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.

 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