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Differential Diagnosis for…
Cardiac External Medicine Hematological Head
Dyspnea Alopecia Abnormal hemostasis Delirium
Chest Pain Acanthosis nigricans Hypercoagulability Dementia
Palpitations Clubbing Hemolytic Anemia Ataxia
Cardiac Enlargement Cyanosis Thrombocytopenia Asterixis
Murmurs Erythema Nodosum Thrombocytosis Amnesia
Orthostatic Hypotension Subcutaneous Nodules Lymphocytosis Anisocoria
Pulse Pressure Vesicubullous lesions Rheumatoid Factor Epistaxis
Abnormalities Nodules and Arthritis Hyperviscocity Headaches
Elevated JVP Exanthems Eosinophilia Seizures
Paradoxical Splitting Hand and Foot Rash Syncope
Continuous Murmurs Splinter hemorrhages GI/Abdominal Vertigo
Livedo reticularis Abdominal Pain
Hypertension Yellow discoloration Abdominal distention Neck
Congestive Heart Failure Mechanical obstruction Cervical lymphaden
(Acute) Endo GI bleed Dysphagia / Odynop
Small testes Vomiting
Lungs Delayed puberty Diarrhea Neuro
Cough Hirsutism Mononeuritis Multip
Wheezing Liver
Hemoptysis Ascites
Cavitary lesion of lungs OB/Gyn Splenomegaly
Pleural Effusion Postmenopausal bleeding Cysts
Cyanosis Amenorrhea
Renal
Musculoskeletal Hematuria
Joint Pain (see joint pathology)
Muscle Weakness (see myopathy)
Back Pain

Electrolyte Abnormalities (see other)

Pediatrics
Failure to Thrive
Mental Retardation
Precocious puberty / Late Puberty

Ddx for opportunistic pathogens in AIDS patients

Causes of Dyspnea

Heart disease
Left ventricular failure
Restrictive cardiomyopathy
Constrictive pericarditis
Pulmonary venous obstruction
Mitral stenosis
Cor triatriatum
 Left atrial myxoma
Left atrial thrombus
Tamponade
Lung disease
Obstructive airways disease
Chronic obstructive pulmonary disease
Asthma
Restrictive lung disease
Interstitial or diffuse alveolar lung disease
Disorders of chest wall and bellows function
Kyphoscoliosis
Arthritis
Neuromuscular disease
Obesity
Vascular disease
Pulmonary embolism
Primary pulmonary hypertension
High altitude exposure Anemia
Anxiety (hyperventilation syndrome)

Causes of Chest Pain

Heart disease
Angina pectoris
Atheromatous coronary artery disease
Nonatheromatous coronary artery disease
Aortic stenosis (AS)
Aortic insufficiency (AI)
Idiopathic hypertrophic subaortic stenosis (HOCM, IHSS)
Myocardial infarction
Congestive cardiomyopathy
Pulmonary hypertension
Mitral valve prolapse (click-murmur) syndrome (MVP)
Pericarditis
Dissection of the aorta
Pulmonary disease
Pulmonary embolism
Pleuritis
Pneumothorax
Pneumonia
Tumor
Collagen disease – mechanism?
Atelectasis – mechanism?
Musculoskeletal disease
Arthritis
Costochondritis (Tietze syndrome)
Bursitis
Intravertebral disc disease
Thoracic outlet syndrome
 Muscle spasm
Fracture
Metastatic tumor or hematologic (leukemia) or plasma cell (myeloma) malignancy
Neural disease
Intercostal neuritis
Herpes zoster
Gastrointestinal disorders ("referred" chest pain)
Hiatal hernia
Cholecystitis
Pancreatitis
Ulcer disease
Bowel disease
Neoplasm
Emotional duress or anxiety (e.g., neurocirculatory asthenia, Da Costa syndrome)

Causes of Hemoptysis

General:
Massive Hemoptysis ≥ 600 ml in 24 hrs (place affected lung in dependent position, ?rigid
bronchoscopy, ?intubation)
Most common in US: bronchitis, lung cancer
Hemoptysis + acute pleuritic pain  PE
Hemoptysis + chronic copious sputum  bronchiectasis

Cardiac
Pulmonary venous hypertension
Left ventricular failure
Mitral stenosis
Eisenmenger syndrome
Pulmonary [see endobronchial Ddx]
Infection
Bronchitis (1st)
Bronchiectasis
Tb (2nd)
Pneumonitis
Abscess
Lung cancer (3rd)
Trauma or foreign body
Alveolar hemorrhage
Vascular
Rupture of AV fistula
Thoracic aortic aneurysm
Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
Primary pulmonary hypertension
Pulmonary embolism
Goodpasture’s syndrome
Arthritides
Polyarteritis nodosa (PAN)
Wegener's granulomatosis
SLE
Bleeding diathesis

Endobronchial Lesions
 Endobronchial carcinoma
Metastatic endobronchial tumor
Melanoma
Endometrial or ovarian carcinoma
Thyroid carcinoma
Renal cell carcinoma
Kaposi’s sarcoma
Calcified carcinoid tumor
Endometrial endometriosis
Benign tumor or pyogenic granuloma
Granulation tissue
Response to foreign body irritation
Trauma
Vasculitis, Wegener’s
Lymphomatoid granulomatosis
Sarcoidosis
Fungal infection
aspergillosis, phaeohyphomycosis, sporotrichosis, blastomycosis, histoplasmosis,
coccidioidomycosis
Tuberculosis
Broncholithiasis

Causes of Palpitations

Extra systoles
Atrial premature beats
AV junctional (nodal) premature beats
Ventricular premature beats
Tachyarrhythmias
Supraventricular
Regular
Sinus tachycardia
Paroxysmal supraventricular tachycardia
AV junctional tachycardia
Atrial flutter
Irregular
Atrial fibrillation
Paroxysmal supraventricular tachycardia or atrial flutter with block
Multifocal atrial tachycardia
Ventricular tachycardia
Bradycardia
Sinus bradycardia
Sinus arrest
2nd or 3rd degree AV block
Conditions associated with increased force of cardiac contraction
Thyrotoxicosis
Anemia
Fever
Certain drugs, including catecholamines and cardiac glycosides
Anxiety states

Causes of Cardiac Enlargement

Congestive heart failure

 Valvular heart disease
Volume or pressure overload (e.g., L to R shunts, systemic arterial hypertension)
Heart muscle disease (ischemia or cardiomyopathy)
High-output failure
Ventricular aneurysm
Large stroke volume
Athlete's heart
Complete heart block
Pericardial effusion
Cardiac cysts and tumors
Absence of the pericardium

Common Causes of Murmurs

Valvular heart disease

Stenosis
Insufficiency of congenital or acquired etiology
Nonvalvular outflow obstruction
Supravalvular and subvalvular outflow obstruction
Idiopathic hypertrophic subaortic stenosis (HOCM, IHSS)
Shunts (extracardiac and intracardiac)
Complex congenital heart disease producing turbulence
Physiologic murmurs
Hyperdynamic states
Anemia
Fever
Thyrotoxicosis
Pregnancy
AV fistula
Excitement
Flow across normal valves in high-volume states
Diastolic rumble in mitral and tricuspid regurgitation,
atrial and ventricular septal defect, patent ductus arteriosus
Complete heart block
Austin Flint murmur of aortic regurgitation
Innocent murmurs of childhood
Anatomic distortion producing turbulence
Straight back syndrome
Pectus excavatum
Chest deformity
High to low pressure communication
Ruptured sinus of Valsalva aneurysm
Coronary fistula
Anomalous origin of left coronary artery from pulmonary artery
AV fistula
Arteriopulmonary connection
Dilatation or stenosis of large or small vessels
Aneurysm or dilatation of aorta or pulmonary artery
Coarctation
Peripheral pulmonary stenosis
 Atherosclerotic vascular narrowing
Pulmonary embolism
Alteration of arterial or venous flow in nonconstricted vessels
Venous hum
Mammary soufflé
High brachiocephalic flow in children
High flow in collateral vessels
Intercostal/bronchial collaterals in coarctation of aorta, pulmonic stenosis, or atresia
Aortic regurgitation
Sounds resembling murmurs
Fusion of S3 and S4 gallops
Prolonged gallop sounds
Pericardial and pleural friction rubs

Causes of Orthostatic Hypotension

Idiopathic
Hyponatremia
Hypovolemia
Drugs (e.g., tranquilizers, vasodilators)
CNS disease (e.g., syringomyelia, tabes dorsalis)
Addison's disease
Pheochromocytoma
Wernicke syndrome
Amyloidosis
Diabetes mellitus
Primary autonomic insufficiency
After sympathectomy
Physical deconditioning

Continuous Murmurs

Location of Murmur Differential Diagnosis

First to second left intercostal spaces (and under left clavicle) Patent ductus arteriosus

Second to fourth left intercostal spaces Aorticopulmonary septal defect

Usually best heard in the second to third left intercostal spaces; Surgical shunts, such as aortopulmonary
occasionally may be best heard at the right of the sternum in the anastomoses
same area
Usually best heard along the lower left sternal border, although it Rupture of sinus of Valsalva aneurysm
may be audible over the entire precordium
Audible over the left precordium Coronary AV fistulae

May be audible anywhere that they occur AV fistulae

Pulse Pressure Abnormalities

 Increased Pulse Pressure Narrow Pulse Pressure

Sinus bradycardia Severe heart failure (please understand how)

Complete heart block Shock

Emotion Aortic stenosis (usually occurs but is not always present)

Exercise Hypovolemia

Aortic regurgitation Vasoconstrictive agents

AV fistulae
Fever
Anemia
Hyperthyroidism
Beri-beri
Inelastic aorta (elderly patients)
Abnormal connections between aorta and pulmonary
artery (patent ductus arteriosus, aorticopulmonary
window)
Rupture of sinus of Valsalva aneurysm

Arterial Pulse Abnormalities

Abnormality Description

Anacrotic pulse A small, slowly rising pulse with a notch on the ascending
limb, such that there are two deflections on the upstroke of the
carotid
Bisferiens pulse Two palpable systolic peaks of almost equal height

Dicrotic pulse A second peak during diastole

Waterhammer pulse Characterized by rapid and sudden systolic expansion

Idiopathic hypertrophic subaortic stenosis A carotid pulse with a very rapid upstroke. sometimes having a
pulse bisferiens quality

Elevated Jugular Venous Pressure (JVP)

Right ventricular failure

Vascular pulmonic stenosis
Infundibular pulmonary stenosis
Pulmonary hypertension
Tricuspid stenosis or insufficiency
Hypervolemia
Pericardial tamponade
Constrictive pericarditis
Superior vena caval obstruction

Paradoxical Splitting of the Second Heart Sound

Elevated PAP?
Left bundle branch block
Right ventricular ectopic beats
Right ventricular pacing
Angina pectoris
Left ventricular failure
Left ventricular outflow obstruction
Severe systemic hypertension

Note: Paradoxical splitting occurs in some but not all patients with these abnormalities

Cough

Pulmonary-related

Cardiac-related
MS may produce bouts of coughing (confused with bronchitis)
Hemoptysis from heart disease (rare)
sputum usually white, but can be blood streaked (high pulmonary pressure from chronic
CHF, MS, Eisenmenger’s, impinging aortic aneurysm)

Wheezing

RAD (Asthma)
cardiac wheezing - don’t forget about this – which responds to albuterol also –

Cavitary lesion of lungs [characteristic wall pattern] [NEJM]

Infectious
Bacteria (thick): S. aureus, S pneumo (only type 3), Pseudomonas, klebsiella, legionella,
H. influenza Tb (Gohn complex), M. avium, rhodococcus, actinomyces/nocardia,
burkholderia, peptostreptococcus, prevotela, bacteroides, fusobacterium
Parasites: entamoeba, toxoplasma, paragonimiasis, echinococcus (think lower lobe, R >
L)
Fungal: histoplasma (variable)
blastomycosis, cryptococcus (thick)
aspergillosis, coccidioides (thin)
mucor, penicillum marneffei, PCP
Developmental: sequestration (thick or thin), bronchial cyst (thin)
Immunology: Wegener’s (thick, irregular), Goodpasteur’s (bilateral), rheumatoid, sarcoidosis
(variable)
Neoplasm: pulmonary (SCC) (thick, irregular), metastasis (adenoma or sarcoma) and Hodgkin’s
lymphoma (thick or thin), adenoma, teratoma
 Vascular: septic thromboembolism (thick or thin, shaggy wall)
Inhaled: silicosis, coal worker’s (thick, irregular)
Other: Blebs or bullae (when infected) / cystic bronchiectasis, pulmonary laceration

Pleural Effusion (see lungs)

PE: dullness to percussion, hyporesonance, decreased fremitus (increased with pneumonia), large
effusion may shift trachea to opposite side / not generally associated with pain
Exudate criteria: protein > 3 (0.5 ratio) / LDH > 200 (0.6 ratio)
Clues: RF or glucose < 20  RA / leukoerythrogenic cells (so-called LE cells)  SLE / 2x
amylase  pancreatitis/ruptured esophagus / Hct > 20%  hemothorax / increased lymphocytes
 Tb or malignancy

Heart
CHF
Left and right heart failure (if unilateral, usually right-sided)
Pulmonary venous hypertension with right heart failure
Autoimmune phenomena after heart injury
Postpericardotomy syndrome / Dressler’s syndrome (post-MI)
Lungs
Inflammation (pleura or lung)
Infection
Malignancy (can get pain with mesothelioma)
PE
Collagen disease with pulmonary involvement: SLE, RA
Trauma: hemothorax, chylothorax (thoracic duct), esophagus
Abdominal
Pancreatitis (left sided effusion)
Abscess
Abdominal ascites
Meig’s
Hydronephrosis
Systemic
Hypothyroidism
Hypoalbuminemia
Nephrotic syndrome
Drugs: nitrofurantoin, dantrolene, dopamine agonists, amiodarone, quinidine, IL-2

Erythema Nodosum (see derm)

usually painful

Infectious
Post-Strep pharyngitis (ARF)
Yersinia enteritis
Chlamydia
Mycoplasma
TB
Atypical mycobacterial infection (M. lepra)
Immunodeficiency-related infection
 Endocarditis
Infectious mononucleosis
Autoimmune
Sarcoidosis (Lofgren’s)
HSP
SLE
IBD (ulcerative colitis)
Behçet’s (see below)
Drug-related
oral contraceptives / sulfonamides, bromides, gold

Note:
Female > male (5:1) mean age 31 yrs
Acute phase reactant may be elevated without correlation to underlying disease

Other (not exactly erythema nodosum)

Behçet’s, superficial thrombophlebitis, cutaneous vasculitides

Subcutaneous nodules

Infections: a jillion
Neoplasms: neuroblastoma

Onchocerciasis (parasite)

Nodules and Arthritis

RA, SLE, gout, sarcoid, sporotrichosis, MRH, type II hyperlipidemia, palmer fasciitis, CrEST

Splinter hemorrhages
Endocarditis / rheumatoid arthritis / vasculitis?

Livedo Reticularis
Atheroembolic syndrome
PAN
Type II cryoglobulinemia
APS (Snedden syndrome)

Exanthems

 See more on infectious exanthems

Petechial Rashes
Serious infections: Neisseria meningitides, RMSF, atypical measles
Other: endocarditis, DIC
Desquamation
Toxic shock syndrome, Kawasaki’s, scarlet fever, drug reactions

Hand and Foot Rash

 Secondary syphilis
Reiter’s
RMSF

Yellow Discoloration of Skin

Carotenemia
Hypothyroidism
Liver disease
Renal disease
Diabetes (rarely) [pic]

Clubbing (rated as 0 to 4+)

Pulmonary: Chronic pneumonia / pulmonary abscess / empyema

Interstitial pneumonitis / CF or other bronchiectasis
Interstitial fibrosis / pulmonary alveolar proteinosis

Cardio: cyanotic congenital heart disease / subacute bacterial endocarditis

GI: UC or Crohn’s / polyposis / biliary cirrhosis/atresia

Neoplasms, familial, thyrotoxicosis

Precocious Puberty

Central
hamartomas producing LHRH
disinhibition (radiation therapy, etc.)

upregulation of LH receptors (only affects boys since girls require LH and FSH)
HCG tumor – applies to boys (modest testicular enlargement)
McCune-Albright – deficient GS-alpha (failure to hydrolyze GTP to GDP) – produces
hyperfunction of several endocrine secretors
– more in girls than boys
CAH – precocity in boys, ambiguity in girls

Peripheral
ovarian tumor
functional ovarian cysts
adrenal tumor
oral contraceptives

Cyanosis

Peripheral cyanosis
Decreased blood flow in vasoconstricted states with high oxygen extraction
Reduced cardiac output Shock
Congestive heart failure
Cold exposure
 Peripheral arterial and/or venous disease
Central cyanosis
Arterial unsaturation due to impaired gas exchange in lungs
Hypoxia due to general hypoventilation with increased PCO, and decreased PaO2
Regional hypoventilation with respect to perfusion
Perfusion of unventilated regions of lung
Impaired diffusion
Low inspired oxygen tension
Right-to-left shunts
Intracardiac
Extracardiac
Hemoglobinopathy
False cyanosis
Argyria

Musculoskeletal

Back Pain

Trauma: injury to bone, joint, ligament

Mechanical: pregnancy, obesity, fatigue, scoliosis
Degenerative: osteoarthritis
Infectious: osteomyelitis, subarachnoid or spinal abscess, Tb, meningitis, basilar pneumonia
Metabolic: osteoporosis, osteomalacia
Vascular: leaking aortic aneurysm, subarachnoid or spinal hemorrhage/infarction
Neoplastic: myeloma, Hodgkin’s, pancreatic CA, mets from breast, prostate, lung
GI: penetrating ulcer, pancreatitis, cholelithiasis, IBD
Renal: hydronephrosis, stones, neoplasm, renal infarction, pyelonephritis
Heme: sickle cell crisis, acute hemolysis
GYN: uterine tumors, ovarian tumors, dysmenorrhea, salpingitis, uterine prolapse
Inflammatory: ankylosing spondylitis, psoriatic arthritis, Reiter’s
Lumbosacral strain
Psychogenic: malingering, hysteria, anxiety
Endocrine: adrenal hemorrhage or infarction

Breast Mass

Fibrocystic breasts
Benign tumors (fibroadenoma, papilloma)
Mastitis (acute bacterial mastitis, chronic mastitis)
Malignant neoplasm
Fat necrosis
Hematoma
Duct ectasia
Mammary adenosis

Ascites

Portal hypertension/cirrhosis
Hypoalbuminemia: nephrotic syndrome, protein losing gastroenteropathy, starvation
 Hepatic congestions: CHF, constrictive pericarditis, tricuspid insufficiency, hepatic vein
obstruction (Budd-Chiari syndrome), IVC or portal vein obstruction
Peritoneal infection: Tb and other bacteria, fungal, parasite
Neoplasm: primary vs. mets, lymphoma, leukemia, myeloid metaplasia
Lymphatic obstruction: mediastinal tumors, trauma to thoracic duct, filariasis
Ovarian disease: Meigs syndrome, struma ovarii
Chronic pancreatitis or pseudocyst
Urinary, biliary or chylous extravasation
Hypothyroidism (myxedema)

Splenomegaly

Hematologic: Hodgkin and Non-Hodgkin lymphoma, CML, CLL, hairy cell leukemia, PRV,
myelofibrosis, POEMS, WM
Infectious: psittacosis, histoplasmosis, schistosomiasis, SBE, EBV, AIDS, malaria,
leischmaniasis, splenic abscess
Others: Felty’s, malignant mastocytosis, spherocytosis, thalassemia, sarcoidosis, berylliosis,
portal hypertension, Gaucher’s, Niemann-Pick

Hepatic Cysts

Neoplasm
Cystadenoma
Cystadenocarcinoma
Squamous cell carcinoma
colon, ovary, pancreas, neuroendocrine

Non-Neoplasm
Simple cyst, ciliated foregut cyst, APKD, biloma, Caroli’s disease

Infection
Echinococcus, pyogenic abscess, actinomyces, Entamoeba histolytica

Delayed puberty – incomplete list

Central hypogonadism
25% have Kallman’s syndrome (central hypogonadism and anosmia)
Pseudo-something
Autoimmune
Turner’s

Small testes

Exogenous steroids (mild shrinkage)

Klinefelter’s (small)
Kallman’s (very small)
Certain pituitary tumors (takes years to secondarily shrink testes a lot)
 Myotonic dystrophy and non-dystonic myotonias

Hirsutism

PCOS
exogenous
Drugs: minoxidil, phenytoin, diazoxide, cyclosporin
Free testosterone increase (altered SHBG)
CAH (21, 11, 3)
prolactinemia
ovarian tumor: sertoli-leydig, granulosa-theca, hilar (Leydig), luteoma of pregnancy, cystadenoma,
Krukenberg’s
Cushing’s or other adrenal tumors
theca lutein cysts, stromal hyperplasia and hyperthecosis

Alopecia

Non-scarring
Telogen effluvium
Androgenetic alopecia
Alopecia areata
Tinea capitis
Traumatic alopecia
Drugs (usu. reversible): heparin, PTU, vitamin A, colchicines, amphetamines
Scarring
Lichen planus
Cutaneous lupus
Linear scleroderma
Chemotherapy agents: daunorubicin, others

Acanthosis nigricans [in progress; see path]

Insulin resistance
Gastric carcinoma

Failure To Thrive (FTT)

Neglect (1st)
Congenital heart disease
GI malformations – pyloric stenosis, atresia?, Hirschprung’s
Malabsorption: celiac sprue
Late presenting MSUD / familial dysautonomia
FAS
Metabolic: abetalipoproteinemia, methylmalonic aciduria,

Congenital nephrogenic diabetes

Neoplasms: neuroblastoma,

Mental Retardation (very incomplete)

 Fetal Alcohol Syndrome (FAS)
Trisomy 21 (Down’s), Fragile X,
Other Congenital:
Rett’s, DMD, NF (40-50%), tuberous sclerosis, Prader-Willi, Angelman, Velo-Cardio-
Facial, Williams, Chediak-Higashi,
Metabolic: Hurler’s, maple syrup urine, homocystinuria (variable), methylmalonic aciduria,
galactosemia, Lesch-Nyhan, mother with PKU (uncontrolled),
Infections: congenital rubella
Teratogens: phenytoin,
CNS Trauma: stroke,

Deafness (very incomplete)

Congenital disorders
Congenital infections (rubella, CMV,
Drug toxicity: aminoglycosides,

Delirium

CNS lesion
Head injury: CVA, ICH
Infection
Mass lesion: hematoma, tumor
Seizure, postictal
No lesion
Metabolic encephalopathy
Anoxia (hypoxemia, underperfusion, PE, sleep apnea, etc.)
Hepatic encephalopathy
Uremic encephalopathy
Hypo or hyperglycemia
Hypo or hyperthyroid
Hyponatremia
Hypercalcemia
Toxic encephalopathy
Drug withdrawal (alcohol, benzodiazepines, narcotics, others)
Drug toxicity (Dilantin, others)
Substance abuse
Infections causing systemic/CNS effect (usually in elderly)

Dementia (most common  Alzheimer’s, multi-infarct, depression)

Degenerative: Alzheimer’s, Huntington’s, Parkinson’s

Endocrine: thyroid, parathyroid, pituitary, adrenal
Metabolic: alcohol, electrolytes, B12, glucose, liver, renal, Wilson’s
Exogenous: heavy metals, CO, drugs
Neoplasia
Trauma: subdural hematoma
Infection: meningitis, encephalitis, abscess, endocarditis, HIV, syphilis, prion, lyme
Affective: depression
 Stroke/Structure: multi-infarct dementia, ischemia, vasculitis, normal pressure hydrocephalus

Coma

Metabolic
CVA  bilateral hemispheric or basilar to RAS

Headaches

Acute:
SAH, hemorrhagic stroke, meningitis, seizure, acutely elevated IC, hypertensive
encephalopathy, post-LP, ocular disease (glaucoma, iritis), new migraine
Subacute:
temporal arteritis, PRV, intracranial tumor, subdural hematoma, pseudotumor cerebri,
trigeminal/glossopharyngeal neuralgia, postherpetic neuralgia, hypertension
Chronic:
migraine, cluster, tension, sinusitis, dental disease, neck pain (including cervical
radiculopathy)

Seizures (incomplete)

Infection
Meningitis,
Toxins - Shigella, ETEC
Febrile – roseola

Sturge-Weber
Metabolic: porphyria (Swedish), neuronal ceroid lipofuscinosis

Electrolyte
congenital syndromes - Rett’s, Melas, FAS, tuberous sclerosis, Sturge-Weber,
metabolic - neuronal ceroid lipofuscinosis

chronic pancreatitis (late)

Ataxia

Vertebral-basilar ischemia / lateral medullary syndrome of Wallenberg

Diabetic neuropathy
Tabes dorsalis
Nurtritional: Wernicke’s ataxia, B12 deficiency
MS and other demyelinating
Meningomyelopathy (e.g. s/p meningitis)
Cerebellar neoplasm (neuroblastomas), hemorrhage, abscess, infarct
Paraneoplastic
Parainfectious: Guillain-Barré syndrome, acute ataxia of childhood and young adults
Toxins: phenytoin, alcohol, sedatives, organophosphates, lead
Wilson’s disease (hepatolenticular degeneration)
Hypothyroidism
Myopathy
 Cerebellar and spinocerebellar degeneration
Congenital: spinocerebellar ataxia type 1, acute cerebellar ataxia, ataxia-telangiectasia,
Friedreich’s ataxia
Metabolic: Abetalipoproteinemia, Hartnup’s
Frontal lobe lesions: tumors, thrombosis of anterior cerebral artery, hydrocephalus (and NPH)
Labyrinthine destruction: neoplasm, injury, inflammation, compression
Hysteria
AIDS

Asterixis
Liver and/or Kidney dysfunction
Drugs: tegretol

Amnesia
Degenerative (e.g. Alzheimer’s, Hungtington’s)
CVA (esp. thalamus, basal forebrain, hippocampus)
Trauma, post-surgical
Infection (HSV, meningitis)
Wernicke-Korsakoff syndrome
Brain anoxia
Hypoglycemia
CNS neoplasm
Creutzfeldt-Jakob disease
Medications (midazolam and other BZ’s)
Psychosis
Malingering

Anisocoria

Mydriatic or miotic drugs

Prosthetic eye
Inflammation (keratitis, iridocyclitis)
Infection (HSV, meningitis, encephalitis, Tb, diptheria, botulism)
Subdural hemorrhage
Cavernous sinus thrombosis
Intracranial neoplasm
Cerebral aneurysm
Glaucoma
CNS degenerative
Internal carotid ischemia
Toxic polyneuritis (alcohol, lead)
Adie’s syndrome
Horner’s syndrome
DM
Trauma, congenital

Mononeuritis Multiplex
Diabetes mellitus
Infectious: HIV, lyme, leprosy
 Vasculitis: SLE, Sjogren’s
Paraneoplastic: leukemia, lymphoma (rare), Castleman’s disease, angioimmunoblastic
lymphadenopathy with dysproteinemia, plasma-cell dyscrasia, monoclonal gammopathy of
undetermined significance
Amyloidosis
Sarcoidosis
Cryoglobulinemia (HCV)
Hereditary susceptibility to pressure palsies

Epistaxis

Trauma
Nose-picking
Foreign body
URI
Nasal Polyps
Antihistamine Xs
Telangiectasia
Blood dyscrasias
Pertussis

Congestive Heart Failure (Acute)

Myocardial infarction
Pulmonary embolism
Infection
Anemia
Thyrotoxicosis / pregnancy
Arrhythmias / rheumatic, other myocarditis
Infective endocarditis
Physical, dietary, fluid, environmental and emotional
Systemic hypertension

Syncope [NEJM]

Yield of H&P (45%)

Causes: vasovagal (20%), arrhythmias (15%), neurologic disease (10%), unknown (30%)

 Focus on cardiac abnormalities / get BP in both arms!

Get ECG 1st (5% yield, but very important) / if positive, echo/stress may follow / a random
echo detects unsuspected abnormalities in 5-10% / Holter monitor sensitivity is 20% @24 hrs,
some say 40% @48 hrs / continuous-loop event monitoring (will catch ~10% of undiagnosed
recurrent syncope / EP studies are okay for tachycardias but are low S/S for bradycardias
 Chemistries et al are very low yield (2%) unless indicated (can suggest seizures)
 CT head (4% yield), EEG (2% yield), transcranial dopplers only if suggested
 Hospitalization  anything suggesting cardiac causes, severe orthostasis, drug-reaction
 Treatment B-blockers?, pacemakers?, other specific treatments

Cardiac output
 Neurocardiogenic
- may have clonic jerks of face, limbs appearing seizure-like
- usu. have prodrome allowing patient to sit down rather than suddenly drop
Vasovagal or (true cardiac response) (18%)
parasympathetic response to undue cardiac distension or strenuous contractions
Situational (5%)
young people  stress, fear, pain
elderly  postprandial, often follows meals with alcohol
Carotid sinus hypersensitivity (1%)
leads to bradycardia and hypotension, diagnosis of exclusion (unless you can
induce it with carotid massage, which has a 0.3% risk of inducing CVA)
Cough/Micturition syncope
valsalva or straining (that promotes parasympathetic tone and decreases venous
return via pressurizing SVC/IVC; thus decreasing cardiac output)

Arrhythmias: VT/SVT, prolonged QT interval, heart block/conduction defect

Left ventricular outflow obstruction

Valvular aortic stenosis
Supravalvular aortic stenosis
Discrete subvalvular aortic stenosis
Obstructive cardiomyopathy (HOCM)
Tetralogy of Fallot (TOF)

Other cardiac: atrial myxoma, massive MI, restrictive/constrictive myocardial (amyloid), or

pericardial disease (tamponade)

Orthostatic hypotension (see hypotension) (8% overall; 30% in elderly population)

 Drug (medication-induced, peripheral neuropathy (DM, alcohol, nutritional,
amyloid, idiopathic, Shy-Drager, deconditioning, sympathectomy, Guillain-Barré),
hypovolemia (adrenal insufficiency, blood loss, etc)

Test  patient sits for 5 minutes, then stands for 3 minutes / Chemical Tilt Tests
approach 90% specificity
Metabolic
Hypoglycemia
Hypoxia (including PE, pulmonary HTN)
Hyperventilation
Neurologic (10%)
Seizures
atonic seizures or ictal bradycardic (rare)
Note: some spasms may occur resulting from CNS hypoperfusion (so
hypotension
appears like a true seizure)
CVA/TIA: focal cerebral ischemia to RAS / random carotid U/S is very low yield
Subarachnoid hemorrhage
Basilar artery migraine – rare but true
Arnold-Chiari malformation
Narcolepsy
 Glossopharyngeal neuralgia
Tumor
Colloid cyst of 3rd ventricle
Other Vascular
Subclavian steal syndrome
Aortic Dissection - always check BP in both arms!!
Vasculitis
Psychiatric, factitious (uncommon) (2%)

Vertigo [see neuro]

Lasting ( > 24 hrs): vestibular neuritis, brainstem stroke, multiple sclerosis

Hours or minutes: Meniere’s, TIA, migraine, seizures (rarely), perilymph fistula
Seconds: BPPV

Hypotension

Nonneurogenic causes
Cardiac pump failure: MI, constrictive pericarditis, aortic stenosis, tachy/bradyarrhythmias
Hypovolemia: straining on urination/defecation, dehydration, diarrhea, hemorrhage, burns, salt-
losing nephropathy (hyponatremia), Addison's (cortisol and aldosterone), diabetes insipidus
Venous pooling: alcohol, postprandiol dilation of splanchnic vessels (morphine?), vigorous
exercise with dilation of skeletal vessel beds, heat, fever, prolonged recumbency of standing,
sepsis
Drugs: antihypertensives, diuretics, vasodilators (nitrates/hydralazine), alpha/beta blockers, CNS
sedatives (barbiturates, opiates), TCA’s, phenothiazines

Physical deconditioning
Pheochromocytoma?
Idiopathic

Neurogenic causes
Primary ANS
Multisystem atrophy (?Bradbury-Eggelston, Shy-Drager syndrome)
Pure ANS failure
Subacute dysautonomia
Secondary ANS
Brain and brainstem: tumor, stroke, multiple sclerosis, post-sympathectomy
Spinal cord: transverse myelitis, syringomyelia, tumor, tabes dorsalis
Peripheral nervous system
diabetes, Guillain-Barré, alcoholic polyneuropathy (Wernicke), HIV, Amyloidosis,
porphyria

Hypertension
Essential
Pre-eclampsia
Pheochromocytoma
Renal artery stenosis (aldosteronemia)
Rheumatoid Factor
RA (80%)
Sjogren’s (50–80%)
SLE (50%)
PSS (15-20%)
Polymyositis (15-20%)
Arteritis (15-20%)
Endocarditis, TB, other chronic infections (fungal)
Chronic liver disease and/or cryoglobulins
Drug abuse (IV)
Aging

Hyperviscocity

PRV (very common)

POEMS syndrome
WM (50%)
MM (< 5%, even with cryoglobulinemia)

Hyperviscocity absent: CML, AMMM, CML, Hodgkin’s, Heavy-chain diseases, amyloidosis

Lymphocytosis

Pertussis
infectious lymphocytosis
CMV
EBV
Tuberculosis
Toxoplasmosis
chronic inflammatory disorders
autoimmune syndromes

Abnormal Hemostasis

Thrombocytopenia
Malignancy
Decreased clotting factors
DIC
autoimmune (anti-VIII)
congenital (hereditary hemorrhagic telangiectasia, vWD)
Uremia
Medications: coumadin, ASA, plavix

Hypercoagulability

Risk Factors: sedentary, post-operative, OCP/estrogens, pregnancy

Acquired:
malignancy (Trousseau’s) – mostly venous
myeloproliferative – arterial/venous
 PNH
connective (SLE)
Behçet’s
Buerger’s Vasculitis – arterial/venous
Polycythemia Vera
Primary Thrombocythemia
TTP – arterial and venous
DIC
DM (nephrotic syndrome)
CHF (stasis?)

Congenital
APA syndrome – arterial/venous
APC resistance (Factor V Leiden)
Protein C deficiency / Protein S deficiency
Antithrombin deficiency
Dysfibrinogenemia
Hyperhomocystinuria - arterial
Prothrombin G20210A

Anemia (see work-up)

Drugs: AZT, quinidine, chloramphenicol, methyldopa, benzene, cancer drugs

Blood loss: menstruation, GI/GU bleeds
Hemolytic anemia
Deficiency: Iron, Folic acid
Infection: sepsis, AIDS, malaria
Chronic: cancer, ESRD, endocrine
Genetic: Thalassemia, sickle cell, many others

Hemolytic anemia (see other)

mechanical
artificial valves, DIC, TTP
autoimmune
warm – drug-induced
cold agglutinin syndrome - Mycoplasma pneumoniae and (rarely) EBV
paroxysmal cold hemoglobinuria - anti-P antigen
alloimmune - erythroblastosis fetalis / transfusion rxn

Thrombocytopenia (see thrombocytosis)

For just bleeding, consider other causes of abnormal hemostasis

Inpatient = *

Pregnancy
Decreased production
 Myelodysplasia (myelofibrosis, malignancy)
Chemicals, alcohol, drugs, radiation, viruses
Decreased survival
Hypersplenism
ITP
APS/SLE*
Lymphoma
Infection: HIV
Cavernous hemangioma
DIC/Sepsis*
TTP*
HUS
Post-transfusion purpura* (rare, 5-10 days after, multigravida women)
Drug-induced thrombocytopenia
Alcohol (shortens lifespan)
Medications: quinidine, quinine, sulfonamide, B-lactams, thiazides, gold, heparin (HIT)

Cardiac disease
HIT
Use of IIb/IIIa antagonists
Adenosine diphosphate antagonists
CABG
Intra-aortic balloon pump

Eosinophilia

AEC > 500-750

Neoplasm
Allergy
Adrenal insufficiency
Connective tissue disease
Parasite infection or Pancreatitis
Other: atheroembolic vasculitis, IBD, sarcoidosis, TB, parasitic infection

Cervical lymphadenopathy

cat Scratch,
Cyclic Neutropenia
HIV
Many others

Dysphagia

Solids – carcinoma, esophageal web or ring, dysphagia lusoria (anomalous blood vessel)
Liquids/solids – scleroderma, achalasia, diffuse esophageal spasm
Transfer dysphagia – neuromuscular disorder (many including polymyositis)

Odynophagia
Motor disorders – (achalasia, spasm)
Mucosal disruption
Chemical ingestion
Peptic esophagitis
Infectious esophagitis (HIV, candida, HSV, CMV, MAI)
Drug-induced esophagitis – KCl, tetracycline, clindamycin, quinidine, Fe supplements, ascorbic
acid)
Radiation esophagitis

Postmenopausal bleeding

Exogenous estrogens (30%)

Atrophic vaginitis/endometritis (30%)
Endometrial cancer (15%)
Endometrial or cervical polyps (10%)
Endometrial hyperplasia (5%)
Other: cervical CA, uterine sarcoma, urethral carbuncle, trauma (10%)

Amenorrhea (see other)

Primary: Turner’s, gonadal dysgenesis, 17-alpha-hydroxylase deficiency

Ovarian: pregnancy, PCO, ovarian failure
gonadal stromal tumors
Pituitary/Central Axis
hyper/hypothyroid, stress, anorexia, neoplasm, post-partum hemorrhage, surgery, XRT
prolactinemia: idiopathic, drugs (D2 blockers),
Uterovaginal: congential (imperforate hymen, imperforate cervix, imperforate or absent vagina,
mullerian agenesis), acquired (destruction of endometrium with curettage (Ascherman’s), trauma,
hysterectomy
Other: metabolic (liver, kidney), malnutrition, rapid weight loss, obesity, endocrine (Cushing’s,
Graves’, hypothyroidism)

Work-up: UPT / prolactin, TSH / Progestin challenge then Estrogen/Progestin challenge / FSH /
MRI
Note: no such thing as post-pill amenorrhea (you must work it up, you can’t blow it off)

Primary Amenorrhea

Gonadal causes
Gonadal dysgenesis (Turner's syndrome)
Testicular feminization syndrome
Resistant ovary syndrome
Extragonadal causes
Hypopituitarism
Hypogonadotropic hypogonadism
Delayed menarche
Congenital adrenal hyperplasia
Abnormalities of the uterus or vagina

Secondary Amenorrhea
 Pregnancy
Menopause
Uterine causes
Intrauterine synechiae (Ascherman’s syndrome)
Hysterectomy
Hypothalamic-pituitary causes (45%)
Hypopituitarism
Hypothalamic (psychogenic) amenorrhea
Exercise, stress, nutrition/malnutrition, chronic illness
Discontinuation of oral contraceptives
Infiltrative: craniopharyngioma, sarcoidosis, histiocytosis
Empty sella syndrome, Sheehan syndrome
Ovarian causes
Primary ovarian failure (premature menopause)
Oophorectomy
Radiotherapy, chemotherapy
Estrogen excess
Ovarian tumors
Prolactin excess
Pituitary tumors (18%)
Thyroid disease (hypothyroid)
Androgen excess
Polycystic ovary syndrome (PCOS) (30%)
Overproduction of adrenal androgen (adrenal hyperplasia)
Ovarian tumors

Oligomenorrhea

Definition: menses at infrequent intervals > 40 days or < 9/yr

Many of same as above

Hypoglycemia

Diabetes
Pancreatitis

Hemolysis

Cold agglutinins
PRV

Hypertension

Renal
Glomerulonephritis
Pyelonephritis
Parenchymal (cystic, etc.)
Obstructive uropathy
Nephrotic syndrome
 Renal tumor
Renal failure
Renal trauma
Neurologic
Increased ICP
Hemorrhage
Brain injury
Familial dysautonomia
Drugs and toxins
Oral contraceptives
Corticosteroids
Cyclosporin
Cocaine
Endocrine
Congenital adrenal hyperplasia
Cushing syndrome
Hyperthyroidism
Pheochromocytoma
Hyperparathyroidism (how?)
Hyperaldosteronism
SIADH
Vascular
Coarctation of the aorta
Renal vein thrombosis
Renal artery stenosis
Large AV fistula
Infective endocarditis
Vasculitis
Other
Chronic upper airway obstruction
Preeclampsia
Neurofibromatosis
Hypercalcemia
Malignant hyperthermia
Hypernatremia
Acute intermittent porphyria
Drugs
Both medical and illicit (cocaine, etc.)
Pain, anxiety
Essential hypertension

Abdominal Pain Differential (work-up)

Diffuse or Any Quadrant

Early appendicitis
Aortic aneurysm
Gastroenteritis
Diverticulitis
 Peritonitis
Adhesions
Small bowel obstruction
Large bowel obstruction (intussusception, volvulus, tumor)
Mesenteric insufficiency or infarction
Pancreatitis
IBD
Irritable bowel
Mesenteric adenitis
Metabolic: toxins, lead poisoning, uremia, drug overdose, DKA, heavy metal poisoning
Sickle cell crisis
Pneumonia (rare)
Trauma
UTI, PID
Other: acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, HSP, adrenal insufficiency,
MI (can present w/ abdominal pain)

Epigastric

Gastric: PUD, gastric outlet obstruction, gastric ulcer

Duodenal: PUD, duodenitis
Biliary: cholecystitis, cholangitis
Hepatitis
Pancreatitis
SBO, early appendicitis
Cardiovascular: angina, MI, pericarditis, aortic dissection
Pneumonia, pleurisy, pneumothorax
Supraphrenic abscess

Suprapubic

Colon: obstruction or gangrene, diverticulitis, appendicitis

Reproductive: ectopic pregnancy, Mettelschmerz, torsion of ovary or ovarian cyst, PID,
salpingitis, endometriosis, rupture of endometrioma
Cystitis, rupture of bladder

Periumbilical

Intestinal: SBO, gangrene, early appendicitis

Mesenteric thrombosis, aortic dissection
Pancreatitis
Uremia, DKA

RUQ

Gastric: PUD/DUD, alcoholic gastritis, neoplasm, pyloric stenosis, hiatal hernia

Biliary: gall stones, cholecystitis, cholangitis, neoplasm
Hepatic: hepatitis, abscess, hepatic congestion, neoplasm (e.g. HCC), trauma
Intestine: diverticulosis, retrocecal appendicitis, intestinal obstruction, high fecal impaction,
perforation
 HELLP (via capsular distention)
Pancreas: pancreatitis, neoplasm, stone in ampulla
Renal: stones, infection, inflammation (e.g. pyelonephritis), neoplasm, rupture of kidney
Pulmonary: pneumonia, pulmonary infarction, pleurisy
Cardiac: inferior MI, pericarditis
Other: cutaneous herpes zoster, trauma, Fitz-Hugh-Curtis syndrome (perihepatitis)

LUQ

Same as RUQ plus:

Splenic: splenomegaly, splenic infarction, ruptured spleen, splenic abscess

RLQ

Intestinal: acute appendicitis, regional enteritis, incarcerated hernia, diverticulitis, small or large
bowel obstruction, perforation of ulcer/intestine, Meckel’s diverticulitis
Reproductive: ectopic pregnancy, Mettelschmerz, torsion of ovary or ovarian cyst, ovarian tumor,
PID, TOA, salpingitis, endometriosis, rupture of endometrioma, seminal vasculitis
Renal (as above), aortic dissection, biliary/hepatic (can be lower quadrant)
Psoas abscess

LLQ

Same as RLQ (including appendicitis if appendix on wrong side)

Abdominal Distention

Excessive gas
Intraabdominal infection
Extraabdominal infection (sepsis, pneumonia, empyema, osteomyelitis of spine)
Trauma
Retroperitoneal irritation (renal colic, neoplasm, infection)
Vascular insufficiency (thrombosis, embolism)
Metabolic/toxic (hypokalemia, uremia, lead poisoning)
Chemical irritation (perforated ulcer, bile, pancreatitis)
Peritoneal inflammation
Severe pain, pain medication

Mechanical Obstruction

Neoplasm (intraluminal, extraluminal)

Adhesions
Endometriosis
Infection (intraabdominal abscess, diverticulitis)
Gallstones
Foreign body, bezoar
Pregnancy
Hernia
Volvulus
 Stenosis at surgical anastomosis, radiation stenosis
Fecaliths
IBD
Hematoma
Other: parasite, SMA syndrome, pneumatosis intestinalis, annular pancreas, Hirschprung’s,
intussusception, meconium

GI Bleeding [NEJM]

Upper GI Bleeding
PUD/DUD
Gastroesophageal varices

Lower GI Bleeding
Diverticulosis
AV Malformation

Work-up
Rectal – brisk upper GI bleed is cathartic, should see melena, hematochezia
NG lavage
Barium swallow?
EGD
tagged RBC scan (requires 0.1 cc/min)
SMA angiogram (requires 1 cc/min)
colonoscopy

Treatment for Variceal (see other)

Treatment for Non-Variceal [2003 consensus]

2 large bore IV’s

aggressive fluid and blood products
consider NG lavage
consider early (< 24 hrs endoscopy)
IV pantoprazole 80 mg bolus then 8 mg/hr
No proven benefit of octreotide or somatostatin in non-variceal bleeds although may
consider for persistent bleeding if endoscopy unavailable
consider testing and treatment for H. pylori after resolution of acute illness

Vomiting

Gastroenteritis
Gastritis/gastric ulcer
Motion sickness
Gastroparesis (see below)
Gastric outlet obstruction
Small bowel obstruction (usually above mid-jejunum)
Systemic illness (high fever/severe pain)
Peritonitis
pregnancy (including hyperemesis gravidarum or acute fatty liver of pregnancy)
 Drugs or toxins (including chemotherapy)
Increased intracranial pressure
CVA (cerebellar)
Psychogenic vomiting/eating disorder

Delayed Gastric Emptying

Post-vagotomy, DM, viral, GERD, brainstem lesions, anorexia, tachygastria

Rapid Gastric Emptying

Dumping syndrome, pancreatic insufficiency, celiac sprue, ZES, duodenal ulcer

Diarrhea

Viral: Rotavirus, Norwalk, Adenovirus, Astrovirus, Coronavirus, Coxsackievirus, Hepatitis A,

CMV, Primary HIV
Bacterial: SSYC, E.coli, C. difficile, Whipple’s, Legionella, Mycoplasma, Neisseria,
Cryptosporidium, Isosporidium, MAI, primary intestinal Tb
Toxins: Vibrio, E. coli, Campylobacter, Yersinia, Klebsiella, C. difficile, C. perfringens, C.
botulinum, B. cereus, TSST
Fungal: histoplasmosis
Parasites: all of them. Bastards! (e.g. Giardia, Entamoeba)
Food poisoning: S. aureus, B. Cereus, Listeria, etc.
Ciguatoxin (dinoflagellates eaten by fish  CNS + GI toxin)
Scomboid (histamines in overripe fish)
Exogenous: laxatives, drugs, toxic chemicals
Other: IBD, celiac, bacterial overgrowth, mesenteric ischemia, allergy, anaphylaxis, Behçet’s,
Churg-Strauss, idiopathic inflammation, chronic radiation enterocolitis, short bowel syndrome
(fatty acid and/or bile salt malabsorption), carbohydrate malabsorption (sorbitol, fructose), GVHD
(dermatitis, hepatic cholestasis, enteritis), alcoholic diarrhea (acute/chronic)

Secretory

Laxatives (many different kinds)

Meds/drugs
Diuretics, caffeine, theophylline, cholinergic drugs (eye drops, bladder
stimulants), cholinesterase inhibitors, quinidine/quinine, colchicine, ACE
inhibitors, H2 blockers, SSRI’s, prostaglandins, others
Toxins (see bacteria)
Metals, mushrooms, organophosphates, seafood toxins, MSG
Hormone-producing tumors
Vipoma and ganlioneuromas
Medullary carcinoma of thyroid (calcitonin and prostaglandins)
Mastocytosis (histamine)
Villous adenoma (prostaglandins)

Increased or uncoordinated motility

Irritable bowel syndrome, infectious, hyperthyroidism, carcinoid, scleroderma (early), too

many carbs, DM, Shy-Drager syndrome*, mass lesion of brain stem*, carcinoma-
 associated visceral neuropathy, amyloidosis (local neuropathy), idiopathic primary visceral
neuropathy / *may respond to clonidine

Hospital Acquired Diarrhea

C. diff (20% of nosocomial infections overall), EHEC

Meds: colchicine, cholestyramine, antibiotics
Chemotherapy or XRT / Rx: loperamide and NSAIDs
Immunosuppressed (more susceptible to nosocomial viral diarrhea)
Fecal impaction
Liquid formulations (of any med) (typical patient on NG meds may get 20 g sorbitol/day)
Enteral feeding (unclear reasons)
Physiology Points that people forget
Cortisol has pressor effects on vasculature too!
Steroids reduce Ca absorption from GI tract