gastroenterology, Pediatric Gastroenterology and Vascular and Interventional Radiology
Treatment of Gastrointestinal bleeding (stomach, intestine bleeding)
Therapy depends on the site and severity of bleeding but may include: proton pump inhibitors
(omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers (cimetidine/Tagamet, ranitidine/Zantac),
endoscopic or colonoscopic cauterization of bleeding, intravenous fluids, blood transfusions, and
antibiotics if caused by H. pylori. Hospitalization may be recommended for significant gastrointestinal
bleeding.
b. Hemorrhoids
Description of Hemorrhoid (enlarged rectal veins)

Dilated veins, similar to varicose veins, that are found in the anal canal (internal hemorrhoids), or at the
anal opening (external hemorrhoids). They are often chronic and become a problem when they bleed,
become painful, develop a blood clot or enlarge. Hemorrhoids may be more likely to develop if you have
been pregnant or tend to sit for prolonged periods, or have constipation, liver disease (cirrhosis), or
infections of the anal canal. In general, internal hemorrhoids bleed but are not painful. External
hemorrhoids are painful but usually do not bleed as much as internal hemorrhoids.
Symptoms of Hemorrhoid (enlarged rectal veins)
Rectal pain, rectal bleeding, fullness in rectum, constipation.
Tests for Hemorrhoid (enlarged rectal veins)
Workup
A history and physical exam will be performed. A sigmoidoscopy or colonoscopy may be recommended
to confirm that the source of bleeding is from hemorrhoids.
Specialists
Colon and Rectal Surgery, Family Practice, General Surgery, Internal Medicine, Pediatric Surgery and
Pediatrics
Treatment of Hemorrhoid (enlarged rectal veins)
Treatment includes: Sitz baths (sitting in warm water), anti-inflammatory suppositories, increased fiber
in the diet, stool softeners, and, in severe cases, surgical resection. The surgeon may band the
hemorrhoid or remove them.
c. Anal fissure (tear)
Description of Anal fissure (tear)
A tear in the lining of the lower anal canal. Most anal fissures happen when a large, hard stool
overstretches the anal opening and tears the delicate inner lining.
Symptoms of Anal fissure (tear)
Rectal pain, constipation, bloody stool.
Tests for Anal fissure (tear)
Workup
A history and physical exam will be performed. Additional tests may include an anoscopy.
Additional tests that may be required

Anoscopy
Specialists
Colon and Rectal Surgery, Family Practice, Internal Medicine and Pediatrics
Treatment of Anal fissure (tear)
Treatment may include: stool softeners, addition of bulk into diet (substances that absorb water while in
the intestinal tract), cleansing more gently, petroleum jelly, sitz bath, anesthetic ointment, and/or
topical muscle relaxants.
d. Gastroenteritis (inflammation of the stomach and intestinal lining)
Description of Gastroenteritis (intestinal infection)
An inflammation of the stomach and/or intestinal lining. It is one of the most common causes of nausea,
vomiting and diarrhea. Gastroenteritis has numerous causes: including infectious organisms (viruses,
bacteria, etc.), food poisoning, and stress. This disorder can be very serious in the very young and very
old causing life threatening dehydration. Internationally this is one of the leading causes of death of
patients of all ages.
Symptoms of Gastroenteritis (intestinal infection)
Nausea, vomiting, diarrhea, abdominal cramping or pain, fever, weakness, dizziness. Occasionally,
bleeding complicates gastroenteritis.
Tests for Gastroenteritis (intestinal infection)
Workup
A history and physical exam will be performed. Other tests include stool studies to identify the organism
responsible for the infection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Lipase and Urinalysis (UA)
Additional tests that may be required
Stool ova and parasite exam, Stool WBC's, Stool culture
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Gastroenteritis (intestinal infection)

Treatment includes: fluids (by mouth, or, if necessary, intravenously), anti-nausea medications, and antidiarrheal medications. Hospitalization may be recommended for marked dehydration.
e. Colon polyps (large intestine tumors)
Description of Colon polyps (large intestine tumors)
Small growths in the large intestine (colon). The growths stick out from the inner lining of the colon, and
push into the empty space inside the colon. Colon polyps usually are harmless although some will turn
into cancers. Whether cancerous or not, polyps can bleed. Polyps are more common in patients with the
following characteristics: eat low fiber diets, family history of polyps, overweight, cigarette smoker, over
50 years old or family history of colon cancer. Some families have genetic conditions that cause multiple
family members to have multiple polyps. One such condition is called familial adenomatous polyposis.
The incidence of these polyps becoming cancerous is quite high and many doctors recommend removal
of the colon to prevent cancer.
Symptoms of Colon polyps (large intestine tumors)
Rectal bleeding, bloody stools, maroon stools. Rarely large polyps can cause a bowel obstruction leading
to abdominal pain, abdominal distension and constipation.
Tests for Colon polyps (large intestine tumors)
Workup
A history and physical exam will be done. A colonoscopy or sigmoidoscopy will be done to make the
diagnosis. Special CT scans can diagnose polyps as well.
Tests
Colonoscopy and CT Scan
Additional tests that may be required
sigmoidoscopy
Specialists
Gastroenterology, General Surgery, Pediatric Gastroenterology and Surgical Oncology
Treatment of Colon polyps (large intestine tumors)
Polyps generally are removed and examined under a microscope to detect early cancer and to prevent
the polyps from becoming cancer later. Most polyps can be removed through the scope the doctor uses
to identify the polyps (colonoscopy). Rarely a polyp is too large to be removed during colonoscopy and
surgery is required. If a patient has familial adenomatous polyposis complete colon removal is
recommended.

Additional Causes

a. Gastric ulcer (stomach ulcer) *CRITICAL
Description of Gastric ulcer (stomach ulcer)
An erosion of the lining of the stomach. At times these ulcers can cause life-threatening bleeding. Rarely
the ulcers are secondary to cancer. An infection with the bacteria Helicobacter pylori (H. pylori) can
increase the incidence and severity of the disease. The following conditions increase the risk of this
disorder: drinking alcohol, use of nonsteroidal anti-inflammatory drugs / NSAIDs (ibuprofen, naproxen,
aspirin), smoking, and physical stress (infections, trauma, hospital admissions). Rarely the ulcer can
extend through the entire lining of the stomach (perforation) and result in a life threatening abdominal
infection (peritonitis).
Symptoms of Gastric ulcer (stomach ulcer)
Abdominal pain, nausea, vomiting, vomiting blood, vomiting material that has the appearance of coffee
grounds, black stools (melena), bloody stools, burning in chest.
Tests for Gastric ulcer (stomach ulcer)
Workup
A history and physical exam will be performed. Other tests to determine the extent of disease include:
nasogastric tube lavage, rectal exam, EGD (esophagogastroduodenoscopy), and blood tests.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Lipase
and X-ray
Additional tests that may be required
Endoscopy, urea breath test, H.Pylori test, Clotting studies, Type and screen, Gastric culture
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Gastric ulcer (stomach ulcer)
Treatment depends on the severity of the illness and includes: proton pump inhibitors
(omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers (cimetidine/Tagamet, ranitidine/Zantac),
endoscopic cauterization of bleeding, intravenous fluids, blood transfusions, antibiotics if caused by H.
pylori, and hospitalization. Surgery may be necessary if complications, such as perforation or
uncontrolled bleeding, develop.

b. Crohn's disease (Intestinal inflammation) *CRITICAL
Description of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
A recurrent inflammatory disease affecting the gastrointestinal tract. Sections of the intestinal tract
most commonly affected include the lower part of the small intestine (ileum) and the large intestine
(colon); however, any part of the digestive tract, from mouth to rectum, may be involved. It is an
autoimmune disease and is most common in people between the ages of 15 and 35. Other risk factors
are a family history of Crohn's disease, Jewish ancestry and smoking.
Symptoms of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Crampy abdominal pain, nausea, vomiting, loss of appetite, watery or bloody diarrhea, fever, joint pain,
painful bowel movements, weight loss , fatigue, black stools (melena), and skin, eye or joint
inflammation (arthritis)
Tests for Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Workup
A history and physical exam will be performed. Other tests to confirm the diagnosis and identify
complications may be performed, including a barium enema or upper GI series, colonoscopy, CT scan or
MRI. Stool tests may be recommended to check for blood or other causes of symptoms, such as
infection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, MRI and X-ray
Additional tests that may be required
Upper GI series, colonoscopy
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
Aminosalicylates (5-ASAs) help control inflammation, and can be given rectally or orally. Corticosteroids
(prednisone and methylprednisolone) are used to treat moderate to severe Crohn's disease. They may
be taken by mouth or inserted into the rectum. Azathioprine and 6-mercaptopurine are
immunomodulators and they help reduce the need for corticosteroids and can help heal some fistulas.
Antibiotics may be used for abscesses or fistulas. Infliximab (Remicade), adalimumab (Humira),
certolizumab (Cimzia), and natalizumab (Tysabri) are powerful anti-inflammatory immune modulators
(called "biologics") that are used for severe cases that don't respond to other treatments. Surgery may
be needed for fistulas or active disease that does not respond to medications. For more information

contact the National Digestive Diseases Information Clearinghouse at:
http://www.digestive.niddk.nih.gov or (800)891-5389
(800)891-5389. Further information is
available at the Crohn's and Colitis Foundation of America at: http://ccfa.org
c. Gastritis (stomach inflammation)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
d. Irritable bowel syndrome (IBS)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
e. Diverticulosis
Description of Diverticulosis (weakening of the large intestine wall)
A condition in which the wall of the large intestine bulges out like a balloon. The multiple bulges are
called diverticula. The complications of diverticulosis include infection (diverticulitis) and bleeding. The
disorder is more common with advancing age: over 50% of patients older than 60 have diverticula.
Other risk factors for acquiring diverticulosis include constipation, a diet that is low in dietary fiber
content or high in fat and high intake of meat and red meat. Many patients have diverticulosis without
having any symptoms.
Symptoms of Diverticulosis (weakening of the large intestine wall)
Most people with diverticulosis do not have any discomfort or symptoms. Symptoms may include:
abdominal pain (usually in the lower left abdomen), bloating, constipation.
Tests for Diverticulosis (weakening of the large intestine wall)
Workup
A history and physical exam will be done. The following tests can diagnose diverticulosis: abdominal CT
scan, colonoscopy, barium enema, or abdominal MRI.
Tests
CT Scan and MRI
Additional tests that may be required
colonoscopy, barium enema
Specialists
Family Practice, Gastroenterology and Internal Medicine
Treatment of Diverticulosis (weakening of the large intestine wall)

Therapy depends on the severity of the symptoms and whether or not diverticulitis is involved. A highfiber diet and pain medications help relieve symptoms in most cases of diverticulosis. Mild diverticulitis
can be treated with oral antibiotics (levofloxacin/Levaquin, metronidazole/Flagyl), and pain medications.
More serious cases require intravenous antibiotics and possible surgery.
f.

Bacterial dysentery (Bloody diarrhea) *CRITICAL

Description of Bacterial dysentery (bacterial infection of the intestines)
Diarrhea characterized as frequent loose stools, often with blood and mucus. The diarrhea is caused by
inflammation of the large intestine secondary to a bacterial infection. The most common bacteria
causing this infection are shigella, salmonella, and campylobacter. The infection is usually acquired by
eating spoiled food or infected water.
Symptoms of Bacterial dysentery (bacterial infection of the intestines)
Diarrhea, loose stools, bloody stools, abdominal pain, rectal pain, fever, nausea, vomiting.
Tests for Bacterial dysentery (bacterial infection of the intestines)
Workup
A history and physical exam will be performed. Labs will be done to rule out electrolyte abnormalities
and anemia. Stool studies will be performed to determine the cause.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Stool culture, Stool for ova and parasites
Specialists
Family Practice, Gastroenterology, Infectious Disease Medicine, Internal Medicine, Pediatric
Gastroenterology, Pediatric Infectious Disease Medicine and Pediatrics
Reviewed by Harvard Medical School
Treatment of Bacterial dysentery (bacterial infection of the intestines)
Treatment depends on the severity of the infection and the bacteria causing the infection. Treatment
can include antibiotics, observation, and either oral or intravenous fluids to reverse dehydration.
g. Colonic diverticulitis (large intestine inflammation of diverticula) *CRITICAL
Description of Colonic diverticulitis (inflammation of pouches in the large intestine)

A diverticulum is an outpouching of the colon that develop as one ages. Diverticulitis occurs when the
opening of these pouches become blocked and get inflamed or infected. The pain is in the lower
abdomen and more likely on the left. If severe, the diverticulum can perforate and lead to a life
threatening infection.
Symptoms of Colonic diverticulitis (inflammation of pouches in the large intestine)
Lower abdominal pain (more common on the left), diarrhea, fever, nausea, vomiting, low blood
pressure.
Tests for Colonic diverticulitis (inflammation of pouches in the large intestine)
Workup
A history and physical exam will be performed. Blood tests and a CT scan or MRI may be performed to
define the disease and determine the extent of the involvement. A CT scan is especially useful in
identifying a perforation and/or abscess.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI), Urinalysis (UA) and X-ray
Specialists
Family Practice, Gastroenterology and Internal Medicine
Treatment of Colonic diverticulitis (inflammation of pouches in the large intestine)
If not severe, diverticulitis can be treated with oral antibiotics, More serious cases require intravenous
antibiotics and bowel rest. Abscesses require drainage either percutaneously or surgically. If the
infection is severe the affected colon may need to be removed surgically.
h. Ulcerative colitis (large intestine inflammation)
Description of Ulcerative colitis (large intestine inflammation)
An inflammatory disease of the colon (large intestine) characterized by ulceration and episodes of
bloody diarrhea. The inflammation begins in the rectum and spreads upward. The ulcerated areas
become inflamed and may form small abscesses in the lining of the large intestine. The symptoms can
be confused with an infection of the colon. The symptoms are recurrent. It is most commonly seen in
women between the ages 15 and 40. There is an increased incidence of colon cancer associated with
ulcerative colitis.
Symptoms of Ulcerative colitis (large intestine inflammation)

Diarrhea, often with blood and mucous, crampy abdominal pain, fever, weight loss, rectal discomfort
that leads to frequent visits to the bathroom.
Tests for Ulcerative colitis (large intestine inflammation)
Workup
A history and physical exam will be performed. The most common test to establish the diagnosis is
colonoscopy. Blood work is done to look for anemia and markers of inflammation such as ESR and CRP.
Abdominal CT scan be done to rule out complications of colitis.
Additional tests that may be required
colonoscopy with biopsy, barium enema
Specialists
Family Practice, Gastroenterology, General Surgery, Internal Medicine, Pediatric Gastroenterology and
Pediatrics
Treatment of Ulcerative colitis (large intestine inflammation)
The goal of therapy is to calm inflammation, which will help relieve symptoms, decrease attacks and
allow the colon to heal. Treatment may include: hospitalization, corticosteroids, 5-aminosalicylates such
as mesalamine (Asacol), immunomodulators (azathioprine/Imuran, 6-mercaptopurine/6-MP, and
infliximab/Remicade). Surgery to remove the entire colon (total colectomy) may be necessary if the
disease cannot be controlled with medication. This will cure the disease and remove the risk of colon
cancer.
i.

Colon cancer (large intestine tumor) *CRITICAL

Description of Colon cancer (large intestine tumor)
Cancer that develops in the large intestine (colon). Colon cancer can develop from certain types of
benign polyps, called adenomas. Colon cancer usually grows slowly, but it may reach a very large size.
The cancer can obstruct the intestinal tract and/or spread to nearby organs, especially the liver.
Detection of these cancers is readily done through colonoscopy. The earlier these cancers are detected
the more likely the patient will survive the disease. Colon cancer is rare in patients less than 50. Besides
advancing age, risk factors for this disorder include: inflammatory bowel disease (ulcerative colitis and
Crohn's disease), family history of colon cancer or adenomas, eating a high saturated fat/low fiber diet,
a sedentary lifestyle, alcohol use, smoking, and familial adenomatous polyposis. Ethnic heritage may
also play a role, as the disease is highest in Alaska natives and lowest in Hispanics and Filipinos.
Symptoms of Colon cancer (large intestine tumor)
Abdominal pain, abdominal bloating, nausea, vomiting, constipation, fatigue, unexplained weight loss,
anemia, blood in stools.

Tests for Colon cancer (large intestine tumor)
Workup
A history and physical exam will be performed. Colonoscopy and colon biopsy will be performed to
confirm the diagnosis. Additional tests include: CT scan, MRI and/or Positron Emission Tomography
(PET) scan to identify metastases.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Magnetic resonance
imaging (MRI)
Additional tests that may be required
Colonoscopy, colon biopsy
Specialists
Blood and Cancer Care (hematology and oncology), Gastroenterology, General Surgery and Surgical
Oncology
Treatment of Colon cancer (large intestine tumor)
Therapy depends on the extent of the disease. If the disease is not advanced, surgical removal of the
tumor may be curative. Chemotherapy and radiation therapy treatment is used for residual tumor and
any metastases. American Cancer Society: (800)227-2345
j.

Intestinal volvulus (twisting of intestine) *CRITICAL

Description of Intestinal volvulus (twisting of intestine)
Twisting of the bowel causing a blockage of food material and usually decreased blood flow to the
affected intestine. The intestine can die causing peritonitis and death. The volvulus may occur in
children due to a congenital abnormality while in adults it is associated with overuse of laxatives and
psychiatric disease (or its treatment). Often, no cause can be identified.
Symptoms of Intestinal volvulus (twisting of intestine)
Abdominal fullness, gaseous, abdominal distention, abdominal pain and cramping, vomiting, failure to
pass gas or stool (severe constipation), diarrhea.
Tests for Intestinal volvulus (twisting of intestine)
Workup
A history and physical exam will be performed. Imaging studies are performed to establish the diagnosis.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, Urinalysis (UA)
and X-ray
Additional tests that may be required
Barium enema, upper GI and small bowel series
Specialists
General Surgery and Pediatric Surgery
Treatment of Intestinal volvulus (twisting of intestine)
Most cases of volvulus require surgical correction. At times a volvulus of the colon can be decompressed
without surgery. Small intestinal volvuli usually require surgery to untwist the bowel and then attach the
intestine to the abdominal wall to prevent recurrence.
k. Rectal cancer (tumor) CRITICAL
Description of Rectal cancer (tumor)
An abnormal and cancerous growth of cells of the rectum. The rectum is the last part of the large
intestine attaching to the anus. The rectum's primary function is to store formed stool in preparation for
evacuation bowel movement. The following things increase the risk of rectal cancer: older age, smoking,
high-fat diet, and personal or family history of polyps or colorectal cancer.
Symptoms of Rectal cancer (tumor)
Rectal pain, painful bowel movements, constipation, abdominal pain, rectal bleeding, unexplained
weight loss.
Tests for Rectal cancer (tumor)
Workup
A history and physical exam will be performed. A colonoscopy and a biopsy can confirm the diagnosis.
Imaging and blood tests can help determine the extent of disease.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Magnetic resonance
imaging (MRI)
Additional tests that may be required
CEA (carcinoembryonic antigen), Colonoscopy, Biopsy

Specialists
Colon and Rectal Surgery, General Surgery, Pediatric Surgery and Surgical Oncology
Treatment of Rectal cancer (tumor)
Treatment depends on the extent of the cancer and may include: surgery, chemotherapy, and/or
radiation therapy. American Cancer Society: (800)227-2345

13. BLOOD IN URINE (HEMATURIA)
COMMON CAUSES
a. Urinary tract infection(UTI)
Description of Bladder infection (cystitis, UTI, urinary tract infection)
Acute infections of the urinary tract can be separated into upper and lower tract infections. The bladder
is the most common site of all infections (cystitis).It is a lower tract infection. Upper tract infections
involve the ureters and kidneys. Kidney infections (pyelonephritis) can be very serious with high fever,
vomiting, and severe pain. Because of the shorter urethras in women they are more prone to develop
urinary tract infections than men. Most urinary tract infections are caused by bacteria. Catheterization
of the bladder increases the risk of the infection. In patents with a weakened immune system (diabetics,
patients receiving chemotherapy, HIV/AIDS, elderly) prompt treatment is needed because of the
increased chance of a life threatening infection developing.
Symptoms of Bladder infection (cystitis, UTI, urinary tract infection)
Cloudy urine, blood in the urine (hematuria), foul or strong urine odor, frequent or urgent need to
urinate, need to urinate at night (nocturia), pain or burning with urination (dysuria), pressure below the
umbilicus of the abdomen. Upper tract infections cause flank pain, fever, loss of appetite, nausea and
vomiting. Elderly patients can experience significant confusion.
Tests for Bladder infection (cystitis, UTI, urinary tract infection)
Workup
A history and physical exam will be performed. A urine analysis (UA) and culture will establish the
diagnosis and identify the organism.
Tests
Urinalysis (UA) and Urine Culture
Additional tests that may be required
Urine culture

Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Bladder infection (cystitis, UTI, urinary tract infection)
Therapy depends on whether the person has a simple lower tract infection vs. an upper tract infection
and the severity of illness. Treatment includes: antibiotics, medications to decrease the burning
(phenazopyridine/Pyridium), and/or pain medications. A urinalysis is sometimes recommended after
treatment to ensure the infection has gone away.
b. Prostatitis (prostate inflammation)
Description of Prostatitis (prostate inflammation)
Infection of the prostate gland, and can be either an acute or a chronic condition. The prostate gland is
located under the bladder, where it surrounds the urethra (the bladder's drainage tube). The gland is a
source of fluid for semen. The inflammation can irritate or put pressure on the tube connecting the
bladder to the penis (urethra), resulting in difficultly urinating, and urinary retention. Palpation of the
prostate during a rectal exam revels a very tender prostate. Rarely an abscess can develop. This disorder
is most often seen in 20-40 year old men, in those with a urinary catheter, and with patients having
unprotected sex with multiple partners.
Symptoms of Prostatitis (prostate inflammation)
Chills and fever, lower abdominal discomfort, pain in the area between the genitals and the anus,
burning with urination, difficulty urinating, urinary retention, painful ejaculation, painful bowel
movement, back pain.
Tests for Prostatitis (prostate inflammation)
Workup
A history and physical exam will be performed. Diagnosis is made by feeling the prostate during a rectal
exam and testing for signs of inflammation in the urine. A urine culture can identify the bacteria.
Tests
CT Scan and Urinalysis (UA)
Additional tests that may be required
Urine culture
Specialists
Family Practice, Internal Medicine and Urology

Treatment of Prostatitis (prostate inflammation)
Oral antibiotics are usually effective. The most commonly used are: trimethoprim-sulfamethoxazole
(Bactrim), fluoroquinolones (Floxin, Cipro, Levaquin), and tetracycline derivatives. If a STD is considered
the source, a shot of ceftriaxone followed by oral doxycycline or ofloxacin is recommended. Rarely
intravenous antibiotics are needed. Most patients require more than a month-long time of treatment to
eradicate the infection.
c. Bladder infection (Cystitis)
*NEMA OPISA NA SAJTU (Sorry, but the page you were trying to find does not exist.
d. Nephrolithiasis (Kidney stone )
Description of Kidney stone (nephrolithiasis)
Kidney stones are small, solid particles that form in one or both kidneys. The majority of kidney stones
contain calcium oxalate. Other types of stones contain uric acid, struvite, and cystine. They generally do
not cause problems until they enter the tube connecting the kidney to the bladder (ureter) causing
obstruction of the urine flow from the kidney to the bladder. The obstruction causes severe pain. The
following conditions increase the risk of developing kidney stones: obesity, a family history of the
disorder, diets high in protein, previous gastric bypass surgery, and dehydration.
Symptoms of Kidney stone (nephrolithiasis)
Flank, back and or abdominal pain; pain often radiates to the groin: abnormal urine color, blood in the
urine; nausea, vomiting; painful urination; urinary frequency/urgency, urinary hesitancy.
Tests for Kidney stone (nephrolithiasis)
Workup
A history and physical exam will be performed. A urine analysis is done to look for red blood cells. A CT
scan is the standard method of diagnosis. An ultrasound can demonstrate the dilation of the ureter and
kidney, suggesting a blocked ureter.
Tests
CT Scan, Ultrasound and Urinalysis (UA)
Additional tests that may be required
Intravenous pyelogram
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology

Treatment of Kidney stone (nephrolithiasis)
Vigorous oral or intravenous fluids, pain medications and anti-nausea medications are the primary
treatments. Most stones less than 6mm in size will pass on their own. Stones that don't pass on their
own will need to be removed during a cystoscopy or other surgical procedure. For additional
information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390.
e. Bladder stone, urinary
Description of Bladder stone, urinary
Small collections of minerals that form in the bladder, the organ in the pelvis that stores urine. Bladder
stones, also called bladder calculi, often form when urine sits in the bladder allowing the minerals to
develop. Bladder stones usually occur secondary to another condition, such as an enlarged prostate or a
urinary tract infection.
Symptoms of Bladder stone, urinary
Dark urine, bloody urine, painful urination, abdominal pain, pain at tip of penis, urine infection, urinary
retention.
Tests for Bladder stone, urinary
Workup
A history and physical exam will be performed. Additional tests include: urinalysis (UA), cystoscopy, and
a X-ray.
Tests
Urinalysis (UA) and X-ray
Additional tests that may be required
Cystoscopy
Specialists
Urology
Treatment of Bladder stone, urinary
Treatment includes: drinking plenty of fluids, cystoscopic removal, and/or lithotripsy. For additional
information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390.

Additional Causes
a. Renal trauma (kidney trauma)
Description of Renal trauma (kidney trauma)
Trauma to the kidney can be as simple as bruising that causes only temporary symptoms of bloody
urine. It can also be more serious, causing kidney failure. Trauma is usually blunt injury (motor vehicle
accident or fall) but can be a penetrating injury (gunshot wound or stab wound). Symptoms and
treatment depend on the injury.
Symptoms of Renal trauma (kidney trauma)
Symptoms depend on the injury but may include: flank pain (kidney pain), bloody urine, no urine
production (anuria), decreased urine output (oliguria).
Tests for Renal trauma (kidney trauma)
Workup
A history and physical exam will be performed. A CT scan is the most common test used to see kidney
injury after trauma.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI), Ultrasound and Urinalysis (UA)
Additional tests that may be required
Intravenous pyelography (IVP), angiography,
Specialists
Trauma Surgery
Treatment of Renal trauma (kidney trauma)
Treatment depends on the severity of the injury. Repeated blood tests or ultrasound tests are used for
close observation after an injury of the kidney. Drainage of a pocket of blood (hematoma) around the
kidney may be necessary. Surgery may be necessary. It is possible to survive with only one kidney after
trauma injures the other kidney.
b. Kidney cancer (tumor)
Description of Kidney cancer (tumor)
An cancerous growth of cells in the kidney. In adults renal cell carcinoma is the most common form of
kidney cancer and arises from the renal tubule. Surgery is the primary mode of therapy. Renal cell

carcinoma is resistant to radiation therapy and chemotherapy, although some cases respond to
immunotherapy. The following conditions increase the risk of this disorder: family history of kidney
cancer, high blood pressure, smoking, obesity, male gender, and receiving dialysis treatments. Among
children, a common form of kidney cancer is called a Wilms' tumor.
Symptoms of Kidney cancer (tumor)
Abdominal pain, abnormal urine color (dark, rusty, or brown), back pain, blood in the urine, unexplained
weight loss, enlargement of the scrotum, flank pain, swelling or enlargement of the abdomen.
Tests for Kidney cancer (tumor)
Workup
A history and physical exam will be performed. Imaging tests, such as ultrasound, MRI or CT scan may be
recommended to identify the tumor and to determine the extent of the disease. A biopsy may be
performed to confirm the diagnosis.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI) and Urinalysis (UA)
Additional tests that may be required
IVP (Intravenous pyelogram), renal arteriography, urine cytology
Specialists
Blood and Cancer Care (hematology and oncology), Pediatric Hematology and Oncology and Urology
Treatment of Kidney cancer (tumor)
Surgical removal of all or part of the kidney (nephrectomy) is the primary mode of treatment, and may
include removal of the bladder and surrounding lymph nodes. Radiation and chemotherapy is generally
not effective. A cure is unlikely unless all of the cancer is removed with surgery. For more information
contact the American Cancer Society: (800)227-2345 and Kidney Cancer Association: (800)850-9132
c. Epididymitis (Testicle organ inflammation)
m Description of Inflammation of testicular tubes (epididymitis)
The epididymis is a long coiled tubular structure located next to the testicle. Inflammation of the
epididymis may produce testicular pain and fever. Infection is the most common cause and the bacteria
normally come from the urethra or bladder.
Symptoms of Inflammation of testicular tubes (epididymitis)

Testicular pain, scrotal swelling, fever, discharge from the penis (urethral discharge), blood in the
semen, painful urination, frequent urination, painful ejaculation, lower abdominal pain.
Tests for Inflammation of testicular tubes (epididymitis)
Workup
A history and physical exam will be performed. A urinalysis (UA) and urethra culture are done. If
testicular torsion is a consideration a testicular ultrasound may be ordered.
Tests
Ultrasound and Urinalysis (UA)
Additional tests that may be required
Urethral culture
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Inflammation of testicular tubes (epididymitis)
Antibiotics are prescribed. If the infection is felt to be sexually transmitted treatment for chlamydia and
gonorrhea is typically given and the sexual partners are treated as well to prevent recurrence. Pain
medicines and/or nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol) are given for comfort.
d. Pyelonephritis (kidney infection)
Description of Pyelonephritis (kidney infection)
A bacterial infection involving the kidneys. It is more common in females, although it affects both
genders and all ages. Kidney infections in males are more likely if the bladder does not drain easily (one
cause of this problem is a large prostate.) Bladder infections are common in women, and the typical
cause of a kidney infection in a female is migration of bacteria from the bladder infection. The infection
travels up the tube (ureter) that drains into the bladder from the kidneys.
Symptoms of Pyelonephritis (kidney infection)
Flank pain, back pain, occasionally abdominal pain, fever, chills, warm skin, vomiting, nausea, fatigue,
painful urination, urinary frequency, urinary urgency, need to urinate at night (nocturia), cloudy urine,
blood in the urine, foul or strong urine odor, confusion.
Tests for Pyelonephritis (kidney infection)
Workup

A history and physical exam will be performed. Blood tests will be done to check on the function of the
kidneys, to check for spread of bacteria into the blood. A urine test can identify the infection and culture
of the urine can reveal the type of bacteria that is involved. If a kidney stone is suspected a CT scan will
be done.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Pregnancy (BHCG) test
and Urinalysis (UA)
Additional tests that may be required
Urine culture
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Pyelonephritis (kidney infection)
Intravenous fluids, pain medications, anti-nausea medications and antibiotics are the mainstay of
therapy. Patients with severe infections or with depressed immune systems will be admitted to the
hospital. A co-existing blockage of a ureter from a kidney stone is a surgical emergency requiring
removal of the blockage to prevent a life threatening infection.
e. Idiopathic thrombocytopenia purpura (ITP, low platelets)
* OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
f.

Prostate cancer

nDescription of Prostate cancer (male anatomy cancer)
The prostate gland is located below the bladder and it surrounds the urethra (the bladder's drainage
tube). Prostate cancer is very common men over 60. Although a blood test (prostate specific antigen)
can detect cancer in an early stage, screening for this cancer and treating it early might cause more
harm than good. (Too many men have complications from treatment to make it sensible to treat all
cancers that are in an early stage). The US Preventative Services Task Force recommends against having
screening tests for prostate cancer. Prostate cancer that is advanced can metastasize and cause death.
Reviewed by Harvard Medical School
Symptoms of Prostate cancer (male anatomy cancer)
Many patients have no symptoms. Symptoms include: urinary hesitancy (delayed or slowed start of
urinary stream), urinary dribbling, urinary retention, painful urination, painful ejaculation, lower back
pain, painful bowel movement, pain in locations where cancer has spread to bones.

Reviewed by Harvard Medical School
Tests for Prostate cancer (male anatomy cancer)
Workup
A history and physical exam will be performed, including a rectal exam (your doctor can feel your
prostate to see if it has a lump or is enlarged). Tests include prostate specific antigen test (a blood test),
ultrasound with prostate biopsy, bone scan, Positron Emission Tomography (PET) scan.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Ultrasound and Urinalysis
(UA)
Additional tests that may be required
Urine or prostatic fluid cytology, prostate biopsy, a bone scan, Positron Emission Tomagraphy (PET)
scan, PSA , AMACR (genetic marker).
Do I Need This Test?
Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal
exam. There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of
prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant.
Physicians should not offer or order PSA screening unless they are prepared to engage in shared
decision making that enables an informed choice by patients.
How this was created and why it is important

The American Academy of Family Physicians and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists

Urology
Treatment of Prostate cancer (male anatomy cancer)
The appropriate treatment of prostate cancer depends on the extent of the cancer, the age of the
patient and the health of the patient. Treatment options include: "Watchful waiting" (this means wait
for symptoms before getting treatment), "Active surveillance" (This means monitoring the cancer with
repeated exams and biopsies, with treatment when the cancer changes to a more advanced stage),
surgery, radiation therapy, implanted radioactive beads (brachytherapy), hormone therapy,
chemotherapy. For more information contact the American Cancer Society: (800)227-2345
g. Bladder cancer
Description of Bladder cancer
A type of cancer that occurs in the bladder. The bladder is the organ in the pelvis that stores urine.
Bladder cancer arises form abnormal growth of cells that line the bladder. This disorder is more common
in older patients and in males. Luckily most of these cancers are caught before they spread (metastasize)
but they tend to recur requiring retesting of a patient throughout their life.
Symptoms of Bladder cancer
Abdominal pain, bloody urine, urinary retention, fatigue.
Tests for Bladder cancer
Workup
A history and physical exam will be performed. Additional tests include: urine analysis, urine cytology,
cystoscopy, bladder biopsy, and a CT scan.
Tests
CT Scan and Urinalysis (UA)
Additional tests that may be required
Bladder biopsy, urine cytology
Specialists
Surgical Oncology and Urology
Treatment of Bladder cancer
Treatment includes: surgery, chemotherapy, and/or immunotherapy. For more information contact the
American Cancer Society: (800) 227-2345

h. Renal infarct (kidney damage from an area of blocked blood flow)
Description of Renal infarct (kidney damage from an area of blocked blood flow)
A blockage of blood flow to an area of the kidney causing death of tissue in a small section of a kidney.
Usually, a renal infarct happens when a blood clot (embolus) that has formed in the heart or on a heart
valve floats through the circulation into the kidney. This blood clot then blocks flow to part of the
kidney. The disorder is most commonly seen in patients with an infected heart valve (endocarditis) or
heart failure. More rarely it is associated with: inflammation of the artery (vasculitis), trauma, cancer, or
after surgery. The most common symptoms are back pain and bloody urine (hematuria).
Symptoms of Renal infarct (kidney damage from an area of blocked blood flow)
Sudden onset of back pain, sudden onset of flank pain, bloody urine (hematuria).
Tests for Renal infarct (kidney damage from an area of blocked blood flow)
Workup
A history and physical exam will be performed. The problem is usually seen on a CT scan. Blood tests to
check kidney function and to identify blood clotting abnormalities will probably be done. An
echocardiogram (heart ultrasound) is used to view heart valves, where a clot can originally form.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Magnetic resonance imaging (MRI), Ultrasound and Urinalysis (UA)
Additional tests that may be required
Angiography, renal scintigraphy, intravenous pyelography (IVP), PT (Protime), PTT (Partial
Thromboplastin Time)
Specialists
Nephrology and Pediatric Nephrology
Treatment of Renal infarct (kidney damage from an area of blocked blood flow)
Most of the time a renal infarct is treated with pain medicines and the clot is not removed. However,
the source of the clot needs to be found and treatment must be given to prevent recurrence. If this is a
heart valve infection or problem, the treatment might include surgery or antibiotic treatment. For
additional information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390
i.

Benign prostatic hyperplasia (prostate enlargement)

Description of Benign prostatic hyperplasia (prostate enlargement)

Benign Prostatic Hyperplasia (BPH) is caused by the enlargement of the prostate gland. The prostate
surrounds the urethra and is located in the pelvis. The urethra is a tube that carries urine from the
bladder to the penis. As the prostate enlarges it compresses the urethra making urination difficult. This
disorder is felt to be a normal part of becoming older, although some men experience worse symptoms
than others.
Symptoms of Benign prostatic hyperplasia (prostate enlargement)
Slowed or delayed start of the urinary stream, weak urine stream, dribbling after urinating, straining to
urinate, strong and sudden urge to urinate, incomplete emptying of your bladder, needing to urinate
two or more times per night, urinary retention (complete inability to urinate).
Tests for Benign prostatic hyperplasia (prostate enlargement)
Workup
A history and physical exam will be performed, with special attention paid to the rectal exam. Additional
tests may include: urine analysis, blood test for prostate-specific antigen (PSA), urine flow rate, postvoid residual urine test to see how much urine is left in the bladder after urination.
Tests
CT Scan and Urinalysis (UA)
Additional tests that may be required
Prostatic specific antigen, cystoscopy
Specialists
Family Practice, Internal Medicine and Urology
Treatment of Benign prostatic hyperplasia (prostate enlargement)
Drugs to decrease the size of the prostate (finasteride and dutasteride). Alpha 1-blockers (doxazosin,
prazosin, tamsulosin, terazosin, and alfuzosin) to increase the flow of the urine. Surgical resection of the
prostate is sometimes necessary. The most common surgeries are a transurethral resection of the
prostate (TURP), laser surgery and microwave therapy.
j.

Warfarin (Coumadin, Jantoven) overdose

Description of Warfarin (Coumadin, Jantoven) overdose
Warfarin inhibits vitamin K dependent coagulation factors. It is used to thin the blood in patients who
have had deep vein thrombosis (DVT) or pulmonary embolism or have a high risk of forming blood clots
in the heart secondary to atrial fibrillation or mechanical heart valve replacement. Almost all overdoses
occur because of errors in dosing and/or drug-drug interactions. The overdose may cause no symptoms

and only be recognized on a blood test that demonstrates a high Prothrombin Time (PT) or high INR
(International Normalized Ratio). However, overdoses can lead to life threatening bleeding.
Symptoms of Warfarin (Coumadin, Jantoven) overdose
Excess bleeding can occur anywhere in the body, including: nosebleeds, bleeding gums, vomiting blood,
vomiting coffee ground material, bloody stools, black stools (melena), bleeding in and around the brain.
Tests for Warfarin (Coumadin, Jantoven) overdose
Workup
A history and physical exam will be performed. A high PT/INR makes the diagnosis of an overdose of
warfarin.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Pregnancy (BHCG)
test
Additional tests that may be required
PT (Protime)
Specialists
Blood and Cancer Care (hematology and oncology), Medical Toxicology and Pediatric Hematology and
Oncology
Treatment of Warfarin (Coumadin, Jantoven) overdose
Warfarin is immediately discontinued. A slightly elevated INR is treated by not taking warfarin for one or
two days and restarting at a lower dose. Higher INRs without symptoms are treated with low dose oral
vitamin K. Very high INR levels and/or active bleeding are usually treated with intravenous vitamin K.
Patients with bleeding may also need intravenous fluids, red blood cell transfusions, fresh frozen plasma
and/or factor IX concentrate administration. For more information and help call your local poison center
at 1-800-222-1222
k. Urethritis (infection of urethra)
Description of Urethritis (infection of urethra)
Inflammation of the urethra. The urethra is the tube that carries urine from the bladder to the outside
of the body. The disease is classified as gonococcal urethritis or non-gonococcal urethritis (NGU). NGU
has both infectious and non-infectious causes. In men, a thick yellow discharge usually indicates a
gonococcal urethritis; while clear discharge is more suggestive of NGU. The disorder is difficult to
diagnose in women because discharge may not be present. Both sexes may experience burning with

urination. The causes of NGU include adenovirus, Chlamydia trachomatis, Escherichia coli, Herpes
simplex, Mycoplasma genitalium, Reiter's syndrome, and trichomonas.
Symptoms of Urethritis (infection of urethra)
Painful urination, discharge from the penis, itching of the penis.
Tests for Urethritis (infection of urethra)
Workup
A history and physical exam will be performed. A urethral culture done with a swab or urinary culture
helps determine which infection is causing the urethritis. Urethral swabs yield better results in men
compared to urine cultures.
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Urology
Treatment of Urethritis (infection of urethra)
Treatment depends on the cause of the disorder. Antibiotics will be prescribed if the cause is a bacterial
infection.
l.

Goodpasture syndrome (disease of kidneys and lungs)

Description of Goodpasture syndrome (disease of kidneys and lungs)
An autoimmune disease that attacks the kidneys and lungs and can result in kidney failure. The body
normally makes antibodies to fight infection. In this disorder the antibodies are made against the body,
specifically the anti-glomerular basement membrane. This attack of the immune system can cause
bleeding in the lungs and kidney damage. Viral infections or exposure to certain toxins can trigger this
immune response. Men are eight times more likely to acquire this disease.
Symptoms of Goodpasture syndrome (disease of kidneys and lungs)
Dry cough, coughing of blood, breathing problems, decreased urination, bloody urine, painful urination,
leg swelling, high blood pressure, vomiting, weakness, fatigue.
Tests for Goodpasture syndrome (disease of kidneys and lungs)
Workup
A history and physical exam will be done. Blood tests to measure kidney and lung function will be done.
A chest x-ray or CT scan will be obtained as well. Biopsies of the lung and kidney may be performed to
look at the tissue under the microscope.
Tests

X-ray
Additional tests that may be required
Arterial blood gas, basic metabolic panel, lung biopsy, kidney biopsy
Specialists
Nephrology, Pediatric Nephrology, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Goodpasture syndrome (disease of kidneys and lungs)
The harmful antibodies need to be removed. Thus usually is done with plasmapheresis, a technology
that replaces the blood plasma (and proteins in it) with plasma from another person. Steroids and
immune suppressing drugs are used to reduce inflammation. High blood pressure will be treated with
medications as well. A kidney transplant is sometimes needed for severe kidney damage
m. Renal vein thrombosis (kidney vein clot)
Description of Renal vein thrombosis (kidney vein clot)
A blood clot that forms in the vein that drains blood from the kidney. The most common cause is
dehydration. Other causes include: trauma to the abdomen or back, cancer, scar formation of the vein,
abdominal aortic aneurysm, blood clotting disorders, or any other blockage of the vein.
Symptoms of Renal vein thrombosis (kidney vein clot)
Bloody urine, decreased urine output, flank pain (kidney pain), upper abdominal pain.
Tests for Renal vein thrombosis (kidney vein clot)
Workup
A history and physical exam will be performed. Tests to diagnose the disorder and determine the extent
of the disease will be done including a renal ultrasound. A CT scan and/or MRI may also be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer, Magnetic
resonance imaging (MRI), Ultrasound and Urinalysis (UA)
Additional tests that may be required
PT (Protime), PTT (Partial Thromboplastin Time)
Specialists
Nephrology, Pediatric Nephrology and Vascular and Interventional Radiology

Treatment of Renal vein thrombosis (kidney vein clot)
Anticoagulation to prevent extension of the clot, and allow the body to dissolve the clot is the main
treatment. For additional information contact the National Kidney and Urologic Diseases Information
Clearinghouse at: http://www.kidney.niddk.nih.gov or call (800)891-5390
n. Renal failure, acute (sudden kidney failure)
Description of Renal failure, acute (sudden kidney failure)
A sudden failure of the kidneys to function. Kidneys are essential to maintain the fluid balance in the
body and control the body's chemistry. Kidney failure leads to a buildup of fluid and an increase in waste
products in the blood stream. One serious side effect is an elevation in the body's potassium level which
can lead to life threatening heart arrhythmias and death. There are many causes of this disorder.
Common causes of acute kidney failure include infections, use of dye for CT scans or heart studies,
medication reactions, auto immune diseases, severe dehydration, blocked flow of urine.
Symptoms of Renal failure, acute (sudden kidney failure)
Acute renal failure may not cause any symptoms, until it progresses to a late stage. Decrease in amount
of urine (oliguria), urination stops (anuria), excessive urination at night (nocturia), ankle swelling, leg
swelling, generalized swelling, increasing size of abdomen, metallic taste in mouth, changes in mental
status or mood, seizures, hand tremor (shaking), nausea or vomiting, fatigue, high blood pressure,
itching.
Tests for Renal failure, acute (sudden kidney failure)
Workup
A history and physical exam will be performed. Blood tests show kidney function. A renal ultrasound is
done to check for blocked drainage from the kidneys (this is a fixable cause of acute renal failure, but it
must be found quickly for best chances of recovery).
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Magnetic resonance imaging (MRI), Ultrasound, Urinalysis (UA) and X-ray
Additional tests that may be required
Arterial blood gas (ABG), urine chemistry tests
Specialists
Nephrology and Pediatric Nephrology
Treatment of Renal failure, acute (sudden kidney failure)

Once the cause is found, the treatment may be obvious. Usually IV fluids are given to see if this can
improve the function of the kidneys. Treatment may also include dietary and fluid restrictions, diuretics
(water pills), and/or dialysis. If there is an associated life threatening potassium elevation emergent
treatment may be needed to bring the potassium level down including: Kayexalate, insulin and glucose,
intravenous calcium, and sodium bicarbonate. For additional information contact the National Kidney
and Urologic Diseases Information Clearinghouse at: http://www.kidney.niddk.nih.gov or call (800)8915390.
o. Renal failure, chronic (ongoing kidney failure)
Description of Renal failure, chronic (ongoing kidney failure)
Kidneys are essential to maintain the fluid balance in the body and control the body's chemistry. Kidney
failure leads to a build-up of fluid and an increase in waste products in the blood stream. One serious
side effect is an elevation in the body's potassium level which can lead to life threatening heart
arrhythmias and death. There are many causes of this disorder with diabetes and high blood pressure
being the most common. Unfortunately symptoms are usually not experienced until over 90% of the
kidney function has been lost. This is why it is important for patients with high blood pressure and
diabetes to have frequent medical check-ups.
Symptoms of Renal failure, chronic (ongoing kidney failure)
Fatigue, general ill feeling, small amount of urine or no urine, generalized itching (pruritus), headache,
nausea, vomiting, unintentional weight loss, blood in the vomit or in stools, decreased alertness,
confusion, delirium, coma, decreased sensation in the hands and feet, easy bruising or bleeding,
increased or decreased urine output, muscle twitching or cramps, seizures.
Tests for Renal failure, chronic (ongoing kidney failure)
Workup
A history and physical exam will be performed. Blood tests identify and monitor the kidney failure. A
renal ultrasound is usually done to make sure blocked urine flow is not contributing to the kidney
failure.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Ultrasound and Urinalysis (UA)
Additional tests that may be required
Arterial blood gas (ABG), urine chemistry tests
Specialists
Family Practice, Internal Medicine, Nephrology, Pediatric Nephrology and Pediatrics

Treatment of Renal failure, chronic (ongoing kidney failure)
The goal of treatment is to control symptoms, reduce complications, and slow the progression of the
disease. Treatment options include dietary and fluid restrictions, diuretics (water pills), blood
transfusions, and/or dialysis. Diseases that cause the chronic kidney failure must be controlled and
treated as appropriate. Some patients may be candidates for kidney transplantation. For additional
information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390
p. Sickle cell disease (disease of red blood cells)
Description of Sickle cell disease (disease of red blood cells)
A disorder that causes abnormal red blood cells, and these cells can clog blood vessels. Sickle cell
disease is the most common of the inherited blood disorders, and is seen primarily in black Americans
and black Africans. A sickle cell crisis causes pain because blood vessels become blocked and the
defective red blood cells can damage organs in the body. The most commonly affected organs include:
lungs, liver, bone, muscles, brain, spleen, penis, eyes, and kidneys. Patients also experience chronic
anemia.
Symptoms of Sickle cell disease (disease of red blood cells)
Abdominal pain, chest pain, flank pain, bone pain, breathlessness, delayed growth and puberty, fatigue,
fever, jaundice, rapid heart rate, susceptibility to infections, ulcers on the lower legs (in adolescents and
adults), anemia.
Tests for Sickle cell disease (disease of red blood cells)
Workup
A history and physical exam will be performed. Tests will be performed to diagnose and monitor the
disease.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Hemoglobin electrophoresis, sickle cell test
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Sickle cell disease (disease of red blood cells)

The goal of therapy is to control symptoms, and to limit the frequency of crises. Hydroxyurea (Hydrea) is
used to reduce the acute episodes of pain but is not effective in all patients. An acute episode is treated
with the following: intravenous fluids, supplemental oxygen, pain medications, antibiotics (if infection is
found), and/or blood transfusions. For additional information contact the National Heart, Lung and
Blood Institute Health Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573. For more
information contact: Sickle Cell Disease Association of America: (800)421-8453

14. BLOOD IN VOMIT
Common Causes
a. Peptic ulcer (Ulcer in the stomach or duodenum)

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b. Esophageal varices
Description of Esophageal varices (dilation of esophageal veins)
The esophagus is the tube that connects the mouth to the stomach. Varices are dilated veins most
commonly found near the esophagus or stomach. The most common cause of esophageal varices is
scarring of the liver (cirrhosis) from longstanding alcohol abuse. Cirrhosis causes a back-up of blood in
the esophageal veins which leads to the development of varices. Bleeding esophageal varices can be lifethreatening.
Symptoms of Esophageal varices (dilation of esophageal veins)
Vomiting blood or a material that resembles coffee grounds, chest pain, breathing problems, fainting,
black stools (melena), anemia, fatigue.
Tests for Esophageal varices (dilation of esophageal veins)
Workup
A history and physical exam will be performed. Additional tests may include:
Esophagogastroduodenoscopy (EGD), or esophagram (barium swallow), and blood tests to measure the
red blood cell count and the ability to clot blood.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Esophagogastroduodenoscopy (EGD), esophagram, protime, partial thromboplastin
Specialists

Gastroenterology and Vascular and Interventional Radiology
Treatment of Esophageal varices (dilation of esophageal veins)
For small, non-bleeding varices no treatment may be necessary although close monitoring is
recommended. Certain medications (such as beta-blockers and nitrates) may reduce the risk of bleeding.
For those that are enlarging, bleeding or appear to be at risk for bleeding, ligation or injection of the
varices through the endoscope are the most common initial treatments. A transjugular intrahepatic
portosystemic shunt (TIPS) may be performed to reduce the back-up pressure in the esophageal veins.
In severe cases liver transplant is the only effective treatment.
c. Nose bleed (epistaxis)
Description of Nose bleed (epistaxis)
Bleeding from the nose. The most common cause is trauma from a finger or foreign body, or from drying
of the nasal mucosa. Most bleeding is from the front part of the nose along the nasal septum. In this
area is a collection of small arteries and veins called Kiesselbach's plexus and irritation of the nasal
mucosa in this area can result in significant bleeding. Bleeding from the rear of the nose (posterior
epistaxis) is more difficult to control and may require admission to the hospital.
Symptoms of Nose bleed (epistaxis)
Bleeding from the nose, facial pressure, spitting, coughing or vomiting blood that has drained posteriorly
into the esophagus or upper airways.
Tests for Nose bleed (epistaxis)
Workup
A history and physical exam will be performed. Direct examination of the nose will be done.
Tests
Complete blood count (CBC)
Additional tests that may be required
Protime, partial thromboplastin
Specialists
Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric ENT (Otolaryngology) and
Pediatrics
Treatment of Nose bleed (epistaxis)

The area of bleeding may be cauterized to stop the bleeding. Packing with Vaseline gauze, a special
sponge, or a balloon may also be performed. Placement of a posterior balloon requires admission to the
hospital. While waiting to get medical attention squeezing the soft part of the nose can temporarily stop
bleeding.
d. Mallory Weiss syndrome (esophageal tear)
Description of Mallory Weiss syndrome (esophageal tear)
Refers to a superficial tear in the lower part of the esophagus that occurs during forceful vomiting,
prolonged vomiting, or persistent coughing. These tears may cause severe bleeding. Any disorder that
causes vomiting or coughing can cause this disorder.
Symptoms of Mallory Weiss syndrome (esophageal tear)
Vomiting blood, vomiting coffee ground material, bloody stools, black stools (melena), chest pain.
Tests for Mallory Weiss syndrome (esophageal tear)
Workup
A history and physical exam will be performed. Additional tests include: an EGD
(esophagogastroduodenoscopy), tests to measure the blood count and ability to clot blood, X-ray and/or
CT scan to rule out esophageal rupture.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and X-ray
Additional tests that may be required
EGD (esophagogastroduodenoscopy), PT, PTT (Partial Thromboplastin Time)
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Mallory Weiss syndrome (esophageal tear)
The tear and bleeding usually resolve without special treatment. Surgery is rarely required. Proton pump
inhibitors (omeprazole/Prilosec, pantoprazole/Protonix) or H2 blockers (cimetidine/Tagamet,
ranitidine/Zantac) may be given. Blood transfusions may be necessary if the bleeding is severe. Excessive
bleeding or persistent bleeding may require endoscopy or surgery to stop the bleeding.
e. Gastrointestinal bleeding (stomach, intestine bleeding)
Description of Gastrointestinal bleeding (stomach, intestine bleeding)

The digestive tract begins with the mouth and includes esophagus, stomach, small and large intestine,
and ends at the anus. Bleeding may occur anywhere along this pathway and may be visible in vomit or in
the stool. The bleeding can be slow and persistent causing anemia and black stools (melena) or fast and
extensive resulting in bright red blood in the stool and dizziness. Rapid gastrointestinal bleeding can be a
life threatening illness.
Symptoms of Gastrointestinal bleeding (stomach, intestine bleeding)
Slow bleeding of a small amount of blood may cause no symptoms. When symptoms are present, they
include: vomiting blood, vomiting material with the appearance of coffee grounds, blood in the stool
(melena or bright red blood), weakness, dizziness, fainting, or abdominal pain.
Tests for Gastrointestinal bleeding (stomach, intestine bleeding)
Workup
A history and physical exam will be performed. Other tests to determine the extent of disease include:
nasogastric tube lavage, rectal exam, EGD (esophagogastroduodenoscopy), colonoscopy, and blood
tests.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Lipase and X-ray
Additional tests that may be required
Endoscopy, Clotting studies, Type and screen
Specialists
Gastroenterology, Pediatric Gastroenterology and Vascular and Interventional Radiology
Treatment of Gastrointestinal bleeding (stomach, intestine bleeding)
Therapy depends on the site and severity of bleeding but may include: proton pump inhibitors
(omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers (cimetidine/Tagamet, ranitidine/Zantac),
endoscopic or colonoscopic cauterization of bleeding, intravenous fluids, blood transfusions, and
antibiotics if caused by H. pylori. Hospitalization may be recommended for significant gastrointestinal
bleeding.
Additional Causes
a. Malabsorption syndrome (abnormal intestinal digestion)
Description of Malabsorption syndrome (abnormal intestinal digestion)

Characterized by poor absorption of nutrients, vitamins and minerals from the intestinal tract into the
bloodstream. Many diseases cause malabsorption, such as celiac disease, certain medications, certain
types of cancer, certain types of surgery, chronic liver disease, chronic pancreatitis, Crohn's disease, and
persistent parasite infections.
Symptoms of Malabsorption syndrome (abnormal intestinal digestion)
Bloating, cramping, gas, chronic diarrhea, foul smelling and greasy stools, weight loss, decreased muscle
mass.
Tests for Malabsorption syndrome (abnormal intestinal digestion)
Workup
A history and physical exam will be performed. Multiple tests to determine the cause of the
malabsorption may be performed including blood tests, stool studies, abdominal CT scan, and
endoscopy.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and Urinalysis (UA)
Additional tests that may be required
D-xylose test, hydrogen breath test, qualitative stool fat test, quantitative stool fat test, schilling test for
vitamin B12, secretin stimulation test, small bowel biopsy, stool culture, culture of small intestine
aspirate
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Malabsorption syndrome (abnormal intestinal digestion)
Treatment will depend upon the specific disease or condition causing the malabsorption. If the cause is
chronic pancreatitis, taking oral pancreatic enzymes may help. In addition, therapy will include efforts to
correct protein, calorie, vitamin and mineral deficiencies. Intravenous fluids, vitamins, and nutrient
replacement may be necessary if oral intake is not sufficient.
b. Gastritis (stomach inflammation)
Description of Gastritis (stomach inflammation)
An irritation, inflammation, erosion or infection of the stomach lining. It can be acute or chronic.
Gastritis can be present with either a gastric erosion or gastric ulcer. An infection with the bacteria
Helicobacter pylori (H. pylori) can increase the incidence and severity of the disease. The following
conditions increase the risk of this disorder: drinking alcohol, use of nonsteroidal anti-inflammatory

drugs / NSAIDs (ibuprofen, naproxen, aspirin), smoking, and serious illness or stress (such as an infection
or trauma).
Symptoms of Gastritis (stomach inflammation)
Abdominal pain, nausea, vomiting, black stools (melena), bloody stools, burning in chest. Gastritis may
cause no symptoms.
Tests for Gastritis (stomach inflammation)
Workup
A history and physical exam will be performed. Other tests to determine the extent of disease include:
nasogastric tube lavage, rectal exam, EGD (esophagogastroduodenoscopy), and blood tests.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Lipase
Additional tests that may be required
Clotting studies, Type and screen, Gastric culture
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Gastritis (stomach inflammation)
Treatment depends on the severity of the illness and includes: proton pump inhibitors
(omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers (cimetidine/Tagamet, ranitidine/Zantac), and
antibiotics if caused by H. pylori. For severe symptoms, bleeding or complications of gastritis,
hospitalization may be recommended.
c. Hiatal hernia (stomach pushes through diaphragm)
Description of Hiatal hernia (stomach pushes through diaphragm)
Part of the stomach protrudes upward into the chest, through an opening in the diaphragm. The
diaphragm is the muscle separating the chest from the abdomen and is used for breathing. The hiatal
hernia can allow acid to enter the esophagus causing pain and ulceration of the esophagus.
Symptoms of Hiatal hernia (stomach pushes through diaphragm)
A hiatal hernia may cause no symptoms. However, chest pain, pain with swallowing, belching, and
heartburn (gastro-esophageal reflux disease, GERD) are common.

Tests for Hiatal hernia (stomach pushes through diaphragm)
Workup
A history and physical exam will be performed. An EGD (esophagogastroduodenoscopy), or CT scan may
be helpful to confirm the diagnosis although a hiatal hernia can often be seen on a routine chest x-ray.
Tests
CT Scan
Additional tests that may be required
Esophagram
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Hiatal hernia (stomach pushes through diaphragm)
Treatment includes: proton pump inhibitors (omeprazole/Prilosec, pantoprazole/Protonix), H2 blockers
(cimetidine/Tagamet, ranitidine/Zantac), and/or antacids. It is recommended to avoid eating just prior
to lying down to sleep, and raising the head of the bed to prevent acid from entering the esophagus.
Surgery is performed for persistent and severe cases
d. Stomach cancer (gastric cancer)
Description of Stomach cancer (gastric cancer)
An abnormal growth of cells in the stomach. The most common type of cancer comes from the cells that
produce mucous in the stomach and is called adenocarcinoma. Adenocarcinoma of the stomach is more
common in other countries such as Japan and is occurring less in the United States. Other types include
lymphoma, carcinoid tumor, and gastrointestinal stromal tumor (GIST). A diet low in fruits and
vegetables, family history of stomach cancer, pernicious anemia, Helicobacter pylori infection, blood
type A, smoking, and gastric polyps increase the risk of acquiring this cancer. These cancers can be very
serious and a patient's ability to survive this disorder depends on the type of cancer and the size and
spread of the tumor when it is discovered.
Symptoms of Stomach cancer (gastric cancer)
Abdominal pain, dark stools, difficulty swallowing, excessive belching, general decline in health, loss of
appetite, nausea and vomiting, premature abdominal fullness after meals, unintentional weight loss,
vague abdominal fullness, vomiting blood, weakness or fatigue.
Tests for Stomach cancer (gastric cancer)
Workup

A history and physical exam will be done. The provider may do following tests to diagnose gastric
cancer: Complete Blood Count (CBC), stool test for occult blood, esophagogastroduodenoscopy (EGD),
and upper GI series.
Tests
Complete blood count (CBC), CT Scan and Upper GI series
Additional tests that may be required
esophagogastroduodenoscopy (EGD), stool test and upper GI series
Specialists
Blood and Cancer Care (hematology and oncology), Gastroenterology, Pediatric Gastroenterology,
Pediatric Hematology and Oncology and Surgical Oncology
e. Kaposi Sarcoma (type of cancer)
Description of Kaposi Sarcoma (type of cancer)
A cancer that may involve the skin, mouth, throat, nose, intestines, liver, and lung. The abnormal growth
occurs in the cells that line blood vessels and lymphatic channels. The cancer cells can grow rapidly. This
type of cancer is most often found in patients with acquired immunodeficiency syndrome (AIDS), and in
those on immunosuppressive medications. Another form occurs in elderly men of Mediterranean
ancestry.
Symptoms of Kaposi Sarcoma (type of cancer)
Bluish-red or purple skin lesions that appear on the feet or ankles, thighs, arms, hands, face, or another
part of the body. Other symptoms may include: vomiting blood, blood from rectum, shortness of breath,
cough with bloody sputum.
Tests for Kaposi Sarcoma (type of cancer)
Workup
A history and physical exam will be performed. A biopsy confirms the diagnosis.
Additional tests that may be required
Skin lesion biopsy, endoscopy
Specialists
Blood and Cancer Care (hematology and oncology), HIV and AIDS Specialist, Pediatric Hematology and
Oncology and Surgical Oncology

Treatment of Kaposi Sarcoma (type of cancer)
Treatment decisions depend on the extent and location of the lesions, as well as the person's symptoms
and degree of immunosuppression. Common treatments include radiation therapy, surgery, and/or
chemotherapy. Improving immune function can also be helpful. For example, tumors may shrink if
antiviral therapy against the AIDS virus is administered or if immune-suppressing medications are
stopped.
f.

Esophagitis (esophageal inflammation)

Description of Esophagitis (esophageal inflammation)
The esophagus is the tube that connects the mouth to the stomach. Esophagitis is inflammation of the
lining of the esophagus. This inflammation may be due to an infection, radiation, irritation from acid
reflux, or other irritants. The most common cause is the back up of acidic fluid from the stomach - a
syndrome call GERD (gastroesophageal reflux disease).
Symptoms of Esophagitis (esophageal inflammation)
Pain with swallowing, reflux symptoms (often called "heartburn"), chest pain, nausea, sore throat,
hoarseness.
Tests for Esophagitis (esophageal inflammation)
Workup
A history and physical exam will be performed. Direct visualization with esophagogastroduodenoscopy
(EGD) may be recommended if initial treatment fails.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Lipase,
Troponin and X-ray
Additional tests that may be required
Endoscopy, Upper GI, fungal cultures
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Esophagitis (esophageal inflammation)
Treatment of the underlying cause is essential for recovery. Medications for esophagitis include: proton
pump inhibitors (omeprazole/Prilosec, pantoprazole/Protonix), H2 Blockers (cimetidine/Tagamet,
ranitidine/Zantac), anti-inflammatory medications, anti-nausea medications, and treatment for infection
(such as antifungal medications).

g. Gastroenteritis (intestinal infection)
An inflammation of the stomach and/or intestinal lining. It is one of the most common causes of nausea,
vomiting and diarrhea. Gastroenteritis has numerous causes: including infectious organisms (viruses,
bacteria, etc.), food poisoning, and stress. This disorder can be very serious in the very young and very
old causing life threatening dehydration. Internationally this is one of the leading causes of death of
patients of all ages.
Symptoms of Gastroenteritis (intestinal infection)
Nausea, vomiting, diarrhea, abdominal cramping or pain, fever, weakness, dizziness. Occasionally,
bleeding complicates gastroenteritis.
Tests for Gastroenteritis (intestinal infection)
Workup
A history and physical exam will be performed. Other tests include stool studies to identify the organism
responsible for the infection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Lipase and Urinalysis (UA)
Additional tests that may be required
Stool ova and parasite exam, Stool WBC's, Stool culture
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Gastroenteritis (intestinal infection)
Treatment includes: fluids (by mouth, or, if necessary, intravenously), anti-nausea medications, and antidiarrheal medications. Hospitalization may be recommended for marked dehydration.
h. Small bowel lymphoma (intestinal lymph node cancer)
Description of Small bowel lymphoma (intestinal lymph node cancer)
A tumor of the lymph nodes of the small intestine. It most often occurs in the 5th or 6th decade and is
more common in men. It is associated with the following diseases, or conditions: celiac disease, Crohn's
disease, autoimmune disease, HIV, organ transplant patients, and patients on chemotherapy.
Symptoms of Small bowel lymphoma (intestinal lymph node cancer)

Abdominal pain, bowel obstruction, vomiting, weight loss, vomiting blood, bloody stools, black stools
(melena).
Tests for Small bowel lymphoma (intestinal lymph node cancer)
Workup
A history and physical exam will be performed. A CT scan or small bowel series is performed to establish
the diagnosis.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
Small bowel series
Specialists
Blood and Cancer Care (hematology and oncology)
Treatment of Small bowel lymphoma (intestinal lymph node cancer)
Treatment includes surgery, chemotherapy, and/or radiation therapy.
i.

Gastroesophageal reflux (GERD, heartburn)

Description of Gastroesophageal reflux (GERD, heartburn)
Backward flow of contents from the stomach into the esophagus causes gastroesophageal reflux or
heartburn. The digestive fluid in the stomach irritates the lining of the esophagus, and over a long period
of time can cause esophageal damage, including narrowing (stricture) and a condition called Barrett's
esophagus (a precancerous change in the cells of the lower esophagus). Lying flat while sleeping may
worsen the symptoms. The following conditions increase the risk of this condition: drinking alcohol,
obesity, smoking, pregnancy, diabetes, and scleroderma.
Symptoms of Gastroesophageal reflux (GERD, heartburn)
Burning in the throat and chest, bitter taste in the mouth, burning pain in chest that goes away with
antacids, regurgitation of food into the throat, nausea, chronic cough, hoarseness.
Tests for Gastroesophageal reflux (GERD, heartburn)
Workup

A history and physical exam will be performed. Other tests may be performed to rule out other causes
of pain. An esophagogastroduodenoscopy (EGD) may be performed to visualize the esophageal
irritation.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin and X-ray
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Gastroesophageal reflux (GERD, heartburn)
Patients should avoid lifestyle activities that worsen the disease. Treatment depends on the severity of
the illness and includes: proton pump inhibitors (omeprazole/Prilosec, pantoprazole/Protonix), H2
blockers (cimetidine/Tagamet, ranitidine/Zantac), antacids, and pro-motility drugs
(metoclopramide/Reglan). Surgery may be recommended for severe and persistent symptoms, including
fundoplication. For more information contact the National Digestive Diseases Information Clearinghouse
at: http://digestive.niddk.nih.gov or call (800) 891-5389
j.

Thrombocytopenia (low platelet count)

Description of Thrombocytopenia (low platelet count)
Not having enough blood platelets. Platelets are blood cells made in the bone marrow that help clot the
blood. Patients with this disorder experience bleeding into the skin (petechiae and purpura) and
bleeding from almost any organ. The disorder can be life threatening. There are many types and causes
of thrombocytopenia, such as: immune thrombocytopenic purpura (ITP), thrombotic thrombocytopenic
purpura (TTP), drug induced thrombocytopenia from chemotherapy or heparin therapy, alcohol abuse,
myelodysplastic syndrome and other bone marrow diseases, and infections.
Symptoms of Thrombocytopenia (low platelet count)
Bruising, nosebleeds, bleeding gums, pinpoint red spots on the skin (petechiae), red-blue patches on the
skin (purpura), bleeding from the urine or stools, black stools (melena), cuts that have prolonged
bleeding.
Tests for Thrombocytopenia (low platelet count)
Workup
A history and physical exam will be performed. Other tests to determine the cause of the low platelets
will be done. A bone marrow biopsy may be done.
Tests

Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Bone marrow biopsy, PT (Protime), PTT (Partial Thromboplastin Time)
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Thrombocytopenia (low platelet count)
Therapy depends on the cause of the condition, the severity of the deficiency, and if there is any
associated on-going bleeding. Treatment may include: platelet transfusions, intravenous
immunoglobulin, plasmapheresis, plasma exchange, corticosteroids, and/or surgical removal of the
spleen. For additional information contact the National Heart, Lung and Blood Institute Health
Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573
k. Alcoholism
*OVO JE VEC RANIJE OPISANO U TEKSTU I SADA SE PONAVLJA
l.

Warfarin (Coumadin, Jantoven) overdose
*OVO JE VEC RANIJE OPISANO U TEKSTU I SADA SE PONAVLJA
m. Intussusception (telescoping intestine)

Description of Intussusception (telescoping intestine)
A telescoping of the bowel into itself that can cause a bowel obstruction and decreased blood supply to
the portion of the intestine involved. It can affect all ages and both sexes, but is more common in babies
5-10 months of age. Urgent treatment is needed for this disorder to prevent an intestinal perforation,
peritonitis and death. The cause of this disorder is unknown.
Symptoms of Intussusception (telescoping intestine)
Bloody mucus-like bowel movement ("currant jelly" stool), fever, low blood pressure, stool mixed with
blood and mucus, vomiting, confusion, episodic abdominal pain.
Tests for Intussusception (telescoping intestine)
Workup
A history and physical exam will be performed. An abdominal X-ray, air or contrast enema, or abdominal
CT scan can all make the diagnosis. The air or contrast enema is considered the diagnostic test of choice
for children.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and X-ray
Additional tests that may be required
Air or contrast enema
Specialists
Gastroenterology, General Surgery, Pediatric Gastroenterology and Pediatric Surgery
Treatment of Intussusception (telescoping intestine)
For adults with intussusception, treatment may not be necessary; close observation may be all that is
necessary. Children require reduction of the telescoping bowel. This can frequently be performed by a
radiologist with an air or contrast enema. This procedure carries some risk of bowel perforation. If the
enema is unsuccessful surgery will usually be required to relieve the intussusception and remove any
permanently damaged intestine. Intravenous fluids will be given and the stomach will be decompressed
with a naso-gastric tube.
n. Esophageal cancer (tumor)
Description of Esophageal cancer (tumor)
The esophagus is the tube that connects the mouth to the stomach. Esophageal cancer usually begins in
the lower third of the esophagus, and occurs predominantly in adults over the age of 50. Esophageal
cancer has often spread by the time it is diagnosed or soon after. It is more common in smokers, heavy
alcohol drinkers and those with Barrett's esophagus.
Symptoms of Esophageal cancer (tumor)
Chest pain, vomiting undigested food, blood or material that looks like coffee grounds, weight loss,
difficulty swallowing, heartburn, black stools (melena).
Tests for Esophageal cancer (tumor)
Workup
A history and physical exam will be performed. Additional tests may include: barium swallow,
esophagogastroduodenoscopy (EGD) and biopsy; a chest CT scan or MRI may be recommended to
determine the extent of the disease.
Tests
CT Scan and Magnetic resonance imaging (MRI)
Additional tests that may be required

Esophagogastroduodenoscopy (EGD), biopsy
Specialists
Blood and Cancer Care (hematology and oncology), Cardiothoracic Surgery, Gastroenterology, Surgical
Oncology and Thoracic Surgery
Treatment of Esophageal cancer (tumor)
If the cancer only involves the esophagus, surgery may be the only treatment needed. For more
advanced cases chemotherapy and/or radiation therapy may also be offered. If the cancer is far
advanced palliative treatment may be the only appropriate option. American Cancer Society: (800)2272345
o. Intestinal volvulus (twisting of intestine)
Description of Intestinal volvulus (twisting of intestine)
Twisting of the bowel causing a blockage of food material and usually decreased blood flow to the
affected intestine. The intestine can die causing peritonitis and death. The volvulus may occur in
children due to a congenital abnormality while in adults it is associated with overuse of laxatives and
psychiatric disease (or its treatment). Often, no cause can be identified.
Symptoms of Intestinal volvulus (twisting of intestine)
Abdominal fullness, gaseous, abdominal distention, abdominal pain and cramping, vomiting, failure to
pass gas or stool (severe constipation), diarrhea.
Tests for Intestinal volvulus (twisting of intestine)
Workup
A history and physical exam will be performed. Imaging studies are performed to establish the diagnosis.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, Urinalysis (UA)
and X-ray
Additional tests that may be required
Barium enema, upper GI and small bowel series
Specialists
General Surgery and Pediatric Surgery
Treatment of Intestinal volvulus (twisting of intestine)

Most cases of volvulus require surgical correction. At times a volvulus of the colon can be decompressed
without surgery. Small intestinal volvuli usually require surgery to untwist the bowel and then attach the
intestine to the abdominal wall to prevent recurrence.
p. Nonsteroidal anti-inflammatory drug overdose (Motrin, Advil)
Description of Nonsteroidal anti-inflammatory drug overdose (Motrin, Advil)
Ibuprofen(Motrin/Advil), naproxen (Naprosyn), indomethacin (Indocin), aspirin, and celecoxib (Celebrex)
are some common NSAIDs (non-steroidal anti-inflammatory drugs). NSAID overdoses are rarely lethal
but can cause serious injury. Significant ingestions can cause vomiting, stomach ulcers, confusion
(altered mental status), metabolic abnormalities, and kidney damage. There are over 300,000 calls to US
Poison Control Centers per year related to NSAIDs.
Symptoms of Nonsteroidal anti-inflammatory drug overdose (Motrin, Advil)
Abdominal pain, nausea, vomiting, anxiety, tremors, confusion (altered mental status), vomiting blood
or material with the appearance of coffee grounds, black stools (melena), decreased urination, ringing in
ears (tinnitus).
Tests for Nonsteroidal anti-inflammatory drug overdose (Motrin, Advil)
Workup
A history and physical exam will be performed. Tests to identify other ingestions and organ damage
(such as kidney failure) will be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG),
Pregnancy (BHCG) test and Urinalysis (UA)
Additional tests that may be required
Acetaminophen (Tylenol) level, salicylate level
Specialists
Medical Toxicology
Treatment of Nonsteroidal anti-inflammatory drug overdose (Motrin, Advil)
There is no specific antidote. Treatment may include: observation, intravenous fluids and monitoring. If
significant kidney failure occurs dialysis may be recommended. For more information and help call your
local poison center at 1-800-222-1222

q. Cirrhosis (liver failure and scarring)
Description of Cirrhosis (liver failure and scarring)
A liver disease that persists over a long period of time, resulting in a progressive destruction of the liver.
Normal liver function is essential for many reasons, including its production of blood clotting factors and
its role in detoxifying the blood. In the end stages patients experience excessive bleeding, and can
become confused. There are many causes with alcohol and viral infections being the most common.
Hepatitis B and C are the most common viral infections related to this disorder. Less common causes of
cirrhosis include autoimmune diseases, medications, hemochromatosis and Wilson's disease.
Symptoms of Cirrhosis (liver failure and scarring)
Abdominal pain, abdominal bloating, easy bleeding, vomiting, confusion, yellowing skin, weakness.
Tests for Cirrhosis (liver failure and scarring)
Workup
A history and physical exam will be performed. Blood tests will be performed to determine the cause
and severity of the liver damage. An ultrasound of the liver or other imaging tests may be recommended
as well.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Ultrasound
Additional tests that may be required
Hepatitis profile, protime
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Cirrhosis (liver failure and scarring)
Treatment depends on the cause of the liver failure and the extent of the liver failure but may include:
diuretics for fluid overload, lactulose for confusion, blood products or vitamin K for bleeding, and/or
antibiotics for infection. For more information contact the National Digestive Diseases Information
Clearinghouse at: http://digestive.niddk.nih.gov or (800) 891-5389 American Liver Foundation (800)4654837
r.

Henoch Schönlein purpura (blood vessel inflammation)

Description of Henoch Schönlein purpura (blood vessel inflammation)

A disease in which small blood vessels become inflamed (vasculitis) which causes purple spots on the
skin (purpura). Other symptoms include: joint pain, vomiting, abdominal pain, diarrhea, and
inflammation of the kidneys (glomerulonephritis). It is more common in children than adults. The cause
of the disease is unknown. It is characterized by an abnormal immune response. A serious intestinal
disorder called intussusception can be associated with this disorder.
Symptoms of Henoch Schönlein purpura (blood vessel inflammation)
Abdominal pain, black or bloody stools, vomiting. diarrhea, joint pain, purple spots on the skin
(purpura).
Tests for Henoch Schönlein purpura (blood vessel inflammation)
Workup
A history and physical exam will be performed. Tests to determine the severity of the disease will be
performed, often including blood and urine tests, abdominal CT scan and, in some cases a skin and/or
kidney biopsy..
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Skin biopsy
Specialists
Blood and Cancer Care (hematology and oncology) and Pediatric Hematology and Oncology
Treatment of Henoch Schönlein purpura (blood vessel inflammation)
Supportive treatment is provided, including intravenous fluids and, if necessary, blood transfusions.
Occasionally the following treatments are administered: steroids, nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), acetaminophen (Tylenol),
dapsone, azathioprine, intravenous immunoglobulin, and plasmapheresis
s. Hemoptysis (coughing blood)
ÄŒDescription of Hemoptysis (coughing blood)
Coughing of blood. The blood usually comes from the lung or the tubes that carry air in the lungs
(trachea, bronchi, bronchioles). This disorder is a serious symptom requiring urgent medical attention.
Hemoptysis can be caused by many things, including infections, cancers, blood clots, and trauma.
Reviewed by Harvard Medical School

Symptoms of Hemoptysis (coughing blood)
Chest pain, fever, shortness of breath, blood in sputum.
Reviewed by Harvard Medical School
Tests for Hemoptysis (coughing blood)
Workup
A history and physical exam will be performed. Hospitalization may be recommended. Imaging tests,
such as a chest x-ray or CT scan are commonly performed to evaluate hemoptysis. Bronchoscopy may be
recommended to identify the site of bleeding, to biopsy any abnormality seen and, in some cases, to
stop the bleeding.
Tests
Activated partial thromboplastin (aPTT or PTT), Complete blood count (CBC), Comprehensive metabolic
panel (CMP), CT Scan, Electrocardiogram (EKG), Magnetic resonance imaging (MRI), Prothrombin test
(PT, INR), Type and screen and X-ray
Additional tests that may be required
Bronchoscopy
Specialists
Pediatric Pulmonology and Pulmonology
Treatment of Hemoptysis (coughing blood)
The goal of therapy is to stop the bleeding, replace the lost blood if necessary and prevent the patient
from breathing the blood into the lungs. Treatment may include: mechanical intubation, bronchoscopy,
blood transfusions, and surgery.
t.

Tonsillitis (tonsil infection)

Description of Tonsillitis (tonsil infection)
An infection of the tonsils. The infection can be caused by a bacterium such as streptococcus or a virus
such as Ebstein-Barr virus, which causes infectious mononucleosis. Tonsils are located at the back of the
throat. It can be very difficult to differentiate between a bacterial and viral cause without performing a
rapid strep test or throat culture. Rarely, some cases of tonsillitis can turn into an abscess (peritonsillar
abscess) requiring drainage of the infected fluid.
Symptoms of Tonsillitis (tonsil infection)

Sore throat, difficulty swallowing, fever, chills, headache, ear pain, voice changes, loss of voice, bad
breath.
Tests for Tonsillitis (tonsil infection)
Workup
A history and physical exam will be performed. A rapid stress test and/or throat culture can help
differentiate between a viral and bacterial cause. A blood test for mononucleosis may also be done.
Additional tests that may be required
Rapid strep test, throat culture, mono spot
Specialists
Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric ENT (Otolaryngology) and
Pediatrics
Treatment of Tonsillitis (tonsil infection)
Therapy depends on the cause of the tonsillitis but may include: antibiotics, nonsteroidal antiinflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), pain medications
such as acetaminophen (Tylenol), and steroids. Some tonsillitis cases are not bacterial and antibiotics
will not be helpful. Surgery to remove the tonsils may be recommended for repeated infections
15. BLOOD SHOT EYES
a. Allergic conjunctivitis (allergic reaction in the eye)
Description of Allergic conjunctivitis (allergic reaction in the eye)
An inflammation of the tissue lining the eyelids (conjunctiva) due to an allergic reaction. The most
common allergens are pollen and dander. The conjunctiva become red, swollen, and itchy. Excessive
tearing.
Symptoms of Allergic conjunctivitis (allergic reaction in the eye)
Red eyes, dilated vessels in the clear tissue covering white of the eye, intense itching, burning, puffy
eyelids, tearing, clear eye discharge. The symptoms may be seasonal.
Tests for Allergic conjunctivitis (allergic reaction in the eye)
Workup
A history and physical exam will be performed. Generally no tests are necessary to make the diagnosis.
Allergy testing may be performed to define specific allergens.

Specialists
Family Practice, Internal Medicine, Ophthalmology and Pediatrics
Treatment of Allergic conjunctivitis (allergic reaction in the eye)
The best treatment is avoiding exposure to the cause or allergen. Oral or topical antihistamines with or
without a decongestant helps relieve itching and swelling. Severe cases that don’t respond to
antihistamines may require prescription medications
b. Blepharitis (eyelid swelling)
Description of Blepharitis (eyelid swelling)
Blepharitis affects the skin of the eyelids, and it usually involves the lid margins. It occurs when tiny oil
glands located near the base of the eyelashes malfunction allowing bacterial overgrowth to occur. The
eyelids become inflamed, irritated and itchy.
Symptoms of Blepharitis (eyelid swelling)
Eyelid crusting, eyelid redness, eyelid itching, eyelid burning, eyelid swelling.
Tests for Blepharitis (eyelid swelling)
Workup
A history and physical exam will be performed.
Specialists
Family Practice, Internal Medicine, Ophthalmology and Pediatrics
Treatment of Blepharitis (eyelid swelling)
The primary treatment is careful daily cleansing of the lid margins using baby shampoo or special
cleansers. Antibiotic ointments are also used to control bacterial overgrowth.
c. Conjunctivitis (pink eye)
Description of Conjunctivitis (pink eye)
The conjunctiva is a thin, transparent membrane that covers the white part of the eye and eyelids.
Conjunctivitis can occur from infection, inflammation or allergies. Infections can result from virus or
bacteria although viral causes are more common. Infectious conjunctivitis occurs more commonly in
children and can be very contagious.
Symptoms of Conjunctivitis (pink eye)
Eye redness, itching, pain, irritation and discharge.

Tests for Conjunctivitis (pink eye)
Workup
A history and physical exam will be performed. Full ophthalmology exam may be performed to rule out
other causes of eye redness.
Additional tests that may be required
Culture of the eye discharge
Specialists
Family Practice, Internal Medicine, Ophthalmology and Pediatrics
Treatment of Conjunctivitis (pink eye)
Therapy depends on the cause of the conjunctivitis. Treatment includes: topical allergy or antibiotic
medications. If an infectious process is suspected family members must be careful to not come in
contact with the discharge from the infected eye to prevent the infection from spreading to others.
d. Corneal abrasion (scrape on eye)
Description of Corneal abrasion (scrape on eye)
A scratch (abrasion) to the transparent covering of the center of the eye called the cornea. The cornea
allows light to enter the eye, where it strikes the retina and is eventually interpreted by the brain as
vision. Trauma to the eye can cause a scratch (abrasion) to the cornea. If the abrasion does not heal
correctly an infection can develop resulting in permanent scarring and decreased vision. If the abrasion
is caused by metal, a rust ring can develop in the cornea. This rust ring will need to be removed to
prevent scarring of the cornea.
Symptoms of Corneal abrasion (scrape on eye)
Eye pain, eye redness, eye swelling, decreased vision, light sensitivity, increased tearing, foreign body
sensation of the eye.
Tests for Corneal abrasion (scrape on eye)
Workup
A history and physical exam will be completed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology

Treatment of Corneal abrasion (scrape on eye)
Treatment includes antibiotic solution and/or ointment to prevent infection. Eye patching is used for
comfort only since patches have not been shown to speed healing. If the patient's tetanus status is not
up to date a tetanus booster may be given.
e. Corneal foreign body (object in the eye)
Description of Corneal foreign body (object in the eye)
A foreign object that hits the cornea can cause an injury. The cornea is a transparent covering of the
center of the eye. It allows light to penetrate into the eye, where it strikes the retina and is eventually
interpreted by the brain as vision. The cornea is soft and the foreign object may become lodged in it. If
the foreign object is metal a rust ring can develop around the injury as well. If the foreign body and the
rust ring are not removed a corneal scar can occur resulting in permanent vision loss.
Symptoms of Corneal foreign body (object in the eye)
Redness, foreign body sensation, increased tearing, eye pain, decreased vision, light sensitivity.
Tests for Corneal foreign body (object in the eye)
Workup
A history and physical exam will be performed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology
Treatment of Corneal foreign body (object in the eye)
Removal of the foreign body. If a rust ring has developed it must be removed with an ophthalmic burr to
prevent permanent scarring. Antibiotic drops and/or ointment are used to prevent infection. If the
patient's tetanus status is not up to date a tetanus booster may be given
f.

Corneal ulcer

Description of Corneal ulcer
A corneal ulcer is an inflammation and erosion of an area of the cornea (clear dome shaped window on
front of eye). A corneal ulcer can be sight-threatening and requires urgent medical attention. Corneal
ulcers can be caused by infection, especially in contact lens wearers, or may be a symptom of
autoimmune diseases such as rheumatoid arthritis, polyarteritis nodosa and systemic lupus
eythematosus.
Symptoms of Corneal ulcer

Symptoms include bloodshot eyes, watery eyes, light sensitivity, blurred vision, itching, discharge, a
white patch on the cornea and eye pain.
Tests for Corneal ulcer
Workup
A history and physical exam will be performed. A test using flouroscein dye to better visualize the
cornea will likely be performed using a special examination tool such as a slit lamp or Wood's lamp.
Culture of the eye, as well as, blood tests may also be performed depending on the suspected cause of
the ulcer.
Additional tests that may be required
Bacterial culture and sensitivity, Herpes PCR assay, Herpes viral culture, BMP, Creatine kinase,
antinuclear antibody (ANA), antineutrophil cytoplasmic antibody (C-ANCA), fungal culture, Anti-Sci-70
antibody tests and anticentromere antibodies (CREST variant)
Specialists
Infectious Disease Medicine, Internal Medicine, Ophthalmology, Pediatric Ophthalmology, Pediatric
Rheumatology and Rheumatology
Treatment of Corneal ulcer
Treatment varies depending on the cause of the ulcer. Medical treatment may be attempted with
immunosuppressive medications or antibiotics. However, medical treatment is frequently ineffective.
Surgical removal and repair of the ulcer is often required
g. Pterygium (growth on the eye)
Description of Pterygium (growth on the eye)
A non-cancerous growth that involves the conjunctiva of the eye. The conjunctiva is the white part of
the eye surrounding the colored part of the eye (iris). The pterygium is white to yellow in color and can
grow onto the iris. They tend to grow slowly and usually do not affect the vision of the eye. Having more
exposure to sun light such as living near the equator or working outside increases the likelihood of
developing pterygium. The disorder occurs twice as often in males as females and is rarely seen before
the age of 20.
Symptoms of Pterygium (growth on the eye)
Many patients do not have any symptoms. Others experience: eye redness, foreign body sensation,
swelling, itching, and blurry vision.
Tests for Pterygium (growth on the eye)

Workup
A history and physical exam will be done. An examination using a slit lamp may be performed to rule out
any other growths or problems with the eye.
Specialists
Family Practice, Internal Medicine, Ophthalmology and Pediatrics
Treatment of Pterygium (growth on the eye)
Surgery to remove the pterygium is done when the vision is affected, if symptoms recur, or for cosmetic
reasons
h. Subconjunctival hemorrhage (blood covering white part of the eye)
Description of Subconjunctival hemorrhage (blood covering white part of the eye)
Blood that collects beneath the covering of the white part of the eye (sclera). This covering is called the
conjunctiva and the disorder occurs when a small blood vessel in the conjunctiva breaks and bleeds. It
can occur with or without injury, and can occur after a forceful sneeze or cough. There are few
symptoms and many times the blood is noticed in the morning or by someone besides the patient. The
disorder occurs more often in people who are taking blood thinners or who have a condition that makes
it harder for their blood to clot.
Symptoms of Subconjunctival hemorrhage (blood covering white part of the eye)
Blood in the white part of the eye, minor eye discomfort may rarely be present.
Tests for Subconjunctival hemorrhage (blood covering white part of the eye)
Workup
A history and physical will be done. The provider may do a detailed eye exam using a slit lamp to ensure
there are no other injuries. The patient's ability to clot blood may be tested.
Tests
Activated partial thromboplastin (aPTT or PTT), Complete blood count (CBC) and Prothrombin test (PT,
INR)
Specialists
Ophthalmology
Treatment of Subconjunctival hemorrhage (blood covering white part of the eye)

No treatment is needed unless a problem with blood clotting is identified. The red spot goes away over
the next week or two.
i.

Uveitis (iritis, eye inflammation)

Description of Uveitis (iritis, eye inflammation)
The uvea is the portion of the eye that contains the iris, the ciliary body and the choroid. This area is also
called the anterior chamber. Uveitis or iritis is inflammation of this area. It is most commonly seen
between the ages 20 to 50. It can be serious, causing permanent loss of vision. Uveitis may occur
without any identified cause, but it is often caused by autoimmune diseases (rheumatoid arthritis,
ankylosing spondylitis), inflammatory conditions (Crohn's disease, ulcerative colitis), trauma, and
infections (toxoplasmosis, syphilis, tuberculosis).
Reviewed by Harvard Medical School
Symptoms of Uveitis (iritis, eye inflammation)
Redness of the eye, blurred vision, sensitivity to light, floating spots in the vision, eye pain, irregularly
shaped pupil.
Tests for Uveitis (iritis, eye inflammation)
Workup
A history and physical exam will be performed. The slit lamp exam is used to make the diagnosis.
Depending on the suspected cause, other tests may be done.
Specialists
Ophthalmology
Treatment of Uveitis (iritis, eye inflammation)
The goal of therapy is to control the inflammation, reduce the symptoms and determine the cause of
the disorder. Treatment includes: corticosteroid eye drops and pain medications.

16. BLOODY DIARRHEA
a. Campylobacter infection (intestinal bacterial infection)
Description of Campylobacter infection (intestinal bacterial infection)
One of the most common causes of diarrhea in the United States, affecting over one million people
every year. People usually get infected by eating or drinking contaminated food or water, often raw
poultry, fresh produce, or unpasteurized milk. A person can also be infected by close contact with an
infected person or animal. Symptoms begin 2-4 days after infection and generally last one week.

Symptoms of Campylobacter infection (intestinal bacterial infection)
Diarrhea (which may be bloody), nausea, vomiting, abdominal pain, fever, weakness.
Reviewed by Harvard Medical School
Tests for Campylobacter infection (intestinal bacterial infection)
Workup
A history and physical exam will be performed. Blood tests will be done to determine dehydration and
stool cultures performed to identify bacteria.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
stool cultures, blood cultures
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Campylobacter infection (intestinal bacterial infection)
Intravenous fluids for dehydration and reversal of any electrolyte abnormalities (blood chemistry
problems). Antibiotics are often prescribed but the infection will often resolve on its own.
b. Clostridium difficile (C. Diff)
Description of Clostridium difficile (C. Diff)
Bacteria that cause infection in the large intestine (colitis). It usually occurs 4-5 days after taking a strong
antibiotic, and is more commonly found in patients who have been in a hospital or nursing home. Older
patients and those with a weakened immune system get more serious infections. The range of illness is
wide causing anything from simple diarrhea to a life threatening infection. There are an increasing
number of cases among hospitalized patients, in which the bacteria in one patient are passed to other
patients. This is called a nosocomial infection.
Symptoms of Clostridium difficile (C. Diff)
Diarrhea, abdominal cramping and pain, fever, bloody stools, nausea, vomiting, weight loss, fainting.
Tests for Clostridium difficile (C. Diff)
Workup

A history and physical exam will be performed. A stool sample will be tested to look for the toxins C.
difficile produces. A colonoscopy may be done to examine the inside of the colon. Rarely a CT scan will
be performed to look for damage done by the infection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
Stool studies to identify the C. difficile toxin, colonoscopy
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Clostridium difficile (C. Diff)
The mainstay of treatment is giving the oral antibiotics metronidazole/Flagyl or vancomycin/Vancocin. If
the diarrhea has been severe the patient may be dehydrated or have problems with the blood chemistry
requiring intravenous fluids. Rarely the infection is severe enough to cause a hole in the intestine
(perforation) requiring surgical removal of the intestine.
c. Colitis (large intestine inflammation)
Description of Colitis (large intestine inflammation)
Inflammation of the colon; common causes including infection or low blood flow (ischemia), though it
may be of unknown cause (as with Crohn's disease or ulcerative colitis).
Symptoms of Colitis (large intestine inflammation)
Diarrhea, abdominal pain, nausea, vomiting, blood in stools, weight loss, fever.
Tests for Colitis (large intestine inflammation)
Workup
A history and physical exam will be performed. Stool studies will be done to identify triggers for colitis
such as bacteria, parasites or clostridium difficile toxin. A colon biopsy may be done to rule out
inflammatory bowel disease or ischemic colitis.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Additional tests that may be required
Colonoscopy, stool cultures, stool for clostridium dificile, colon biopsy

Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Colitis (large intestine inflammation)
Treatment depends on the cause of the colitis but may include: antibiotics, anti-inflammatory
medications, or steroids. If severe, surgical resection may be necessary. For more information contact
the National Digestive Diseases Information Clearinghouse at: http://www.digestive.niddk.nih.gov or
(800)891-5389. Further information is available at the Crohn's and Colitis Foundation of America at:
http://ccfa.org
d. Colonic diverticulitis (inflammation of pouches in the large intestine)
Description of Colonic diverticulitis (inflammation of pouches in the large intestine)
A diverticulum is an outpouching of the colon that develop as one ages. Diverticulitis occurs when the
opening of these pouches become blocked and get inflamed or infected. The pain is in the lower
abdomen and more likely on the left. If severe, the diverticulum can perforate and lead to a life
threatening infection.
Symptoms of Colonic diverticulitis (inflammation of pouches in the large intestine)
Lower abdominal pain (more common on the left), diarrhea, fever, nausea, vomiting, low blood
pressure.
Tests for Colonic diverticulitis (inflammation of pouches in the large intestine)
Workup
A history and physical exam will be performed. Blood tests and a CT scan or MRI may be performed to
define the disease and determine the extent of the involvement. A CT scan is especially useful in
identifying a perforation and/or abscess.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI), Urinalysis (UA) and X-ray
Specialists
Family Practice, Gastroenterology and Internal Medicine
Treatment of Colonic diverticulitis (inflammation of pouches in the large intestine)
If not severe, diverticulitis can be treated with oral antibiotics, More serious cases require intravenous
antibiotics and bowel rest. Abscesses require drainage either percutaneously or surgically. If the
infection is severe the affected colon may need to be removed surgically.

e. Crohn's disease (regional enteritis, Crohn's colitis, intestinal inflammation)
*OVO JE VEC OPISANO U RANIJEM TEKSTU, SADA SE PONAVLJA
f.

E. coli infection (Escherichia coli, bacterial infection)

Description of E. coli infection (Escherichia coli, bacterial infection)
E. coli (Escherichia Coli) is the name of a bacterium that lives in the digestive tracts of humans and
animals. E coli a common cause or infection in the urine. E. Coli infection can also be discovered in the
intestines, blood and occasionally in other organs. One type, E. coli 0157:H7 can cause hemolytic uremic
syndrome (HUS). HUS can result in severe bloody diarrhea, kidney failure and death. The infection arises
from ingesting contaminated food or water.
Symptoms of E. coli infection (Escherichia coli, bacterial infection)
Depends of the site infection but may include: diarrhea, a painful, burning sensation with urination,
fever, bloody diarrhea, abdominal pain, flank pain, low blood pressure.
Tests for E. coli infection (Escherichia coli, bacterial infection)
Workup
A history and physical exam will be performed. Tests include: cultures of urine, blood and/or stool to
identify the E. coli bacteria.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Cultures of blood, urine, and stool
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of E. coli infection (Escherichia coli, bacterial infection)
Intravenous fluids and antibiotics are typically administered.
g. Food poisoning
Description of Food poisoning
Food poisoning occurs when a patient consumes food or water that contains certain bacteria, viruses, or
parasites. The disorder can also occur when the toxins from these organisms are ingested. The most

frequent causes are listed here with the food they are commonly associated with in parentheses:
Campylobacter (meat and chicken), Shigella (produce), Salmonella (meat, egg yolks, milk, chicken),
Clostridium perfringens (meat), Escherichia coli O157:H7 (meat, produce, milk), Giardia lamblia
(produce, water), Hepatitis A (food from infected handler, shell fish, water), Noroviruses or Norwalk-like
viruses (produce, shellfish), Rotavirus (produce), Staphylococcus aureus (meat, salads, cream sauces,
cream-filled pastries), Vibrio vulnificus (shellfish). The best way to avoid illness is to cook food
thoroughly. Unfortunately infected food handlers can pass on the organism after the food has been
cooked.
Symptoms of Food poisoning
The start of symptoms depends on the organism causing the infection but generally is 8 hours to a few
days. The symptoms include: abdominal pain, nausea, vomiting, diarrhea, fever, chills headache,
weakness, bloody diarrhea.
Tests for Food poisoning
Workup
A history and physical exam will be done. Tests to determine the cause of the food poisoning will be
performed. Blood tests to diagnose dehydration, and body chemistry abnormalities (electrolytes) may
be done.
Tests
Colonoscopy, Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan,
Esophagogastroduodenoscopy (EGD) and Stool culture
Additional tests that may be required
Stool cultures, colonoscopy, esophagogastroduodenoscopy (EGD
Specialists
Family Practice, Gastroenterology, Infectious Disease Medicine, Internal Medicine, Pediatric
Gastroenterology, Pediatric Infectious Disease Medicine and Pediatrics
Treatment of Food poisoning
Some episodes will resolve on their own. Therapy depends on the severity of the symptoms and the
organism causing the food poisoning. Treatment may include: oral re-hydration therapy, intravenous
fluids, anti-nausea medications (promethazine/Phenergan, ondansetron/Zofran), antibiotics or antiparasite medications. Most cases of bacterial poisoning will not require antibiotics. First aid consists of
drinking plenty of fluids, sports drinks contain both sugar and electrolytes and are a good choice.
Children should be given store bought electrolyte solutions (Pedialyte etc.). Avoid caffeinated drinks and

those containing milk. Medications to slow down the diarrhea should not be taken if there is a fever,
abdominal pain or blood in the stool without first consulting a healthcare provider.
h. Intestinal ischemia (decreased intestinal blood flow)
Description of Intestinal ischemia (decreased intestinal blood flow)
Results from decreased blood supply to the intestines. The arteries typically become blocked with
atherosclerosis, but can also be obstructed from a blood clot that travels to the artery from another
location (an embolus) or inflammation of an intestinal artery (vasculitis). Intestinal ischemia can also
develop due to low blood pressure, from a twisting of the bowel (volvulus), or from an internal hernia. If
the ischemia continues, the intestines can die (infarction) and result in peritonitis and death.
Symptoms of Intestinal ischemia (decreased intestinal blood flow)
Abdominal pain that is more intense than the tenderness, diarrhea, fever, vomiting, low blood pressure,
abdominal distension, blood in the stool.
Tests for Intestinal ischemia (decreased intestinal blood flow)
Workup
A history and physical exam will be performed. Laboratory tests may show a high white blood cell count
(a marker of infection) and increased acid in the bloodstream. Other tests that can be helpful in
establishing the diagnosis include abdominal CT scan or an angiogram.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, Urinalysis (UA)
and X-ray
Additional tests that may be required
Angiogram, arterial blood gas, lactate
Specialists
General Surgery and Pediatric Surgery
Treatment of Intestinal ischemia (decreased intestinal blood flow)
Treatment often requires surgery although if ischemia is relieved before infarction occurs, surgery may
be avoided. Surgery typically involves removal of the damaged portion of the intestine. The cause of the
ischemia must also be reversed to prevent recurrence
i.

Salmonella infection (common bacterial intestinal infection)

Description of Salmonella infection (common bacterial intestinal infection)

Salmonella infections are very common, and may cause up to one-third of all the cases of diarrhea
produced by contaminated food. The most commonly infected foods are: meats, chicken, milk,
unpasteurized cheese, eggs and cocoa beans. The disease most commonly affects the gastrointestinal
tract and resolves without treatment. Some strains of salmonella can cause the condition "typhoid,"
which causes bloodstream infection, abdominal pain, fever and a rash.
Symptoms of Salmonella infection (common bacterial intestinal infection)
Abdominal pain, abdominal cramping, abdominal tenderness, diarrhea, nausea, vomiting, fever, chills,
muscle pain.
Tests for Salmonella infection (common bacterial intestinal infection)
Workup
A history and physical exam will be performed. Cultures of the stool and/or blood can establish the
diagnosis. Other tests may be done to define the extent of disease.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Stool cultures
Specialists
Gastroenterology, Infectious Disease Medicine, Pediatric Gastroenterology and Pediatric Infectious
Disease Medicine
Treatment of Salmonella infection (common bacterial intestinal infection)
Salmonella infections other than typhoid usually cause symptoms for a week or less even without
antibiotic treatment. Otherwise healthy people who get salmonella do not need antibiotics. All
immunocompromised patients should receive antibiotics, as well as those who have typhoid.
Intravenous fluids and electrolyte replacement will be given as well for significant dehydration.
j.

Shigellosis (bacterial intestinal infection)

Description of Shigellosis (bacterial intestinal infection)
An intestinal disease caused by the bacteria shigella. The main sign of infection is diarrhea, which is
often bloody. The infection is acquired through direct contact with infected stool, or obtained by eating
contaminated food, or drinking contaminated water. Young children are most susceptible. Patients with
normal immune systems will generally recover without treatment. Shigella can result in severe
dehydration, seizures, toxic megacolon, rectal prolapse and hemolytic uremic syndrome.

Symptoms of Shigellosis (bacterial intestinal infection)
Diarrhea, bloody diarrhea, abdominal pain, fever, nausea, vomiting.
Tests for Shigellosis (bacterial intestinal infection)
Workup
A history and physical exam will be performed. Cultures of the stool establish the diagnosis. Blood tests
may be performed to define the extent of dehydration.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Stool cultures
Specialists
Family Practice, Gastroenterology, Infectious Disease Medicine, Internal Medicine, Pediatric
Gastroenterology, Pediatric Infectious Disease Medicine and Pediatrics
Treatment of Shigellosis (bacterial intestinal infection)
Most patients are treated with antibiotics. Dehydration is treated with intravenous fluids, and any body
chemistry abnormalities (electrolytes) will be corrected
k. Ulcerative colitis (large intestine inflammation)
*OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA
l. Warfarin (Coumadin) use
*OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA
17. BLOODY NOSE (EPISTAXIS)
a. Allergic rhinitis (allergic reaction in the nose)
Description of Allergic rhinitis (allergic reaction in the nose)
Inflammation of the mucus membranes of the nose and upper respiratory tract can occur in response to
an irritant. In allergic rhinitis, the hypersensitive response of the immune system occurs in response to
airborne allergens. This is a common disorder, affecting at least a quarter of the population. Patients
experience runny nose and sneezing.
Symptoms of Allergic rhinitis (allergic reaction in the nose)
Sneezing, rhinorrhea (runny nose), cough, itchy eyes, watery eyes.

Tests for Allergic rhinitis (allergic reaction in the nose)
Workup
A history and physical exam will be performed.
Specialists
Allergy and Immunology, Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric
Allergy and Immunology and Pediatrics
Treatment of Allergic rhinitis (allergic reaction in the nose)
Treatment includes: antihistamines, steroid nasal sprays, and/or eye drops. Patients are encouraged to
avoid known irritants and triggers of the symptoms.
b. Bleeding tendency (bleeding disorder)
Description of Bleeding tendency (bleeding disorder)
Bleeding disorders are a group of conditions involving the body's blood clotting process. Such disorders
can lead to heavy and prolonged bleeding after an injury. Causes of excessive bleeding include:
medications such as warfarin, clopidogrel, and aspirin; low platelets (thrombocytopenia); liver failure;
and hemophilia.
Symptoms of Bleeding tendency (bleeding disorder)
Abnormal menstrual bleeding, bleeding into joints, excess bruising, heavy bleeding, nose bleeds.
Tests for Bleeding tendency (bleeding disorder)
Workup
A history and physical exam will be performed. Blood tests will be performed to determine the cause of
the abnormal bleeding.
Tests
Complete blood count (CBC)
Additional tests that may be required
Bleeding time, Platelet aggregation test, Protime, Partial throboplastin time
Specialists
Blood and Cancer Care (hematology and oncology) and Pediatric Hematology and Oncology
Treatment of Bleeding tendency (bleeding disorder)

Treatment depends on the type of disorder. It may include factor replacement, fresh frozen plasma, red
blood cell transfusion, platelet transfusion, vitamin K.
c. Dry air nasal irritation
Description of Dry air nasal irritation
Dry air nasal irritation can result in nasal bleeding (epistaxis) and nasal pain.
Symptoms of Dry air nasal irritation
Bloody nose, nasal pain or irritation.
Tests for Dry air nasal irritation
Workup
A history and physical exam will be performed.
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Dry air nasal irritation
Treatment includes running a humidifier at night and nasal saline spray. These therapies can reduce the
frequency of irritation and nose bleeds
d. Hypertension (high blood pressure)
Description of Hypertension (high blood pressure)
A termed used for high blood pressure. There are two numbers with the first number representing the
systolic pressure (normal less than 140) and the second number the diastolic (normal if less than 90).
Hypertension usually causes no symptoms but is a major risk factor for a number of serious long term
problems including heart attacks, stroke and kidney failure.
Symptoms of Hypertension (high blood pressure)
Usually none. If the level is very high the following may be experienced: chest pain, headache, shortness
of breath, confusion.
Tests for Hypertension (high blood pressure)
Workup
A history and physical exam will be performed. Tests may be performed to look for causes of
hypertension or damage related to hypertension.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and X-ray
Specialists
Cardiology, Family Practice, Internal Medicine and Pediatrics
Treatment of Hypertension (high blood pressure)
Treatment includes salt restriction, loss of excess weight, exercise and, in many cases, medications to
reduce the pressure
e. Nasal polyps (growths)
Description of Nasal polyps (growths)
Non-malignant growths in the nasal cavities. The polyps consist of inflamed nasal mucosa. They are
usually inside both sides of the nose. They can grow large and numerous enough to cause nasal
distension and obstruction of the airway. They are more common in patients with asthma, hay fever,
cystic fibrosis or chronic sinus infections.
Symptoms of Nasal polyps (growths)
Mouth breathing, nasal obstruction, runny nose, congestion.
Tests for Nasal polyps (growths)
Workup
A history and physical exam will be performed. Examining the nose shows grayish grape-like growths in
the nasal cavity.
Specialists
Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric ENT (Otolaryngology) and
Pediatrics
Treatment of Nasal polyps (growths)
Treatment depends on the symptoms and the size of the polyps. They are most often treated with a
nasal corticosteroid spray. For very large polyps, patients may take a short course of oral corticosteroid
(prednisone). Large persistent polyps may require surgery.
f.

Nasal trauma (injury)

Description of Nasal trauma (injury)

Traumatic injury to the nose is common, with fractures and nose bleeds being the most frequent
injuries. The majority of traumatic nose bleeds stop without treatment. Associated injuries commonly
occur. Patients with septal hematomas (blue mass on septum), cerebrospinal fluid rhinorrhea (clear fluid
from the nose), malocclusion (malalignment of the teeth), or extra ocular movement defects (double
vision) will need their associated injuries managed in conjunction with the nasal trauma.
Symptoms of Nasal trauma (injury)
Deformity, nasal pain, swelling, nose bleed.
Tests for Nasal trauma (injury)
Workup
A history and physical exam will be performed. X-rays are usually not helpful. If associated injuries are
suspected then a CT or MRI scan will be done.
Specialists
Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric ENT (Otolaryngology) and
Pediatrics
Treatment of Nasal trauma (injury)
Treatment includes: nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn or Aleve) and pain medications such as acetaminophen (Tylenol). In some cases,
surgery may be necessary
g. Nose bleed (epistaxis)
,MDescription of Nose bleed (epistaxis)
Bleeding from the nose. The most common cause is trauma from a finger or foreign body, or from drying
of the nasal mucosa. Most bleeding is from the front part of the nose along the nasal septum. In this
area is a collection of small arteries and veins called Kiesselbach's plexus and irritation of the nasal
mucosa in this area can result in significant bleeding. Bleeding from the rear of the nose (posterior
epistaxis) is more difficult to control and may require admission to the hospital.
Symptoms of Nose bleed (epistaxis)
Bleeding from the nose, facial pressure, spitting, coughing or vomiting blood that has drained posteriorly
into the esophagus or upper airways.
Tests for Nose bleed (epistaxis)
Workup
A history and physical exam will be performed. Direct examination of the nose will be done.

Tests
Complete blood count (CBC)
Additional tests that may be required
Protime, partial thromboplastin
Specialists
Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine, Pediatric ENT (Otolaryngology) and
Pediatrics
Treatment of Nose bleed (epistaxis)
The area of bleeding may be cauterized to stop the bleeding. Packing with Vaseline gauze, a special
sponge, or a balloon may also be performed. Placement of a posterior balloon requires admission to the
hospital. While waiting to get medical attention squeezing the soft part of the nose can temporarily stop
bleeding
h. Septal perforation (hole in the skin between nostrils)
Description of Septal perforation (hole in the skin between nostrils)
A hole (perforation) in the nasal septum, the tissue that separates the nostrils. Common causes include:
previous nasal surgery, previous nasal fracture, frequent use of nasal steroid sprays, and other causes.
Symptoms of Septal perforation (hole in the skin between nostrils)
Frequent nasal crusting, nose bleeding, whistling while breathing, nasal obstruction, runny nose.
Tests for Septal perforation (hole in the skin between nostrils)
Workup
A history and physical exam will be performed. The diagnosis is made by directly examining the nose.
Specialists
Ear, Nose, and Throat (ENT) and Pediatric ENT (Otolaryngology)
Treatment of Septal perforation (hole in the skin between nostrils)
Treatment ranges from saline sprays to surgical repair
i.

Sinusitis (sinus infection)

Description of Sinusitis (sinus infection)

Sinusitis is the inflammation or infection of the sinuses. The sinuses are cavities in the facial portion of
the skull, and lined by mucosa. Sinusitis is the inflammation or infection of these sinuses. It develops
most frequently in the maxillary sinuses (under the eyes) and the ethmoid sinuses. In more serious
infections the infection can involve the bone (osteomyelitis). Rarely the infection can extend into the
brain and be life threatening.
Symptoms of Sinusitis (sinus infection)
Pain in the face, cough, fatigue, fever, headache, pain behind the eyes, toothache, facial tenderness,
nasal congestion and discharge, sore throat, postnasal drip.
Reviewed by Harvard Medical School
Tests for Sinusitis (sinus infection)
Workup
A history and physical exam will be performed. At times a CT scan or MRI will be done.
Tests
CT Scan, Culture and Magnetic resonance imaging (MRI)
Do I Need This Test?
Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated
acute rhinosinusitis. Viral infections cause the majority of acute rhinosinusitis and only 0.5 percent to 2
percent progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two
weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus
CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute
rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin
should be first-line antibiotic treatment for most acute rhinosinusitis.
How this was created and why it is important

The American Academy of Allergy Asthma & Immunology and the ABIM foundation joined forces to
develop and distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists

Ear, Nose, and Throat (ENT), Family Practice, Internal Medicine and Pediatrics
Treatment of Sinusitis (sinus infection)
Sinusitis from allergy is treated with antihistamines, nasal sprays, decongestants or allergy shots. Sinus
infections caused by viruses do not require antibiotics but are treated with: acetaminophen (Tylenol),
nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn),
and decongestants. Bacterial sinusitis will be treated with antibiotics including: amoxicillin (Amoxil),
cefaclor (Ceclor), levofloxacin (Levaquin), loracarbef (Lorabid), clarithromycin (Biaxin), azithromycin
(Zithromax), or sulfamethoxazole/trimethoprim (Bactrim, Septra).
j.

Warfarin (Coumadin) use

*OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA

18. BLUE SKIN TONE
a. Asthma
Description of Asthma
An inflammatory disease of the lungs characterized by reversible airway obstruction. The tubes that
carry air in the lungs are called bronchi and bronchioles. In asthma these tubes become narrowed
because of abnormal muscular contraction of the tubes and from inflammation. The mucous lining of
these tubes become irritated and secrete mucous and white blood cells into the airways, making the
narrowing worse. In some patients this narrowing occurs in response to an irritant such as cold air, dust,
pollen, exercise, or tobacco smoke. The severity of symptoms varies greatly among patients, ranging
from a mild irritant to life threatening collapse.
Symptoms of Asthma
Shortness of breath, wheezing, cough, low oxygen, fainting.
Tests for Asthma
Workup
A history and physical exam will be performed. Peak expiratory flow rate will be taken to measure the
lungs function and effects of treatment. A chest X-ray will be taken if infection is suspected.
Tests
X-ray
Additional tests that may be required
Peak expiratory flow rate, allergy testing

Do I Need This Test?
Don’t diagnose or manage asthma without spirometry. Clinicians often rely solely upon symptoms when
diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes.
Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this
procedure. Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring
control. History and physical exam alone may over- or under-estimate asthma control. Beyond the
increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and
treatment.
How this was created and why it is important

The American Academy of Allergy Asthma & Immunology and the ABIM foundation joined forces to
develop and distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists
Allergy and Immunology, Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and
Pulmonology
Treatment of Asthma
Rescue therapy for acute symptoms: most often a short-acting beta-agonists bronchodilator, such as an
albuterol meter dose inhaler. Control therapy to reduce inflammation and keep bronchi open: inhaled
corticosteroids, long-acting beta agonist bronchodilators, oral leukotriene antagonists, and/or inhaled
cromolyn are used most frequently. For severe asthma flares, oral or intravenous corticosteroids and
frequent inhaled bronchodilators with a combination of albuterol and ipratropium (DuoNeb). For
additional information contact the National Heart, Lung and Blood Institute Health Information Center
at: http://www.nhlbi.nih.gov or call (301)592-8573 Asthma and Allergy Foundation of America: (800)
727-8562 American Lung Association: (800)586-4872 National Jewish Medical and Research Center:
(800)222-5864
b. Chronic obstructive pulmonary disease (COPD, emphysema)
Description of Chronic obstructive pulmonary disease (COPD, emphysema)
A disorder that results in chronic blockage of the airways of the lungs. The two most common types of
chronic obstructive pulmonary disease (COPD) are emphysema and chronic bronchitis. The primary

cause is smoking although not all patients who smoke get COPD. The extent of disease and symptoms
experienced can vary widely.
Symptoms of Chronic obstructive pulmonary disease (COPD, emphysema)
Shortness of breath, cough, cough with colored sputum, chest pain, wheezing, fatigue, bluish
discoloration of skin.
Tests for Chronic obstructive pulmonary disease (COPD, emphysema)
Workup
A history and physical exam will be performed. X-rays and pulmonary function tests will be done to
determine the extent of disease. A CT scan may be performed as well.
Tests
CT Scan and X-ray
Additional tests that may be required
Pulmonary function tests
Specialists
Family Practice, Internal Medicine and Pulmonology
Treatment of Chronic obstructive pulmonary disease (COPD, emphysema)
Treatment depends of the severity of symptoms but may include: bronchodilators (such as albuterol or
Atrovent), steroids, and/or antibiotics. Surgery to remove portions of severely affected lung and/or a
lung transplant may be necessary for severe involvement. For additional information contact the
National Heart, Lung and Blood Institute Health Information Center at: http://www.nhlbi.nih.gov or call
(301)592-8573. American Lung Association: (800)586-4872 National Jewish Medical and Research Center
(800)222-5864
c. Congestive heart failure (CHF)
Description of Congestive heart failure (CHF)
The heart pumps blood through the arteries and veins. With congestive heart failure, the pumping force
of the heart is reduced. Left sided heart failure results in fluid backing up into the lungs causing
breathing problems, and right sided heart failure produces fluid in the legs (edema) and the abdomen
(ascites). Congestive heart failure (CHF) can have many causes with the most common being high blood
pressure (hypertension), heart attacks, viral heart infections (myocarditis), congenital heart defects, and
valvular heart disease. Patients with known CHF can experience worsening symptoms if they eat too
much salt, stop taking their medications or have another co-existing illness such as pneumonia.

Symptoms of Congestive heart failure (CHF)
Shortness of breath, especially if lying flat (orthopnea), awaking suddenly gasping for air (paroxysmal
nocturnal dyspnea), swollen legs (edema), distended abdomen (ascites), shortness of breath with
exercise.
Tests for Congestive heart failure (CHF)
Workup
A history and physical exam will be performed. The goal is to identify the cause of the heart failure and
reverse the adverse effects. Once the cause is identified the extent of the disease can be assessed by
performing X-rays, blood tests and an echocardiogram.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Troponin
and X-ray
Additional tests that may be required
Echocardiogram, Brain natrietic peptide
Specialists
Cardiology, Family Practice and Internal Medicine
Treatment of Congestive heart failure (CHF)
Therapy depends on the extent of the disease and the severity of the symptoms. Treatment includes:
controlling the blood pressure and reducing the work of the heart with blood pressure medications,
increasing the urine output with diuretics, and maximizing oxygen with supplemental oxygen. Reversing
the cause of the CHF exacerbation is essential to recovery. For severe cases that do not improve with
standard medications, heart transplant may be recommended. For more information contact the
National Heart, Lung, and Blood Institute Health Information Center at: http://www.nhlbi.nih.gov or call
(301)592-8573
d. Hypothermia (extreme cold exposure)
Description of Hypothermia (extreme cold exposure)
Exposure to cold can cause a dangerously low body temperature (hypothermia). The very old, very
young, those with chronic illnesses, and the intoxicated are most susceptible. Becoming wet causes a
particularly rapid drop in body temperature. Death can result from cardiovascular collapse.
Symptoms of Hypothermia (extreme cold exposure)
Shivering, confusion, slow heart rate, low blood pressure, weakness.

Tests for Hypothermia (extreme cold exposure)
Workup
A history and physical exam will be performed. Blood tests will be done to determine damage from the
hypothermia. An EKG may be performed to look for cardiac abnormalities resulting from hypothermia.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG),
Urinalysis (UA) and X-ray
Specialists
Emergency Medicine
Treatment of Hypothermia (extreme cold exposure)
Rewarming and removing the wet clothes are essential. The method of warming depends on how low
the temperature is and what symptoms are present. Treatment may include: passive warming with
external warming devices, or active warming by the injection of pre-warmed fluids, providing warmed
oxygen or by warming the blood directly (using a procedure called "arteriovenous heated
countercurrent exchange."
e. Hypoxia (lack of oxygen)
Description of Hypoxia (lack of oxygen)
A condition of low oxygen concentration in the blood. Adequate oxygen levels require a proper
functioning of the airways, lungs and heart. Any defect in this chain can cause low oxygen. Low oxygen
may be caused by: infection (sepsis), lung infection (such as pneumonia), blood clots in lung, heart
failure, airway obstruction, the effects of drugs or medications, and head injury.
Symptoms of Hypoxia (lack of oxygen)
Shortness of breath, confusion, cyanosis (blue discoloration), anxiety, fatigue.
Tests for Hypoxia (lack of oxygen)
Workup
A history and physical exam will be performed. Tests will be done to determine the cause of the low
oxygen level and its severity. For example, a chest x-ray, oxygen saturation level and/or an arterial blood
gas may be measured.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Blood cultures, urine culture
Specialists
Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Hypoxia (lack of oxygen)
The most immediate priorities are to reverse the cause of hypoxia and to administer enough oxygen to
increase blood levels out of a dangerous range. Oxygen may be provided with a nasal cannula, face
mask, or a ventilator if severe
f.

Medication reaction

Description of Medication reaction
Any allergic reaction or symptom that is caused by a medication. The reactions can be mild such as
nausea. They can be life threatening such anaphylaxis—low blood pressure, fainting and collapse. Small
children and the elderly are most susceptible to medication reactions. A medication reaction should be
considered as a possible cause for a sudden change in behavior or new symptom in children and the
elderly. Over the counter medications can also cause serious side effects. Even medications that initially
were tolerated without a problem can result in serious reactions. Some medication reactions are caused
by taking too much of the drug requiring a decrease in a patient's dose. For specific reactions review the
adverse reaction section of the medication being taken.
Symptoms of Medication reaction
Symptoms depend on the medication being taken. Mild to moderate symptoms include nausea,
vomiting, abdominal pain, diarrhea, headache, easy bruising. More serious symptoms include breathing
problems, low blood pressure, fainting, facial swelling, intestinal bleeding, or low blood sugar (glucose).
Tests for Medication reaction
Workup
A history and physical exam will be done. Further tests will depend on the symptoms being experienced.
The provider may remove the medication and observe to see if the symptoms go away. If available a
drug level may be performed to measure the amount of medication in the body.
Specialists
Family Practice, Internal Medicine, Medical Toxicology and Pediatrics

Treatment of Medication reaction
Treatment depends on the reaction and the medication being taken. Patients should always discuss with
their healthcare provider before abruptly stopping a medication since some drugs require a gradual
reduction to prevent serious side effects.
g. Narcotic (morphine, heroin) overdose
Description of Narcotic (morphine, heroin) overdose
A life threatening condition where too much narcotic is taken resulting in decreased breathing and if
untreated death. Loss of normal swallowing reflexes can occur; and if the patient vomits the stomach
contents can enter the lungs. This is called aspiration and can result in a serious lung infection called
aspiration pneumonia. A heart attack or stroke can occur because depressed breathing decreases
oxygen supply to the heart and brain.
Symptoms of Narcotic (morphine, heroin) overdose
Confusion, coma, vomiting, poor or no respiratory effort, blue skin (cyanosis), weak pulse.
Tests for Narcotic (morphine, heroin) overdose
Workup
A history and physical exam will be performed. Tests include an electrocardiogram (EKG) to look for
heart rhythm abnormalities, chest x-ray to look for aspiration pneumonia and blood tests to look for
electrolyte abnormalities and liver and kidney malfunction.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Pregnancy (BHCG) test, Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Urine or serum toxicology screen
Specialists
Emergency Medicine and Medical Toxicology
Treatment of Narcotic (morphine, heroin) overdose
These patients need immediate treatment to prevent permanent brain damage and death. A narcotic
antagonist is administered, most commonly naloxone (Narcan). Naloxone can be given in the vein
(intravenous), in the muscle (intramuscular / IM), under the skin (subcutaneously) or down a breathing
tube (endotracheal tube). It has a rapid onset of action. If the patient is a chronic user of narcotics
he/she will experience acute narcotic withdrawal upon administering of the drug. The other deleterious

effects of the overdose will be treated as well. For more information call the National Poison Control
Phone Number 1-800-222-1222
h. Pneumonia (lung infection)
Description of Pneumonia (lung infection)
Infection in the lung. The air cells can fill with fluid (pus) causing shortness of breath and breathing
problems. Pneumonia can be severe and is a common cause of death. Certain risk factors, such as
smoking, excessive alcohol use, diabetes, depressed immune systems, and poor nutrition increase the
risk of developing pneumonia. The pneumococcal vaccination (Pneumovax) protects against the most
common cause of bacterial pneumonia.
Symptoms of Pneumonia (lung infection)
Cough with greenish or yellow sputum, bloody sputum, fever with shaking chills, sharp or stabbing chest
pain, chest pain worsened by deep breathing or coughing, rapid, shallow breathing, shortness of breath,
weak pulse.
Tests for Pneumonia (lung infection)
Workup
A history and physical exam will be performed. An X-ray can confirm the diagnosis. Blood tests, sputum
cultures, and blood cultures can identify the cause and severity of the infection. Occasionally a CT scan is
performed as well especially if an associated pleural effusion is present.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and X-ray
Additional tests that may be required
Blood cultures, Sputum cultures, Arterial blood gas (ABG)
Specialists
Family Practice, Internal Medicine, Pediatric Pulmonology, Pediatrics and Pulmonology
Treatment of Pneumonia (lung infection)
Antibiotics (azithromycin, clarithromycin, erythromycin, levofloxacin, ceftriaxone, doxycycline).
Pneumonia treatment may require a stay in the hospital for intravenous antibiotics. Supplemental
oxygen may be needed until the pneumonia improves. Severe cases can require mechanical ventilation.
For additional information contact the National Heart, Lung and Blood Institute Health Information
Center at: http://www.nhlbi.nih.gov or call (301)592-8573. American Lung Association: (800)586-4872
National Jewish Medical and Research Center: (800)222-5864

i.

Pulmonary edema (fluid build-up in the lungs)

Description of Pulmonary edema (fluid build-up in the lungs)
Fluid in the air sacs (alveoli) of the lung. The fluid moves from the small blood vessels in the lung
(capillaries) into the air sacs when there is damage to the lung, or if there is a backup of pressure from
the heart. This fluid (edema) in the air sacs prevents normal oxygen exchange and if left untreated can
be lethal. Common causes include: heart failure, heart attack, heart valve dysfunction, pneumonia,
toxins, smoke inhalation (from a fire), kidney failure, high altitude exposure, or adverse drug reactions.
Symptoms of Pulmonary edema (fluid build-up in the lungs)
Shortness of breath, difficulty breathing, grunting or gurgling sounds with breathing, wheezing,
increased shortness of breath with lying down (orthopnea), cough, anxiety, restlessness, excessive
sweating.
Tests for Pulmonary edema (fluid build-up in the lungs)
Workup
A history and physical exam with a stethoscope will be performed. A chest X-ray shows the fluid in the
lungs. Other tests may include blood tests or an echocardiogram (ultrasound of the heart) to identify the
cause.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG),
Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required
Arterial blood gas (ABG), Echocardiogram, Brain natriuretic peptide.
Specialists
Cardiology, Family Practice, Internal Medicine, Pediatric Cardiology, Pediatric Pulmonology and
Pulmonology
Treatment of Pulmonary edema (fluid build-up in the lungs)
The goal of treatment is to supply oxygen, remove the fluid build-up, and reverse the cause of the fluid.
Oxygen is given through a face mask or through nasal "prongs." In severe cases breathing may require
use of a ventilator until the condition improves. Medications to reduce the fluid in the lungs include:
diuretics and blood pressure control. The cause of the fluid buildup should be rapidly identified and
treated. For additional information contact the National Heart, Lung and Blood Institute Health
Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573. American Lung Association:
(800)586-4872 National Jewish Medical and Research Center: (800)222-5864

j.

Pulmonary embolism (blood clot in the lungs)

Description of Pulmonary embolism (blood clot in the lungs)
A blood clot in a pulmonary artery (the circulation of the lung.) Blood clots typically start in a vein in the
leg. A clot builds up stuck to the wall of the vein, and some or all of the clot can break off, pass through
the heart, and then float into a pulmonary artery. These arteries get progressively smaller and the clot
(embolus) eventually lodges into one of these arteries preventing blood flow. These clots make
circulation through the lungs inefficient so the lungs do not work as well. When the clot is very large
(called a saddle embolus) it can result in rapid death. The following increase the risk of blood clots:
recent surgery, previous blood clots, cancer, immobilization, sitting for prolonged periods of time, birth
control pills, surgery and pregnancy.
Symptoms of Pulmonary embolism (blood clot in the lungs)
Cough, shortness of breath, pain in ribs during breathing (pleuritic chest pain), chest pain, rapid
breathing, rapid heart rate, blue discoloration of the skin (cyanosis), weak pulse, confusion.
Tests for Pulmonary embolism (blood clot in the lungs)
Workup
A history and physical exam will be performed. Tests including a chest x-ray, an EKG (electrocardiogram),
and ultrasound of the veins in the leg are done. The diagnosis is confirmed with a CT scan of the chest or
less commonly, a specialized scan called a ventilation and perfusion scan.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Troponin, Ultrasound and X-ray
Additional tests that may be required
PT (Protime), PTT (Partial Thromboplastin Time), CT angiogram (CTA) of the chest, ventilation and
perfusion scan, pulmonary angiogram
Do I Need This Test?
In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive Ddimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic
test. In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative
high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.
How this was created and why it is important

The American College of Physicians and the ABIM foundation joined forces to develop and distribute
evidence based recommendations on when medical tests and procedures may be appropriate. Content
was written to help physicians, patients and other health care stakeholders to think, to practice and
partake in shared decision making to avoid unnecessary and at times harmful tests and procedures
based on your condition or symptoms. Choosing Wisely recommendations should not be used to
establish coverage decisions or exclusions.
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology, Pediatric Pulmonology and Pulmonology
Treatment of Pulmonary embolism (blood clot in the lungs)
Most of the time, a pulmonary embolus requires a hospital stay for initial treatment. Immediate lifethreatening pulmonary embolisms require dissolving the clot (thrombolysis) with a medication: tissue
plasminogen activator (t-PA), streptokinase, or urokinase. Medications to stabilize the clot and to
prevent further clots are given and include: heparin, enoxaparin (Lovenox), and/or warfarin (Coumadin).
Emergency treatments may include mechanical ventilation to maintain oxygen levels, and pressors to
increase the blood pressure. For additional information contact the National Heart, Lung and Blood
Institute Health Information Center at: http://www.nhlbi.nih.gov or call (301)592-8573. American Lung
Association: (800)586-4872 National Jewish Medical and Research Center: (800)222-5864
k. Raynaud's disease (blood vessel constriction)
Description of Raynaud's disease (blood vessel constriction)
A disease of the blood vessels called arteries, usually involving the fingers, toes and nose. The small
arteries in this disorder narrow when exposed to cold temperature. This decreases blood flow to the
affected body part causing it to turn white and blue. The arteries then widen, blood flow returns and the
area turns red and throbs. In severe cases the decreased blood flow can cause ulcers and death of the
tissue. There are two types of Raynaud's: primary and secondary. Primary Raynaud's occurs without any
other associated diseases. Secondary Raynaud's, also called Raynaud's phenomenon, is caused by
another disease usually an auto- immune disorder such as lupus, scleroderma, or rheumatoid arthritis.

The cause of primary Raynaud's is not known but it is more common in women and in people from cold
climates.
Symptoms of Raynaud's disease (blood vessel constriction)
Symptoms vary but include: cold fingers and toes, white to blue skin discoloration when exposed to
cold, numbness when exposed to cold. When circulation returns patients experience pins and needles,
swelling, throbbing, and redness. Stress can cause similar changes as cold.
Reviewed by Harvard Medical School
Tests for Raynaud's disease (blood vessel constriction)
Workup
A history and physical exam will be done. The healthcare provider may perform a simple test called a
cold-stimulation test. This test involves placing the hands in cool water or exposing to cold air, to trigger
an episode of Raynaud's. If there is a suspicion of secondary Raynaud's other tests may be done to
diagnose the disease.
Specialists
Family Practice, Internal Medicine, Pediatrics and Rheumatology
Treatment of Raynaud's disease (blood vessel constriction)
Therapy depends on the severity of the symptoms. Avoiding cold exposure to the affected body part is
simply all that is needed in some patients. Medications are sometimes used including: nifedipine (Adalat
CC, Procardia), amlodipine (Norvasc), felodipine (Plendil), prazosin (Minipress), doxazosin (Cardura), and
nitroglycerin. Surgery or injections to reduce the activity of sympathetic nerves can be performed in
severe cases. Patients with Raynaud's should avoid over the counter pseudoephedrine (Actifed, ChlorTrimeton, Sudafed), beta blocker medications, and birth control pills.

19. BLURRY VISION
Causes for Blindness
a. Amaurosis fugax (momentary vision loss in one eye)
Description of Amaurosis fugax (momentary vision loss in one eye)
A sudden loss of vision in one eye caused by a blockage of blood flow to the retinal artery. The retinal
artery feeds the retina. The retina captures the light in the back of the eye and transmits these images
to the brain. This condition is sometimes followed by a stroke and is considered very serious. The
blockage of the retinal artery is usually due to a piece of plaque that builds up in the carotid arteries in
the neck. The carotid arteries supply blood to the brain. The plaque buildup is caused by atherosclerosis,
and consists of fat deposits and calcium.

Symptoms of Amaurosis fugax (momentary vision loss in one eye)
Sudden loss of vision in one eye. The decreased vision can lasts seconds to hours. The loss of vision can
be complete or is sometimes described as a veil being pulled over the eye. The loss of vision is usually
painless.
Tests for Amaurosis fugax (momentary vision loss in one eye)
Workup
A history and physical exam will be done. The eyes will be examined and the blockage of the retinal
artery can sometimes be seen. A CT scan and/or MRI of the brain will be done. Imaging studies of the
neck such as an ultrasound may also be performed to look for blockages of the carotid artery. Blood
tests are also routinely examined.
Specialists
Ophthalmology, Vascular and Interventional Radiology and Vascular Surgery
Treatment of Amaurosis fugax (momentary vision loss in one eye)
Immediate therapy is aimed at removing the blockage of the retinal artery Since time is very important
immediate medical assistance is needed. Treatment options include surgery, interventional vascular
treatment with clot busting medications, and medications. The medications most commonly prescribed
include: aspirin, clopidogrel, and aspirin and dipyridamole. Treatment after an episode of amaurosis
fugax, to prevent it from recurring, involves various lifestyle changes, medicines and techniques for
reducing the plaque buildup in the carotid arteries
b. Carotid artery stenosis (neck artery narrowing)
Description of Carotid artery stenosis (neck artery narrowing)
The carotid arteries carry blood from the heart to the brain. Blockages typically occur from
atherosclerosis but congenital abnormalities and trauma can result in narrowing of the arteries
(stenosis). A stroke can occur if the narrowing suddenly becomes blocked with a clot or a piece of
material (called plaque) breaks off and blocks an artery inside the brain.
Symptoms of Carotid artery stenosis (neck artery narrowing)
No symptoms, unless there is insufficient blood flow to part of the brain to allow normal brain function.
If that occurs, symptoms may include weakness, numbness, slurred speech, confusion, incoordination,
or decreased vision. Temporary symptoms are called a transient ischemic attack (TIA). Permanent
symptoms are a stroke.
Tests for Carotid artery stenosis (neck artery narrowing)
Workup

A history and physical exam will be performed. A carotid ultrasound is often the first test. More detail is
gained by obtaining a CT angiogram (CTA), or MR angiogram (MRA).
Tests
Ultrasound
Additional tests that may be required
CTA, MRA
Do I Need This Test?
Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. There is good evidence
that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the
benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death,
stroke and myocardial infarction.
How this was created and why it is important

The American Academy of Family Physicians and the ABIM foundation joined forces to develop and
distribute evidence based recommendations on when medical tests and procedures may be
appropriate. Content was written to help physicians, patients and other health care stakeholders to
think, to practice and partake in shared decision making to avoid unnecessary and at times harmful tests
and procedures based on your condition or symptoms. Choosing Wisely recommendations should not
be used to establish coverage decisions or exclusions.
Specialists
Vascular Surgery
Treatment of Carotid artery stenosis (neck artery narrowing)
Therapy depends on the severity of the degree of blockage and severity of symptoms. Therapy for mild
to moderate blockages is aimed at reducing further atherosclerosis with lifestyle changes and keeping
blood pressure and cholesterol levels in the normal range. Also aspirin or other anti-platelet drug is
given to prevent clots inside the carotid artery. More severe blockages that cause symptoms may
require stenting of the artery or surgery (endarterectomy).

c. Cataracts (clouding of the eye lens)
MDescription of Cataracts (clouding of the eye lens)
Clouding of the lens of the eye. Normally, light that enters the eye passes through a clear lens and falls
on the retina, in the back of the eye. When the lens is clouded, this decreases vision. Typically a cataract
occurs slowly and commonly happens as one gets older. Trauma to the eye and congenital abnormalities
can cause the cataract to form more quickly. The following conditions can increase the likelihood of
developing a cataract: smoking, steroid medications, diabetes, high blood pressure, alcoholism,
exposure to sunlight without wearing glasses, obesity, previous eye injury or eye disease, and a family
history of cataracts.
Symptoms of Cataracts (clouding of the eye lens)
The symptoms typically appear slowly and include: decreased vision, cloudy vision, sensitivity to bright
light, problems seeing colors, difficulty seeing at night, or seeing double in one eye.
Tests for Cataracts (clouding of the eye lens)
Workup
A history and physical exam will be done. A visual acuity test will demonstrate deceased vision. The
provider will do a slit lamp exam which magnifies the eye and allows the examiner to look deep into the
eye and see the clouded lens. The pupil of the eye may be dilated as well for better visualization.
Specialists
Ophthalmology
Treatment of Cataracts (clouding of the eye lens)
Surgery is required to remove the cloudy lens and replace it with a replacement lens. Rarely the lens is
removed and a replacement lens cannot be inserted requiring a contact lens or pair of glasses to
improve the eyesight.
d. Cerebral vascular accident (stroke)
Description of Cerebral vascular accident (stroke)
A sudden interruption of blood flow to a portion of the brain causing injury. Some strokes are associated
with bleeding into the damaged area. Most strokes are caused by a blocked artery in the brain from
hardening of the arteries (atherosclerosis) or from a blood clot that travels from another area
(embolus). The symptoms experienced depend on the artery blocked. Survival and the best outcome
depend on seeking medical care immediately. Also known as a stroke.
Symptoms of Cerebral vascular accident (stroke)

Weakness of an arm, leg, side of the face, or any part of the body. Numbness, decreased sensation,
vision changes, slurred speech, inability to speak, inability to understand speech, difficulty reading or
writing, swallowing difficulty, drooling, loss of memory, vertigo (spinning sensation), loss of balance or
coordination, personality changes, mood changes (depression, apathy), drowsiness, lethargy, or loss of
consciousness, uncontrollable eye movements, double vision, nausea, vomiting.
Tests for Cerebral vascular accident (stroke)
Workup
A history and physical exam will be performed. Tests to identify the location and cause of the stroke will
be performed.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG),
Magnetic resonance imaging (MRI), Ultrasound and X-ray
Additional tests that may be required
Head and Neck CTA, carotid ultrasound, echocardiogram, PT (Protime), PTT (Partial Thromboplastin
Time)
Specialists
Neurology, Pediatric Neurology and Vascular and Interventional Radiology
Treatment of Cerebral vascular accident (stroke)
A stroke is a medical emergency. Therapy depends on the size of the stroke, its location in the brain, the
medications the patient is taking, how long the symptoms have been present and other associated
diseases. Treatment may include: blood pressure medication, anti-platelet medications (aspirin,
clopidogrel/Plavix), anticoagulants (heparin, enoxaparin, warfarin), thrombolysis (tissue plasminogen
activator/t-PA), intravascular thrombolysis, physical therapy, speech therapy, and/or occupational
therapy. Blood pressure and cholesterol medications are usually recommended to prevent a recurrence
e. Corneal abrasion (scrape on eye)
Description of Corneal abrasion (scrape on eye)
A scratch (abrasion) to the transparent covering of the center of the eye called the cornea. The cornea
allows light to enter the eye, where it strikes the retina and is eventually interpreted by the brain as
vision. Trauma to the eye can cause a scratch (abrasion) to the cornea. If the abrasion does not heal
correctly an infection can develop resulting in permanent scarring and decreased vision. If the abrasion
is caused by metal, a rust ring can develop in the cornea. This rust ring will need to be removed to
prevent scarring of the cornea.

Symptoms of Corneal abrasion (scrape on eye)
Eye pain, eye redness, eye swelling, decreased vision, light sensitivity, increased tearing, foreign body
sensation of the eye.
Tests for Corneal abrasion (scrape on eye)
Workup
A history and physical exam will be completed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology
Treatment of Corneal abrasion (scrape on eye)
Treatment includes antibiotic solution and/or ointment to prevent infection. Eye patching is used for
comfort only since patches have not been shown to speed healing. If the patient's tetanus status is not
up to date a tetanus booster may be given
f.

Corneal foreign body (object in the eye)

Description of Corneal foreign body (object in the eye)
A foreign object that hits the cornea can cause an injury. The cornea is a transparent covering of the
center of the eye. It allows light to penetrate into the eye, where it strikes the retina and is eventually
interpreted by the brain as vision. The cornea is soft and the foreign object may become lodged in it. If
the foreign object is metal a rust ring can develop around the injury as well. If the foreign body and the
rust ring are not removed a corneal scar can occur resulting in permanent vision loss.
Symptoms of Corneal foreign body (object in the eye)
Redness, foreign body sensation, increased tearing, eye pain, decreased vision, light sensitivity.
Tests for Corneal foreign body (object in the eye)
Workup
A history and physical exam will be performed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology
Treatment of Corneal foreign body (object in the eye)

Removal of the foreign body. If a rust ring has developed it must be removed with an ophthalmic burr to
prevent permanent scarring. Antibiotic drops and/or ointment are used to prevent infection. If the
patient's tetanus status is not up to date a tetanus booster may be given
g. Detached retina (retinal detachment)
Description of Detached retina (retinal detachment)
The retina is pulled away from the back of the eye (choroid) causing the cells of the retina to lose their
blood supply. The retina is the "film" of the eye that allows light to be detected and is necessary for
proper sight. The longer the retina stays detached the more likely permanent damage and permanent
loss of vision will occur. Early diagnosis and treatment can save the vision of the eye. The most common
causes of this disorder include: trauma, diabetes, and inflammation of the eye and aging of the jelly-like
fluid in front of the retina (the vitreous). Retinal detachment is more common in patients over 40, those
with a family history of the disease, and in extreme near sightedness.
Symptoms of Detached retina (retinal detachment)
Sudden appearance of floaters (spots or strings in the field of vision), sudden flashes of light, loss of
vision (described as a shadow or veil), sudden blurry vision.
Tests for Detached retina (retinal detachment)
Workup
A history and physical exam will be done. The provider can sometimes see the detachment of the retina
with an ophthalmoscope (a special magnifying viewer). Many times the defect in the retina cannot be
seen unless an ophthalmologist uses a special lens called a gonioscope.
Specialists
Ophthalmology
Treatment of Detached retina (retinal detachment)
Treatment within the first 24-48 hours of the sudden symptoms is essential: the longer the retina is
detached the more likely permanent loss of sight will occur. Very simple and small detachments may not
require treatment. However, particularly if the retina also is torn, immediate treatment is required. The
most common treatments use beams of laser light, or freezing (cryopexy). Surgery for the detachment
includes: pneumatic retinopexy, scleral buckling, or vitrectomy.
h. Diabetes (high blood sugar)
Description of Diabetes (high blood sugar)
A chronic disease of metabolism distinguished by the body's inability to produce enough insulin, and/or
a resistance to the insulin being made. Insulin is necessary for body cells to transport sugar into the cells

and to process carbohydrates, fat, and protein efficiently. Patients with diabetes have too much glucose
in their circulation causing damage to almost every organ in their body. There are three types of
diabetes: Type 1 is usually found in younger patients and requires insulin, Type 2 develops later in life
and is more commonly associated with obesity, and gestational diabetes is associated with pregnancy.
Symptoms of Diabetes (high blood sugar)
Increased urination, increased drinking of fluids, increased appetite, nausea, fatigue, blurry vision,
numbness or tingling in the feet..
Tests for Diabetes (high blood sugar)
Workup
A history and physical exam will be performed. Glucose measurements are performed randomly and as
a fasting level first thing in the morning. A hemoglobin A1C can measure the average glucose level over
time. With very high glucose levels or high acid levels in the body, serum ketones and an arterial blood
gas may be measured to rule out a serious complication called diabetic ketoacidosis (DKA).
Tests
Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Serum ketones, hemoglobin A1C, arterial blood gas
Specialists
Diabetes, Endocrinology and Metabolism, Family Practice, Internal Medicine, Pediatric Endocrinology
and Pediatrics
Treatment of Diabetes (high blood sugar)
Type 1 diabetes requires supplemental insulin either as an injection or as an intermittent continuous
infusion delivered from an insulin pump. The insulin doses required are dependent on glucose
measurements performed during the day. Type 2 diabetes times can often be controlled with weight
loss, dietary discretion and exercise. Type 2 diabetes often requires oral hypoglycemic medications and
may also require insulin. For more information contact National Diabetes Information Clearinghouse:
http://diabetes.niddk.nih.gov or (800)860-8747 American Diabetes Association: (800)342-2383
i.

Farsightedness (hyperopia/hypermetropia)

Description of Farsightedness (hyperopia/hypermetropia)
Farsightedness is the difficulty seeing close objects. It is an inherited disorder in most cases and is
caused by an eye that is too short from front to back.

Symptoms of Farsightedness (hyperopia/hypermetropia)
Symptoms include difficulty seeing objects that are close, headaches and crossed eyes in children.
Tests for Farsightedness (hyperopia/hypermetropia)
Workup
A complete history and physical will be performed. A specific ophthalmologic exam and visual testing
will be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology
Treatment of Farsightedness (hyperopia/hypermetropia)
Treatment usually consists of prescribing glasses or contacts to correct the vision problems. Some cases
can be be corrected by laser surgery (LASIK).
j.

Head trauma

Description of Head trauma
Head injuries range from minor trauma to concussions, unconsciousness and death. Traumatic injury to
the brain can cause bleeding on the surface of the brain or within the brain. The brain can be
permanently damaged by this trauma. Coma occurs when the central portion of the brain is unable to
activate or stimulate the rest of the brain to wakefulness or when there is extensive injury to the brain.
Head injuries can also produce fractures of the skull. Depressed skull fractures can cause a piece of bone
to penetrate or deform the brain. Basilar skull fractures involve the base of the skull. They can injure the
nerves that pass through these regions and produce cerebrospinal fluid leaks.
Symptoms of Head trauma
Headache, bleeding from the face or scalp, nose or ear, bruising behind ear, dizziness, visual problems,
ringing in the ears (tinnitus), nausea, vomiting, neurologic abnormalities, confusion, instability, paralysis
of a leg or arm, abnormal breathing, seizures, unconsciousness.
Tests for Head trauma
Workup
A history and physical exam will be performed with particular attention to neurologic abnormalities. A
CT scan and/or MRI may be recommended to rule out fractures, bruising of the brain, and bleeding into
or near the brain.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Urinalysis (UA) and X-ray
Specialists
Neurosurgery and Pediatric Neurosurgery
Treatment of Head trauma
Therapy is determined by the severity of the injury and may include: observation, diuretics (mannitol) to
decrease swelling, anti-seizure medications, anti-nausea medications, mechanical ventilation, and/or
neurosurgery. Steroids are no longer recommended..
k. Macular degeneration (chronic eye disease)
Description of Macular degeneration (chronic eye disease)
This disorder destroys the central vision of the eye. It is the leading cause of vision loss in patients over
60. The macula is a part of the retina that enables one to see fine detail. Over time the cells of the
macula die causing a gradual and painless loss of eyesight. The cause of macular degeneration is
unknown but the following conditions increase the risk of developing this disorder: family history of the
problem, increasing age, high blood pressure, high cholesterol, smoking, being white, and being female.
Symptoms of Macular degeneration (chronic eye disease)
Gradual loss of eyesight. Needing brighter light to read, increased blurry vision, increased problems
reading, problems recognizing faces, a blind spot in the center of vision.
Tests for Macular degeneration (chronic eye disease)
Workup
A history and physical exam will be done. The central vision is tested using an Amsler grid. The retina is
examined using a magnifier called an ophthalmoscope to see characteristic changes of the macula. An
angiogram of the retina or special pictures of the retina using optical coherence tomography may be
done.
Specialists
Ophthalmology
Treatment of Macular degeneration (chronic eye disease)
The vision loss of this disorder cannot be reversed but it can be slowed down. It is recommended
patients take Vitamin C, Vitamin E, beta carotene, copper and zinc supplements. Patients should stop
smoking. Special magnifying glasses may help patients read. There are more investigational drugs
available for certain subsets of patients with this disorder (Anecortave acetate/Retaane,
pegaptanib/Macugen).

l.

Migraine (type of headache)

Description of Migraine (type of headache)
A common, but very particular type of headache. The typical migraine headache is throbbing or
pulsating, and often is associated with nausea and intolerance to light and sound. Many people
experience an aura, usually visual changes, before the headache. The headache is usually intense and
often incapacitating and is frequently accompanied by nausea and vomiting and an intolerance to light
(photophobia). Migraines are believed to be triggered by brain chemicals, but their exact cause of these
headaches is not known. Migraines often first occur during the teenage years and are more common in
women. Patients who have family members with migraines are at increased risk to develop these
headaches.
Symptoms of Migraine (type of headache)
Severe headache (throbbing, pounding, pulsating), nausea, vomiting, sensitivity to light or sound. An
aura may precede the headache consisting of seeing stars or zigzag lines, tunnel vision, or a temporary
blind spot.
Tests for Migraine (type of headache)
Workup
A history and physical exam will be performed. Tests to rule out other causes of the headaches may be
done.
Tests
CT Scan and Magnetic resonance imaging (MRI)
Additional tests that may be required
Lumbar puncture
Specialists
Family Practice, Internal Medicine, Neurology, Pain Medicine, Pediatric Neurology and Pediatrics
Treatment of Migraine (type of headache)
Therapy depends on the severity of the headaches. Several different types of medications may be used
including: ergots like dihydroergotamine, ergots with caffeine (Cafergot); and/or triptans like
sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and zolmitriptan
(Zomig). They can be taken orally, nasally or as a self-injection. Medications to help prevent the
frequency and severity of migraines include certain antidepressants, blood pressure medications, and
anti-seizure drugs. For more information contact the American Headache Society: (800)255-2243

m. Presbyopia (aging vision)
Description of Presbyopia (aging vision)
Presbyopia is the difficulty focusing on objects that are close due to a hardening of the lens in the eye.
The lens naturally begins to harden as we age. This hardening begins as early as age ten but symptoms
usually do not begin until age forty.
Symptoms of Presbyopia (aging vision)
Symptoms include difficulty seeing objects that are close, headaches and eye fatigue.
Tests for Presbyopia (aging vision)
Workup
A complete history and physical will be performed. A specific ophthalmologic exam and visual testing
will be performed.
Specialists
Family Practice, Internal Medicine and Ophthalmology
Treatment of Presbyopia (aging vision)
Treatment usually consists of prescribing glasses or contacts to correct the vision problems. Over-thecounter readers may be effective for some individuals
n. Transient ischemic attack (TIA, reversible stroke)
Description of Transient ischemic attack (TIA, reversible stroke)
A temporary decrease in the blood supply to some part of the brain. The affected part of the brain does
not function properly, producing the symptoms observed. The syndrome looks similar to a stroke except
the symptoms last less than 24 hours and the majority resolve in the first hour. The most common
causes of TIA are atherosclerosis and atrial fibrillation. These patients need a prompt work-up to identify
and treat the cause of the TIA because of the high risk of stroke, especially within the first week after a
TIA.
Symptoms of Transient ischemic attack (TIA, reversible stroke)
Weakness or numbness on one side of the face or body, slurred speech, inability to speak, transient
visual loss in one eye, sensation that the room is moving (vertigo), loss of balance, lack of coordination.
Tests for Transient ischemic attack (TIA, reversible stroke)
Workup

A history and physical exam will be performed. Tests to determine the cause of the symptoms, and
identify any blocked arteries or irregular heart beat will be done. These tests often include a head CT
scan or brain MRI, EKG monitoring and ultrasound exam of the carotid arteries.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG)
and Magnetic resonance imaging (MRI)
Additional tests that may be required
Carotid ultrasound, CT angiogram, MR angiogram
Specialists
Neurology
Treatment of Transient ischemic attack (TIA, reversible stroke)
The goal is to prevent the development of a stroke. Specific treatment depends on what is causing the
decreased blood flow to the brain and may include: platelet inhibitors (aspirin, clopidogrel/Plavix,
aspirin/extended-release dipyridamole/Aggrenox), anti-coagulants (heparin, enoxaparin, warfarin),
and/or carotid artery surgery.
o. Uveitis (iritis, eye inflammation)
Description of Uveitis (iritis, eye inflammation)
The uvea is the portion of the eye that contains the iris, the ciliary body and the choroid. This area is also
called the anterior chamber. Uveitis or iritis is inflammation of this area. It is most commonly seen
between the ages 20 to 50. It can be serious, causing permanent loss of vision. Uveitis may occur
without any identified cause, but it is often caused by autoimmune diseases (rheumatoid arthritis,
ankylosing spondylitis), inflammatory conditions (Crohn's disease, ulcerative colitis), trauma, and
infections (toxoplasmosis, syphilis, tuberculosis).
Symptoms of Uveitis (iritis, eye inflammation)
Redness of the eye, blurred vision, sensitivity to light, floating spots in the vision, eye pain, irregularly
shaped pupil.
Tests for Uveitis (iritis, eye inflammation)
Workup
A history and physical exam will be performed. The slit lamp exam is used to make the diagnosis.
Depending on the suspected cause, other tests may be done.
Specialists

Ophthalmology
Treatment of Uveitis (iritis, eye inflammation)
The goal of therapy is to control the inflammation, reduce the symptoms and determine the cause of
the disorder. Treatment includes: corticosteroid eye drops and pain medications

20. BLURRY VISION
Causes for Blurry vision
a. Acute angle closure glaucoma (increased inner eye pressure)
Description of Acute angle closure glaucoma (increased inner eye pressure)
Increased pressure within the eye. Acute closed angle glaucoma is less common than chronic open angle
glaucoma. It is caused by a narrowing in the pathway where aqueous humor (the fluid in the front part
of the eye) exits. This fluid accumulates and causes increased pressure which can cause eye pain,
nausea, headache, and visual loss.
Symptoms of Acute angle closure glaucoma (increased inner eye pressure)
Eye pain, eye redness, headache, nausea, vomiting, loss of sight, tearing.
Tests for Acute angle closure glaucoma (increased inner eye pressure)
Workup
A history and physical exam will be performed. A full eye exam should also be done.
Additional tests that may be required
Tonometry
Specialists
Ophthalmology
Treatment of Acute angle closure glaucoma (increased inner eye pressure)
Treatment options include laser therapy, medications, and/or surgical repair.
b. Corneal abrasion (scrape on eye)
Description of Corneal abrasion (scrape on eye)
A scratch (abrasion) to the transparent covering of the center of the eye called the cornea. The cornea
allows light to enter the eye, where it strikes the retina and is eventually interpreted by the brain as

vision. Trauma to the eye can cause a scratch (abrasion) to the cornea. If the abrasion does not heal
correctly an infection can develop resulting in permanent scarring and decreased vision. If the abrasion
is caused by metal, a rust ring can develop in the cornea. This rust ring will need to be removed to
prevent scarring of the cornea.
Symptoms of Corneal abrasion (scrape on eye)
Eye pain, eye redness, eye swelling, decreased vision, light sensitivity, increased tearing, foreign body
sensation of the eye.
Tests for Corneal abrasion (scrape on eye)
Workup
A history and physical exam will be completed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology and Pediatric Ophthalmology

Treatment of Corneal abrasion (scrape on eye)
Treatment includes antibiotic solution and/or ointment to prevent infection. Eye patching is used for
comfort only since patches have not been shown to speed healing. If the patient's tetanus status is not
up to date a tetanus booster may be given.
c. Corneal foreign body (object in the eye)
Description of Corneal foreign body (object in the eye)
A foreign object that hits the cornea can cause an injury. The cornea is a transparent covering of the
center of the eye. It allows light to penetrate into the eye, where it strikes the retina and is eventually
interpreted by the brain as vision. The cornea is soft and the foreign object may become lodged in it. If
the foreign object is metal a rust ring can develop around the injury as well. If the foreign body and the
rust ring are not removed a corneal scar can occur resulting in permanent vision loss.
Symptoms of Corneal foreign body (object in the eye)
Redness, foreign body sensation, increased tearing, eye pain, decreased vision, light sensitivity.
Tests for Corneal foreign body (object in the eye)
Workup

A history and physical exam will be performed. Complete ophthalmologic exam using a slit lamp to rule
out foreign bodies in the cornea or other injuries may be performed.
Specialists
Ophthalmology
Treatment of Corneal foreign body (object in the eye)
Removal of the foreign body. If a rust ring has developed it must be removed with an ophthalmic burr to
prevent permanent scarring. Antibiotic drops and/or ointment are used to prevent infection. If the
patient's tetanus status is not up to date a tetanus booster may be given.
d. Glaucoma (elevated eye pressure)
Description of Glaucoma (elevated eye pressure)
Disorder in which the pressure within the eye is increased. It results from the excess production of fluid
within the front of the eye. Normally, the fluid produced is absorbed at the same rate. When this
balance is upset, pressure may build up in the eye. If the abnormally high pressure is not reduced
damage to the nerve of the eye (optic nerve) can occur resulting in the loss of sight. Pre-Glaucoma is
suspected with increased intraocular pressure, with no perceived damage to the disc or visual field.
Symptoms of Glaucoma (elevated eye pressure)
Decreased vision, pain, nausea, visual disturbances, headache, eye redness.
Tests for Glaucoma (elevated eye pressure)
Workup
A history and physical exam will be performed. Intraocular pressures will be measured during a painless
procedure in which a puff of air is blown into the eye. This is a part of a routine eye examination with an
eye specialist
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Ultrasound
Additional tests that may be required
Pressure in the eye must be measured
Specialists
Ophthalmology
Treatment of Glaucoma (elevated eye pressure)

Treatment consists of glaucoma medications, and/or surgery. The medications include eye drops and
oral medications. The most common eye drops are beta-blockers (levobunolol/Betagan,
timolol/Timoptic, betaxolol/Betoptic, metipranolol/OptiPranolol), alpha-agonists
(apraclonidine/Iopidine, brimonidine/Alphagan), carbonic anhydrase inhibitors (dorzolamide/Trusopt,
brinzolamide/Azopt), prostaglandins (latanoprost/Xalatan, bimatoprost/Lumigan, travoprost/Travatan),
miotic or cholinergic drugs (pilocarpine/Pilopine, carbachol/Isopto Carbachol), and epinephrine agents
(dipivefrin/Propine). The oral medications most commonly used are carbonic anhydrase inhibitors:
acetazolamide/Diamox and methazolamide/Neptazane. Glaucoma Research Foundation: (800)826-6693
e. Migraine (type of headache)
Description of Migraine (type of headache)
A common, but very particular type of headache. The typical migraine headache is throbbing or
pulsating, and often is associated with nausea and intolerance to light and sound. Many people
experience an aura, usually visual changes, before the headache. The headache is usually intense and
often incapacitating and is frequently accompanied by nausea and vomiting and an intolerance to light
(photophobia). Migraines are believed to be triggered by brain chemicals, but their exact cause of these
headaches is not known. Migraines often first occur during the teenage years and are more common in
women. Patients who have family members with migraines are at increased risk to develop these
headaches.
Symptoms of Migraine (type of headache)
Severe headache (throbbing, pounding, pulsating), nausea, vomiting, sensitivity to light or sound. An
aura may precede the headache consisting of seeing stars or zigzag lines, tunnel vision, or a temporary
blind spot.
Tests for Migraine (type of headache)
Workup
A history and physical exam will be performed. Tests to rule out other causes of the headaches may be
done.
Tests
CT Scan and Magnetic resonance imaging (MRI)
Additional tests that may be required
Lumbar puncture
Specialists
Family Practice, Internal Medicine, Neurology, Pain Medicine, Pediatric Neurology and Pediatrics

Treatment of Migraine (type of headache)
Therapy depends on the severity of the headaches. Several different types of medications may be used
including: ergots like dihydroergotamine, ergots with caffeine (Cafergot); and/or triptans like
sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), frovatriptan (Frova), and zolmitriptan
(Zomig). They can be taken orally, nasally or as a self-injection. Medications to help prevent the
frequency and severity of migraines include certain antidepressants, blood pressure medications, and
anti-seizure drugs. For more information contact the American Headache Society: (800)255-2243.
f.

Orbital cellulitis (soft tissue eye infection)

Description of Orbital cellulitis (soft tissue eye infection)
A bacterial infection of the fat and small muscles surrounding the eye. In children Haemophilus influenza
is a common bacteria, other pathogens include: Staphylococcus aureus, Streptococcus pneumoniae, and
beta-hemolytic streptococci. Other causes include a stye, bug bites, or a recent eyelid injury. The
infection can be very serious and lead to blindness.
Symptoms of Orbital cellulitis (soft tissue eye infection)
Fever, painful swelling of upper and lower eyelids, shiny red or purple eyelid, eye pain, eye pain with
movement, double vision, decreased vision, bulging eyes.
Tests for Orbital cellulitis (soft tissue eye infection)
Workup
A history and physical exam will be performed. A CT scan or MRI will be used to see the severity and size
of the infection. Blood tests are appropriate to check for spread of infection (blood cultures).
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan and Magnetic resonance
imaging (MRI)
Additional tests that may be required
Blood cultures
Specialists
Infectious Disease Medicine, Ophthalmology and Pediatric Infectious Disease Medicine
Treatment of Orbital cellulitis (soft tissue eye infection)
Aggressive treatment is required since an orbital cellulitis infection can quickly worsen and can cause
blindness. People with this condition are admitted to the hospital and intravenous antibiotics are used.
Surgery may be needed to drain an abscess (pocket of bacteria), if an abscess is part of the infection.

g. Uveitis (iritis, eye inflammation)
Description of Uveitis (iritis, eye inflammation)
The uvea is the portion of the eye that contains the iris, the ciliary body and the choroid. This area is also
called the anterior chamber. Uveitis or iritis is inflammation of this area. It is most commonly seen
between the ages 20 to 50. It can be serious, causing permanent loss of vision. Uveitis may occur
without any identified cause, but it is often caused by autoimmune diseases (rheumatoid arthritis,
ankylosing spondylitis), inflammatory conditions (Crohn's disease, ulcerative colitis), trauma, and
infections (toxoplasmosis, syphilis, tuberculosis).
Symptoms of Uveitis (iritis, eye inflammation)
Redness of the eye, blurred vision, sensitivity to light, floating spots in the vision, eye pain, irregularly
shaped pupil.
Tests for Uveitis (iritis, eye inflammation)
Workup
A history and physical exam will be performed. The slit lamp exam is used to make the diagnosis.
Depending on the suspected cause, other tests may be done.
Specialists
Ophthalmology
Treatment of Uveitis (iritis, eye inflammation)
The goal of therapy is to control the inflammation, reduce the symptoms and determine the cause of
the disorder. Treatment includes: corticosteroid eye drops and pain medications.

21. BLODY ACHES
a. Febrile (fever) illness
Description of Febrile (fever) illness
A fever is the body's way of reacting to something abnormal in the body. Fevers, on their own, aren't
bad for you unless they become too high or last too long though they can make you feel awful. The
cause of the fever is the bigger concern. Fevers may help the body fight infections but that should not
prevent a patient from trying to lower the temperature. Fevers can be caused by a number of conditions
including: infections, reactions to medications, reactions to blood transfusions, cancer, or autoimmune
diseases.
Symptoms of Febrile (fever) illness

Elevated temperature, weakness, chills, sweats, uncontrollable shivering (rigors), dizziness, body aches.
Tests for Febrile (fever) illness
Workup
A history and physical exam will be performed. Lab and imaging tests may be performed to search for a
source of infection or other cause of fever.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Urinalysis (UA) and X-ray
Additional tests that may be required
Blood culture, urine culture, spinal fluid cultures if headache and neck rigidity
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Febrile (fever) illness
Therapy depends on the cause of the fever. Treatment includes: nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn), acetaminophen (Tylenol),
antibiotics if a bacterial infection is suspected, and hospital admission if the patient is
immunocompromised or seriously ill.
b. Fibromyalgia (chronic pain disorder)
Description of Fibromyalgia (chronic pain disorder)
Characterized by chronic, widespread pain and tenderness in multiple areas of the body. It can be
associated with impaired sleep, fatigue and poor concentration. The disorder is common among women
between the ages of 20 and 50.
Symptoms of Fibromyalgia (chronic pain disorder)
Pain, achy joints, muscle pain and cramping, weakness, fatigue, non-restorative sleep.
Tests for Fibromyalgia (chronic pain disorder)
Workup
A history and physical exam will be performed. Imaging studies and blood tests may be recommended
to identify another cause of pain. Test results tend to be normal in people with fibromyalgia.
Tests

Complete blood count (CBC), Comprehensive metabolic panel (CMP), Lipase, Magnetic resonance
imaging (MRI), Pregnancy (BHCG) test and Urinalysis (UA)
Additional tests that may be required
Rheumatologic studies to rule out other causes of joint and muscle pain
Specialists
Family Practice, Internal Medicine and Rheumatology
Treatment of Fibromyalgia (chronic pain disorder)
Treatment may include stress reduction, exercise, and psychotherapy in addition to medications.
Medications include: pain medications, antidepressants, and anti-seizure medications (anti-convulsants).
For more information contact: Fibromyalgia Network: (800)853-2929
c. Influenza (seasonal flu)
Description of Influenza (seasonal flu)
A common, viral respiratory infection. It is contagious with an incubation period of 24 to 48 hours after
exposure. There are three main types of influenza (A, B, C). Only type A can change its structure from
year to year giving it the ability to produce widespread outbreaks. Because the strains causing outbreaks
vary from year to year, vaccinations are required yearly. The disease is usually self-limited (resolves
without treatment), but can be fatal in the very young, very old, or if there is a coexisting depression of
the immune system. It is difficult to tell the difference between a cold and the flu based on symptoms
alone. Special tests must be done within the first few days of illness to determine if you have the flu. In
general the flu is worse than the common cold and symptoms such as fever (usually over 101F) and
body aches are more severe with the flu.
Symptoms of Influenza (seasonal flu)
Fever, headache, tiredness (fatigue), chills, dry cough, sore throat, stuffy and congested nose, muscle
aches and stiffness. The fever in influenza tends to be higher (> 101 F or 38.3 C) than in other viral upper
respiratory infections (URIs) such as the common cold. The muscle aches and fatigue tend to be more
severe as well.
Tests for Influenza (seasonal flu)
Workup
A history and physical exam will be performed. A nasopharyngeal swab to detect the viral antigen may
be performed. A chest X-ray may be performed to rule out pneumonia.
Tests

Complete blood count (CBC) and X-ray
Additional tests that may be required
Rapid flu test (antigen test)
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Influenza (seasonal flu)
Rest and medications to reverse the fever such as acetaminophen(Tylenol) and/or ibuprofen (Motrin,
Advil) are administered to reduce the symptoms. Patients are encouraged to drink plenty of fluids.
Antiviral medications can be given but should be started within 40 hours of symptoms. Each year the
effectiveness of these drugs changes and selection is based on the type of influenza and the resistance
of the virus. The two antivirals recommended by the CDC are oseltamivir (Tamiflu) and zanamivir
(Relenza). These medications can also be given to prevent the disease after an exposure (prophylaxis).
Yearly flu vaccine is the most important step in protecting against the flu viruses. Use our provider
search function to find the closest available location near you. For more information:
http://www.flu.gov
d. Muscle spasm (charley horse)
Description of Muscle spasm (charley horse)
A muscle spasm also known as a Charley horse typically occurs after vigorous exercise. The affected
muscle contracts involuntarily and will not relax. It can occur in any muscle of the body but typically
involves the legs, arms and neck. Other causes include dehydration and changes in a patient's body
chemistry with abnormal levels of minerals. Low blood levels of potassium, magnesium and calcium are
the most frequent causes of a Charley horse, but sometimes no cause can be found. More rarely muscle
spasms can occur if the nerve supplying the muscle is injured or irritated.
Symptoms of Muscle spasm (charley horse)
Uncontrolled muscle contraction, pain in the muscles involved, inability to relax the muscle, loss of
function of the muscle during the contraction, muscle twitching.
Tests for Muscle spasm (charley horse)
Workup
A history and physical will be done. Generally no other tests are done. If the healthcare provider
suspects alterations in the body chemistry a blood test may be done. If an irritated nerve is suspected a
MRI of the neck or back may be performed.
Tests

Magnetic resonance imaging (MRI)
Additional tests that may be required
Potassium and calcium levels
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Muscle spasm (charley horse)
Typically stretching and massaging the muscle will allow the muscle to relax. Rest and better
conditioning before repeating the exercise can prevent a repeat episode. If dehydration is present
drinking fluids will prevent recurrence. Sports drinks are typically better for dehydration since they
replenish some of the missing minerals in the body. If the spasms continue to occur or are severe the
healthcare provider may evaluate the blood chemistry or look for an irritated nerve.
e. Muscle tear
Description of Muscle tear
A tear in a muscle. Any muscle in the body can be torn and the most common cause is an injury that
stretches the muscle suddenly. A direct blow to the muscle can also cause a tear of the muscle. Most of
these injuries will heal on their own with simple splinting. If there is an associated ligament or tendon
damage then surgery may be needed.
Symptoms of Muscle tear
Pain, swelling, decreased movement, bruising (hematoma), pain with movement.
Tests for Muscle tear
Workup
A history and physical will be done. Sometimes an x-ray is performed to identify a broken bone. A MRI is
the only study that show damage to the muscle, ligaments and tendons.
Tests
Magnetic resonance imaging (MRI) and X-ray
Specialists
Family Practice, Internal Medicine, Pediatric Sports Medicine, Pediatrics and Sports Medicine
Treatment of Muscle tear

Most of these injuries will heal on their own with splinting of the affected area. If there is a great deal of
muscle damage, or associated tendon or ligament injury surgery may be needed. Pain medications and
non-steroidal anti-inflammatory medications may be prescribed.
f.

Overuse syndrome (injury from repetitive activity)

Description of Overuse syndrome (injury from repetitive activity)
Muscle or nerve pain caused by repetitive use of a muscle or by clenching (tight contraction) of a
muscle. Examples of overuse syndromes include: carpal tunnel syndrome, tarsal tunnel syndrome,
tennis elbow, tendonitis, temporomandibular joint (TMJ) syndrome and certain sprains and strains. Also
called cumulative trauma disorder or repetitive strain injury.
Symptoms of Overuse syndrome (injury from repetitive activity)
Pain, tingling of the skin, tenderness, stiffness, decreased range of motion.
Tests for Overuse syndrome (injury from repetitive activity)
Workup
A history and physical exam will be performed. Most of the time overuse syndromes can be identified
without special tests.
Tests
Magnetic resonance imaging (MRI) and X-ray
Specialists
Family Practice, Internal Medicine, Orthopedic Surgery, Pediatric Sports Medicine, Pediatrics, Podiatry
and Sports Medicine
Treatment of Overuse syndrome (injury from repetitive activity)
Treatment includes identifying the activity that resulted in symptoms and reducing or modifying this
activity. Nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn) or acetaminophen (Tylenol) can relieve pain. Injection, splinting, bracing, or
physical therapy may be recommended.
g. Polymyalgia rheumatica (PMR, muscle and joint disorder)
Description of Polymyalgia rheumatica (PMR, muscle and joint disorder)
An inflammatory disorder involving severe aching and stiffness in the neck, shoulder and hip areas. The
exact cause is unknown. Biopsies of achy muscles are normal when evaluated microscopically. In some
people, the disorder is related to temporal arteritis (giant cell arteritis). It rarely occurs before age 50.

Symptoms of Polymyalgia rheumatica (PMR, muscle and joint disorder)
Fatigue (excessive tiredness), low grade fever, hip pain, joint stiffness, joint pain, malaise (general ill
feeling), muscle pain, neck pain, neck stiffness, shoulder pain, unintentional weight loss. If associated
with temporal arteritis: headache, tender temporal arteries, vision changes.
Tests for Polymyalgia rheumatica (PMR, muscle and joint disorder)
Workup
A history and physical exam will be performed. A blood test to measure an erythrocyte sedimentation
rate (ESR, also called sed rate) and/or a C-reactive protein (CRP) level are performed. An elevated
reading in one or both tests in the appropriate clinical setting supports the diagnosis. Additional studies
may be done to rule out other possible causes of the symptoms.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Erythrocyte sedimentation rate
(ESR) and Urinalysis (UA)
Additional tests that may be required
CPK
Specialists
Internal Medicine and Rheumatology
Treatment of Polymyalgia rheumatica (PMR, muscle and joint disorder)
The usual treatment is corticosteroids (prednisone) in moderate to low doses. Treatment usually
continues for at least one year and sometimes low dose corticosteroids are needed indefinitely. If
temporal arteritis is being considered, treatment with high dose corticosteroids needs to begin urgently
to prevent blindness
h. Rhabdomyolysis (severe muscle breakdown)
Description of Rhabdomyolysis (severe muscle breakdown)
A breakdown of the muscle cells. It most commonly occurs after a person has been unconscious for
several hours—lying heavily without shifting one's weight can lead to muscle breakdown.
Rhabdomyolysis (muscle breakdown) also occurs after extreme exercise or seizures, and can be a
complication (side effect) of certain medications. Cholesterol lowering drugs named statins
(atorvastatin/Lipitor, lovastatin/Mevacor, simvastatin/Zocor etc.) can result in this problem. Muscle
breakdown releases the protein myoglobin into the blood. Myoglobin harms the kidney and can cause
kidney failure.

Symptoms of Rhabdomyolysis (severe muscle breakdown)
Dark urine color, reddish urine, general weakness, muscle stiffness or aching (myalgia), muscle
tenderness, weakness of the affected muscles.
Tests for Rhabdomyolysis (severe muscle breakdown)
Workup
A history and physical exam will be performed. The diagnosis is made by finding an elevated creatinine
kinase (CPK) in the blood. Blood tests will check the function of the kidneys.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Urinalysis (UA)
Additional tests that may be required
Creatinine kinase (CPK), myoglobin
Specialists
Nephrology and Pediatric Nephrology
Treatment of Rhabdomyolysis (severe muscle breakdown)
The main treatment is IV fluids to maximize how much urine is made. This helps to "rinse" the kidneys
and can help to prevent kidney failure. Treatment may include sodium bicarbonate, potassium and
magnesium supplements.
i.

Swine Flu (H1N1 Influenza)

Description of Swine Flu (H1N1 Influenza)
Swine flu is an influenza type A virus that has been identified as the H1N1 strain that normally can only
be transmitted from pigs to human. The swine flu outbreak of 2009 is a genetic combination of avian,
swine and human flu. This strain can be passed from human to human. The severity of this disease
varies widely, ranging from fever and cough to pneumonia and death.
Symptoms of Swine Flu (H1N1 Influenza)
Fever, chills, muscle aches, headache, cough, runny nose, sore throat, shortness of breath. The fever in
influenza tends to be higher (> 101 F or 38.3 C) than in other upper respiratory infection caused by viral
illnesses such as the common cold. The muscle aches and fatigue tend to be more severe as well.
Tests for Swine Flu (H1N1 Influenza)

Workup
A history and physical will be done. A chest x-ray may be performed to rule out a lung infection
(pneumonia).
Tests
X-ray
Additional tests that may be required
Rapid influenza swab
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Swine Flu (H1N1 Influenza)
The strain of swine flu seen in 2009 is sensitive to the anti-viral medications oseltamivir (Tamiflu) and
zanamivir (Relenza). Treatment should be started within 40 hours of symptoms to be most effective.
Patients with swine flu should avoid close contact with other people to prevent the spread. The fever
and other symptoms can be reduced by taking ibuprofen (Motrin) and/or acetaminophen (Tylenol).
Influenza vaccination can help prevent infection with the H1N1 virus.

22. BOIL(FURUNCALE)
a. Anorectal (perirectal) abscess
Description of Anorectal (perirectal) abscess
A collection of pus in the anal or rectal region. Most common between ages 20 and 40. Men are affected
more often than women. The most common cause is a blocked anal gland that becomes infected with
bacteria.
Symptoms of Anorectal (perirectal) abscess
Painful bowel movements, tender lump or swelling at the edge of the anus, fever, discharge of pus from
the rectum.
Tests for Anorectal (perirectal) abscess
Workup
A history and physical exam will be performed including a rectal exam and possibly anoscopy. If the
abscess is large a CT scan may be done to identify the extent of the abscess.

Tests
CT Scan
Specialists
Colon and Rectal Surgery, General Surgery and Pediatric Surgery
Treatment of Anorectal (perirectal) abscess
Incision and drainage of the abscess. If the abscess is large or into the deep tissue surgery may be
required. The abscess is typically packed with gauze and the dressing is changed every 1-2 days until the
area heals. Antibiotics may be given.
b. Cluster of pus-filled sacs (carbuncle)
Description of Cluster of pus-filled sacs (carbuncle)
An abscess (collection of pus caused by a bacterial infection) that is larger than a boil—as small as a
peanut to as large as a golf ball. The infection arises from hair follicles and rapidly turns into an abscess
(a collection of pus). The most common kind of bacteria causing an abscess is Staphylococcus aureus. A
more dangerous, antibiotic-resistant form of Staphylococcus aureus, called MRSA (methicillin resistant
Staphylococcus aureus), is becoming more common. Abscesses can occur anywhere on the body but are
more commonly found on the back, neck or in skin areas that are shaved frequently. The infection can
be contagious and is more common in those people with diabetes or other disorders that depress the
immune system.
Symptoms of Cluster of pus-filled sacs (carbuncle)
Swollen red area of skin that is tender. The affected area is warm to the touch. There may be a white
center and oozing of pus. Associated symptoms may include fatigue, fever, and nausea.
Tests for Cluster of pus-filled sacs (carbuncle)
Workup
A history and physical will be done. No other tests are generally necessary.
Tests
Wound culture
Specialists
Dermatology, Family Practice, Internal Medicine and Pediatrics
Treatment of Cluster of pus-filled sacs (carbuncle)

Drainage of the material in the carbuncle must occur for complete recovery. This can occur
spontaneously and can be helped by placing a warm moist cloth over the area. At times this is not
successful requiring a medical provider to open the area with a small scalpel, to drain the pus out.
Antibiotics may be prescribed by mouth such as cephalexin (Keflex), clindamycin (Cleocin), or
erythromycin (Ery-Tab). If the provider is concerned about MRSA (methicillin resistant staphylococcus
aureus) sulfamethoxazole/trimethoprim (Bactrim, Septra) or linezolid (Zyvox) may be prescribed. At
times a topical antibiotic such as mupirocin (Bactroban) may be administered.
c. Dental abscess (tooth infection)
Description of Dental abscess (tooth infection)
Tooth decay may eventually spread to the root of the tooth, the gingival (gum) and surrounding bone.
As the infection progresses, an abscess (a collection of pus) can develop. This can produce loosening of
the tooth. An abscess can spread to or form in the bone.
Symptoms of Dental abscess (tooth infection)
Pain, swelling, sour taste, discharge from tooth or root of tooth, facial swelling, gum swelling.
Tests for Dental abscess (tooth infection)
Workup
A history and physical exam will be performed. A panorex and/or CT scan may be performed to
delineate the extent of disease.
Tests
CT Scan
Additional tests that may be required
Panorex X-ray,
Specialists
Dentistry, Dentistry - Pediatric and Oral and Maxillofacial Surgery
Treatment of Dental abscess (tooth infection)
Antibiotics and drainage of the abscess are necessary. A root canal and/or tooth removal may be
needed if the decay is severe.
d. Methicillin-resistant Staphylococcus aureus (MRSA, type of bacteria)
Description of Methicillin-resistant Staphylococcus aureus (MRSA, type of bacteria)

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial infection caused by a particular type of
Staphylococcus aureus bacteria. The bacteria are resistant to the usual antibiotics and require treatment
with special drugs not ordinarily used. The bacteria can be found on the skin and in the nose but does
not always cause an infection. These people are colonized, but do not actually become ill. The infection
can involve any part of the body but most commonly affects the skin and soft tissue (cellulitis) or causes
a collection of pus (abscess). In the past MRSA was almost exclusively seen in hospitalized patients
(hospital acquired MRSA) but now is more commonly seen in otherwise healthy individuals unrelated to
a hospital or nursing home visit (community acquired MRSA). Certain people are at increased risk for
developing community acquired MRSA including: those playing contact sports, people living in crowded
conditions (dorms etc.), those sharing towels and sports equipment, patients with weakened immune
systems, and people associated with healthcare workers. The infections can be localized to the skin or
become widespread and fatal. Young children are especially susceptible to the more serious form.
Symptoms of Methicillin-resistant Staphylococcus aureus (MRSA, type of bacteria)
Red, swollen, and painful patches of skin. Pustular drainage (yellow foul smelling fluid), fever, skin
abscess, warmth around the infected area, red streaks traveling up the arm or leg (lymphangitis). More
serious infections cause chest pain, chills, fatigue, fever, general ill feeling (malaise), headache, muscle
aches, red skin rash, shortness of breath, fainting, low blood pressure.
Tests for Methicillin-resistant Staphylococcus aureus (MRSA, type of bacteria)
Workup
A history and physical exam will be performed. Additional testing will depend on the clinical situation.
Identification of MRSA is typically done by culturing the wound, blood or urine. An imaging study may be
done to determine the presence of a collection of pus (abscess) or the extent of the disease. Other tests
may be performed to determine damage to other organs.
Tests
Blood culture, Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic
resonance imaging (MRI), Ultrasound, Urine Culture, Wound culture and X-ray
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Methicillin-resistant Staphylococcus aureus (MRSA, type of bacteria)
Treatment depends on the extent of the infection. A simple collection of pus often only requires incision
and drainage of the pus. More serious MRSA infections require antibiotics. The decision to use oral or
intravenous medications depends on how serious the infection is and the health state of the patient.
Resistance to antibiotics is becoming an increasing problem. The medications currently used include:

trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS), linezolid (Zyvox), daptomycin
(Cubicin), and vancomycin (Vancocin, Vancoled). Those with very serious infections may require blood
pressure and respiratory support as well as treatment for end organ damage, such as renal failure.
e. Peritonsillar abscess (collection of pus around tonsils)
Description of Peritonsillar abscess (collection of pus around tonsils)
A collection of pus in or around an infected tonsil. The swelling can become large enough to interfere
with breathing. Surgical drainage of the abscess is required. This problem can occur after strep throat
infection.
Symptoms of Peritonsillar abscess (collection of pus around tonsils)
Sore throat (may be severe), asymmetrical swelling of the tonsils, swelling extending onto the roof of
the mouth, shifting of the uvula to one side, tender glands of the jaw and throat, facial swelling,
drooling, headache, fever, chills, difficulty and pain with opening the mouth.
Tests for Peritonsillar abscess (collection of pus around tonsils)
Workup
A history and physical exam will be performed. A sample of drained abscess fluid may be sent for
culture. A CT scan may be performed to establish the diagnosis and determine its extent.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and CT Scan
Specialists
Ear, Nose, and Throat (ENT) and Pediatric ENT (Otolaryngology)
Treatment of Peritonsillar abscess (collection of pus around tonsils)
Antibiotics are given either orally or intravenously. Most abscesses will be drained through an incision in
the tonsil. Nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol), and steroids may be
administered. Surgery to remove the tonsils (tonsillectomy) may be considered.
f.

Skin abscess (collection of pus)

Description of Skin abscess (collection of pus)
A collection of infected material just under the skin. The body walls off the infection, which traps the
infected fluid. If untreated, the abscess can slowly grow or spontaneously erupt through the skin,
leaking purulent fluid. Occasionally the infection can enter the blood stream and cause a life threatening

illness. The disorder is usually secondary to a bacterial infection and is frequently caused by a
staphylococcal bacteria.
Symptoms of Skin abscess (collection of pus)
Pain, swelling, redness, tenderness, increased warmth of the skin overlying the abscess, hardened skin
over the abscess.
Tests for Skin abscess (collection of pus)
Workup
A history and physical exam will be performed. This is diagnosed without additional tests. A culture of
the infected material may be done.
Additional tests that may be required
Culture
Specialists
Family Practice, General Surgery, Internal Medicine and Pediatrics
Treatment of Skin abscess (collection of pus)
Some abscess can be treated with warm moist compresses. Most require incision and drainage of the
abscess. If there is significant redness around the abscess (cellulitis) an antibiotic may be given.
Methicillin resistant staphylococcus (MRSA) is becoming more prevalent and an antibiotic effective
against this bacteria may be chosen
g. Staphylococcus aureus (type of bacteria)
Description of Staphylococcus aureus (type of bacteria)
A bacterial infection that can involve any part of the body, but most commonly affects the skin and soft
tissue (cellulitis) or causes a collection of pus (abscess). Staph bacteria are commonly found on the skin
and in the nose but does not always cause an infection. These people are colonized but do not actually
become ill. The infection can be localized to the skin or become widespread and lethal. The infection
more commonly occurs in those with weakened immune systems, burns, surgical wounds, and patients
with invasive devices such as urinary catheters, intravenous catheters, dialysis catheters, or breathing
tubes. Methicillin resistant staphylococcus aureus (MRSA) is a special type of staphylococcus that is
becoming more common and is harder to treat, requiring special antibiotics.
Symptoms of Staphylococcus aureus (type of bacteria)
Red, swollen, and painful patches of skin. Pustular drainage (yellow foul smelling fluid), fever, skin
abscess, warmth around the infected area, red streaks traveling up the arm or leg (lymphangitis). More

serious infections cause chills, fatigue, fever, general ill feeling (malaise), headache, muscle aches, red
skin rash, shortness of breath, fainting, low blood pressure.
Tests for Staphylococcus aureus (type of bacteria)
Workup
A history and physical exam will be performed. Additional testing will depend on the clinical situation.
Identification of the Staphylococcal bacteria is typically done by culturing the wound, blood or urine. An
imaging study may be done to determine the presence of a collection of pus (abscess) or the extent of
the disease. Other tests may be performed to determine damage to other organs.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI), Ultrasound, Urinalysis (UA) and X-ray
Additional tests that may be required
Blood culture, wound culture, urine culture
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Staphylococcus aureus (type of bacteria)
Treatment depends on the extent of the infection. A simple collection of pus often only requires incision
and drainage of the pus. More serious infections require antibiotics. The decision to use oral or
intravenous medications depends on how serious the infection is and the health state of the patient.
The medications currently used include: cephalexin (Keflex), trimethoprim-sulfamethoxazole (Bactrim,
Bactrim DS, Septra, Septra DS), methicillin, nafcillin, and cefazolin (Ancef). Resistance to antibiotics is
becoming an increasing problem, and methicillin resistant staph (MRSA) requires special antibiotics.

23. BRADYCARDIA (SLOW HEART RATE)
a. Arrhythmia (abnormal heart rhythm)
Description of Arrhythmia (abnormal heart rhythm)
An abnormal heart rhythm occurs when the electrical impulses traveling through the heart become
disrupted. This can cause the heart to beat too fast, too slow or irregularly. The condition can be very
serious causing the patient to faint or even die. The major causes of this disorder are heart attacks,
congestive heart failure, congenital heart problems, and diseases of the heart valves.

Symptoms of Arrhythmia (abnormal heart rhythm)
Palpitations (heart racing or skipping), light-headedness, shortness of breath, fainting, anxiety, chest
pain.
Reviewed by Harvard Medical School
Tests for Arrhythmia (abnormal heart rhythm)
Workup
A history, physical exam and EKG(electrocardiogram) will be performed. Additional tests may include:
blood tests to rule out electrolyte or thyroid abnormality, and an echocardiogram to look for heart
muscle or heart valve abnormalities. A portable heart monitor (Holter monitor) may be attached to
watch heart rate and rhythm for 24 hours or more. For some arrhythmias, patients undergo a study
called an electrophysiologic (EP) evaluation in a cardiac catheterization suite.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG) and
Troponin
Additional tests that may be required
Thyroid stimulating hormone, echocardiogram, Holter monitor
Specialists
Cardiology and Pediatric Cardiology
Treatment of Arrhythmia (abnormal heart rhythm)
Treatment is based on the cause of the arrhythmia and may include medications, a pacemaker,
implantable defibrillator or ablation of abnormal electrical tissue in the heart seen during
electrophysiologic (EP) evaluation. For more information contact the National Heart, Lung and Blood
Institute Health Information Center at http://www.nhlbi.nih.gov or call (301)592-8573
b. Atrioventricular node conduction block (heart block)
Description of Atrioventricular node conduction block (heart block)
A partial or complete interruption of impulse transmission from the small chambers of the heart
(atrium) to the large chambers of the heart (ventricles). The most common causes are medications, a
heart attack, electrolyte abnormalities (such as high blood potassium level), and scarring of the
conduction system. The most common drugs causing this disorder are calcium channel blockers, betablockers and digoxin. The blocked impulses result in an abnormally slow heart rate. This disorder can be
very serious and if untreated result in death.

Symptoms of Atrioventricular node conduction block (heart block)
Light-headedness, slow heart rate, irregular heart rate, weakness, fainting, shortness of breath.
Tests for Atrioventricular node conduction block (heart block)
Workup
A history and physical exam will be performed. An EKG will be performed to characterize the type of AV
block and to diagnose a co-existing heart attack. Lab tests will be done to diagnose an electrolyte
abnormality.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Troponin
and X-ray
Specialists
Cardiology and Pediatric Cardiology
Treatment of Atrioventricular node conduction block (heart block)
Treatment depends on the type of AV block but may include observation, cessation of the offending
medications, correction of electrolyte abnormalities or the insertion of a pacemaker.
c. Congestive heart failure (CHF)
Description of Congestive heart failure (CHF)
The heart pumps blood through the arteries and veins. With congestive heart failure, the pumping force
of the heart is reduced. Left sided heart failure results in fluid backing up into the lungs causing
breathing problems, and right sided heart failure produces fluid in the legs (edema) and the abdomen
(ascites). Congestive heart failure (CHF) can have many causes with the most common being high blood
pressure (hypertension), heart attacks, viral heart infections (myocarditis), congenital heart defects, and
valvular heart disease. Patients with known CHF can experience worsening symptoms if they eat too
much salt, stop taking their medications or have another co-existing illness such as pneumonia.
Symptoms of Congestive heart failure (CHF)
Shortness of breath, especially if lying flat (orthopnea), awaking suddenly gasping for air (paroxysmal
nocturnal dyspnea), swollen legs (edema), distended abdomen (ascites), shortness of breath with
exercise.
Tests for Congestive heart failure (CHF)
Workup

A history and physical exam will be performed. The goal is to identify the cause of the heart failure and
reverse the adverse effects. Once the cause is identified the extent of the disease can be assessed by
performing X-rays, blood tests and an echocardiogram.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Electrocardiogram (EKG), Troponin
and X-ray
Additional tests that may be required
Echocardiogram, Brain natrietic peptide
Specialists
Cardiology, Family Practice and Internal Medicine
Treatment of Congestive heart failure (CHF)
Therapy depends on the extent of the disease and the severity of the symptoms. Treatment includes:
controlling the blood pressure and reducing the work of the heart with blood pressure medications,
increasing the urine output with diuretics, and maximizing oxygen with supplemental oxygen. Reversing
the cause of the CHF exacerbation is essential to recovery. For severe cases that do not improve with
standard medications, heart transplant may be recommended. For more information contact the
National Heart, Lung, and Blood Institute Health Information Center at: http://www.nhlbi.nih.gov or call
(301)592-8573
d. Heart attack (acute myocardial infarction, AMI)
Description of Heart attack (acute myocardial infarction, AMI)
Damage or death of heart muscle caused by a blockage of an artery (coronary artery) that supplies blood
to a part of the heart. Symptoms can vary widely and can be atypical in the elderly, diabetics and
women. The most common cause of the blockage is buildup of fat and calcium in the artery
(atherosclerosis). Conditions such as high blood pressure, high cholesterol, smoking, family history of
heart attacks and diabetes can all increase the chances of having a heart attack. Rapid treatment
reduces, but does not eliminate, the risk of death. Longer term consequences of having had a heart
attack include heart failure and stroke.
Symptoms of Heart attack (acute myocardial infarction, AMI)
Chest pain (typically described as squeezing, crushing, or band like), some people may have little or no
chest pain (elderly, diabetics, or women). Other symptoms include: jaw pain, arm pain, back pain,
abdominal pain, shortness of breath, sweating, nausea, vomiting, apprehension, fainting, dizziness.
Tests for Heart attack (acute myocardial infarction, AMI)

Workup
A history and physical exam will be performed. An EKG can provide strong evidence of a heart attack. A
coronary angiogram can definitively identify the coronary artery blockage. A high resolution chest CT
scan may also demonstrate the blockage. CT scans can also rule out other diseases that can clinically
mimic a heart attack. An echocardiogram can demonstrate a poorly functioning heart.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Coronary angiogram,
Echocardiogram (ECHO), Electrocardiogram (EKG), Troponin and X-ray
Specialists
Cardiology and Cardiothoracic Surgery
Treatment of Heart attack (acute myocardial infarction, AMI)
Treatment is aimed at improving the blood flow to the heart, treating life threatening arrhythmias, and
maximizing the heart function. During a heart attack, clot busting medications (alteplase/t-PA) often are
used to break apart the blood clot that has stopped blood flow to one part of the heart. In people with
angina (and sometimes in people having heart attacks), coronary (heart) artery blockages are reduced
by the following: balloon angioplasty, stent placement, surgical bypass, blood thinners and/or antiplatelet medications (aspirin, abciximab/ReoPro, eptifibatide/Integrilin, clopidogrel/Plavix). When
arrhythmias are present they are treated with medications (amiodarone), cardioversion or a pacemaker.
Medications for blood pressure and cholesterol (statins) are also frequently used. For additional
information contact the National Heart, Lung and Blood Institute Health Information Center at:
http://www.nhlbi.nih.gov or call (301)592-8573 American Heart Association: (800)242-8721
e. Hypothyroidism (low thyroid hormone)
Description of Hypothyroidism (low thyroid hormone)
A condition of low thyroid hormone. The thyroid gland is located in the front of the neck. Thyroid
hormone helps control metabolism. Low thyroid hormone is caused by abnormalities of the thyroid
gland, pituitary gland, or hypothalamus. For people who take thyroid hormone medication,
hypothyroidism may be due to an insufficient dose. Low thyroid hormone can affect all bodily functions
and if severe may cause coma (myxedema) and death.
Symptoms of Hypothyroidism (low thyroid hormone)
Cold intolerance, fatigue, abnormal menstrual cycles, unexplained weight gain, depression, thin and
brittle hair, hoarseness, thickening skin, leg swelling, confusion, lethargy, coma.
Tests for Hypothyroidism (low thyroid hormone)
Workup

A history and physical exam will be performed. Tests will be performed to determine the cause of the
low thyroid hormone.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Electrocardiogram (EKG)
and Urinalysis (UA)
Additional tests that may be required
Thyroid stimulating hormone (TSH), T4, T3
Specialists
Diabetes, Endocrinology and Metabolism, Family Practice, Internal Medicine, Pediatric Endocrinology
and Pediatrics
Treatment of Hypothyroidism (low thyroid hormone)
The goal of therapy is to reverse the cause of hypothyroidism and to return the thyroid hormone levels
to normal. Oral thyroid hormone is usually effective but severe hypothyroidism may require intravenous
treatment. Myxedema coma, the most dangerous form of the disease, requires immediate treatment,
including intravenous thyroid replacement, steroids, and other supportive measures. For more
information contact the National Endocrine and Metabolic Diseases Information Service at
http://www.endocrine.niddk.nih.gov or call (888)828-0904.
f.

Medication reaction

Description of Medication reaction
Any allergic reaction or symptom that is caused by a medication. The reactions can be mild such as
nausea. They can be life threatening such anaphylaxis—low blood pressure, fainting and collapse. Small
children and the elderly are most susceptible to medication reactions. A medication reaction should be
considered as a possible cause for a sudden change in behavior or new symptom in children and the
elderly. Over the counter medications can also cause serious side effects. Even medications that initially
were tolerated without a problem can result in serious reactions. Some medication reactions are caused
by taking too much of the drug requiring a decrease in a patient's dose. For specific reactions review the
adverse reaction section of the medication being taken.
Symptoms of Medication reaction
Symptoms depend on the medication being taken. Mild to moderate symptoms include nausea,
vomiting, abdominal pain, diarrhea, headache, easy bruising. More serious symptoms include breathing
problems, low blood pressure, fainting, facial swelling, intestinal bleeding, or low blood sugar (glucose).
Tests for Medication reaction

Workup
A history and physical exam will be done. Further tests will depend on the symptoms being experienced.
The provider may remove the medication and observe to see if the symptoms go away. If available a
drug level may be performed to measure the amount of medication in the body.
Specialists
Family Practice, Internal Medicine, Medical Toxicology and Pediatrics
Treatment of Medication reaction
Treatment depends on the reaction and the medication being taken. Patients should always discuss with
their healthcare provider before abruptly stopping a medication since some drugs require a gradual
reduction to prevent serious side effects.
g. Myocarditis (heart muscle inflammation)
Description of Myocarditis (heart muscle inflammation)
Inflammation of the heart muscle (myocardium). The disease can be from an infection (usually viral) or
from a complication of an underlying illness, injury, radiation therapy, or toxic reactions to drugs.
Inflammation of the lining surrounding the heart can also occur (pericarditis). The severity of the disease
can vary widely and the prognosis varies. Many people completely recover. Others have permanent
heart damage and heart failure.
Symptoms of Myocarditis (heart muscle inflammation)
Chest pain, shortness of breath, palpitations, fainting, fatigue, exercise intolerance. There may be no
symptoms.
Tests for Myocarditis (heart muscle inflammation)
Workup
A history and physical exam will be performed. Initial testing includes blood tests, an electrocardiogram
(EKG) and echocardiogram. Cardiac catheterization to look to rule out coronary artery disease may be
performed, especially in people over age 40. In some cases, a heart muscle biopsy (endomyocardial
biopsy) is recommended.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, D-Dimer,
Electrocardiogram (EKG), Magnetic resonance imaging (MRI), Troponin, Urinalysis (UA) and X-ray
Additional tests that may be required

Blood cultures, antibody tests against the heart muscle and the body, heart muscle biopsy
(endomyocardial biopsy), echocardiogram
Specialists
Cardiology and Pediatric Cardiology
Treatment of Myocarditis (heart muscle inflammation)
If the cause of inflammation is diagnosed, treatment will be aimed at the underlying condition. Without
a specific diagnosis, drug therapy will be used to treat heart failure and to help prevent the heart failure
from getting worse. Abnormal heart rhythms (arrhythmias) may require additional medications, a
pacemaker, or an automated implantable cardioverter-defibrillator (AICD). For more information
contact the National Heart, Lung and Blood Institute Health Information Center at:
http://www.nhlbi.nih.gov or call (301)592-8573

24. BRUISING
a. Hemophilia (inherited bleeding disorder)
Description of Hemophilia (inherited bleeding disorder)
A bleeding disorder that may be caused by one of several blood clotting factor deficiencies. Classic
Hemophilia, or Hemophilia A, is caused by a deficiency of factor VIII. Hemophilia B, (Christmas disease),
occurs with a deficiency of factor IX. These diseases are usually genetic and usually occur only in males.
Due to mutations, new cases can arise in families with no history of the disorder. Hemophilia can cause
dangerous episodes of bleeding.
Symptoms of Hemophilia (inherited bleeding disorder)
Blood in stool, easy bruising, heavy periods, bleeding gums, bleeding in joints.
Tests for Hemophilia (inherited bleeding disorder)
Workup
A history and physical exam will be performed. Factor studies are completed to diagnose the specific
clotting disorder.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Clotting studies, PT (Protime), PTT (Partial thromboplastin time)

Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Hemophilia (inherited bleeding disorder)
Therapy is determined by the type of hemophilia, the severity of the clotting deficiency, and the
symptoms being experienced. The goal is to stop the bleeding, and replace the needed blood factor. For
more information contact: National Hemophilia Foundation: (800)424-2634
b. Low platelets (thrombocytopenia)
Description of Low platelets (thrombocytopenia)
Platelets are cells that help the body form blood clots. Low platelets, also called thrombocytopenia, can
occur from insufficient production of platelets, or from increased destruction. Some causes are: immune
thrombocytopenic purpura (ITP), drug-induced immune thrombocytopenia, drug-induced nonimmune
thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), disseminated intravascular
coagulation (DIC), an enlarged spleen, aplastic anemia, cancer and infection.
Symptoms of Low platelets (thrombocytopenia)
Easy bruising, easy bleeding, reddish-purple spots on skin (petechiae).
Tests for Low platelets (thrombocytopenia)
Workup
A history and physical exam will be performed. Tests will be performed to determine the cause of the
low platelets. A bone marrow biopsy may be recommended.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP) and Urinalysis (UA)
Additional tests that may be required
Platelet associated antibodies, Bone marrow biopsy, PT, PTT (Partial Thromboplastin Time) (Partial
Thromboplastin Time)
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Low platelets (thrombocytopenia)

Treatment depends on the cause of the low platelets. While evaluation and treatment are ongoing,
transfusion of platelets may be helpful for severe bleeding. Unfortunately, transfused platelets do not
last long in the body and are only a temporary treatment.
c. Myelodysplastic syndrome (bone marrow failure)
Description of Myelodysplastic syndrome (bone marrow failure)
A syndrome where the stem cells in the bone marrow fail to develop normally into the white blood cells,
red blood cells and platelets needed for normal bodily function. There is a range of severity with some
patients experiencing serious low red blood cells, excessive bleeding, and an increase in infections. This
disorder can be life threatening and in some cases it can progress to leukemia. The disease is most often
seen in patients greater than 60 and is more common in men. The following conditions increase the risk
of this disorder: previous treatment for cancer, a family history of the disease, smoking, and exposure to
certain chemicals.
Symptoms of Myelodysplastic syndrome (bone marrow failure)
Fatigue, pin point reddish-purple skin blotches, frequent infections, easy bruising, shortness of breath,
pale skin (anemia).
Tests for Myelodysplastic syndrome (bone marrow failure)
Workup
A history and physical exam will be performed. Blood tests will be done to determine the number and
types of blood cells. A bone marrow biopsy will be done to establish the diagnosis, evaluate the stem
cells and look for cancers and genetic defects.
Tests
Complete blood count (CBC)
Additional tests that may be required
Bone marrow biopsy
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice and Internal Medicine
Treatment of Myelodysplastic syndrome (bone marrow failure)
Therapy depends on the severity of disease and the chromosomal defect present but may include:
erythropoietin or darbepoetin to stimulate red blood cell production, azacitidine (Vidaza) and decitabine
(Dacogen) to stimulate stem cell transformation into mature cells, and lenalidomide (Revlimid) in cases

with a specific chromosome abnormality. Other treatment options include: blood transfusion,
chemotherapy and stem cell transplantation.
d. Von Willebrand's disease
Description of Von Willebrand's disease
Von Willebrand's Disease is a bleeding disorder that affects the body's ability to clot. It is most often an
inherited disorder that results from low levels of Von Willebrand's protein. This protein acts as the glue
that holds tiny cells called platelets together during the formation of a clot. Von Willebrand's disease is
relatively common and affects both males and females.
Symptoms of Von Willebrand's disease
Symptoms include easy bruising, prolonged bleeding, and significant bleeding during menstrual periods
in women (menorrhagia).
Tests for Von Willebrand's disease
Workup
A complete history and physical will be performed. Blood tests will be ordered to evaluate the amount
and function of the Von Willebrand's factor in your blood.
Tests
Activated partial thromboplastin (aPTT or PTT), Bleeding time, Complete blood count (CBC) and
Prothrombin test (PT, INR)
Additional tests that may be required
Von Willebrand factor (VWF) antigen, platelet function test (PFA-100), Von Willebrand factor multimers,
factor VIII clotting activity, Ristocetin cofactor activity
Specialists
Blood and Cancer Care (hematology and oncology), Family Practice, Internal Medicine, Pediatric
Hematology and Oncology and Pediatrics
Treatment of Von Willebrand's disease
Treatment may vary depending on the severity of your disease. Desmopressin (DDAVP) is the most
common treatment and can be administered via a nasal spray. DDAVP is a synthetic hormone that
stimulates the release of more Von Willibrand factor. Other treatment options include contraceptives
for women, clot-stabilizing medications such as aminocaproic acid (Amicar) and transxemic acid
(Cyklokapron), and clotting factor infusions.

e. Warfarin (Coumadin) use
*OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA
25. BULGING ABDOMEN
a. Ascites (fluid in the abdomen)
Description of Ascites (fluid in the abdomen)
Excess fluid in the space (the peritoneal cavity) inside the abdomen that is not occupied by abdominal
organs. There are many causes of ascites with the most common being liver failure and cancer. The fluid
build-up can become severe enough to make breathing difficult, because the fluid pushes upward on the
lungs and preventing their normal expansion. The fluid can also become infected leading to spontaneous
bacterial peritonitis, a potentially life threatening condition.
Symptoms of Ascites (fluid in the abdomen)
Abdominal swelling, weight gain, abdominal pain, difficulty breathing.
Tests for Ascites (fluid in the abdomen)
Workup
A history and physical exam will be performed. The provider may take ascites fluid from the abdomen to
analyze it. This is called a paracentesis. A CT scan, ultrasound and/or MRI may be done to help
determine the cause of the fluid.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI) and Ultrasound
Additional tests that may be required
Cell count, protein, LDH, Gram stain, culture
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Ascites (fluid in the abdomen)
Therapy is aimed at determining and reversing the cause of the ascites. Simply removing the fluid
(paracentesis) is many times only a temporary solution since the fluid accumulates over time,
sometimes very quickly within days. Medicines that increase urine output called diuretics are frequently
used with the most common being spironolactone (Aldactone) and furosemide (Lasix). Decreasing salt
intake can also sometimes help prevent the fluid from returning

b. Celiac disease (celiac sprue)
Description of Celiac disease (celiac sprue)
An inherited, autoimmune disease in which the lining of the small intestine is damaged from eating
gluten and other proteins found in wheat, barley, rye, and oats. The disease causes diarrhea,
malabsorption, steatorrhea, nutritional and vitamin deficiencies, and in children can result in failure to
thrive and short stature. This disorder is more common in patients who have Type 1 diabetes,
autoimmune disorders, microscopic colitis, lactose intolerance, Down syndrome, and intestinal cancer.
Avoiding foods with gluten allows the intestine to heal but this can take months or even years for
complete resolution of symptoms.
Symptoms of Celiac disease (celiac sprue)
Abdominal pain, abdominal distension, constipation, decreased appetite, diarrhea, nausea, vomiting,
lactose intolerance, fatty stools, weight loss.
Tests for Celiac disease (celiac sprue)
Workup
A history and physical exam will be performed. Blood tests to detect antibodies in the blood. Endoscopy
and biopsy of small intestine may be necessary.
Tests
Complete blood count (CBC) and Comprehensive metabolic panel (CMP)
Additional tests that may be required
Endoscopy, biopsy, antibody detection
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Reviewed by Harvard Medical School
Treatment of Celiac disease (celiac sprue)
Treatment includes avoidance of any gluten in the diet including all foods made from wheat, rye, and
barley. Examples include: breads, cereals, pasta, crackers, cakes, pies, cookies, and gravies. Counseling
by a Nutritionist may be particularly helpful. For more information contact the National Digestive
Diseases Information Clearinghouse at: http://digestive.niddk.nih.gov or (800)891-5389
c. Constipation

Description of Constipation
Difficult, uncomfortable, or infrequent bowel movements. The feces is typically hard and dry.
Constipation is usually harmless, but it can indicate an underlying disorder. When severe constipation
can lead to fecal impaction, and if not relieved can result in intestinal obstruction. The primary causes of
constipation include dehydration, sedentary lifestyle, medications (especially narcotics), stress,
pregnancy, laxative abuse, depression, a diet that is low in fiber, and low thyroid levels.
Symptoms of Constipation
Inability to have a bowel movement, rectal pain, abdominal cramping, nausea, vomiting.
Reviewed by Harvard Medical School
Tests for Constipation
Workup
A history and physical exam will be performed. Generally no tests beyond an examination is needed
although a blood thyroid test may be recommended . Occasionally a CT scan is performed to rule out
other more serious causes.
Tests
CT Scan and X-ray
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Treatment of Constipation
Treatment includes: medications to increase the water content of stool, laxatives, enemas, and/or
digital disimpaction. Prevention of recurrence is important and involves increasing dietary fiber, exercise
and staying hydrated. Chronic use of stool softeners may be needed. Changing medications that might
be contributing to constipation (such as certain pain medications) may be helpful.
d. Inguinal hernia (groin hernia)
**OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA
e. Irritable bowel syndrome (IBS, chronic intestinal pain and cramping)
**OVO JE VEC RANIJE OPISANO U TEKSTU, SADA SE PONAVLJA
f.

Lactose intolerance

Description of Lactose intolerance

Deficiency of lactase- the enzyme made in the small intestine that helps metabolize lactose. Also called
lactase deficiency. Lactose is the primary sugar found in milk products. Not all patients with low levels of
lactase experience symptoms. Patients must have low levels of lactase and have symptoms to be
diagnosed with this disorder. Lactase deficiency can occur with aging, or after a physical stress such as
bowel surgery, infections of the small intestine, or with celiac disease.
Symptoms of Lactose intolerance
Symptoms usually begin 30 minutes to 2 hours after eating a meal containing lactose and include:
diarrhea, nausea, abdominal pain, bloating, gas, and excess fat in stool (steatorrhea). Most patients only
experience mild symptoms but for some they are severe.
Tests for Lactose intolerance
Workup
A history and physical exam will be done. 3 tests can be performed to diagnose lactose intolerance:
lactose tolerance test, hydrogen breath test, and stool acidity test. Only the stool acidity test is
appropriate for infants and small children.
Additional tests that may be required
lactose tolerance test, hydrogen breath test, stool acidity test
Specialists
Family Practice, Gastroenterology, Internal Medicine, Pediatric Gastroenterology and Pediatrics
Reviewed by Harvard Medical School
Treatment of Lactose intolerance
The best treatment is to avoid eating foods high in lactose. The missing enzyme lactase can be taken as a
pill prior to eating a meal high in lactose and some find relief with this remedy.
g. Malabsorption syndrome (abnormal intestinal digestion)
Description of Malabsorption syndrome (abnormal intestinal digestion)
Characterized by poor absorption of nutrients, vitamins and minerals from the intestinal tract into the
bloodstream. Many diseases cause malabsorption, such as celiac disease, certain medications, certain
types of cancer, certain types of surgery, chronic liver disease, chronic pancreatitis, Crohn's disease, and
persistent parasite infections.
Symptoms of Malabsorption syndrome (abnormal intestinal digestion)
Bloating, cramping, gas, chronic diarrhea, foul smelling and greasy stools, weight loss, decreased muscle
mass.

Tests for Malabsorption syndrome (abnormal intestinal digestion)
Workup
A history and physical exam will be performed. Multiple tests to determine the cause of the
malabsorption may be performed including blood tests, stool studies, abdominal CT scan, and
endoscopy.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase and Urinalysis (UA)
Additional tests that may be required
D-xylose test, hydrogen breath test, qualitative stool fat test, quantitative stool fat test, schilling test for
vitamin B12, secretin stimulation test, small bowel biopsy, stool culture, culture of small intestine
aspirate
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Malabsorption syndrome (abnormal intestinal digestion)
Treatment will depend upon the specific disease or condition causing the malabsorption. If the cause is
chronic pancreatitis, taking oral pancreatic enzymes may help. In addition, therapy will include efforts to
correct protein, calorie, vitamin and mineral deficiencies. Intravenous fluids, vitamins, and nutrient
replacement may be necessary if oral intake is not sufficient.
h. Paralytic Ileus (intestinal paralysis)
Description of Paralytic Ileus (intestinal paralysis)
A temporary paralysis of a portion of the intestines after an abdominal surgery. The syndrome causes
constipation, abdominal distension, and sometimes vomiting. It usually resolves on its own but may limit
the ability to eat for some days following surgery.
Symptoms of Paralytic Ileus (intestinal paralysis)
Absent bowel sounds, abdominal fullness, gaseous abdominal distention, abdominal pain and cramping,
vomiting, failure to pass gas or stool (constipation), diarrhea.
Tests for Paralytic Ileus (intestinal paralysis)
Workup
A history and physical exam will be performed. Usually the diagnosis is obvious if surgery has just
occurred. Abdominal X-rays may be done to confirm the problem.

Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Lipase, Urinalysis (UA)
and X-ray
Additional tests that may be required
Barium enema, upper GI and small bowel series
Specialists
Gastroenterology and Pediatric Gastroenterology
Treatment of Paralytic Ileus (intestinal paralysis)
A nasogastric (NG) tube from the nose to the stomach can relieve nausea. This problem almost always
improves on its own within a few days.
i.

Urine retention (inability to urinate)

Description of Urine retention (inability to urinate)
The inability to empty the bladder. Urinary retention can be caused by an obstruction in the urinary
tract or by nerve problems that interfere with signals between the brain and the bladder. There are
many causes, and the disorder can occur over a long period of time (chronic) or abruptly (acute). People
with chronic retention are able to urinate but the stream is decreased and many times they cannot
empty the bladder completely. Acute retention is an emergency since the kidneys can fail if the urine is
not able to drain. In men, an enlarged prostate is the most common reason for urinary retention.
Symptoms of Urine retention (inability to urinate)
Lower abdominal pain, flank pain, lower abdominal distension, dribbling of urine, urinary frequency.
Tests for Urine retention (inability to urinate)
Workup
A history and physical exam will be performed. A bladder ultrasound and/or catheter insertion to
measure the amount of urine retained in the bladder after voiding. Blood tests for BUN and creatinine
to assess kidney function.
Tests
CT Scan, Ultrasound and Urinalysis (UA)
Additional tests that may be required
Urodynamic tests, bladder scan, cystoscopy

Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Urine retention (inability to urinate)
Therapy is aimed at relieving the obstruction and reversing the cause of the retention. Initial treatment
is insertion of a catheter into the bladder. Antibiotics are given if the urine is infected. Men with an
enlarged prostate may require surgery. For additional information contact the National Kidney and
Urologic Diseases Information Clearinghouse at: http://www.kidney.niddk.nih.gov or call (800)891-5390.

26. BURNING WITH URINATION
COMMON CAUSES
a. Bladder infection (cystitis, UTI, urinary tract infection)
Description of Bladder infection (cystitis, UTI, urinary tract infection)
Acute infections of the urinary tract can be separated into upper and lower tract infections. The bladder
is the most common site of all infections (cystitis).It is a lower tract infection. Upper tract infections
involve the ureters and kidneys. Kidney infections (pyelonephritis) can be very serious with high fever,
vomiting, and severe pain. Because of the shorter urethras in women they are more prone to develop
urinary tract infections than men. Most urinary tract infections are caused by bacteria. Catheterization
of the bladder increases the risk of the infection. In patents with a weakened immune system (diabetics,
patients receiving chemotherapy, HIV/AIDS, elderly) prompt treatment is needed because of the
increased chance of a life threatening infection developing.
Symptoms of Bladder infection (cystitis, UTI, urinary tract infection)
Cloudy urine, blood in the urine (hematuria), foul or strong urine odor, frequent or urgent need to
urinate, need to urinate at night (nocturia), pain or burning with urination (dysuria), pressure below the
umbilicus of the abdomen. Upper tract infections cause flank pain, fever, loss of appetite, nausea and
vomiting. Elderly patients can experience significant confusion.
Tests for Bladder infection (cystitis, UTI, urinary tract infection)
Workup
A history and physical exam will be performed. A urine analysis (UA) and culture will establish the
diagnosis and identify the organism.
Tests
Urinalysis (UA) and Urine Culture
Additional tests that may be required

Urine culture
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Bladder infection (cystitis, UTI, urinary tract infection)
Therapy depends on whether the person has a simple lower tract infection vs. an upper tract infection
and the severity of illness. Treatment includes: antibiotics, medications to decrease the burning
(phenazopyridine/Pyridium), and/or pain medications. A urinalysis is sometimes recommended after
treatment to ensure the infection has gone away.
b. Urethritis (infection of urethra)
MDescription of Urethritis (infection of urethra)
Inflammation of the urethra. The urethra is the tube that carries urine from the bladder to the outside
of the body. The disease is classified as gonococcal urethritis or non-gonococcal urethritis (NGU). NGU
has both infectious and non-infectious causes. In men, a thick yellow discharge usually indicates a
gonococcal urethritis; while clear discharge is more suggestive of NGU. The disorder is difficult to
diagnose in women because discharge may not be present. Both sexes may experience burning with
urination. The causes of NGU include adenovirus, Chlamydia trachomatis, Escherichia coli, Herpes
simplex, Mycoplasma genitalium, Reiter's syndrome, and trichomonas.
Symptoms of Urethritis (infection of urethra)
Painful urination, discharge from the penis, itching of the penis.
Tests for Urethritis (infection of urethra)
Workup
A history and physical exam will be performed. A urethral culture done with a swab or urinary culture
helps determine which infection is causing the urethritis. Urethral swabs yield better results in men
compared to urine cultures.
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Urology
Treatment of Urethritis (infection of urethra)
Treatment depends on the cause of the disorder. Antibiotics will be prescribed if the cause is a bacterial
infection.
c. Prostatitis (prostate inflammation)

Description of Prostatitis (prostate inflammation)
Infection of the prostate gland, and can be either an acute or a chronic condition. The prostate gland is
located under the bladder, where it surrounds the urethra (the bladder's drainage tube). The gland is a
source of fluid for semen. The inflammation can irritate or put pressure on the tube connecting the
bladder to the penis (urethra), resulting in difficultly urinating, and urinary retention. Palpation of the
prostate during a rectal exam revels a very tender prostate. Rarely an abscess can develop. This disorder
is most often seen in 20-40 year old men, in those with a urinary catheter, and with patients having
unprotected sex with multiple partners.
Symptoms of Prostatitis (prostate inflammation)
Chills and fever, lower abdominal discomfort, pain in the area between the genitals and the anus,
burning with urination, difficulty urinating, urinary retention, painful ejaculation, painful bowel
movement, back pain.
Tests for Prostatitis (prostate inflammation)
Workup
A history and physical exam will be performed. Diagnosis is made by feeling the prostate during a rectal
exam and testing for signs of inflammation in the urine. A urine culture can identify the bacteria.
Tests
CT Scan and Urinalysis (UA)
Additional tests that may be required
Urine culture
Specialists
Family Practice, Internal Medicine and Urology
Treatment of Prostatitis (prostate inflammation)
Oral antibiotics are usually effective. The most commonly used are: trimethoprim-sulfamethoxazole
(Bactrim), fluoroquinolones (Floxin, Cipro, Levaquin), and tetracycline derivatives. If a STD is considered
the source, a shot of ceftriaxone followed by oral doxycycline or ofloxacin is recommended. Rarely
intravenous antibiotics are needed. Most patients require more than a month-long time of treatment to
eradicate the infection.
d. Kidney stone (nephrolithiasis)
*OVO JE VEC OPISANO U RANIJEM TEKSTU I SADA SE PONAVLJA
e. Sexually transmitted disease (STD)

Description of Sexually transmitted disease (STD)
Any one of a group of diseases that may be caused by viruses or bacteria and are spread during sexual
activity. They typically cause symptoms of the genitalia or urinary tract, but many are asymptomatic.
They may also lead to generalized disease, particularly in the chronic form. Having more than one sexual
partner increases the risk of acquiring the disease. The most common STDs are chlamydia, gonorrhea,
viral hepatitis, genital herpes, HIV/AIDS, human papillomavirus, pelvic inflammatory disease, syphilis,
and trichomoniasis.
Symptoms of Sexually transmitted disease (STD)
Symptoms depend on the infecting agent, but may include: penile discharge, painful urination, painful
sores on the genitalia, pimples on the genitalia, pain with sexual intercourse.
Reviewed by Harvard Medical School
Tests for Sexually transmitted disease (STD)
Workup
A history and physical exam will be performed. Penile, urinary, rectal, cervical, or pharyngeal cultures
are performed to identify the infecting organism. Syphilis is diagnosed with a blood test (RPR, VDRL).
Tests
Cervical culture, throat culture, Urinalysis (UA) and Urine Culture
Additional tests that may be required
RPR, VDRL
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Sexually transmitted disease (STD)
Treatment depends on the organism causing the infection but may include: antibiotics, or anti-viral
medications
ADDITIONAL CAUSES
a. Chlamydia trachomatis infection (STD)
Description of Chlamydia trachomatis infection (STD)
This is one of the most common sexually transmitted diseases (STDs) in the United States and is caused
by the bacteria Chlamydia trachomatis. The bacteria infect the urine canal (urethra) of men and women

and the cervix of women. Most patients with this condition do not have any symptoms and can pass the
disease to their sexual partners without knowing it. Untreated Chlamydia infections can spread to a
woman's fallopian tubes and uterus causing pelvic inflammatory disease (PID). PID can result in chronic
pelvic pain, infertility, and ectopic pregnancies.
Symptoms of Chlamydia trachomatis infection (STD)
Penile discharge, vaginal discharge, painful urination, painful intercourse.
Tests for Chlamydia trachomatis infection (STD)
Workup
A history and physical exam will be performed. Tests will be performed to Identify the organism in the
urethral discharge of males or cervix of females.
Additional tests that may be required
Culture, antibody test, DNA probe
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Chlamydia trachomatis infection (STD)
Treatment includes: antibiotics (tetracyclines, azithromycin or erythromycin), and treatment of all sexual
partners to prevent reinfection.
b. Neurogenic bladder (bladder paralysis)
MDescription of Neurogenic bladder (bladder paralysis)
Nerve damage which prevents the correct transmission of messages from the bladder to the brain. For
the bladder to work properly, the muscles and nerves must work together to hold urine in the bladder
and release it correctly. Nerves carry messages from the bladder to the brain, letting the brain know
when the bladder is full. In a neurogenic bladder, the nerves that are supposed to carry these messages
malfunction. Some causes include nerve disease such as multiple sclerosis; diabetes, trauma to the brain
or spinal cord; and certain infections.
Symptoms of Neurogenic bladder (bladder paralysis)
Inability to voluntarily empty the bladder, urinary incontinence, frequent urinary tract infections.
Tests for Neurogenic bladder (bladder paralysis)
Workup

A history and physical exam will be performed. Blood tests and imaging studies to identify the
underlying cause. The bladder is examined by filling and determining if it can empty normally.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Magnetic resonance
imaging (MRI), Ultrasound and Urinalysis (UA)
Specialists
Neurosurgery, Pediatric Neurosurgery and Urology
Treatment of Neurogenic bladder (bladder paralysis)
When possible, treatment of the underlying condition may help restore bladder function. Other
treatments include: medications, intermittent self-insertion of a urinary catheter, an indwelling urinary
catheter, surgical placement of catheter into the bladder (called a suprapubic catheter). For additional
information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390.
c. Interstitial cystitis (bladder inflammation)
Description of Interstitial cystitis (bladder inflammation)
Characterized by an inflammation of the bladder wall with symptoms similar to those of a urinary tract
infection. The range of symptoms can be mild to severe and debilitating. Women ages 30 to 40 are most
commonly affected. The cause of this disorder is unknown.
ReviSymptoms of Interstitial cystitis (bladder inflammation)
Discomfort or burning during urination; frequent or urgent urination; pain during intercourse; pelvic
pain.
Tests for Interstitial cystitis (bladder inflammation)
Workup
A history and physical exam will be performed. Tests to measure the function of the bladder and
diagnose the disorder may be recommended including cystoscopy and a bladder biopsy. Urine and
blood tests to rule out other conditions (such as bladder infection and sexually transmitted disease) are
often performed.
Tests
Urinalysis (UA)
Additional tests that may be required

Bladder biopsy, cystoscopy, urine culture, urine cytology, video urodynamics
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Interstitial cystitis (bladder inflammation)
There is no cure for the disorder, and there is no well-established, highly effective treatment. The choice
of treatment depends on the individual and their response to prior therapy. Pentosan polysulfate
(Elmiron) is the only medication taken by mouth that is specifically approved for treating interstitial
cystitis. It coats the bladder and relieves symptoms. Other medications that may be used include: pain
medicines, tricyclic antidepressants (amitriptyline/Elavil), and hydroxyzine (Vistaril). Other therapies
include: bladder hydrodistention (filling the bladder with fluid), and bladder training (using relaxation
techniques to train the bladder to go only at specific times). Pelvic relaxation techniques can also help
reduce the discomfort. If severe and unresponsive to any medical treatment surgery may be necessary.
d. Pyelonephritis (kidney infection)
MDescription of Pyelonephritis (kidney infection)
A bacterial infection involving the kidneys. It is more common in females, although it affects both
genders and all ages. Kidney infections in males are more likely if the bladder does not drain easily (one
cause of this problem is a large prostate.) Bladder infections are common in women, and the typical
cause of a kidney infection in a female is migration of bacteria from the bladder infection. The infection
travels up the tube (ureter) that drains into the bladder from the kidneys.
Symptoms of Pyelonephritis (kidney infection)
Flank pain, back pain, occasionally abdominal pain, fever, chills, warm skin, vomiting, nausea, fatigue,
painful urination, urinary frequency, urinary urgency, need to urinate at night (nocturia), cloudy urine,
blood in the urine, foul or strong urine odor, confusion.
Tests for Pyelonephritis (kidney infection)
Workup
A history and physical exam will be performed. Blood tests will be done to check on the function of the
kidneys, to check for spread of bacteria into the blood. A urine test can identify the infection and culture
of the urine can reveal the type of bacteria that is involved. If a kidney stone is suspected a CT scan will
be done.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), CT Scan, Pregnancy (BHCG) test
and Urinalysis (UA)

Additional tests that may be required
Urine culture
Specialists
Family Practice, Infectious Disease Medicine, Internal Medicine, Pediatric Infectious Disease Medicine
and Pediatrics
Treatment of Pyelonephritis (kidney infection)
Intravenous fluids, pain medications, anti-nausea medications and antibiotics are the mainstay of
therapy. Patients with severe infections or with depressed immune systems will be admitted to the
hospital. A co-existing blockage of a ureter from a kidney stone is a surgical emergency requiring
removal of the blockage to prevent a life threatening infection.
e. Genital herpes (HSV type 2 infection)
MDescription of Genital herpes (HSV type 2 infection)
Herpes is a sexually transmitted disease (STD) caused by the herpes simplex virus (HSV). HSV-type 1
commonly causes oral lesions like fever blisters on the mouth or face (oral herpes). HSV-type 2 typically
affects the genital area (genital herpes). The HSV virus cannot be removed from the body once infected
but may cause no symptoms for prolonged periods (it may remain dormant). When dormant, the virus
typically lives within the nerve cells. When a patient experiences emotional or physical stress the lesions
of HSV can return.
Symptoms of Genital herpes (HSV type 2 infection)
Painful blisters and red bumps in the affected area that recur periodically.
Tests for Genital herpes (HSV type 2 infection)
Workup
A history and physical exam will be performed. Culture of a genital lesion may be performed.
Additional tests that may be required
HSV culture, direct fluorescent antibody (DFA) test
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology, Pediatrics and Urology
Treatment of Genital herpes (HSV type 2 infection)

Treatment includes suppression with an antiviral medication (such as acyclovir, famciclovir, or
valacyclovir), pain medications such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory
medications/NSAIDs (ibuprofen/Motrin or Advil, naproxen/Naprosyn).
f.

Candida albicans (yeast infection)

Description of Candida albicans (yeast infection)
A fungus (a form of yeast) that can cause infection of the mouth, throat, and genitalia. In patients with
weakened immune systems infections can be present in the blood. This is a much more serious infection
than the more common mouth or genital infection.. This infection is more common in diabetics, patients
taking antibiotics, and in patients with weakened immune systems (cancer patients, patients with HIV).
This is also a very common infection in healthy women with 75% having a vaginal candida infection in
their lifetime.
Symptoms of Candida albicans (yeast infection)
Itchy skin rash, redness, pain, white cheesy vaginal discharge, white blotches on the penis or in the
mouth, pain with swallowing. With bloodstream infection, high fever, dizziness and fatigue are common.
Tests for Candida albicans (yeast infection)
Workup
A history and physical exam will be performed. Identification of fungus is done either directly with a KOH
stain or by fungal culture. Often the appearance is so typical that testing is not necessary. When
bloodstream infection is suspected, a blood test (called blood cultures) is performed.
Additional tests that may be required
KOH test, fungal culture
Specialists
Family Practice, Internal Medicine and Pediatrics
Treatment of Candida albicans (yeast infection)
Topical antifungal medications can be used for most infections. The most common include:
butoconazole (Gynazole), clotrimazole (Lotrimin), miconazole (Monistat) and terconazole (Terazol).
Many of these are available over the counter without a prescription. A one-time single dose medication
called fluconazole (Diflucan) can be taken by mouth. Infections of the blood can be very difficult to
eradicate and require intravenous medications.
g. Bladder stone, urinary
Description of Bladder stone, urinary

Small collections of minerals that form in the bladder, the organ in the pelvis that stores urine. Bladder
stones, also called bladder calculi, often form when urine sits in the bladder allowing the minerals to
develop. Bladder stones usually occur secondary to another condition, such as an enlarged prostate or a
urinary tract infection.
Symptoms of Bladder stone, urinary
Dark urine, bloody urine, painful urination, abdominal pain, pain at tip of penis, urine infection, urinary
retention.
Tests for Bladder stone, urinary
Workup
A history and physical exam will be performed. Additional tests include: urinalysis (UA), cystoscopy, and
a X-ray.
Tests
Urinalysis (UA) and X-ray
Additional tests that may be required
Cystoscopy
Specialists
Urology
Treatment of Bladder stone, urinary
Treatment includes: drinking plenty of fluids, cystoscopic removal, and/or lithotripsy. For additional
information contact the National Kidney and Urologic Diseases Information Clearinghouse at:
http://www.kidney.niddk.nih.gov or call (800)891-5390.
h. Neisseria gonorrhea infection (sexually transmitted disease)
Description of Neisseria gonorrhea infection (sexually transmitted disease)
An infectious sexually transmitted disease of the reproductive organs. It involves the urethra (the tube
leading from bladder to the outside of the body) in males, and in females, the cervix, uterus and
fallopian tubes. The rectum, throat, joints, and eyes can sometimes be involved in both sexes. If
untreated gonorrhea can cause pelvic inflammatory disease, which can lead to sterility in women.
Symptoms of Neisseria gonorrhea infection (sexually transmitted disease)
Pain with urination, vaginal or penile discharge, rarely can cause a rash and joint pain.

Tests for Neisseria gonorrhea infection (sexually transmitted disease)
Workup
A history and physical exam will be performed. A sample of the affected area or the urine can be sent
for detection of the bacteria either by direct visualization, culture, or chemical detection.
Tests
Complete blood count (CBC), Comprehensive metabolic panel (CMP), Pregnancy (BHCG) test and
Urinalysis (UA)
Additional tests that may be required
Culture of urethra (men) or cervix (women), Antibody tests of urine and genital specimens
Specialists
Family Practice, Internal Medicine, Obstetrics and Gynecology and Pediatrics
Treatment of Neisseria gonorrhea infection (sexually transmitted disease)
Antibiotics are administered. Sexual partners must be treated to prevent reinfection.
i.

Inflammation of testicular tubes (epididymitis)

Description of Inflammation of testicular tubes (epididymitis)
The epididymis is a long coiled tubular structure located next to the testicle. Inflammation of the
epididymis may produce testicular pain and fever. Infection is the most common cause and the bacteria
normally come from the urethra or bladder.
Symptoms of Inflammation of testicular tubes (epididymitis)
Testicular pain, scrotal swelling, fever, discharge from the penis (urethral discharge), blood in the
semen, painful urination, frequent urination, painful ejaculation, lower abdominal pain.
Tests for Inflammation of testicular tubes (epididymitis)
Workup
A history and physical exam will be performed. A urinalysis (UA) and urethra culture are done. If
testicular torsion is a consideration a testicular ultrasound may be ordered.
Tests
Ultrasound and Urinalysis (UA)
Additional tests that may be required

Urethral culture
Specialists
Family Practice, Internal Medicine, Pediatrics and Urology
Treatment of Inflammation of testicular tubes (epididymitis)
Antibiotics are prescribed. If the infection is felt to be sexually transmitted treatment for chlamydia and
gonorrhea is typically given and the sexual partners are treated as well to prevent recurrence. Pain
medicines and/or nonsteroidal anti-inflammatory medications/NSAIDs (ibuprofen/Motrin or Advil,
naproxen/Naprosyn), pain medications such as acetaminophen (Tylenol) are given for comfort.

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