|
Cardiac Congestive
Heart Failure (Acute) Lungs |
External
Medicine Alopecia Acanthosis
nigricans Subcutaneous
Nodules Hand
and Foot Rash Splinter
hemorrhages Livedo
reticularis EndoOB/Gyn Musculoskeletal Joint
Pain (see joint pathology) Muscle
Weakness (see myopathy) |
Hematological Eosinophilia GI/AbdominalLiver Renal |
Head Vertigo Neck NeuroMononeuritis
Multiplex |
Electrolyte Abnormalities (see other)
Pediatrics
Precocious puberty / Late Puberty
Ddx for opportunistic pathogens in AIDS patients
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)
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)
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
Diabetes
mellitus
Primary
autonomic insufficiency
After
sympathectomy
Physical
deconditioning
|
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
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
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
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
Hydronephrosis
Systemic
Hypothyroidism
Hypoalbuminemia
Nephrotic
syndrome
Drugs: nitrofurantoin,
dantrolene, dopamine agonists, amiodarone, quinidine, IL-2
usually painful
Infectious
Post-Strep pharyngitis (ARF)
Yersinia enteritis
Atypical mycobacterial infection (M. lepra)
Immunodeficiency-related infection
Autoimmune
Sarcoidosis (Lofgren’s)
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)
RA, SLE, gout, sarcoid, sporotrichosis, MRH, type II
hyperlipidemia, palmer fasciitis, CrEST
Splinter hemorrhages
Endocarditis / rheumatoid arthritis / vasculitis?
Atheroembolic syndrome
PAN
Type II cryoglobulinemia
APS (Snedden syndrome)
·
See more on infectious exanthems
Petechial Rashes
Serious infections:
Neisseria meningitides, RMSF, atypical measles
Other: endocarditis, DIC
Desquamation
Toxic shock syndrome,
Hand and Foot Rash
Secondary syphilis
Reiter’s
RMSF
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
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
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
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
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
Fibrocystic breasts
Benign tumors (fibroadenoma,
papilloma)
Mastitis (acute bacterial mastitis, chronic
mastitis)
Malignant neoplasm
Fat necrosis
Hematoma
Duct ectasia
Mammary adenosis
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)
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
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
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
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
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,
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 infections (rubella, CMV,
Drug toxicity: aminoglycosides,
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)
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
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)
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
Liver and/or Kidney dysfunction
Drugs: tegretol
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
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
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
Trauma
Nose-picking
Foreign body
URI
Nasal Polyps
Antihistamine Xs
Telangiectasia
Blood dyscrasias
Pertussis
Congestive Heart Failure (Acute)
Myocardial infarction
Infection
Anemia
Thyrotoxicosis / pregnancy
Arrhythmias / rheumatic, other myocarditis
Infective endocarditis
Physical, dietary, fluid, environmental and
emotional
Systemic hypertension
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)
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
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
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
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
PRV (very common)
POEMS syndrome
WM (50%)
MM (< 5%, even with cryoglobulinemia)
Hyperviscocity absent: CML, AMMM, CML, Hodgkin’s, Heavy-chain diseases,
amyloidosis
Pertussis
infectious lymphocytosis
CMV
Tuberculosis
Toxoplasmosis
chronic inflammatory disorders
autoimmune syndromes
Malignancy
Decreased
clotting factors
DIC
autoimmune (anti-VIII)
congenital (hereditary hemorrhagic telangiectasia, vWD)
Uremia
Medications:
coumadin, ASA, plavix
Risk Factors: sedentary, post-operative,
OCP/estrogens, pregnancy
Acquired:
malignancy (Trousseau’s) –
mostly venous
myeloproliferative –
arterial/venous
connective (SLE)
Buerger’s Vasculitis – arterial/venous
TTP – arterial and
venous
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
Drugs: AZT, quinidine,
chloramphenicol, methyldopa, benzene, cancer drugs
Blood loss: menstruation, GI/GU bleeds
Deficiency: Iron, Folic acid
Infection: sepsis, AIDS, malaria
Chronic: cancer, ESRD, endocrine
Genetic: Thalassemia, sickle cell,
many others
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
APS/SLE*
Lymphoma
Infection:
HIV
Cavernous
hemangioma
DIC/Sepsis*
TTP*
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
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)
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%)
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,
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
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
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
Drugs
Both
medical and illicit (cocaine, etc.)
Essential hypertension
Abdominal Pain
Differential (work-up)
Early appendicitis
Aortic aneurysm
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)
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
Reproductive: ectopic
pregnancy, Mettelschmerz, torsion of ovary or ovarian cyst, PID, salpingitis,
endometriosis, rupture of endometrioma
Cystitis, rupture of bladder
Intestinal: SBO, gangrene,
early appendicitis
Mesenteric thrombosis,
aortic dissection
Pancreatitis
Uremia, DKA
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)
Same as RUQ plus:
Splenic: splenomegaly,
splenic infarction, ruptured spleen, splenic abscess
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
Same
as RLQ (including appendicitis if appendix on wrong side)
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
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
Upper GI Bleeding
PUD/DUD
Lower GI Bleeding
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 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
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
Viral: Rotavirus,
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
