GMT Berkeley Field Version 1st Edition

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GLOBAL MEDICL TRAINING
BERKELEY
“Clinical Diagnosis Guideline”
Field Version
Author & Editor: Dat T. Nguyen
First Edition
Published online: 3rd
March 2016

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The field version was written and edited for the purpose of field usage, which
should not be too big, comprehensive and carry essential information. For more
information please check the “Completed Version” or future editions.
Source:
+ GMT Medical and Clinical Guideline (2011) by Wil Johnson, M.D.
+ Harrison’s Principles of Internal Medicine, 11th
edition
+ MIMS Gastroenterology Guide
+ MIMS Cardiology Guide
+ Oxford Handbook of Tropical Medicine, 4th
edition
+ Control of Communicable Diseases Manual, 20th
edition
+ Netter’s Essential Physiology
+ Center for Diseases Control
+ World Health Organization
+ WebMD Online Database
+ Mayo Clinic Online Database
The author or Global Medical Training Berkeley do not own any of the images that can be found
in this guideline

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PART 1: DISORDER OF THE EYES, EARS, NOSE AND THROAT
Section 1: Disorders of the eyes
Cataracts:
Definition:
A cataract is a clouding of the normally clear lens of
your eye. Cataract develops through time, and eventually,
can lead to blindness.
Cause:
+ Aging
+ Injury
+ Hypertension
+ UV light
Risk Factors:
+ Eye injury + Obesity
+ High blood pressure + Diabetes
+ Aging + Smoking
Symptoms:
+ Blurred Vision + Vision loss
+ Inability to see in dim light + Double vision
Treatment:
+ Cataract Surgery
Prevention:
+ Wear Sunglasses
+ Maintain a healthy weight
Conjunctivitis:
Definition:
Inflammation or infection of the outer membrane of the eyeball and the inner eyelid.
Symptoms:

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Treatment:
+ Bacterial: Antibiotics
+ Viral: Antiviral drugs
+ Allergic: Antihistamine, mast-cells stabilizers, or anti-inflammatory eye drops
Prevention:
+ Don't touch your eyes with your hands.
+ Use only clean towels and washcloths
+ Change your pillowcases often.
+ Dispose contact lenses and cosmetics that were used when infected
Risk factors:
+ Exposure to allergic substances
+ Contact lenses
Pterygium:
Definition:
Overgrowth of the conjunctiva
Symptoms:
+ Eye discomfort, irritation, or redness
+ Blurred vision
Cause:
+ Prolonged exposure to UV light
+ Airborne Irritants
Treatment:
+ Eye drop, eye ointment, or medication to ease the inflammation
+ Surgery if the growth interfere vision or cause extreme irritation
Prevention:
+ Wear sunglasses
+ Keep the eyes moist
Section 2: Disorders of the ears
Acute Otitis Media:
Definition:
Inflammation of the outer ear canal
Causes:
Bacteria, virus, or fungus
Symptoms:
+ Pain and inflammation in the ear
+ Itching
+ Pus-formation
+ Hearing loss Figure 3: Black spore due to
fungal infection

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Diagnosis:
+ Lack of cerumen
+ Bacterial: Discharge from ear
+ Fungal: Black spores
Treatment:
+ Bacterial: Antibiotic medication, ear drop, or ointment
+ Fungal: Topical antifungal cream
Section 3: Disorders of the nose and throat
Tonsillitis:
Definition:
Inflammation of the tonsil:
Cause:
Viral or bacterial infection of the tonsil
Symptoms:
+ Sore Throat + Swollen, red tonsil
+ Pain when swallowing + Fever
+ Malaise + Pain in the ears or neck
+ White or yellow patch on the tonsil
Risk factor:
+Young age
+ Frequents exposure to germs
Complications:
+ Difficulty breathing
+ Advance infection with Strep spp. and Staph spp.
Diagnosis:
+ Inspect the throat and tonsil for inflammation
+ Palpate for enlarge lymph node
Treatment:
+ Bacterial: antibiotics
+ Viral: Symptom relief medication (acetaminophen)
+ Surgery in chronic case
Prevention:
+ Personal hygiene
+ Replace toothbrush after being diagnosed with tonsillitis

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Chronic/Acute Sinusitis:
Definition:
Cavities around your nasal passages (sinuses) to become inflamed and swollen. This interferes
with drainage and causes mucus to build up. Chronic Sinusitis persist more than 8 weeks
Cause:
+ Viral, bacterial or fungal infection
+ Tooth infection +
Allergic reaction
Symptoms:
+ Thick, yellow or greenish discharge from the nose
+ Nasal obstruction or congestion, causing difficulty
breathing through your nose
+ Double vision
+ Stiff neck
Risk factors:
+ Allergic conditions
+ Regular exposure to pollutants
+ Immunodeficiency
Complications:
+ Asthma flare-up + Meningitis
+ Vision problem + Ear infection
Treatment:
Symptoms relief:
+ Pain reliever
+ Decongestant
+ Antibiotics (Only for severe conditions)
+ Antifungal medications
Prevention:
+ Avoid upper respiratory infection
+ Manage allergy
+ Avoid cigarette smoke
Lifestyle remedies and therapies:
+ Apply warm and damp towel around nose and cheeks
+ Drink plenty of fluids
+ Sleep with your head elevated

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PART 2: DISORDER OF THE GASTROINTESTINAL SYSTEM
General Anatomy and Physiology of the Gastrointestinal Tract:
Section 1: Disorder of the Upper GI Tract
Esophagitis:
Definition:
Inflammation of the damaged tissue of the esophagus.
Causes:
+ Incompetent lower esophageal sphincter
+ Pain-relieving medications (Aspirin, ibuprofen, etc.)
Risk Factors:
+ Consumption of spicy or citric food
Complication:
+ Esophageal Ulcer
Symptoms:
+ Heartburn
+ Difficulty with swallowing (painful)
+ Chest pain while eating
Treatment:
+ Antacids

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Gastritis:
Definition:
Inflammation, irritation, or erosion of the lining of the stomach
Causes:
+ Helicobacter pylori infection
+ Greasy and spicy food
+ Medications (Aspirin)
+ Consumption of coffee and alcohol
Risk factors:
+ Regular use of pain relievers
+ Older age
Symptoms:
+ Upper abdominal pain
+ Burning sensation in the chest
+ Nausea and vomiting
+ Bloating
Complications:
+ Gastric Ulcer
Prevention:
+ Avoid alcohols, greasy, and spicy food
+ Manage stress
Treatment:
+ Antacids
+ Antibiotics (Amoxicillin)
Peptic Ulcer:
Definition:
Peptic ulcers are open sores that develop on the inside lining of your esophagus, stomach
and the upper portion of your small intestine
Causes:
+ H. pylori infection
+ Medications (Pain relievers)
Risk Factors:
+ Regular use of pain relievers
+ Smoking and drinking alcohols
Symptoms:
+ Pain in the chest and upper abdomen
+ Burning sensation
+ Vomiting of blood
+ Dark blood in stools
Treatment:
+ Antibiotics (Amoxicillin)
+ Antacids

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Dyspepsia:
Definition:
A symptoms complex that refers to pain and discomfort at the upper abdomen due to
indigestion
Causes:
+ Ulcers
+ Parasite
+ Abnormal GI muscle function
Symptoms:
+ Bloating
+ Nausea
+ Cramping
+ Upper abdomen pain
Treatment:
Because this is a symptoms complex, so treatment have to be specific:
+ Anti-parasite drug: Albendazole
+ Changes in diet (avoid spicy food)
Section 2: Disorder of the Lower GI Tract
Colitis:
Definition:
Colitis is a subset of Inflammatory Bowel Disease that characterized by the inflammation
of the colon (large intestine). It includes Ulcerative Colitis and Crohn’s Disease; they are two
different diseases with similar symptoms, but with limited resource, we can’t diagnose the
specific disorder.
Symptoms:
+ Diarrhea with blood (pus in ulcerative colitis)
+ Pain in the lumbar and umbilical region
+ Fever and fatigue
+ Cramping
Treatment/Symptoms relief:
+ Surgery is the only treatment
+ Anti-inflammatory: Corticosteroids
+ Limit fiber and dairy products
+ Low-fat diet
Hemorrhoids:
Definition:
Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding.
Causes:
+ Obesity + Chronic constipation or diarrhea
+ Low-fiber diet + Sitting for a long period of time

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Symptoms:
+ Constipation
+ Blood in stool
+ Pain in rectum area (Hypogastric
region)
Prevention:
+ Eat more fruits, vegetables, and
grains
+ Exercise
+ Avoid sitting for too long
+ Drink plenty of fluid
+ Surgery
+ Pain relievers: Aspirin, ibuprofen, etc.
+ Fiber supplement
Gallstones:
Definition:
Cholelithiasis: Gallstones are hardened deposits from fluid inside the gallbladder
Causes:
+ Bile contains too much cholesterol
+ Retention of bile
Risk factors:
+ Low-fiber diet
+ Older age (>60 years old)
+ Diabetes
+ High-fat, cholesterol diet
Symptoms:
+ Intense pain in the Right hypochondriac region
+ Yellowing of skin and eyes
+ Discomfort after a or greasy meal
Treatment:
+ Surgery

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PART 3: DISORDER OF THE CARDIOVASCULAR SYSTEM
Section 1: Disorder of the Heart
Hypertension:
Definition:
A condition in which the force of the blood against the artery walls is too high.
Risk factors:
+ Aging: Increase as patients grow older (Male >45 y/o; Female > 65 y/o)
+ Family history
+ Being overweight/obese with a sedentary lifestyle
+ Excessive consumption of alcohol and tobacco
+ Diet (Too much sodium, or too little potassium and Vitamin D)
Complications:
+ Heart Attack + Stroke
+ Aneurysm + Heart Failure
Symptoms:
+ Blurred vision and dizziness that lessen when rest
+ Tension Headache
Diagnosis:
Prevention/Relief Factors:
+ Change of Diet
+ Increase physical activities
+ Quit Smoking and Drinking
Congestive Heart Failure:
Definition:
A chronic condition in which the heart doesn't pump blood as well as it should due to
fluid build-up in lungs, abdomen or the lower limbs.
Cause:
+ Past heart attack + Myocarditis
+ Arrhythmia + Hypertension
Risk Factor:
+ Activities or conditions that can cause hypertension

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Symptoms:
+ Cough with shortness of breath
+ Constant fatigue
+ Edema in legs
+ Ascites (bloating of the abdomen)
Complication:
+ Kidney and Liver Damage
+ Heart Arrhythmia
Prevention:
+ Change of Diet
+ Increase physical activities
+ Quit Smoking and Drinking
Treatment:
Cardiac Arrhythmia:
Definition:
Heartbeat is too fast (tachycardia), too slow (bradycardia), or with an irregular rhythm
Risk Factors:
+ Past heart attack + Congenital heart defects
+ Smoking + Stress
+ Electrolyte imbalance
Symptoms:
+ Dizziness + Chest Pain
+ Shortness of Breath
Diagnosis:
+ Listen to patient’s heartbeat and detect any alteration in rhythm and pace.
Prevention:
+ Limit consumption of coffee, cigarettes, and alcohols
+ Healthy diet with reasonable intake of salt
Angina:
Definition:
Patient with angina (ischemic chest pain) feel a central, crushing
chest pain that may radiate to the jaw, neck, one or both arms.
Cause:
Reduced blood flow to the heart
Risk Factors:
+ Smoking + Overweight
+ Diet with high lipid + Sedentary lifestyle
Symptoms:
+ Crushing or burning pain in the chest, jaws, or neck
+ Dizziness and Fatigue
Prevention:
+ Stop smoking + Keep a health weight (Diet and exercise)

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Section 2: Disorder of the vascular system
Varicose Vein:
Definition:
Varicose veins are swollen, twisted veins that you can see just under the skin. They
usually occur in the legs, but also can form in other parts of the body. The condition is benign
Cause:
Unknown cause, but very common in the elderly and in
female
Risk Factors:
+ Obesity
+ Standing for too long
+ Pregnancy
Symptoms:
+ Swollen blood vessels (blue)
+ Swollen legs (common)
+ Aching in the affect limbs
Diagnosis:
+ If the vein is not visible
+ Ask the patient to stand up and palpate the aching area to
feel for the bulges
Treatment:
+ Temporary treatment: Blood Thinner (Aspirin)

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PART 4: DISORDER OF THE RESPIRATORY SYSTEM
Acute bronchitis:
Definition:
A respiratory disease in which the mucus membrane in the lungs' bronchial passages
becomes inflamed.
Cause:
Viral Infections
Symptoms:
+ Coughing, nonproductive (dry) lasts for weeks
+ Runny nose
+ Chest tightness
+ Shortness of breath
+ Sore Throat
+ Fatigue, Malaise
Treatment/Relief Factors:
+ Anti-inflammatory: Ibuprofen
+ Pain Reliever: Acetaminophen
+ Stay away from area with dust and pollutants
+ Cleanse throat with a solution of water, salt and lemon
Pneumonia:
Definition:
Pneumonia is an infection that inflames the alveoli, which got filled with liquid or pus
Cause:
+ Bacteria: Strep. spp., etc.
+ Viral: Coronavirus, etc.
Symptoms:
+ Fever with episodes of chilling and sweating
+ Cough with phlegm
+ Chest pain
+ Shortness of breath
+ Fatigue
Diagnosis:
+ Lung Auscultation: Crackles
Complication:
+ Sepsis (Bacteria in blood)
+ Pleural effusion
+ Lung abscess
Treatment:
+ Antibiotics: Amoxicillin
+ Fever reducers: Ibuprofen, Aspirin
Prevention:
+ Keep the immune system strong (enough sleep, healthy diet, regular exercise)

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Asthma:
Definition:
Asthma is a condition in which your airways narrow and swell and produce extra mucus
Cause:
+ Airborne allergens and pollutants
+ Respiratory infections
+ Strong emotion; stress
+ Physical activities
+ Cold and dry air
Risk Factors:
+ Being overweight
+ Smoking or secondhand smoke
+ Family History
+ Exposure to dust and pollutants
+ Allergy
Symptoms:
+ Coughing
+ Wheezing
+ Fast breathing
+ Chest tightness
Treatment:
+ Salbutamol
Prevention:
+ Avoid strenuous exercise
+ Vaccinate against flu
+ Avoid exacerbating factors
Asthma vs. Bronchitis:
Asthmatic patient: Recurrent episodes; chronic
Bronchitis patient: Isolated incident; no history of asthma

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PART 5: DISORDER OF THE MUSCULOSKELETAL SYSTEM
Arthritis:
Definition:
The inflammation of tissues in the joint. There are two main types of arthritis:
Degenerative Joint Disease (Osteoarthritis) and Rheumatoid Arthritis.
Causes:
+ Wear down of joint’s cartilage
+ Autoimmune
+ Chikungunya (induce autoimmune attack)
Risk Factors:
+ Family history
+ Old age
+ Obesity
+ Previous injury
Symptoms:
+ Sharp or mild pain
+ Stiffness
+ Swelling joint
+ Restricted movement
+ Anti-inflammatory drug: Aspirin,
ibuprofen
+ Pain reliever: Acetaminophen
+ Physical exercise and weight loss
+ Apply ice pack
Costochondritis:
Definition:
Inflammation of the joint and cartilage that connect the ribcage to the sternum. It is a
common false positive pain for heart attack
Cause:
+ Injury and Physical Strain
+ Arthritis
+ Bacterial/Viral infection
Risk factors:
+ Occupation: Physical labor
+ Old age (>40 y/o) (Tietzes in teenager)
Symptoms:
+ Sharp pain in the chest
+ Pain is worsen with deep breath or cough
Treatment:
+ Anti-inflammatory drug: Aspirin, ibuprofen

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Tendonitis:
Definition:
Inflammation of the tendon
Cause:
+ Overuse
+ Injury
+ Arthritis
Risk Factors:
+ Occupation
+ Old age
Symptoms:
+ Dull pain in the affected area
+ Mild swelling
Treatment:
+ Apply ice pack
Osteomyelitis:
Definition:
Infection of the bone, generally in the limbs and spine.
Cause:
+ Sepsis: bacteria in the blood stream
+ Open wounds/past injuries
Symptoms:
+ Fever
+ Lethargy
+ Sharp pain in the infected area
+ Swelling of the area
Complications:
+ Septic arthritis
+ Osteonecrosis
Prevention:
+ Clean and seal the area of the
wound
Treatment:
+ Surgery

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Gout:
Definition:
It is a complex form of arthritis. Gout is characterized by the inflammation of the joints,
typically the big toes) caused by the response of white blood cell on uric acid deposition.
Cause:
+ Uric acid oversaturated in blood and deposition in joint
Risk factors:
+ Alcohol consumption
+ High – protein diet
+ Excessive sugar intake
+ Obesity
Symptoms:
+ Intense pain in the joint
+ Limited range of motion
+ Inflammation and swelling
Complication:
+ Formation of tophus (deposition of uric acid
around the joint) that will cause more pain and
deformation
+ Kidney stone
Prevention:
+ Stay hydrated
+ Adjust diet (lower protein intake)
+ Limited intake of soft drink and alcohol
Treatment:
+ Apply ice pack

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PART 6: DISORDER OF THE URINARY AND REPRODUCTIVE
SYSTEM
Urinary Track Infection:
Definition:
UTI infers to infection in any part of the urinary track. Infection in the Bladder (Cystitis)
and the Urethra (Urethritis) is more common than infection in the Kidney (Acute Pyelonephritis)
Cause:
Bacterial/Viral infection
Risk factors:
+ Sexual active
+ Dehydration
+ Menopause
Symptoms:
Because UTI is an umbrella term for 3 sites of infections, they are somewhat similar; they
share some non-specific symptoms, but each types have different characteristics.
Common symptoms:
+ Urine appear cloudy with strong, foul smell
+ Burning sensation when urinate
+ Strong urge and frequent urination
Specific symptoms:
Cystitis Urethritis Acute Pyelonephritis
+ Lower abdomen discomfort
+ Blood in Urine
+ Discharge
+ Fever
+ Upper back and flank pain
+ Nausea
+ Vomiting
Prevention:
+ Wipe from front to back
+ Drink plenty of water
Treatment:
Bacterial Vaginitis:
Definition:
Inflammation of the vagina that cause by bacterial infection
Cause:
Bacteria
Symptoms:
+ Thin, grey discharge with fishy odor
+ Vaginal itching
+ Burning during urination
Treatment
+ Metronidazole (topical or oral)

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Candidiasis:
Definition:
Inflammation of the vagina that caused by yeast
infection
Cause:
Yeast
Risk Factors:
+ Antibiotic use
+ Diabetes
+ Impaired immune system
Symptoms:
+ Vaginal itching
+ Burning during urination
+ White, curd-like discharge
+ Vaginal pain
Treatment:
+ Anti-fungal medication: Clotrimazole ovulos
Trichomoniasis:
Definition:
Inflammation of the vagina that caused by a protozoan parasite
Cause:
Trichomoniasis, sexually transmitted
Risk factors:
+ Unprotected sex
Symptoms:
Women:
+ Yellow or green discharge with foul smell
+ Pain with urination or intercourse
+ Vaginal itching and burning
Men:
+ Irritation inside the penis
+ Discharge from penis
+ Burning sensation after urination or intercourse
Prevention:
Safe sex
Treatment:
+ Mentronidazole for both partners

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PART 9: DISORDER OF THE SKIN
Scabies:
Definition:
Scabies is an itchy skin condition caused by a tiny burrowing mite. It is very contagious,
and it is spread by direct contact with the infected
Causes:
Sarcoptes scabiei
Symptoms:
+ Itching, worse at night
+ Burrow site create cluster of tiny blisters
Prevention:
+ Wash clothes, towels, bed sheets and blankets
frequently
+ Anti-parasitic drugs
+ Lotion
+ Apply cool water to irritated area
+ Anti-histamines
Tinea Versicolor:
Definition:
Fungal infection that cause small patches of discolored skin
Causes:
Fungi
Risk Factors:
+ Hot, humid weather
+ Oily skin
+ Hormonal changes
+ Weakened immune system
Symptoms:
+ Patches of discolored skin (back, chest,
neck)
+ Mild itching
+ Scaling
Treatment:
+ Anti-Fungal drugs: Clotrimazole
Prevention:
+ Stay cool and dry
+ Don’t share clothes and towels
+ Shower frequently

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Tinea Corporis:
Definition:
Ringworm is an extremely infection fungal infection characterized by a red, circular rash
surround clear skin.
Risk Factors:
+ Young children
+ Damp and humid weather
+ Weakened immune system
Symptoms:
+ Red, circular rash surround clear skin
+ Itchy
+ Result in peeling of skin
Treatment:
+ Anti-fungal cream or drug: Clotrimazole
Prevention:
+ Stay cool and dry
+ Don’t share clothes and towels
+ Shower frequently

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Part 9: Tropical Infectious Diseases
Section 1: Viral Infection
Acquired Immunodeficiency Syndrome:
Definition:
AIDS is a chronic infection of the CD4+ T-cells by the Human Immunodeficiency Virus
(HIV)
Cause:
Contract of HIV via:
+ Unprotected Intercourse
+ Blood transfusion
+ Sharing Needles
+ Pregnancy and Breast Feeding
Symptoms:
HIV Infection is asymptomatic until it reach AIDS (when the CD4+ Count is below 200
cell per microliter)
Because of the destruction of the T-Cell, our immune system got weakened, and unlikely
infection occur (Opportunistic Infection):
Prevention:
+ Safe sex
Chikungunya:
Definition:
Chikungunya is a multi-system disease caused by Chikungunya Virus infection
Cause:
Chikungunya Virus

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Transmission:
+ Non-zoonosis (Only spread human-to-human; human is its natural reservoir)
+ Vector: Aedes aegypti mosquito
Symptoms:
+ Onset 4-7 days after contraction
+ Rash
+ Fever
+ Muscle aches
+ Swollen and dull pain in the joints
Complication:
+ Development of arthritis
Epidemiology:
+ There was recent cases of Chikungunya in Nicaragua
Treatment:
+ No direct treatment
Prevention:
+ Control the mosquito population:
- Get rid of puddle of water around household
- Use insecticide during outbreak
+ Sleep in bed net
Dengue Fever:
Definition:
A mosquito-borne viral infection.
Cause:
Dengue Virus
Transmission:
+ Non-zoonosis (Only spread human-to-human; human is its natural reservoir)
+ Vector: Aedes aegypti mosquito (also spread CHIKV)
Symptoms:
+ Onset 4-7 days after contraction
+ Rash
+ Fever
+ Muscle aches
Epidemiology:
+ Subtropical and tropical region
+ Thrive in raining season
Complications
+ Dengue Hemorrhagic Fever
+ Dengue Shock Syndrome
Treatment:
+ No treatment
+ Drink plenty of fluid

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Section 2: Bacterial Infection:
Tuberculosis:
Definition:
A bacterial infection of the macrophage cell inside the lung that can become latent and
chronic
Cause:
Mycobaterium tuberculosis
Transmission:
Tiny aerosol droplets via air
Symptoms:
+ Coughing that last more than three weeks
+ Weight loss
+ Coughing with blood
+ Chest pain
Risk factors:
+ Immunocompromised
+ HIV Co-infection
+ Smoking
+ Very young or advance age
Prevention:
+ Vaccination
+ Isolate the infected from immunocompromised individuals
Tuberculosis and HIV co-infection

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Section 3: Protozoan and Helminths Infection
Giardiasis and Amoebiasis:
Definition:
These two protozoan infection have similar syndrome and can be treated with the same
medication
Cause:
+ Giardiasis: Giardia intestinales
+ Amoebiasis: Entamoeba Histolytica.
Transmission:
Fecal-oral
Symptoms:
+ Loss of appetite
+ Bloating
+ Watery Diarrhea (with or w/o blood)
Treatment:
+ Metronidazole
Prevention:
+ Drink and use clean water to cook
+ Wash hand with soap
Pinworm:
Definition:
Infection by pinworm
Transmission:
Fecal Oral
Symptoms:
+ Majorly asymptomatic
+ Itchy Butt
+ Nausea
Treatment:
+ Anti-parasite: Mebendazole
Prevention:
+ Wash hand with soap

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