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Ear Pain (Otalgia) - Differential Diagnosis Framework Primary Otalgia - Pain that originates from the ear - Pain that is continuous and progressively worsens is more likely to be associated with infection and primary otalgia Most Common Causes of Primary Otalgia: • Otitis media • Otitis externa Mechanical Causes of Primary Otalgia: • Barotrauma • Eustachian tube dysfunction • Foreign object • Cerumen impaction Infectious Causes of Primary Otalgia: • Otitis externa - Caused by bacterial infections (90%), Fungal infections (10%) • Otitis media: - Streptococcus pneumoniae - Moraxella catarrhalis - Haemophilus influenzae • Bullous myringitis • Malignant otitis externa • Cellulitis of auricle • Mastoiditis • Viral myringitis • Cranial nerve VII: - Ramsay Hunt syndrome - Herpes zoster Neoplastic Causes of Primary Otalgia: • Cholesteatoma • Basal/squamous cell CA • Melanoma Inflammatory Causes of Primary Otalgia: • Granulomatosis with polyangiitis • Relapsing polychondritis - Relapsing, bilateral, erythematous or violaceous opacification on the external ear, sparing the ear lobes Secondary Otalgia: - Pain that originates outside the ear - Intermittent pain is likely to be associated with secondary otalgia Most Common Causes of Primary Otalgia: • Temporomandibular joint syndrome • Dental infections Cranial Nerve V: • TMJ syndrome • Dental infections (caries, abscess, pulpitis) • Trigeminal neuralgia • Sinusitis • Mandibular osteomyelitis • Tumor Cranial nerve IX can refer pain: • Tonsillitis • Pharyngitis • Pharyngeal tumor • Glossopharyngeal neuromas Vagus nerve (irritation): • Myocardial ischemia causing otalgia C2 and C3 cervical nerve roots—cervical spine degeneration: • Tumor • Infection • Inflammatory process Temporal arteritis should be considered in patients 50 years or older who have normal ear examination findings and any of the following symptoms: headache, malaise, weight loss, fever, or anorexia Other Causes of Secondary Otalgia: • Carotidynia • Cervical adenopathy • Cervical spine arthritis • Cricoarytenoid arthritis • Gastroesophageal reflux • Head and neck tumors • Musculoskeletal: myofascial pain, torticollis, cervical disc degeneration, cervical radiculopathy • Oral aphthous ulcers • Thyroiditis (rarely causes isolated otalgia), thyroid carcinoma • Thoracic aneurysms • Other rare causes (subdural hematoma, lung cancer, central line placement, carotid artery aneurysm, Pott puffy tumor) • Lymph node: lymphadenopathy, lymph node malignancies • Gastrointestinal disease: gastroesophageal reflux disease (GERD), esophageal carcinoma • Sialadenitis (infection of salivary gland duct), sialolithiasis (salivary duct stones), salivary gland tumor Clues In History To Narrow Down Ddx: • Pain location • Duration • Aggravating factors • Alleviating factors • Associated symptoms • Previous episodes • Medical history • Smoking status • Alcohol abuse Red Flags: • Dysphagia • Odynophagia • Dysphonia • Hemoptysis • Loss of vision or black spots • Unintended weight loss Physical Exam: • Traction on the auricle • Palpation of the tragus to differentiate disease processes affecting the external ear and ear canal • Otoscopic examination • Oral exam • TMJ • Head, neck, nasal, cervical spine #Earpain #Otalgia #Ear #Pain #Otology #Otolaryngology #differential #diagnosis

Leg Pain - Differential Diagnosis Framework Bone/Joint Causes of Leg Pain: • Fracture • Arthritis • Gout/pseudogout • Trauma • Osteomyelitis • Patellofemoral pain syndrome • Arthritis • Popliteus tendinitis • Malignancy: Osteosarcoma, Ewing sarcoma • Legg-Calve-Perthes disease • Slipped capital femoral epiphysis • Bursitis • IBD • Psoriasis • Hepatitis • Hematoma Venous Causes of Leg Pain: • DVT • Varicose veins • Superficial thrombophlebitis Skin Causes of Leg Pain: • Infection: Cellulitis, Abscess, Necrotizing fasciitis • Inflammation: Wounds/ulcers, Edema Arterial Causes of Leg Pain: • PAD • Limb ischemia • Aortic/Iliac artery aneurysms Nerve Causes of Leg Pain: • Neuropathy (DM, Vit B12, B6, Cu deficiency etc) • Spinal stenosis/nerve compression • Sciatica • Tarsal tunnel syndrome, peroneal neuropathy • Sural nerve entrapment • Infections causing nerve damage: - Epidural abscess - Herpes zoster - HIV - Lyme disease Muscle Causes of Leg Pain: • Rhabdomyolysis • Compartment syndrome • Myositis/pyomyositis • Cramps (electrolyte imbalance) • Tendinitis • Repetitive strain injury • Iliotibial band syndrome • Shin splints • Hamstring strain • Piriformis syndrome Leg Pain Red Flags: • Trauma • Crush injury • DVT (Risks: Recent surgery, Smoking, Contraceptive pill, Immobilization) • Acute limb ischemia/cyanosis - Cool extremity - Prolonged capillary refill - Poor pulses - Hair loss- feet and legs - Brittle nails - Skin ulcers - Shiny skin • Inflammation/cellulitis/abscess • Compartment syndrome - History of blunt trauma, crush - Rigorous exercise - Excessive training 1) Pain 2) Pallor-bruising 3) Paralysis 4) Paresthesia 5) Pulselessness 6) Poikilothermia • Septic arthritis - Rapid onset - Intense joint pain/swelling - Fever/chills - Inability to move the joint #Leg #pain #differential #diagnosis #lower #extremity #msk #physicalexam

Facial Swelling - Differential Diagnosis Framework for Facial Edema Infectious: • Dental abscess • Ludwig's angina • Vincent's angina • Cellulitis • Cervicofacial actinomycosis • Mumps • Lymphadenitis • Sinusitis • Tonsillitis • Peritonsillar abscess • Dentitio difficilie • OM of craniofacial bones • Pott's puffy tumor Autoimmune: • SLE • Dermatomyositis/polymyositis • Adult-onset Still's disease • Sjogren's syndrome Hypersensitivity: • Angioedema • DRESS/DIHS • Nonepidosic angioedema with eosinophilia (NEAE) • Contact dermatitis (CD) Orbital/Periorbital Space: • Cavernous venous thrombosis • Orbital cellulitis • Rhinocerebral mucormycosis • Aspergillosis sinusitis • Trichinosis Salivary Gland: • Sialoadenitis • Parotitis Preeclampsia Dermatologic: • Sunburn • DRESS/DIHS • Rosacea • Solid facial edema of acne Medications: • ACE inhibitors/ARBs • Corticosteroids • Estrogen • Non-steroidal anti-inflammatory drugs • Thiazolidinediones • Calcium channel blockers Trauma: • Ocular trauma/hematoma • LeFort fractures of the midface • Facial fractures in patients with multi-organ trauma • Zygomatic arch fractures associated with trismus • Nasoethmoid fractures • Subcutaneous emphysema Renal: • Nephrotic syndrome • Central venous stenosis/obstruction in hemodialysis patients with central line catheters Endocrine: • Cushing's syndrome • Decompensated hypothyroidism/Myxedema coma Vascular: • SVC syndrome • Bilateral internal jugular vein thrombosis • Central venous stenosis/obstruction in hemodialysis patients with central line catheters Malignancy: • SVC syndrome • Sebaceous gland carcinoma • Multiple myeloma - maxillofacial region • Idiopathic angiosarcoma of the head and neck • Cutaneous lymphomas • Head and neck squamous cell carcinoma • Parapharyngeal space tumors • Richter's syndrome - CLL Others: • Morbihan disease • Melkersson-Rosenthal syndrome • Pseudolymphoma • Heerfordt syndrome - Sarcoidosis • Post-operative • Post-radiotherapy states • Acute mountain sickness #Facial #Swelling #Edema #Differential #Diagnosis #PhysicalExam

Multiple dermatology H&P cheat sheets for the medical student rotating in dermatology or residents needing help with a dermatology history. #diagnosis #dermatology #skin #rash #skinrash #history

The Stages of Syphilis Primary Syphilis - The chancre lesion is the hallmark of primary syphilis. It may appear 10-90 days after exposure. Common sites include penis and labia. Other sites include anus, oral mucosa. Without treatment, chancre disappears in 2-8 weeks. Secondary Syphilis - Rash, pink to brown macules. Involves palms/soles in 50% of cases. - Oral lesions called "mucous patches" resemblin snail tracks. - Symptomatic early neurosyphilis, cranial nerve deficits and/or aseptic meningitis presentation. - Ocular syphilis manifestations including anterior or posterior uveitis. - Genito-inguinal rashes, including tinea-mimicker or heaped-up wart-like lesions called condyloma lata. - Less common internal organ manifestations including acute hepatitis and nephrotic syndrome Latent Syphilis - Latent syphilis refers to asymptomatic infection after the period of primary and secondary syphilis (noticed or unnoticed) has passed. - Early Latent - Early latent refers to asymptomatic patients with positive testing, in whom history can confirm exposure to or symptoms of primary or secondary syphilis within the last year. This is group may receive single-dose penicillin like primary or secondary. - Late Latent - Late latent patients have positive serology but do not meet criteria for early. Thus, multiple doses of penicillin. Late (Tertiary) Syphilis - Late Neurosyphilis. including tabes dorsalis, gait impairments, and dementia. Tabes dorsalis damages the dorsal columns and sensory nerve roots, causing a syndrome of pain and sensory deficits similar to those of B12 deficiency. -Gumma are ulcerating granuIomas on skin, bone, and internal organs. - Cardiovascular effects of late syphilis include aortic aneurysm and coronary arteritis. #Stages #Syphilis #Primary #Secondary #Latent #Tertiary #Diagnosis #Staging ** GrepMed Recommended Text: Comprehensive Review of Infectious Diseases - https://amzn.to/2WTEUXA

This is a cheat sheet for medical students rotating in dermatology or residents needing help with a dermatology history. #diagnosis #dermatology #skin #rash #skinrash #history

Fever and Rash - Differential Diagnosis Framework • Viral: Measles, Infectious Mono (EBV, CMV), Acute HIV, Parvovirus B19, Varicella Zoster, Coxsackie (hand, foot, mouth), Disseminated HSV • Bacterial: Mycoplasma pneumoniae (MIRM), Meningococcal meningitis, Secondary syphilis, Disseminated gonorrhea, Rickettsial diseases, Toxic shock syndrome, TB cutis miliaris disseminate, Cellulitis • Fungal: Cocci, Disseminated histo, Blasto • Noninfectious: SJS/TEN, Erythema Multiforme, DRESS, Sweet syndrome, Vasculitis SCVMC Internal Medicine @SCVMCMed #Fever #Rash #Differential #Diagnosis #dermatology

Vesiculobullous Rashes - THE ALGORITHMIC APPROACH Vesiculobullous rashes provoke significant angst in many physicians (Figure 5, page 14). However, the differential diagnosis can be greatly simplified by categorizing patients with these rashes as febrile or afebrile and noting whether the rash distribution is diffuse or localized. Patients with a diffuse vesiculobullous rash and a fever may have varicella or a more devastating illness, such as smallpox, disseminated gonococcal disease, purpura fulminans, or DIC. Necrotizing fasciitis and hand-foot-and-mouth disease present with localized lesions and fever. In afebrile patients with a diffuse vesiculobullous rash, the differential diagnosis includes bullous pemphigus (BP) and pemphigus vulgaris. These entities are regularly confused, and it is essential to differentiate urgently. However, the differential diagnosis is simpler and less emergent in a patient who is afebrile with a localized vesiculobullous rash; contact dermatitis, herpes zoster, dyshidrotic eczema, and burns (chemical or thermal) are included. #Diagnosis #Dermatology #Vesicular #Vesiculobullous #Rash #Algorithm #Differential

ANTIBIOTICS WITH ANAEROBE COVERAGE - Antibiotics Class Overview 1. Metronidazole (Flagyl)(PO and IV) 2. Clindamycin – classically for infections above the diaphragm, as it also has activity vs microaerophilic streptococci; avoid in intraabdominal infections due high rates of resistance among Bacteroides species (up to 40% or more). 3. Combined PCN/Beta-Lactamase inhibitors: Augmentin, Unasyn, Zosyn, Timentin – all have excellent anaerobic activity, so no need to add Metronidazole (unless for C.diff). Unasyn better for anaerobic infections above the waist, less so for intraabdominal infections (due to high rate of resistance in E.coli). 4. Carbapenems (Imipenem, Meropenem, Ertapenem, Doripenem) – all have excellent anaerobic activity. 5. 2nd Generation Cephalosporins (Cephamycins): Cefoxitin, Cefotetan – beware increasing resistance of Bacteroides (Cefoxitin is better than Cefotetan, but avoid both for serious intraabdominal infections) 6. Moxifloxacin – has data to support its use in intraabdominal infections, but beware increasing resistance among Bacteroides (up to 40%!) 7. Tigecycline – excellent anaerobic activity. #Pharmacology #Antibiotics #Review #Overview #Anaerobe #Anaerobic #Metronidazole #Flagyl #Clindamycin

Aortic Valve Stenosis • Etiology • Severity and Grading • Management Satyendra Dhar, MD @DharSaty #Aortic #Valve #Stenosis #AS #diagnosis #management #cardiology #aorta