| Note: Large images and tables on this page may necessitate printing in landscape mode. Copyright 2007 The McGraw-Hill Companies. All rights reserved. Clinician's Pocket Reference > Chapter 3. Differential Diagnosis: Symptoms, Signs, and Conditions > Differential Diagnosis: Symptoms, Signs, and Conditions: Introduction This chapter is a general guide to commonly encountered symptoms and conditions and their frequent causes primarily in adults unless specified. Remember: "There are more uncommon presentations of common diseases than common presentations of uncommon diseases." |
Abdominal Distention Ascites, intestinal obstruction, cysts (ovarian or renal), tumors, hepatosplenomegaly, aortic aneurysm, uterine enlargement (pregnancy), bladder distention, inflammatory mass |
Abdominal Pain Diffuse: Intestinal angina, early appendicitis, colitis, diabetic ketoacidosis, hereditary angioedema, gastroenteritis, mesenteric thrombosis, mesenteric lymphadenitis, peritonitis, porphyria, sickle cell crisis, uremia, renal colic, renal infarct, pancreatitis Right Upper Quadrant: Dissecting aneurysm, gallbladder disease (cholecystitis, cholangitis, choledocholithiasis), hepatitis, hepatomegaly, pancreatitis, PUD, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarct, appendicitis (retroperitoneal) Left Upper Quadrant: Dissecting aneurysm, esophagitis, hiatal hernia, esophageal rupture, gastritis, pancreatitis, PUD, myocardial infarction, pericarditis, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarction, splenic abscess, splenic rupture, splenic infarction Lower Abdomen: Aortic aneurysm, colitis including inflammatory bowel disease, diverticulitis including Meckel diverticulum, intestinal obstruction, hernia, perforated viscus, pregnancy, ectopic pregnancy, dysmenorrhea, endometriosis, mittelschmerz (ovulation), ovarian cyst or tumor (especially with torsion), PID, renal colic, UTI, rectal hematoma, bladder distention Right Lower Quadrant: Appendicitis, ectopic pregnancy, ovarian cyst or tumor, salpingitis, mittelschmerz, cholecystitis, perforated duodenal ulcer, Crohn disease |
Adrenal Mass Adrenal adenoma, adrenal hyperplasia (unilateral or bilateral), adrenal metastasis (solid tumors, lymphoma, leukemia), adrenocortical carcinoma, pheochromocytoma, adrenal myelolipoma, adrenal cyst, adrenal varices, hemorrhage, congenital adrenal hyperplasia, ganglioneuroma, micronodular adrenal disease |
Alopecia Male pattern baldness (alopecia, androgenic type in both men and women), trauma and hair pulling, congenital, tinea capitis, bacterial folliculitis, telogen arrest, anagen arrest (chemotherapy, radiation therapy), alopecia areata, discoid lupus |
Amenorrhea Pregnancy, menopause (physiologic or premature), severe illness, weight loss, stress, excessive athletic training, physiologically delayed puberty, anatomic anomaly (eg, imperforate hymen, uterine agenesis, etc), gonadal dysgenesis (eg, Turner syndrome), hypothalamic and pituitary tumors, virilizing syndromes (eg, polycystic ovaries, idiopathic hirsutism). Amenorrhea is categorized as primary (never had menses) or secondary (cessation of menses). |
Anorexia Hepatitis, carcinoma (most types, especially advanced), anorexia nervosa, generalized debilitating diseases, digitalis toxicity, uremia, depression, CHF, pulmonary failure, radiation exposure, chemotherapy |
Anuria (See Oliguria and Anuria). |
Arthritis Osteoarthritis, bursitis, tendonitis, connective tissue disease (rheumatoid arthritis, SLE, rheumatic fever, scleroderma, gout, pseudogout, rheumatoid variants [ankylosing spondylitis, psoriatic arthritis, Reiter syndrome]), infection (bacterial, viral, TB, fungal Lyme disease), trauma, sarcoidosis, sickle cell anemia, hemochromatosis, amyloidosis, coagulopathy |
Ascites (See Chapter 13, Peritoneal [Abdominal] Paracentesis for more details.) Use the serum albumin to ascitic albumin difference (serum albumin minus ascites albumin) to help differentiate the cause of ascites. If the difference is > 1.1, portal hypertension is present. If the difference is < 1.1, the cause is not portal hypertension). CHF, tricuspid insufficiency, constrictive pericarditis, venous occlusion (including Budd Chiari syndrome), cirrhosis, pancreatitis, peritonitis (ruptured viscus, TB, bile leak, spontaneous bacterial), tumor (most common ovarian, gastric, uterine, unknown primary, breast, lymphoma), trauma, Meigs syndrome (ovarian fibroma associated with hydrothorax and ascites), myxedema, anasarca (hypoalbuminemia) |
Back Pain Herniated disk, spinal stenosis, ankylosing spondylitis, metastatic tumor, multiple myeloma, mechanical back sprain, vertebral body fracture, osteoporosis-induced fracture, infectious processes (diskitis, osteomyelitis, epidural abscess), referred pain (visceral, vascular) including pyelonephritis, colitis and diverticulitis, cancer, endometriosis, abdominal aortic aneurysm, and psychiatric disorder such as malingering, substance abuse, or depression |
Breast Lump Cancer, fibroadenoma, fibrocystic breast disease, fat necrosis, gynecomastia (male patients, alcoholic patients) |
Chest Pain Deep, Dull, Poorly Localized: Angina, variant angina, unstable angina, AMI, aortic aneurysm, pulmonary embolus, tumor, gallbladder disease, pulmonary HTN Sharp, Well Localized: Pulmonary embolus, pneumothorax, pleurodynia, pericarditis, atypical MI, hyperventilation, hiatal hernia, esophagitis, esophageal spasm, herpes zoster (pain may precede rash by 2 3 d), aortic aneurysm, breast lesions, various bony and soft-tissue abnormalities (rib fractures, costochondritis, muscle damage), perforated ulcer, acute cholecystitis, pancreatitis |
Chills Infection (bacterial with bacteremia, viral, TB, fungal, malaria), neoplasm (Hodgkin disease), drug and transfusion reactions, hypothermia |
Clubbing Pulmonary causes (bronchiectasis, lung abscesses, tuberculosis, neoplasms, fibrosis), AV malformations, cardiac conditions (congenital cyanotic heart diseases, bacterial endocarditis), GI causes (ulcerative and regional enteritis, cirrhosis), hereditary conditions, thyrotoxicosis |
Coma Use the mnemonic AEIOU TIPS: Alcohol, Encephalitis (other CNS causes such as epilepsy, hemorrhage, mass), Insulin (hypoglycemia, hyperglycemia), Opiates (drugs), Uremia (and other metabolic conditions, eg, hypernatremia, hyponatremia, hypercalcemia, hepatic failure, and thiamine deficiency), Trauma, Infection (sepsis), Psychiatric causes (catatonia, psychogenic), Syncope (or decreased cardiac output, eg, from arrhythmia or aortic stenosis). |
Constipation Dehydration, lack of exercise, bedrest, medications (narcotics, anticholinergics, antidepressants, calcium channel blockers such as verapamil, diuretics, clonidine, aluminum- or calcium-containing antacids, 5-HT3-receptor antagonists), laxative abuse, megacolon, spastic colon, chronic suppression of the urge to defecate, fecal impaction (often with paradoxical diarrhea), neoplasm, intestinal obstruction, vascular occlusion of the bowel, inflammatory lesions (diverticulitis, proctitis), hemorrhoids, anal fissures, neurologic disorders (spinal cord lesions or trauma, autonomic insufficiency), depression, diabetes mellitus, porphyria, hypothyroidism, hypercalcemia, hypokalemia, hypomagnesemia |
Cough Acute: Tracheobronchitis, pneumonia, sinusitis, pulmonary edema, foreign body, toxic inhalation, allergy, pharyngitis (viral or bacterial), asthma, GERD, ACE inhibitors, impacted cerumen or foreign body in ear Chronic: Bronchitis (smoker), chronic sinusitis, emphysema, cancer (bronchogenic, head and neck, esophageal), TB, interstitial lung disease including sarcoidosis, fungal infection, bronchiectasis, mediastinal lymphadenopathy, thoracic aneurysm, GERD, ACE inhibitors |
Cyanosis Peripheral: Arterial occlusion and insufficiency, vasospasm and Raynaud disease, venous stasis, venous obstruction Central: Hypoxia, congenital heart disease (right to left shunt), pulmonary embolus, pseudocyanosis (eg, polycythemia vera), methemoglobinemia |
Delirium Metabolic: Hypoglycemia, hypoxia, hyponatremia, hypernatremia, hypercalcemia, hypercarbia, uremia, hyperthyroidism Neurologic: Stroke, subdural and epidural hematoma, subarachnoid hemorrhage, postictal state, concussion and contusion, meningitis, encephalitis, brain tumor Drug- or Toxin-Induced: Lithium intoxication, ethanol, steroids, anticholinergics, sympathomimetics, poisons (eg, mushrooms, carbon monoxide), drugs of abuse including ecstasy (MMDA), gamma hydroxybutyrate (GHB), lysergic acid diethylamide (LSD), phencyclidine (PCP), mescaline Other: Sepsis, thiamine deficiency, niacin deficiency |
Dementia Chronic CNS Disease: Alzheimer disease, senile dementia, Pick disease, Parkinson disease, chronic demyelinating disease (MS), ALS, brain tumor, normal pressure hydrocephalus, Wilson disease, Huntington disease, lipid storage diseases (eg, Tay Sachs) Metabolic: Usually chronic (hypoxia, hypoglycemia, hypocalcemia), hyperammonemia, dialysis, heavy-metal intoxication, pernicious anemia (B12 deficiency), niacin and thiamine deficiency (usually chronic alcoholic), post hepatic coma, medications (barbiturates, phenothiazines, lithium, benzodiazepines, many others) Infectious: AIDS encephalopathy, brain abscess, chronic meningoencephalitis (eg, fungal, neurosyphilis), encephalitis, Jakob Creutzfeldt disease Vascular: Vasculitis, multiple cerebral or cerebellar infarcts Traumatic: Contusion, hemorrhage, subdural hematoma Psychiatric: Sensory deprivation, depression (pseudodementia) |
Diarrhea Acute: Infection (bacterial, viral, fungal, protozoan, parasitic), toxic (food poisoning, chemical), drugs (antibiotics, cholinergic agents, lactulose, magnesium-containing antacids, quinidine, reserpine, guanethidine, metoclopramide, bethanechol, SSRIs, metformin, acarbose, orlistat), appendicitis, diverticular disease, GI bleeding, ischemic colitis, food intolerance, fecal impaction (paradoxical diarrhea), pseudomembranous colitis Chronic: Postoperative state (gastrectomy, vagotomy, extensive bowel resection, resection of ileocecal valve), Zollinger Ellison syndrome, regional enteritis, ulcerative colitis, malabsorption, diverticular disease, carcinoma, villous adenoma, gastrinoma, lymphoma of the bowel, functional bowel disorder (irritable colon, mucous colitis), pseudomembranous colitis, endocrine disease (carcinoid, hyperthyroidism, Addison disease), radiation enteritis, drugs, Whipple disease, amyloidosis, AIDS (Isospora belli, Microsporidia, and Cyclospora are three parasites that can cause diarrhea in HIV patients. Nonparasitic causes include Salmonella typhimurium, Campylobacter jejuni, Mycobacterium avium-intracellulare, and cytomegalovirus and idiopathic factors.) |
Diplopia Problems with the third, fourth, or sixth cranial nerve, eg, from vascular disturbances, meningitis, tumor, demyelination, orbital blow-out fracture, hyperthyroidism, ocular myopathy |
Dizziness Hyperventilation, depression, hypoglycemia, anemia, volume depletion, hypoxia, trauma, M ni re disease, benign positional vertigo, aminoglycoside toxicity, vestibular neuronitis, MS, brainstem ischemia or stroke, posterior fossa lesions, cerebellar ischemia or stroke, autonomic insufficiency, arrhythmia, aortic stenosis, carotid sinus hypersensitivity, postural tachycardia, subclavian steal, vasovagal reaction, medications including vasodilators, benzodiazepines, and anticonvulsants |
Dysphagia Loss of tongue function, pharyngeal dysfunction (myasthenia gravis), Zenker diverticulum, tumors (bronchogenic, head and neck, and esophageal), stricture, esophageal web, Schatzki ring, lower esophageal sphincter spasm, foreign body, aortic aneurysm, achalasia, scleroderma, diabetic neuropathy, amyloidosis, infection (especially candidiasis), dermatomyositis, polymyositis, MS, brainstem infarction |
Dyspnea Laryngeal and tracheal infections and foreign bodies, tumors (both intrinsic and extrinsic), COPD, asthma, pneumonia, aspiration, interstitial lung disease, lung carcinoma, atelectasis, pneumothorax, pleural effusion, hemothorax, pulmonary embolus, pulmonary infarction, carbon monoxide poisoning, any cause of pain from respiratory movements, cardiac and noncardiac pulmonary edema, acute coronary syndrome, arrhythmia, aortic stenosis, aortic insufficiency, mitral stenosis, mitral insufficiency, pericardial tamponade, anemia, abdominal distention, myopathies, neuropathies, spinal cord disorders, phrenic nerve and diaphragmatic disorders, GERD, deconditioning, anxiety |
Dysuria Urethral stricture, stones, blood clot, tumor (bladder, prostate, urethral), prostatic enlargement, infection (urethritis, cystitis, vaginitis, prostatitis), atrophic vaginitis, trauma, bladder spasm, dehydration, urethral syndrome or interstitial cystitis |
Earache Otitis media and externa, mastoiditis, serous otitis, otic barotrauma, foreign body, impacted cerumen, referred pain (dental or TMJ) |
Edema CHF, constrictive pericarditis, liver disease (cirrhosis), nephrotic syndrome, nephritic syndrome, hypoalbuminemia, malnutrition, myxedema, hemiplegia, volume overload, thrombophlebitis, lymphatic obstruction, medications (nifedipine), venous stasis |
Epistaxis Trauma (nose picking, blunt trauma), neoplasm, polyps, foreign body, desiccation, coagulopathy, medications (use of cocaine, nasal sprays), infection (sinusitis), uremia, hypertension (more often a result rather than a cause of epistaxis) |
Failure to Thrive Environmental: Social deprivation, decreased food intake Organic: CNS disorder, intestinal malabsorption, cystic fibrosis, parasites, cleft palate, heart failure, endocrine disease, hypercalcemia, Turner syndrome, renal disease, chronic infection, malignant diseases |
Fever In adults, a morning temperature above 98.8 F (37.2 C) or a night temperature above 99.9 F (37.7 C) is generally defined as a fever. Rectal temperature is generally 1 F (0.6 C) higher and reflects core temperature. Axillary temperature is approximately 1 F (0.6 C) lower than oral temperature. Infection (viral [including HIV and AIDS], bacterial, mycobacterial, fungal, parasitic), neoplasm (lymphoma, leukemia, renal and hepatic carcinoma), connective tissue disease (SLE, vasculitis, rheumatoid arthritis, adult Still disease, temporal arteritis), heat stroke, malignant hyperthermia, thyroid storm, adrenal insufficiency, pulmonary embolus, MI, atrial myxoma, inflammatory bowel disease, factitious factors, drugs (most commonly amphotericin, bleomycin, barbiturates, cephalosporins, methyldopa, penicillins, phenytoin, procainamide, sulfonamides, quinidine, cocaine, LSD, phencyclidine, and amphetamines) |
Fever of Unknown Origin (FUO) In adults, defined as a temperature of 101 F (38.3 C) or greater for at least 3 wk and for which a diagnosis is not established after 1 wk of hospitalization. In children, the minimum duration is 2 wk, and the temperature is at least 101.3 F (38.5 C). TB, fungal infection, endocarditis, abscess (especially hepatic), neoplasm (lymphoma, renal cell, hepatoma, preleukemia), atrial myxoma, connective tissue disease, drugs (see Fever), pulmonary embolus, Crohn disease, ulcerative colitis, hypothalamic injury, factitious factors, temporal arteritis in elderly patients |
Flatulence Aerophagia, food intolerance, disturbances in bowel motility (diabetes, uremia), lactose intolerance, gallbladder disease, medications including acarbose and orlistat |
Frequency Infection (bladder, prostate), excessive fluid intake, use of diuretics (also coffee, tea, or cola), diabetes mellitus, diabetes insipidus, prostatic obstruction, bladder stones, bladder tumors, pregnancy, psychogenic bladder syndrome, neurogenic bladder, interstitial cystitis |
Galactorrhea Hyperprolactinemia, prolonged breast feeding, major stress, pituitary tumors, breast lesions (benign, cancer, inflammatory), idiopathic with menses and after oral contraceptive use |
Gynecomastia Normal (Physiologic): Newborn, adolescence, aging Pathologic: Drugs (cimetidine, spironolactone, estrogens, gonadotropins, antiandrogens [bicalutamide, others], marijuana), decreased testosterone (Klinefelter syndrome, testicular failure or absence), increased estrogen production (hermaphroditism, testicular or lung cancer, adrenal and liver diseases) |
Headache Cluster: Severe, sharp, stabbing, usually unilateral clustered every day to every other day, lasting 1/2 2 hrs, classically occur in the early morning (3 AM) over 1 4 mo Tension: Steady, nonpulsatile bandlike distribution around head, stress-related, increases as day progresses Migraine: Precipitated by a factor such as menses or a food and preceded by an aura; photophobia, N/V, neurologic complaints, unilateral deep, throbbing severe parietal temporal pain Other Types: Benign exertional, benign cough headache, vascular (menstruation, hypertension), ice pick headache, eye strain, acute glaucoma, uveitis, keratitis, sinusitis, dental problems, TMJ disease, trauma, subarachnoid hemorrhage, intracranial mass, carotid or vertebral artery dissection, fever, meningitis, pseudotumor cerebri, trigeminal neuralgia, temporal arteritis (especially in elderly), hypoglycemia, toxin exposure (carbon monoxide poisoning), drugs (vasodilators such as nifedipine [Procardia]), vasculitis |
Heartburn (Pyrosis) GERD, esophagitis, hiatal hernia, peptic ulcer, gallbladder disease, medications (eg, alendronate), tumors, scleroderma, food intolerance. Myocardial ischemia can be mistaken for heartburn. |
Hematemesis, Melenemesis, and Melena Melena: Black tarry stools caused by stomach acid or intestinal bacterial conversion of hemoglobin to the black pigment hematin; suggests blood loss of > 50 100 mL Hematemesis: Vomiting blood Melenemesis: Vomiting of material that looks like coffee grounds Note: These three conditions suggest a bleeding site in the upper GI tract (ie, proximal to the ligament of Treitz) but can be as distal as the right colon with reflux of blood through the pylorus. Swallowed blood (eg, from epistaxis), esophageal varices, esophagitis, Mallory Weiss syndrome, hiatal hernia, gastritis, duodenal or gastric ulcer, duodenitis, gastric carcinoma, tumors (small and large bowel), ischemic colitis, and aortoenteric fistula. Bleeding diathesis and anticoagulation can unmask GI tract abnormality. Medications, eg, bismuth-containing mediations and iron supplements can darken stool. |
Hematochezia Grossly bloody stool. Massive upper GI bleeding (rapid GI transit), hemorrhoids, anal fissure, diverticular disease, angiodysplasia, polyps, carcinoma, inflammatory bowel disease, ischemic colitis |
Hematuria (See also Blood [Hematuria].) First rule out false-positives: myoglobinuria, hemoglobinuria, porphyria. GU neoplasms (malignant and benign), polycystic kidneys, trauma, infection (urethra, bladder, prostate, etc), stones, glomerulonephritis (primary and secondary such as Wegener granulomatosis, SLE, and polyarteritis nodosa), renal infarction, renal vein thrombosis, enterovesical fistula, sickle cell anemia, vigorous exercise (runner's hematuria), accelerated hypertension, factitious and vaginal and rectal bleeding. Bleeding diathesis and anticoagulation can unmask GU tract abnormalities. |
Hemoptysis Infection (pneumonia, bronchitis, fungal, TB), bronchiectasis, cancer (bronchogenic or metastatic), bronchial adenoma, pulmonary embolus, A V malformations, Wegener granulomatosis, Goodpasture syndrome, SLE, pulmonary hemosiderosis, foreign body, trauma, bleeding diatheses, excessive anticoagulation (can unmask respiratory tract abnormalities), cardiogenic pulmonary edema, mitral stenosis |
Hepatomegaly Right-sided CHF, tricuspid stenosis, hepatitis (viral, alcoholic, drug-induced, autoimmune), fatty liver, tumors (primary and metastatic, lymphoma, chronic myelocytic leukemia, lymphocytic leukemia), amyloid, biliary obstruction, hemochromatosis, chronic granulomatous disease, amyloidosis, infection (schistosomiasis, liver abscess, hydatid cysts), hepatic vein thrombosis, Wolman disease. Riedel lobe is a normal variant, elongated right lobe of the liver with normal total liver volume |
Hiccups (Singultus) Uremia, electrolyte disorders, diabetes, medications (benzodiazepines, barbiturates, others), emotionally induced (excitement, fright), gastric distention, CNS disorders, psychogenic, thoracic and diaphragmatic disorders (pneumonia, MI, diaphragmatic irritation), alcohol ingestion |
Hirsutism Idiopathic, familial, adrenal causes (Cushing disease, congenital adrenal hyperplasia, virilizing adenoma or carcinoma), polycystic ovaries, medications (minoxidil, androgens) |
Impotence (Erectile Dysfunction) Psychogenic, vascular, neurologic (spinal cord injury, radical prostatectomy, rectal surgery, aortic bypass), pelvic radiation, medications (common drugs: antihypertensives, especially thiazide diuretics, beta-blockers and methyldopa; antidepressants especially the SSRIs, anticholinergics; addictive medications: alcohol, narcotics; antipsychotics; antiandrogens: histamine H2 blockers, finasteride, LHRH analogues, spironolactone, others); history of priapism, Peyronie disease, testicular failure, hyperprolactinemia |
Incontinence (Urinary) Cystitis, dementia and delirium, stroke, prostatic hypertrophy, fecal impaction, peripheral or autonomic neuropathy, medications (diuretics, sedatives, alpha-blockers), diabetes, spinal cord trauma or lesions, MS, childbirth, surgery (prostate, rectal), aging, acute and chronic medical conditions, estrogen deficiency |
Jaundice Hepatitis (alcoholic, viral, drug-induced, autoimmune), Gilbert disease, Crigler Najjar syndrome, Dubin Johnson syndrome, Wilson disease, drug-induced cholestasis (phenothiazines and estrogen), gallbladder and biliary tract disease (including inflammation, infection, obstruction, and primary and metastatic hepatic tumors), hemolysis, neonatal jaundice, cholestatic jaundice of pregnancy, TPN |
Lymphadenopathy and Splenomegaly Infection (bacterial, fungal, viral, parasitic, rickettsial), benign neoplasm (histiocytosis), malignant neoplasm (primary lymphoma, metastatic), sarcoid, connective tissue disease (eg, rheumatoid arthritis, SLE, Sj gren syndrome), lipid storage diseases, drugs (eg, phenytoin), HIV and AIDS, splenomegaly without lymphadenopathy (cirrhosis, hereditary spherocytosis, hemoglobinopathies, hairy cell leukemia, histiocytosis X, amyloidosis, Wolman disease) |
Melena (See Hematemesis, Melenemesis, and Melena.) |
Nausea and Vomiting Appendicitis, acute cholecystitis, chronic gallbladder disease, PUD, gastritis (especially alcoholic), pancreatitis, gastric distention (diabetic atony, pyloric obstruction), intestinal ischemia, intestinal obstruction, peritonitis, food intolerance, intestinal infection (bacterial, viral, parasitic), acute systemic infections (especially in children), hepatitis, toxins (food poisoning), CNS disorders (tumor, hemorrhagic stroke, hydrocephalus, meningitis; increased intracranial pressure often causes vomiting without nausea), labyrinthitis, M ni re disease, migraine headache, acute coronary syndrome, CHF, endocrine disorders (DKA, adrenal crisis), hypercalcemia, hyperkalemia, hypokalemia, pyelonephritis, nephrolithiasis, uremia, hepatic failure, pregnancy, PID, drugs (opiates, digitalis, chemotherapeutic agents, levodopa, NSAIDs), psychogenic vomiting, porphyria, radiation therapy |
Nystagmus Congenital, vision loss early in life, MS, neoplasms, ocular infarction, toxic or metabolic encephalopathy, alcohol intoxication, thiamine (B1) deficiency, cerebellar degeneration, medications (anticonvulsants, barbiturates, phenothiazines, lithium, others), encephalitis, vascular brainstem lesions, Arnold Chiari malformation, nonpathologic (extreme lateral gaze), opticokinetic nystagmus (attempt to fix gaze on a rapidly moving object, eg, a train) |
Oliguria and Anuria (See also Urinary Indices.) Oliguria is < 500 mL urine/24 h; anuria is < 100 mL urine/24 h in adults. Prerenal: Volume depletion, shock, heart failure, fluids in the third space, renal artery compromise Renal: Glomerular disease, acute tubular necrosis, bilateral cortical necrosis, interstitial disease (acute and chronic interstitial nephritis, urate or hypercalcemic nephropathy), transfusion reaction, myoglobulinuria, radiographic contrast media (especially in diabetic, dehydrated, and elderly patients and those with multiple myeloma), ESRD, drugs (aminoglycosides, amphotericin B, vancomycin, NSAIDs, cephalosporins, penicillins, and sulfonamides), malignant hypertension, ischemia, emboli, thrombosis, TTP, HUS, and DIC Postrenal: Bilateral ureteral obstruction, prostatic obstruction, neurogenic bladder |
Pleural Effusion (See Chapter 13, Thoracentesis, for more details.) Transudate: (Pleural to serum protein ratio < 0.5, pleural to serum LDH ratio < 0.6, and pleural LDH < 2/3 the upper limit of normal for serum LDH), CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis Exudate: (Pleural to serum protein ratio > 0.5, pleural to serum LDH ratio > 0.6, or pleural LDH > 2/3 the upper limit of normal for serum LDH), bacterial or viral pneumonia, pulmonary infarction, TB, rheumatoid arthritis, SLE, malignancy (most common, breast, lung lymphoma, leukemia, ovarian, unknown primary, GI, mesothelioma), pancreatitis, pneumothorax, chest trauma, uremia, peritoneal dialysis Chylothorax: Traumatic or postoperative complication Empyema: Bacteria, fungi, TB, trauma, surgery Hydrothorax: Usually iatrogenic (central venous catheter complication) |
Pruritus Skin lesions (papulosquamous, vesicobullous, eczematous, contact dermatitis, urticaria, folliculitis, neurotic excoriations, fiberglass dermatitis, infestation [eg, scabies], infection), xerosis (dry skin), especially in winter, liver disease, uremia, diabetes, gout, iron deficiency anemia, multiple myeloma, Hodgkin disease, leukemia, polycythemia vera, systemic mastocytosis, intestinal parasites, drug reactions with or without rash (without rash consider allopurinol, birth control pills, captopril, cephalosporins, cimetidine, clonidine, diuretics, HMG-CoA reductase inhibitors, narcotics, penicillin, phenothiazines, phenytoin), pregnancy, psychosomatic factors, neurologic or circulatory disturbances |
Seizures Generalized: Grand mal and petit mal (absence), febrile Partial Seizures: Partial motor, partial sensory, partial complex (psychomotor or temporal lobe, d j vu, automatisms) Causes: Primary or metastatic CNS tumors, trauma, metabolic disorders (eg, hypoglycemia, hypocalcemia, hypomagnesemia, hypophosphatemia, hyponatremia, hypernatremia, acidosis, alkalosis, porphyria, uremia), fever (especially in children), infection (meningitis, encephalitis, abscess), anoxia (arrhythmia, stroke, carbon monoxide poisoning), drugs (alcohol or barbiturate withdrawal, cocaine, amphetamines, ethylene glycol, methanol), lead, collagen vascular disease (SLE), chronic renal failure, trauma, hypertensive encephalopathy, toxemia of pregnancy, neurodegenerative disorders (eg, Alzheimer disease, Down syndrome, neurofibromatosis, tuberous sclerosis, glycogen or lipid storage diseases), Whipple disease, sickle cell disease, psychogenic factors |
Splenomegaly (See Lymphadenopathy and Splenomegaly.) |
Syncope Vasovagal (simple faint). Orthostatic: volume depletion, sympathectomy (either functional or surgical), diabetes, Shy Drager syndrome (idiopathic), drugs (eg, TCAs and diuretics). Postprandial in the elderly. Psychiatric: anxiety (hyperventilation), depression, or conversion disorder. Situational: micturition, cough, Valsalva maneuver, or swallowing. Cardiac: arrhythmia (PAT, AF, VT, sinoatrial or atrioventricular block), pacemaker malfunction, aortic stenosis, hypertrophic cardiomyopathy, primary pulmonary hypertension, atrial myxoma, cardiac tamponade, aortic dissection, subclavian steal syndrome, acute coronary syndrome, pregnancy, hypoglycemia, hypoxia, seizure disorder, migraines, subarachnoid hemorrhage, TIA (vertebrobasilar or, rarely, anterior circulation with simultaneous events or 100% stenosis of the carotid artery with a TIA involving the other side). Idiopathic |
Tremors Resting (Decrease with Movement): Parkinson disease, Wilson disease, brain tumors (rare), medications (SSRI antidepressants, metoclopramide, phenothiazines [tardive dyskinesia]) Action (Present with Movement): Benign essential tremor (familial and senile), cerebellar diseases, withdrawal syndromes (alcohol, benzodiazepines, opiates), normal or physiologic (induced by anxiety, fatigue) Ataxic (Worse at End of Voluntary Movement): MS, cerebellar diseases Other: Medication-induced (caffeine [coffee, tea], steroids, valproic acid, bronchodilators), febrile, hypoglycemic, hyperthyroidism, pheochromocytoma |
Vaginal Bleeding Normal menstrual period, dysfunctional uterine bleeding (premenopausal bleeding, oral contraceptives, luteal phase defect), anovulatory abnormal uterine bleeding (hypothalamic and pituitary disorders, stress, thyroid and adrenal disease, endometriosis), pregnancy-related (ectopic pregnancy, threatened or spontaneous abortion, retained products of gestation), neoplasia (uterine fibroids; cervical polyps; endometrial, cervical, ovarian, and vulvar carcinoma) |
Vaginal Discharge Vaginitis due to Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, herpesvirus, chronic cervicitis, tumors, irritants, foreign bodies, estrogen deficiency |
Vertigo M ni re disease (recurrent vertigo, deafness, tinnitus), labyrinthitis, aminoglycoside toxicity, benign positional vertigo, vestibular neuronitis, brainstem ischemia and infarction, basilar artery migraine, cerebellar infarction, acoustic neuroma, motion sickness, excess of ethanol, quinine, or salicylic acid |
Vomiting (See Nausea and Vomiting.) |
Weight Loss Normal or Increased Appetite: Diabetes, hyperthyroidism, anxiety, drugs (thyroid), carcinoid, malabsorption (sprue, pancreatic deficiency), parasites Decreased Appetite: Depression, anorexia nervosa, GI obstruction, carcinoma, liver disease, severe infection, severe cardiopulmonary disease including end-stage COPD, uremia, adrenal insufficiency, hypercalcemia, hypokalemia, intoxication (alcohol, lead), old age, drugs (amphetamines, digitalis), HIV and AIDS |
Wheezing Large airway difficulty (laryngeal stridor, tracheal stenosis, foreign body, epiglottitis, vocal cord dysfunction), endobronchial tumor, asthma, bronchitis, emphysema, aspiration, pulmonary embolus, anaphylactic reactions, myocardial ischemia with pulmonary edema |
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