TESTICULAR SWELLING
ASK THE FOLLOWING QUESTIONS:
1. Is there pain or tenderness of the testicle? The presence of pain or
tenderness should suggest torsion of the testicle, orchitis, epididymitis,
and a strangulated inguinal hernia.
2. Is the testicle retracted or does elevation of the testicle aggravate
the pain? These findings would suggest torsion of the testicle. An
absent cremasteric reflex should also suggest torsion.
3. Does the swelling transilluminate? If the swelling transilluminates,
the mass or swelling is most likely a hydrocele or spermatocele.
4. Is the swelling reducible? If the swelling is reducible, the mass is
probably an inguinal hernia or varicocele. A mass that does not reduce
could still be an incarcerated inguinal hernia.
DIAGNOSTIC WORKUP
A CBC, sedimentation rate, urinalysis, chemistry panel, and VDRL test
should be done routinely. If a tumor of the testicle is suspected, 24-hour
urine gonadotrophins and alpha-fetoprotein levels may be ordered. If there
is a urethral discharge, a smear and culture for gonorrhea and chlamydia
should be done. If a hernia is strongly suspected, a general surgeon should
be consulted. Testicular scans with technetium-99m and ultrasonography
will help distinguish torsion of the testicle from orchitis or epididymitis.
Scrotal ultrasound may also be useful in differentiating a hematoma,
abscess, or rupture from orchitis. It may also be helpful in evaluating
testicular tumors. A CT scan of the abdomen and pelvis may be necessary
to rule out metastasis.
The expense of some or all of these tests may be avoided by consulting
an urologist early in the diagnostic workup.

612

613

THIRST
ASK THE FOLLOWING QUESTIONS:
1. Is there a positive drug or alcohol history? Alcohol, amitriptyline,
diuretics, and many other drugs may cause excessive thirst.
2. Is there fever? The presence of fever would make one suspect an
infectious disease (see page 198).
3. Is there pallor or shock? Pallor or shock should make one think of
gastrointestinal (GI) bleeding, ruptured ectopic pregnancy, trauma,
and other disorders associated with anemia or shock.
4. Is there significant polyuria? Polyuria that is either significant or
massive would suggest diabetes insipidus, diabetes mellitus, or
thyrotoxicosis. Mild or insignificant polyuria may be because of
hypercalcemia, hyperparathyroidism, and excessive salt intake.
DIAGNOSTIC WORKUP
Routine tests include a CBC, sedimentation rate, urinalysis, chemistry
panel, thyroid panel, glucose tolerance test, blood alcohol level, and 24hour urine collection for sodium, potassium, and calcium. If pituitary
diabetes insipidus is suspected, a CT scan of the brain, the Hickey–Hare
test, and a vasopressin (Pitressin) injection test may need to be done. If
hyperparathyroidism is suspected, a serum PTH assay and x-ray of the
skull and long bones may be done. A consultation with an endocrinologist
may be necessary.

614

615

THROMBOCYTOPENIA
ASK THE FOLLOWING QUESTIONS:
1. What is the WBC count? Thrombocytopenia with a high white count
suggests leukemia or myeloid metaplasia. Thrombocytopenia with a
normal white count suggests idiopathic thrombocytopenic purpura or
drug reaction. Thrombocytopenia with a low white count suggests
lupus erythematosus, aplastic anemia, myelofibrosis, drugs,
myelophthisic anemia, or pernicious anemia.
2. What is the ANA? A positive ANA in the face of thrombocytopenia
and a low white count suggests lupus erythematosus.
DIAGNOSTIC WORKUP
The diagnostic workup should include a CBC, blood smear, sedimentation
rate, urinalysis, serum B12, chemistry panel, ANA, serum haptoglobins,
red cell survival, liver spleen scan, CT scan of the abdomen, and a
hematology consult for bone marrow study.

616

THYROID ENLARGEMENT
ASK THE FOLLOWING QUESTIONS:
1. Is it focal or diffuse? Focal masses in the thyroid, include
thyroglossal cyst, toxic adenoma, colloid cyst, Riedel’s struma,
nontoxic adenoma, and malignancies.
2. Is there movement with protrusion of the tongue? This is a typical
finding in cases of thyroglossal cyst.
3. If focal, are there signs of thyrotoxicosis? The presence of
thyrotoxicosis and a focal mass suggest toxic adenoma.
4. If diffuse, are there signs of thyrotoxicosis? Diffuse thyroid
enlargement with thyrotoxicosis indicates Graves’ disease.
5. Is it tender? The presence of a tender enlarged thyroid suggests
subacute thyroiditis and Hashimoto’s thyroiditis.
DIAGNOSTIC WORKUP
Routine tests include a CBC, sedimentation rate, urinalysis, thyroid profile
with a TSH immunoassay, calcitonin, chemistry panel, chest x-ray, and
EKG. Thyroid antibodies may be tested if Hashimoto’s thyroiditis is
suspected.
The most important study is a thyroid technetium-99m or iodine-123
uptake and scan. If the results of these are abnormal, then an
endocrinologist or general surgeon should be consulted to assist in the
interpretation. If the scan indicates a cold nodule, ultrasonography may be
done to determine whether the nodule is cystic or solid. If it is cystic,
generally it can be aspirated and followed. If it is solid, a CT scan or an
MRI is indicated before a biopsy or aspiration and biopsy are undertaken.
If there are malignant cells or at least suspicious cells for malignancy,
surgery should be done. If the scan reveals a hot nodule and there is
clinical and laboratory evidence of thyrotoxicosis, the patient should be
treated with radioactive iodine or surgery. If the scan shows diffuse uptake
of radioactive materials and there is clinical thyrotoxicosis, the patient also
may be treated with radioactive iodine or surgery.

617

618

TINNITUS
ASK THE FOLLOWING QUESTIONS:
1. Is it subjective or objective? Objective tinnitus is unusual, but it may
indicate glomus tumors, arteriovenous malformations, carotid stenosis,
aneurysms, anemia, a patent Eustachian tube, or myoclonus. Objective
tinnitus means that both the patient and the examiner can hear the
noises.
2. If it is subjective, is it unilateral or bilateral? Unilateral subjective
tinnitus is more likely to be associated with a more serious disorder,
such as Ménière’s disease, acoustic neuroma, cholesteatoma, or
vascular disease. Since von Recklinghausen disease is associated with
acoustic neuromas, look for café au lait spots.
3. Is there a history of trauma? A history of trauma would suggest that
the tinnitus is because of whiplash, concussion, or trauma to the
middle or inner ear.
4. Is there a history of the use of ototoxic drugs? Drugs that may cause
tinnitus include aminoglycosides, tetracyclines, clindamycin, caffeine,
and the tricyclic antidepressants. Aspirin and quinine may also be
associated with tinnitus.
5. Are there abnormalities found on the ear examination?
Abnormalities on the ear examination include cerumen, otitis externa,
otitis media, mastoiditis, and cholesteatomas. The tympanic membrane
may be red in cases of glomus tumors.
6. Is there vertigo and deafness? The presence of vertigo with deafness
should suggest Ménière’s disease, acoustic neuroma, and
cholesteatoma, as well as multiple sclerosis, basilar artery
insufficiency, and brainstem tumors.
7. Are there other neurologic signs? The presence of other neurologic
signs along with vertigo and deafness would suggest multiple
sclerosis, advanced acoustic neuroma, basilar artery occlusion or
insufficiency, brainstem tumors, and central nervous system syphilis.
DIAGNOSTIC WORKUP
The basic workup includes a CBC, sedimentation rate, urinalysis,
chemistry panel, thyroid profile, VDRL test, audiometry, caloric tests
(electronystagmography), and x-ray of the mastoids and petrous bones.
Specialized audiometry may be performed, such as impedance audiometry,
619

Békésy audiometry, and BSEP studies.
If an acoustic neuroma is strongly suspected, a CT scan with iodine
infusion or instillation of 4 mL of oxygen in the subarachnoid space would
be indicated. Gadolinium-enhanced MRI may also diagnose an early
acoustic neuroma. Angiography and venography may help diagnose
objective tinnitus. A spinal tap may be helpful in diagnosing multiple
sclerosis and central nervous system syphilis. A glucose tolerance test may
be indicated to rule out diabetes mellitus.

620

621

TONGUE MASS OR SWELLING
ASK THE FOLLOWING QUESTIONS:
1. Is it painful? Painful swellings of the tongue, include trauma, burns,
herpes simplex, pemphigus, erythema bullosum, carcinoma, Ludwig’s
angina, angioneurotic edema, bee stings, and hemorrhage because of
coagulation disorders.
2. Is the mass or swelling focal or diffuse? Focal masses, include
trauma, herpes simplex, pemphigus, erythema bullosum, carcinoma,
angioma, fibroma, lipoma, mucus cyst, papilloma, or syphilitic
gumma. Diffuse masses, include Ludwig’s angina, angioneurotic
edema, bee sting, hemorrhage, myxedema, acromegaly, cretinism,
mongolism, primary amyloidosis, diffuse lymphoma, and riboflavin
deficiency.
DIAGNOSTIC WORKUP
Focal lesions of the tongue should be referred to an oral surgeon or
dermatologist for biopsy or excision. Diffuse enlargement or swellings
require a workup including CBC, sedimentation rate, urinalysis, chemistry
panel, thyroid panel, VDRL test, and ANA titer. If a coagulation disorder
is suspected, a coagulation profile may be done. If a vitamin deficiency is
suspected, a therapeutic trial of vitamins is indicated. If amyloidosis is
suspected, a biopsy may be done. Other disorders also may require biopsy.
A trial of antibiotics or corticosteroids may be necessary.

622

TONGUE PAIN
Pain in the tongue is rarely an isolated symptom. There is usually a focal
or diffuse inflammation of the tongue or an ulcerating lesion. Diffuse
inflammation is found in antibiotic glossitis, glossitis of avitaminosis
(pernicious anemia), aphthous stomatitis, thrush, streptococcal glossitis,
and acute diffuse glossitis. Focal lesions include cuts and ulcerations from
trauma, such as the bitten tongue or burned tongue (hot pizza, etc.), or
injury from a sharp tooth or jagged dental plate. Other painful focal lesions
are carcinoma, tuberculosis, syphilis (often painless), and herpes simplex
ulcers. When the tongue is completely normal, trigeminal neuralgia,
polymyositis, trichinosis, and calculus of the submaxillary gland should be
considered.
DIAGNOSTIC WORKUP
Most lesions will respond to conservative treatment and time. In patients
with signs of systemic disease and vitamin deficiency, the workup includes
serum B12 and folate level, upper GI series, ANA, and Trichinella
antibody titer. Focal lesions that persist should command a referral to a
dentist or oral surgeon.

623

TONGUE ULCERS
Ulcerations of the tongue are most commonly because of aphthous
stomatitis (canker sore), but they may appear in various stages of syphilis,
in herpes zoster, as a result of repetitive trauma from a sharp or carious
tooth, in tuberculosis, and in carcinoma. The chancre of primary syphilis
rarely causes severe pain, so this will often distinguish the lesion from the
others. To differentiate the other causes, a smear and culture and,
ultimately, a biopsy must be done. Most physicians will find referral to a
dentist or oral surgeon is the best course of action when the ulcer persists.

624

TOOTH AND GUM ABNORMALITIES
As physicians, we often neglect inspection of the teeth. We seem to expect
the dentist to do this part of the examination for us. Multiple cavities are
found in diabetes mellitus, pernicious anemia, and multiparous women.
Separation of the teeth may be a clue to hypopituitarism, whereas teeth
that taper to a thin edge are typical of the screwdriver appearance of
Hutchinson teeth in congenital syphilis. Who has not heard of the dramatic
gum hypertrophy associated with phenytoin use in epileptic children? In
scurvy, the gums become swollen, and the teeth get loose, drop out, or
become misaligned. In dental ectodermal dysplasia, the teeth may be
partially or completely absent, and, at times, there is no evidence of
enamel formation. The dark blue line positioned where the gums meet the
teeth is a sign of lead intoxication.
Mothers frequently complain that their children grind their teeth, but
this is rarely of pathologic significance. Of course, it may be a sign of
malocclusion and temporomandibular joint syndrome, especially in adults.
Yellow teeth is a sign that a child has been affected by tetracyclines
either in utero or early childhood.

625

TRANSIENT ISCHEMIC ATTACKS
ASK THE FOLLOWING QUESTIONS:
1. Is there a carotid bruit? This would suggest a stenosis or ulcerative
plaque in the carotid circulation.
2. Is there a difference in blood pressure of the upper extremities?
This would make a subclavian steal syndrome likely causing vertebralbasilar artery insufficiency.
3. Is the heart beat rate and rhythm irregular? If so, consider the
possibility of atrial fibrillation.
4. Is there a history of myocardial infarction? If so, this may have
caused a mural thrombus. If not, remember an atrial myxoma,
migraine, epilepsy, and subacute bacterial endocarditis are real
possibilities in a transient ischemic attack.
DIAGNOSTIC WORKUP
It is wise to consult a neurologist first. Routine laboratory and x-ray
examinations include a CBC, chemistry panel, urinalysis, coagulation
profile, ANA, sedimentation rate, CRP, cardiac troponins, serum protein
electrophoresis, EKG and chest x-ray. Carotid duplex scans,
echocardiography, and Holter monitoring would be wise if the above
studies are not revealing. Ambulatory blood pressure monitoring may be
useful in patients suspected of having paroxysmal hypertension or postural
hypotension. A CT scan of the brain or an MRI and MRA, wake-and-sleep
EEG can be ordered at the neurologist’s discretion. Ambulatory EEG
monitoring is now possible. A video of the attack may help diagnose
conversion hysteria.

626

627

TREMOR
CASE HISTORY
You are asked to see a 46-year-old white female because of increasing
tremor of her hands for the past year. Following the algorithm, you ask
about weight loss, palpitations, and sweating, and she has none of these
symptoms.
On your examination, there is no tremor at rest and the tremor is most
pronounced on finger to nose testing bilaterally. There are no other
neurologic signs, so you rule out multiple sclerosis, hereditary, and
neoplastic diseases of the cerebellum. On further questioning, you find that
her mother has a similar condition, so you suspect familial or essential
tremor. You would be correct.
ASK THE FOLLOWING QUESTIONS:
1. When does the tremor occur? Intention tremor, which means that the
tremor occurs on movement, would suggest that the patient is
suffering from a familial or senile tremor or multiple sclerosis,
Wilson’s disease, or hereditary familial ataxia. It also may suggest
alcoholism. Nothing is more dramatic than the intention tremor of
alcohol withdrawal. A tremor occurring at rest would suggest
Parkinson’s disease or manganese poisoning. A fine tremor of the
outstretched hands, which is sometimes described as tension tremor,
would suggest hyperthyroidism.
2. The next question to ask is whether there are associated neurologic
findings. A tremor with long tract findings, such as hyperactive
reflexes or Babinski’s sign, would suggest multiple sclerosis, whereas
a fairly symmetrical tremor with no long tract signs or other
neurologic findings would suggest a familial or senile tremor. A
tremor with mental deterioration would suggest Wilson’s disease.
3. Are there associated systemic findings? If the patient has
tachycardia and an enlarged thyroid, one should consider
hyperthyroidism. However, simply tachycardia alone might indicate
that the patient is very sensitive to caffeine. Kayser–Fleischer ring and
enlarged liver would suggest Wilson’s disease. An enlarged liver
alone would suggest alcoholism.

628

DIAGNOSTIC WORKUP
Certainly, a thyroid profile should be done on all cases that present with a
tremor alone. In addition, blood tests for serum copper and ceruloplasmin
should be done when Wilson’s disease is suspected. A drug and alcohol
screen should also be done. If multiple sclerosis, Wilson’s disease, or a
cerebellar tumor is suspected, a CT scan or an MRI of the brain should be
done. When there is doubt as to whether the tremor is a resting or active
tremor, an EMG may be done to separate the two. Most patients presenting
with a mild intention tremor that is symmetrical and not associated with
other neurologic findings will probably have familial or senile tremor, and
the response to beta-blockers can be determined.

629

TRISMUS
True trismus or lockjaw is found in tetanus, rabies, and trichinosis. In
strychnine poisoning, it is a late development, as the twitchings and
convulsions are well established before it appears. Intermittent trismus
may be found in epilepsy and cataplexy. Trismus may be simulated by
impacted wisdom teeth, temporomandibular joint syndrome, scleroderma,
and malingering or hysteria. The diagnostic workup will be obvious in
cases of true trismus. Cases not associated with a systemic disease should
have an EEG and x-ray of the teeth and temporomandibular joints. A
referral to a dental specialist is often in order.

630

UREMIA
ASK THE FOLLOWING QUESTIONS:
1. What is the BUN/creatinine ratio? If this ratio is 20:1 or greater, one
should look for prerenal azotemia. Confirmation with a serum and
urine osmolality will be helpful. If this ratio is 10:1 or less, one should
look for renal diseases or obstructive uropathy.
2. Is the bladder enlarged, or is there significant residual urine?
These findings point to obstructive uropathy, particularly bladder neck
obstruction. If these findings are absent, the cause of the uremia is
most likely a renal disease in cases in which the BUN/creatinine ratio
is 10:1 or less.
3. What drugs is the patient on? ACE inhibitors, diuretics, and
nonsteroidal anti-inflammatory drugs (NSAIDs) can cause renal
failure.
DIAGNOSTIC WORKUP
Two things to do at the outset are a microscopic examination of the urine
and renal and bladder ultrasound. Further workup should include a CBC,
urinalysis, urine culture and colony count, serum and urine osmolality,
chemistry panel, sedimentation rate, arterial blood gas analysis, blood
volume, cystoscopy and retrograde pyelography, a nephrology consult, and
a urology consult. Additional studies include abdominal CT scan and a
renal biopsy.

631

632

URETHRAL DISCHARGE
Most cases of urethral discharge in both males and females are because of
gonorrhea or Chlamydia trachomatis. When the smear and culture are
negative for gonorrhea, a course of tetracycline can be given as a
therapeutic trial to diagnose Chlamydia infection. Alternatively, the urine
can be cultured for chlamydia. A therapeutic trial may not be necessary
because recently, DNA probe testing, nucleic acid amplification and rapid
antigen testing of the urine have become available for gonorrhea and
chlamydia. A swab of the discharge can be utilized for the same testing. If
there are joint pains or uveitis, look for Reiter’s syndrome. Other
etiologies for nongonococcal urethritis are Ureaplasma genitalium and
Trichomonas vaginalis. Alert the laboratory, in advance, if these
organisms are suspected because they may require special culture media
for isolation. A prostate examination should always be done in males, as
acute and chronic prostatitis are common causes of urethral discharge. In
teenagers, a urethral discharge may develop from prolonged abstinence or
excessive masturbation. Rarer causes of urethral discharge are syphilis,
tuberculosis, foreign body, and herpes. Carcinoma of the urethra is
extremely rare. Anyone with a urethral discharge needs a VDRL test and
HIV antibody titer. Sexual partners should be tested as well.

633

URINE COLOR CHANGES
Red urine may be because of hematuria (page 238), hemoglobinuria
(hemolytic anemia), myoglobinuria (muscle trauma, myocardial
infarction), and coproporphyria or uroporphyria (porphyria).
Phenazopyridine hydrochloride (Pyridium) also colors the urine red or
orange. Ingestion of large amounts of beets will also color the urine red.
Brown urine is usually because of hepatitis or obstructive jaundice, but
myoglobin and melanuria may also color the urine brown. Black urine is
found in malignant melanoma. Porphyrins may also color the urine black.
In alkaptonuria, the urine turns black on standing. Green or blue urine may
be found in patients taking methylene blue, indigo carmine, or indigo blue.
Pseudomonas aeruginosa infection may also turn urine green. The key to
the diagnostic workup is to send the urine to the laboratory for complete
analysis and culture. Most of the conditions listed above will have another
symptom that will offer additional keys to the diagnostic workup using
these pages.

634

VAGINAL BLEEDING
ASK THE FOLLOWING QUESTIONS:
1. Is the vaginal examination normal? Cervical, endometrial, and
ovarian carcinomas are the most important possibilities to rule out.
Chronic cervicitis or vaginal trauma are just a few of the other
conditions to consider.
2. Is the pregnancy test positive? This test should always be done in
cases of vaginal bleeding. A positive test suggests threatened abortion,
ectopic pregnancy, or missed abortion among other conditions.
3. Is there a history of use of oral contraceptives or other
contraceptive devices? These most certainly may cause dysfunctional
uterine bleeding.
4. Is there pale conjunctiva or poor nutrition? Consider iron
deficiency anemia or anemia of other causes.
5. Is there tremor, tachycardia, or nonpitting edema? If so, a thyroid
disorder may be the cause.
Negative answers to all these questions prompt an investigation for
blood dyscrasias and collagen disease, but menopause and dysfunctional
uterine bleeding may be the cause.
DIAGNOSTIC WORKUP
A pregnancy test is a must in women of child-bearing age even if the
pelvic examination is normal. A pelvic ultrasound examination is ordered
next. A CBC and serum iron and ferritin should be done because, even
though the initial cause of vaginal bleeding may be dysfunctional bleeding,
the continued blood loss leads to iron deficiency anemia which may
perpetuate the bleeding. For the same reason, a thyroxine (T4) and TSH
should be ordered. An ANA, coagulation profile, and serum protein
electrophoresis may be useful to rule out other systemic causes, but at this
point of time a gynecologist should have been consulted.

635

636

VAGINAL DISCHARGE
ASK THE FOLLOWING QUESTIONS:
1. Is it purulent? A purulent vaginal discharge suggests nonspecific
bacterial vaginitis and gonorrhea. In contrast, the discharge of
bacterial vaginitis is white and has a fishy odor.
2. Is it frothy and yellow? This type of discharge is very often because
of trichomoniasis vaginitis.
3. Is it cheesy and associated with itching? These findings suggest
candidiasis vaginitis.
4. Is it watery and bloodstained? This type of discharge suggests
carcinoma of the cervix or endometrium, polyps, hydatidiform mole,
and chronic cervicitis. If a frankly bloody discharge is noted, consult
the differential diagnosis discussed on page 337.
5. Is it offensive smelling? An offensive smelling discharge would
suggest foreign body in the vagina.
6. Is there inflammation of the cervix? The presence of cervical
inflammation would suggest chronic cervicitis and gonorrhea.
DIAGNOSTIC WORKUP
The most important test is microscopic examination of a saline and
potassium hydroxide preparation. This will diagnose most cases of
trichomoniasis and candidiasis. Gardnerella vaginalis can be diagnosed if
clue cells are found, and the pH of the discharge will be greater than 4.7. If
this is unrevealing, a Gram’s stain for gonorrhea and cultures for
trichomoniasis, candidiasis, chlamydia, G. vaginalis, and gonorrhea may
be done. Recently, DNA probe or rapid antigen testing of urine may be
used to diagnose gonorrhea or chlamydia. If the results of these tests are
negative, look for pinworms. A Pap smear should be done to rule out
malignancy. Polyps or inflamed areas of the cervix should be biopsied.
Colposcopy may help further differentiate a cervical lesion. A dilation and
curettage may be necessary to diagnose endometrial carcinoma and
hydatidiform mole. Occasionally, pelvic ultrasound and CT scan are
necessary. However, before ordering these expensive diagnostic tests, a
gynecologist should be consulted. Patients with documented evidence of
gonorrhea should have a VDRL test and HIV testing. A therapeutic trial of
tetracycline or metronidazole may be successful in bacterial vaginitis.
637

638

VARICOSE VEINS
Varicose veins are common in the lower extremities and are usually not a
sign of other disease. Varicose veins of the rectum are called hemorrhoids
and can be a sign of cirrhosis of the liver or portal vein obstruction from
other causes. Distention of the abdominal veins may be because of
cirrhosis of the liver, thrombosis of the inferior vena cava, or distention of
the abdomen because of a large tumor (e.g., ovarian cyst), ascites, or
massive hepatic or splenic enlargement. Varicose veins of the thorax and
upper extremities are seen in mediastinal malignancies (primary or
metastatic), thoracic aortic aneurysms, and chronic fibrous mediastinitis.
DIAGNOSTIC WORKUP
Obviously, a liver profile will be important. Chest x-ray and a flat plate of
the abdomen should be routine. When these fail to identify a lesion—and
even when they do identify a lesion—it is often necessary to get a CT scan
of the thorax or abdomen. Exploratory surgery may be necessary to
establish a tissue diagnosis, as biopsy may be dangerous.

fetch details from document provided and write a JSON file to be used to create a database with fields of "symptom", "questions", " diagnosticPlan”. Get details from only the document provided only. Don’t skip any detail. Review to make sure every relevant detail was collected. Don’t put the first [ at the beginning and also don’t put ] at the ends for editing purposes but put a comma separating the objects even at the end as shown in the example. Remember this rule

Here is an example below of the format you must follow to give your answers:

{

        "model": "disease.disease",

        "id":  "1.1.2",

        "fields{

"symptom": " CHEST PAIN ",

"questions": [

" Is the chest pain acute or chronic? If it is acute, one must consider
acute myocardial infarction, dissecting aneurysm, pulmonary
embolism, pneumothorax, pericarditis, and fractures. If the chest pain
is chronic, one must consider chronic coronary insufficiency,
esophagitis, hiatal hernia, and various chest wall conditions. The
endocardium is the source of chest pain in mitral valve prolapse.”

“ Is the pain constant or intermittent? Constant pain suggests acute
myocardial infarction, pulmonary infarction, dissecting aneurysm, and
pneumonia. Intermittent pain would suggest coronary insufficiency,
Tietze’s disease, and Da Costa’s syndrome. Intermittent chest pain at
rest may be because of Prinzmetal angina.”

“Is there associated significant hypertension? Significant
hypertension would make one think of dissecting aneurysm, but it is
also found occasionally in acute myocardial infarction.”

“Is the pain relieved by antacids? Relief by antacids should prompt
one to consider reflux esophagitis and hiatal hernia.”

],

"diagnosticPlan ": [

" All patients should have a CBC, sedimentation rate, CRP, ANA, chemistry
panel, lipid profile, VDRL test, chest x-ray, and EKG. If there is sputum, a
smear and culture should be done as soon as possible. A urine drug screen
should be done in young adults. Coronary artery disease in the young
should prompt an investigation for collagen disease.
If a myocardial infarction is suspected, then serial EKGs and tests for
the isoenzyme of creatine kinase (CK-MB) should be done if the initial
EKG and enzymes do not show any significant changes. Serum cardiac
troponin levels may also be diagnostic of a myocardial infarct. Thallium201 scintigraphy is useful in diagnosing both myocardial infarction and
coronary insufficiency. Exercise tolerance tests may help diagnose
coronary insufficiency. Immediate coronary angiography should be
undertaken if the condition deteriorates and in the cases of ST segment
elevation myocardial infarction (STEMI). This can be followed by
immediate balloon angioplasty, reperfusion therapy, or bypass surgery.
Non-STEMI chest pain can be evaluated by CCTA (coronary CT
angiography) first.
If a pulmonary embolism is suspected, arterial blood gases and a
ventilation–perfusion scan or a spiral CT of the chest should be done,
which may also pick up a dissecting aneurysm. D-dimer testing of whole
blood is a sensitive test of pulmonary embolus. It is also elevated in
patients with a dissecting aneurysm. Pulmonary angiography may need to
be done if these are negative and pulmonary embolism is still strongly
suspected. Ultrasonography of the lower extremities will be helpful in
picking up an embolic source as will an MRI of the pelvis. CTA will easily
diagnose a dissecting aneurysm.
If esophageal disease is suspected, an upper GI series with
esophagogram should be done; this can be followed by esophagoscopy and
gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus)
may reproduce the exact pain and distinguish esophageal reflux from a
cardiac source of the pain. Ambulatory pH monitoring may also diagnose
reflux esophagitis. A trial of proton pump inhibitors may obviate the
necessity for all of these tests if it is successful in making the patient
asymptomatic.
If pericarditis is suspected, echocardiography and possibly a CT scan
of the chest and pericardium may be necessary. Coronary angiography
may be necessary to diagnose coronary insufficiency. CCTA and a CT scan for coronary calcium have been helpful in distinguishing which
patients may benefit most from invasive coronary angiography. A negative
CCTA can essentially rule out coronary artery disease. Echocardiography
is also helpful in diagnosing mitral valve prolapse and the various
myocardiopathies. Twenty-four-hour Holter monitoring is useful in
diagnosing many causes of intermittent chest pain.
Referral to a cardiologist or pulmonologist may be appropriate at any
point in this workup. Dissecting aneurysm may be confirmed by a CT
scan, transesophageal echocardiography, or MRI of the chest. "

]
}

},


fields to INSERT records are "symptom", "questions"and " diagnosticPlan. only return the JSON only, don’t write anything else because they are to be used to insert data into a database and Separate each point and write to make to make everything readable in a database. Make sure you extract all diseases from beginning of document to the end