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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 (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; 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)

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 à 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 à 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 à anything suggesting cardiac causes, severe orthostasis, drug-reaction

·        Treatmentà 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 à stress, fear, pain

elderly à 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 à 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 à 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