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Differential Diagnosis for…

Cardiac Dyspnea Chest Pain Palpitations Cardiac Enlargement Murmurs Orthostatic Hypotension Pulse Pressure Abnormalities Elevated JVP Paradoxical Splitting Continuous Murmurs Hypertension Congestive Heart Failure (Acute) Lungs Cough Wheezing Hemoptysis Cavitary lesion of lungs Pleural Effusion Cyanosis

External Medicine Alopecia Acanthosis nigricans Clubbing Cyanosis Erythema Nodosum Subcutaneous Nodules Vesicubullous lesions Nodules and Arthritis Exanthems Hand and Foot Rash Splinter hemorrhages Livedo reticularis Yellow discoloration Endo Small testes Delayed puberty Hirsutism OB/Gyn Postmenopausal bleeding Amenorrhea Musculoskeletal Joint Pain (see joint pathology) Muscle Weakness (see myopathy) Back Pain

Hematological Abnormal hemostasis Hypercoagulability Hemolytic Anemia Thrombocytopenia Thrombocytosis Lymphocytosis Rheumatoid Factor Hyperviscocity Eosinophilia GI/Abdominal Abdominal Pain Abdominal distention Mechanical obstruction GI bleed Vomiting Diarrhea Liver Ascites Splenomegaly Cysts Renal Hematuria

Head Delirium Dementia Ataxia Asterixis Amnesia Anisocoria Epistaxis Headaches Seizures Syncope Vertigo Neck Cervical lymphadenopathy Dysphagia / Odynophagia Neuro Mononeuritis Multiplex

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 à PE

Hemoptysis + chronic copious sputum à bronchiectasis

Cardiac

Pulmonary venous hypertension

Left ventricular failure

Mitral stenosis

Eisenmenger syndrome

Pulmonary [see endobronchial Ddx]

Infection

Bronchitis (1^st)

Bronchiectasis

Tb (2^nd)

Pneumonitis

Abscess

Lung cancer (3^rd)

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

2^nd or 3^rd 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; occasionally may be best heard at the right of the sternum in the same area	Surgical shunts, such as aortopulmonary anastomoses
Usually best heard along the lower left sternal border, although it may be audible over the entire precordium	Rupture of sinus of Valsalva aneurysm
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 pulse	A carotid pulse with a very rapid upstroke. sometimes having a 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 à RA / leukoerythrogenic cells (so-called LE cells) à SLE / 2x amylase à pancreatitis/ruptured esophagus / Hct > 20% à hemothorax / increased lymphocytes à 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)

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