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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pallor of t he Fac e, Nails, or Conjunc t iva

Pallor

of the Face, Nails, or Conjunctiva
Pall or i s al mos t invari ably caus ed by anemi a and is best analyz ed wit h t he appl i cat i on of pathophysiology. Anemi a may be caus ed by decreased product i on of bl ood, i ncreased des t ruct i on of bl ood, or los s of bl ood. Decreased production resul t s from poor nut ri t ion parti cul arl y, poor abs orpt ion or i nt ake of B 1 2 (perni ci ous anemia), iron (i ron defici ency anemi a), and fol i c aci d (mal absorpti on syndrome). It may al so res ul t from suppres sed bone marrow (aplas t ic anemi a) or i nfi l t rat ed bone marrow (l eukemi a or met as t at i c carci noma). Increased destruction is caused by hemolys i s from i nt ri nsi c defect s i n t he red cel ls (e.g., si ckl e cell anemia and t halas semi a) or ext ri nsi c defect s in t he ci rcul at i on (autoi mmune hemol yt ic anemi a of many di sorders). Blood loss may resul t from pept i c ul cers and carci nomas of t he gas t roi nt es t inal (GI) t ract , exces si ve menst ruat ion or met rorrhagia from t umors of t he ut erus, or dys funct i onal ut eri ne bl eeding. These are t he pri nci pal causes of anemi a, but t he reader wi l l be abl e t o t hi nk of several more. W hat i s i mportant here is t o have a sys t emat ic met hod t o recal l t hem. If anemia i s rul ed out , the l ess frequent causes of pall or shoul d be considered. Shock, conges t ive heart fai l ure (CHF), and art eri oscl erosi s cause pal l or by poor circul at ion of bl ood t o t he ski n. Pat ient s who have hypert ensi on may be pal e from refl ex vasomotor s pasms of t he art eri ol es s upplyi ng t he ski n. Aort ic regurgi t at i on and st enosi s, as wel l as mi t ral st enosi s, cause pal l or for t he same reas ons, but t he mal ar fl ush of mi t ral s t enosi s may negat e t hi s . The reason t hat t ubercul osi s, rheumat oi d art hri t i s, carci nomat os is , and glomerul onephri t is cause pall or even when t heir vi ct i ms are not anemi c or hypert ensi ve i s not known.

Approach to the Diagnosis

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The approach t o t he di agnosi s of pal l or i s obviousl y t o check for anemia fi rst ; t hen t o exami ne for t he ot her chronic di s orders. Chest x-ray, elect rocardiogram (ECG), s ediment at i on rat e, and a check for rheumat oi d fact or are all appropri at e i n speci fi c cases .

Other Useful Tests
Compl et e blood count (CBC) (anemi a) Sediment at ion rat e (chroni c i nfect i on) Chemi st ry panel (anemi a of l i ver and kidney dis ease) Serum B 1 2 l evel (pernici ous anemi a) Serum foli c aci d l evel (fol i c aci d defi ci ency) Serum iron and ferri t i n l evel s (i ron defi ci ency anemia) St ool for occul t bl ood (GI bl eedi ng) St ool for ova and paras i t es (anemi a due t o parasi t e infest at ion) Serum hapt oglobi ns (hemol yt i c anemi a) Anti nucl ear ant i body (ANA) analys i s (col l agen disease) Bone marrow examinat ion (apl ast i c anemi a)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Palpit at ions

Palpitations

Because anxi et y i s t he common caus e of pal pi t at i ons, t here is a t remendous t empt at i on to jump t o t hi s conclus i on as t he cause i n an ot herwi se heal t hy-looki ng i ndivi dual . If we use t he mnemoni c VINDICAT E, we may avoi d a mi sdi agnos is in many cas es . V—Vascular causes hel p t o recal l aort i c aneurysms, art eri o venous fi st ul as , anemia, post ural hypot ensi on, migrai ne, and cardi ac disorders such as aort i c regurgi t at i on, aort i c st enosi s, t ri cuspi d i ns uffi ci ency, CHF, and various arrhyt hmi as (see page 77). I—Inflammation remi nds us of fever, peri cardi t is , subacute bact eri al endocardi t is (SBE), and rheumat ic fever. N—Neoplasms are not usual ly as soci at ed wi t h palpi t at ions. D—Deficiency of t hi ami ne can l ead t o beri beri heart di sease res ul t i ng in pal pi t at i ons. I—Intoxication prompts us t o recal l that al cohol , t obacco, coffee, s oft dri nks, and t ea can caus e palpi t at ions. It shoul d als o remi nd us t hat palpi t at ions are common si de effect s of many drugs , incl udi ng di gi t al i s, ami nophyll i ne, s ympat homimet i cs , gangli oni c bl ocking agent s , nit rat es, and ot her drugs . C—Congenital di s orders t hat may caus e palpi t at i ons incl ude patent duct us, vent ri cul ar sept al defect , and hi at al herni a. A—Anxiety is a common caus e of pal pi t at i ons. T —T rauma causes pal pi t at i ons by i nduci ng t he rel ease of epinephri ne, but t here is no diagnos t i c di lemma i n t hese cases . E—Endocrine di s orders t hat cause pal pi t at i ons i ncl ude t hyrotoxi cos is , pheochromocytoma, menopaus al

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syndrome, and hypogl ycemia. P.340

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Pallor of the face, nails, or conjunctiva

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Approach to the Diagnosis
Valvul ar heart di sease, anemi a, and febril e dis orders wil l usual ly be reveal ed on phys i cal exami nati on. It is import ant t o i nqui re about drug, alcohol , and t obacco use. Caffei ne i s a frequent offender. It is helpful t o el imi nat e any sus pi ci ous medicat ions i f pos si bl e. A drug screen may be us eful in many cas es . The ini t i al di agnos t i c workup shoul d i ncl ude a CBC, chemi st ry profi l e, t hyroi d profil e, sediment at i on rat e, ant i -st rept ol ysi n O (ASO) t i t er, ECG, and ches t x-ray. If t hese have normal fi ndings, 24-hour Hol t er moni t ori ng or conti nuous l oop event recordi ng of the ECG s hould be undert aken. P.341

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Palpitation

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Other Useful Tests
24-hour urine cat echol ami ne or vani l lyl mandel ic aci d (VMA) (pheochromocytoma) Arm-t o-t ongue ci rcul at i on t i me (CHF) Echocardiography (CHF, val vular heart di sease) Exercis e t ol erance t es t (coronary i ns uffi ciency) Upper GI s eri es and es ophagram (hi at al hernia) 24-hour blood pressure moni t ori ng (pheochromocyt oma) Psychomet ric t es t i ng (hyst eri a) P.342

Case Presentation #71
A 62-year-ol d physi ci an compl ai ned of frequent l y awakening at ni ght wi t h pal pi t at i ons. It woul d t ake hi m at l east an hour t o go back t o sl eep. He al so had t o uri nat e at least t wi ce at ni ght but denied dayt i me frequency of uri nat i on. He deni ed the us e of al cohol , tobacco, or drugs but usual l y has a cup of coffee in t he morning and a coke at l unch. Question #1. Utilizing your knowledge of physiology and the mnemonic VINDICAT E, what is your differential diagnosis? Physical examination was unremarkable. His blood pressure was 110/70 mm Hg, and his pulse was 66 bpm. Results of laboratory studies and an exercise tolerance test were normal. Vi ew Answer Hypert hyroi di sm Early congest i ve heart fai l ure Pheochromocyt oma Chroni c anxi et y neuros is Fever of unknown origi n Coronary ins uffi ci ency Hiat al herni a and esophagi t is Question #2. What is your diagnosis now? Vi ew Answer Chroni c anxi et y neuros is

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Subst ance abuse Caffeine i nt ol erance Final Diagnosis: Caffei ne int ol erance (All hi s s ymptoms subsi ded upon t he el imi nat i on of caffei ne from hi s di et .)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Papilledema

Papilledema

No anat omi c anal ysi s of t hi s condi t i on is necessary becaus e most cases of papi l ledema are caus ed by i nt racranial pat hology. Three notabl e ext racranial condit i ons are opt i c neuri t i s, hypert ension, and pseudot umor cerebri . The pol ycyt hemia and ri ght heart fai lure of chronic pul monary emphys ema may combine t o produce papil l edema, but t hi s i s uncommon. Anal ysi s of t he int racrani al causes of papi l l edema i s performed us i ng the mnemoni c VINDICAT E. V—Vascular les i ons are aneurys ms and art eri ovenous mal format i ons t hat cause subarachnoid hemorrhages . Severe hypertensi on may l ead t o an i nt racerebral hemorrhage or hypertensi ve encephal opat hy, t hus causing papi l ledema. Cerebral t hrombos is and emboli rarel y l ead t o papi l ledema. I—Infection i s not a common caus e of papi l ledema unles s a space-occupyi ng les i on is produced or t he condi t ion pers i st s. Thus, a brai n absces s is oft en associ at ed wi t h papi l l edema, whereas acut e bact eri al meningi t is is not . Chroni c crypt ococcal meningi t is , syphi li t i c meningi t i s, and t ubercul ous meningi t is , in contras t , are oft en as soci at ed wi t h some degree of papil l edema. Viral encephal i t i s may occas i onall y be associ at ed wi t h papi l l edema. Cavernous si nus t hrombosi s and sept i c t hrombosi s of t he ot her venous si nuses may produce papi l l edema. N—Neoplasms, primary and met as t at i c, are t he most common caus e of papi l l edema. D—Degenerative di seases are rarely t he cause. I—Intoxication brings t o mi nd l ead encephal opat hy, but ot her t oxins and drugs rarel y caus e papi ll edema. C—Congenital mal format i ons that cause papi l l edema

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incl ude t he aneurys ms and art eri ovenous mal format i ons al ready ment ioned pl us t he vari ous t ypes of hydrocephalus , skull deformit i es (oxycephal y), hemophil i a (because of i nt racrani al hemorrhages ), and, occasi onall y, Schi l der disease and ot her congeni t al encephal opat hi es . A—Autoimmune di s orders recall l upus cerebrit i s and periart eri t i s nodos a (when as s oci at ed wi t h s evere hypert ensi on). T —T rauma does not usual ly produce papi l l edema i n t he earl y st ages of concus si ons or epidural or subdural hemat omas, but i n chroni c subdural hemat omas it i s t he rul e. E—Endocrine di s orders bri ng to mi nd t he papil l edema of mal i gnant pheochromocyt omas (wit h hypert ension) and t he fact that ps eudot umor cerebri occurs i n obes e, amenorrheic, and emot i onal ly di st urbed women.

Approach to the Diagnosis
The approach t o t he di agnosi s of papi l l edema i n someone wi t hout hypert ensi on or hypert ensive ret i nopat hy must i ncl ude a t horough neurol ogic exami nat ion and a comput ed tomography (CT) s can. If focal si gns are present or t he CT s can shows posi t i ve fi ndings, referral t o a neuros urgeon is indi cat ed. He or s he can deci de if a magnet i c resonance i maging (MRI) i s i ndicat ed. A spi nal t ap i s contrai ndi cat ed. If t here are no focal si gns, i t may be worthwhi le t o di fferenti at e papi ll edema from opt i c neuri t i s by havi ng an opht halmol ogi st perform a vi sual fiel d exami nat i on. Thi s may als o be hel pful i n different i at i ng pseudot umor cerebri because t here may be bil at eral vi sual defect s in t he inferi or nasal quadrant s . Papil l edema from i ncreased i nt racrani al pres sure wi l l s how only an enlarged bli nd spot (unles s t here i s a t umor of t he opt i c t ract s, radiat i ons, or occi pi t al cort ex), whereas opti c neuri t is wil l s how scot omat a peri pheral t o t he bl ind spot (di sc). Appendi x A wi l l be useful for confirmi ng the di agnos is of a speci fic di s ease.

Other Useful Tests

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CBC (polycyt hemi a) Sediment at ion rat e (cerebral absces s, i nfect ion) Uri nalys i s (renal di s ease associ at ed wi t h hypert ensi on) ANA analysi s (col lagen di sease) P.343

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Papilledema P.344

Bl ood l ead level Vi sual evoked pot ent i al s (opt ic neuri t i s)

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Pulmonary funct i on tes t s (emphys ema) Bl ood volume (pol ycyt hemia vera) 24-hour blood pressure moni t ori ng (hypert ensi on) Spinal tap when i maging st udy i s negat i ve (pseudot umor cerebri)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Parest hesias, Dysest hesias, and Numbness

Paresthesias, Dysesthesias, and Numbness
TABLE 49. Paresthesias, Dysesthesias, and Numbness
V I N D I C A T E Vasc Infla Neo Dege Intox Cong Autoi T rau Endoc ular mmat plas nerat icatio enital mmun ma ory m ive n e Allergi Perip Causal gi a c Pel l a Al coh Porph Infecti Trau Tetany ol i c pat hy yri a ous it i s eri t is a ma of neuron Hem hypop at om arathy roi di s Lacer m Neur eronis oma m Fros t bi t e Scal e Infecti Cont Diabet nus s Cervi c Nerve Tabes Met a Herni ous it i s us i on ic at ion at hy Fract ant i cu neuron Lacer neurop Periart a rine

heral Raynaud disease gra e Art eri os clerosi s eri

Nerv Buerger dis ease Beri b neuro Ischemic neuri t i s Nut ri t Isoni a i onal zi d neuro t oxici pat hy t y Lead and Nerv Leri che e Plex us syndrome Pancoast t umor ars eni c neuro pat hy

nodos at ion Al dost

al ri b ure Spondyl ol i st Fract ure

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Root

dorsa st at i at ed lis c and di s c cal Tuber pri m Cervi cul os i ary s t umo and rs of l umb t he and (mul t i pl e myel ar dyl os cord s pon spi ne i s

hesi s

Herni at ed di s c

oma) Spin Anter Pol io Met a Spon Trans Spi na Guil l ai Fract ure al ior l y myel i st at i dyl os vers e bi fi da n–B Herni at ed c and i s ary myeli t Myel o arré di s c is cel e syndro Hemat oma Syri ng me ia e scl ero si s Epi du pri m Di sc absce t umo s e ci ous ia Cord spi na t i s art er ral occlu ss

di s ea from

radiat omyel Mult i pl

rs of Perni i on

si on Tuber t he c s and

Aorti cul os i cord anem aneur Syphi spi ne

ysm l i s Brai Cereb Neuro Brai n Seni l Al coh At riov Lupus Depr Pi t ui t a n ral lus , t hro , syphi l t umo e r Encep hal it i Brai n nt ia ni l e nt ia ol i sm ent ri c cerebri es se ry t is d ure ural hema t oma t umor egaly sm anom Mult i pl fract Acrom embo i s deme Bromi ul ar

Prese Encep al i es e deme at hy es , ys m sy si s

mbus s hemo absce rrhag ss

hal op Aneur scl ero Subd Opi at Epi l ep

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e Carot id or basil ar art er y ins uff ici enc y Migra ine

barbi t Cereb urat e ral s, et c. pal sy

Anat omi cal l y, t i ngli ng and numbnes s or ot her abnormal sensat ions in t he ext remi t i es res ul t from invol vement of t he peri pheral nerve, t he nerve plexus (brachial or sci at i c), t he nerve root , t he spi nal cord, or the brai n. W hen each of t hese i s cros s-i ndexed wit h t he et i ol ogies sugges t ed by t he mnemoni c VINDICAT E, mos t of t he causes can be devel oped (Tabl e 49). Onl y t he most import ant condi t ions are ment i oned i n t hi s di scus si on. Peripheral nerve. Peri pheral neuropat hi es from al cohol , di abet es, and ot her causes are i mport ant i n t hi s cat egory, but one shoul d not forget vascul ar di seases t hat may caus e parest hesi as , such as peri pheral art eri oscl erosi s, Raynaud s yndrome, and Buerger di sease. In addi t i on, met abol ic di sorders such as t et any and uremia shoul d be consi dered. Chronic acut e infl ammat ory demyel inat i ng pol yneuropat hy (Guil l ai n–Barré s yndrome) i s brought to mi nd here. Fi nall y, nerve ent rapment s such as carpal tunnel syndrome need t o be checked. Nerve plexus. The brachi al pl exus may be i nvol ved by t he scal enus ant icus syndrome, a cervi cal rib, or Pancoast t umor. The s ci at ic pl exus may be compres sed by pel vi c t umors. Nerve root. Herniat ed di sks, spondyl osi s, t abes

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dorsal is , and infi l t rat i on of t he spi ne by t ubercul osi s, met as t at i c t umor, and mult i pl e myel oma need t o be remembered here. Spinal cord. Spinal cord t umors, perni cious anemi a, and t abes dors al i s are t he most i mport ant condi t i ons t o recall here. Brain. Transi ent i schemi c at t acks (TIAs), embol i , and migrai nes are vascul ar di s eases t o remember i n addi t i on t o t he di seases t hat affect the spi nal P.345

cord. The aura of epi lepsy i s al s o i mportant . One would not want t o mi ss brai n t umors, abs cess es, and t oxic encephal opat hy because t hese are pot ent ial l y t reat able.

Approach to the Diagnosis
This woul d be t he same as t he workup of weaknes s in one or more extremi t i es . If t he condi t ion i s i n t he hand, one woul d check for Ti nel and Adson si gns and x-ray t he cervi cal spi ne for a cervi cal ri b or di sk degenerat ion. The next st eps are nerve conduct i on st udies and El ect romyogram (EMG). Object ive s i gns of radicul opat hy are a cl ear i ndicat ion for an MRI or cervi cal myel ography, preferabl y combined wi t h a CT scan. MRI may reveal t i ny di sk herni at i ons. W i t h ass oci at ed pai n i n cert ai n root s, di agnos t i c nerve bl ocks may be indicat ed. If t here i s col dnes s in t he hand, a s t el l at e gangl ion bl ock may be hel pful. If the condi t i on is i n t he l ower extremi t y, a careful exami nat ion of t he arteri al pulses , part i cul arl y t he femoral , is performed. If t hese are abnormal , a flow st udy or femoral angi ography may be indi cat ed. X-rays of t he spi ne t o rul e out a herni at ed di sk or t umor of t he spi ne are done rout i nely. One mus t not forget a pel vi c examinat i on in a femal e. If ot her neurol ogic s igns are pres ent, an MRI or CT s can may be neces sary. W hen a dis k herniat ion i s st i l l li kely, myel ography shoul d be ordered. EMG has the same useful ness here as i n t he upper ext remi t y. W hen a cerebral l esi on

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is suspect ed, a CT s can, MRI, and four-ves sel angi ography shoul d be consi dered.

Other Useful Tests
CBC (anemi a) Chemi st ry panel (hypoparat hyroi di sm, el ect rol yt e di st urbance, uremi a) Fl uorescent t reponemal ant i body absorpt ion (FTA-ABS) t est (neuros yphil i s) Serum B 1 2 and fol i c aci d l evel s (perni ci ous anemia) Schil l ing t es t (pernici ous anemi a) Bl ood l ead level (l ead neuropat hy) ANA analysi s (col lagen di sease) Glucose t ol erance t est (di abet ic neuropat hy) Uri ne porphobil i nogen (porphyri a) Hair anal ysi s for ars enic P.346

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Paresthesias, dysethesias, and numbness P.347

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Paresthesias, dysethesias, and numbness P.348

Paresthesias, dysethesias, and numbness Somat osensory evoked pot ent i al s (mul t i pl e scl erosi s) Spinal tap (neuros yphil i s, mul t i pl e scl erosi s) Anti cent romere ant ibody (s cl eroderma)

Case Presentation #72
A 25-year-ol d whi t e male i nt ern compl ai ned of i nt ermi t t ent

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numbness and t i ngli ng for several months of t he lower ext remi t i es and, to a l ess er extent , t he upper ext remi t i es . He had occasi onal weakness in hi s left arm and hand but was t ol d on an i ns urance examinat i on that t hat was due t o a s cal enus ant i cus syndrome. He denies al cohol or subst ance abus e. Question #1. Utilizing your knowledge of neuroanatomy, what is your differential diagnosis? Further history reveals that he had an episode of optic neuritis at age 17. His neurologic examination reveals hyperactive reflexes of the left upper and lower extremities but is otherwise unremarkable. Vi ew Answer Peripheral neuropat hy Tumor of t he cervi cal spi nal cord Pernici ous anemi a Mult i pl e s cl erosis Basil ar art ery i nsuffi ci ency Parasagit t al meni ngioma Brains t em gli oma Hypoparathyroi di sm Neurosyphi l i s Coll agen dis ease Hypervent i l at i on syndrome Question #2. What is your diagnosis now? Vi ew Answer Mult i pl e s cl erosis Final Diagnosis: Mul t i pl e scl erosi s was confi rmed by MRI of t he cervical spi ne.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pelvic Mass

Pelvic Mass

Pelvic mass A mass in t he pel vi s i s usual l y (but not al ways ) a neoplas m. Is t here a quick way t o recall al l t he vari ous causes whi l e exami ni ng t he pel vi s? Anatomy is the key. Appl y t he mnemoni c MINT t o devel op a li st of t he many pos si bi l it i es (Tabl e 50). Anat omi cal l y, t here are t hree major groups of st ruct ures: the uri nary tract , the femal e geni t al t ract , and t he lower i nt es t i nal t ract . Breaki ng these down i nt o t heir component s , there are t he bl adder and uret ers; t he vagina, cervi x, ut erus, fal l opian t ubes, and ovaries ; and t he rect um and si gmoid col on. In addit i on t o t hese st ruct ures, t he di seases of t he aort a and i li ac vess el s, spi ne, and surrounding muscl es and fasci a must be cons idered. Ot her st ruct ures fi ll t he pel vi s from above. The s mal l int est i nes, t he oment um, and t he appendix may be fel t ; even t he kidney may drop int o t he pel vi s.

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Bladder. Promi nent condi t i ons t hat mus t be consi dered here are st ones , divert i cul a, Hunner ul cer, and carci nomas. A di s t ended bl adder i s decept i ve. Urethra. A cyst ocele and uret hrocel e are fel t easil y during a pelvi c exami nat i on, but if t hey are not , have t he pat i ent s t rai n or st and up. Ureters. A uret eral cal cul us or uret erocele may be fel t . Vagina. Vagi nal carci nomas , prol apsed cervi x or procident i a, rect ocel e, and Bart holi n cyst s may be fel t . A forei gn body (e.g., a pes sary) s houl d be consi dered. Cervix. Carci noma or polyps are t he main cons iderat i ons here, becaus e an i nfl amed cervix does not us uall y cause a mass . Uterus. Fibroi ds are t he most l ikel y t umor t o be fel t , but pregnancy, chroni c endomet ri t i s, chori ocarci noma, and endometri al carci nomas al l pres ent as a mas s. A ret rovert ed ut erus may masquerade as a mas s i n t he cul -de-sac. Fallopian tubes. Tubo-ovari an absces ses and endometri os is of t hese st ruct ures account for most cases . Ect opi c pregnancy i s al ways possi bl e. Ovary. Ovari an cyst s and carci nomas must be considered as wel l as endomet ri osi s. Rectum. Carcinoma, absces ses , divert i cul a, and prolapse are good pos si bi l i t ies here. Feces may masquerade as a mas s. Sigmoid colon. Agai n, t he di sorders ment ioned i n t he sect i on on t he rect um (s ee page 385) must be considered. Granul omat ous or ul cerat ive col i t is may present as a mass . P.350

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TABLE 50. Pelvic Mass
M I Malforma Inflammat Anatomy tion ion Bladder Obst ruct io Hunner n wi t h di vert icul um Urethra Ureters Cal cul i Uret hrocel e Cyst ocel e Double uret er Cal cul us Vagina Uret erocel e Prolapsed Bart holi ni t Carcinoma cervix i s fis t ul a rect um or Cervix Uterus bl adder Cervi ci t is Carcinoma Rupt ure during cy Rect ocel e wit h Forei gn body Tear ul cer N T

Neoplasms T rauma Carcinoma Rupt ure Polyp of t he bl adder

Papil l oma

(rarel y) Polyp Bi cornuat Endomet rit Endometri al e ut erus Ret roversi on is carci noma ma Fi broid Salpi ngit i s Carcinoma (rarel y)

Choriocarci no pregnan

Fallopian T ubes

Ect opi c pregnancy Endomet ri os is Beni gn congeni t al ovari an cys t (e.g., Morgagni )

Ovary

Oophori t i s Cyst adenoma Cyst adenocar cinoma Foll icul ar and granul osa cel l cyst

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Rectum

Prolapse

Infl amed d Rect al absces s

Rect al

Rect ocel e hemorrhoi carci noma

Sigmoid

Fi st ul a Divert i cul Divert i cul i Carcinoma of Forei gn um tis Granuloma t ous col i t i s Ulcerat i ve col i t i s Aneurysm Lordosi s Rheumat oi Met ast at ic Scol ios i s d art hri t i s carci noma Spondyl osi Myel oma s Hodgkin Tubercul os lymphoma polyp body

Arteries Spine

Fract ure Rupt ure d dis c

Miscellane Pelvi c ous ki dney Oment al cys t and adhes ions P.351

is Appendi ci t Pelvi c is Regi onal i lei t is met as t asi s from st omach, e.g.

Bl ood cl ot i n cul -de-s ac Surgi cal absces s

Arteries. It i s unusual for an aort i c or il i ac aneurys m t o be felt here, but they s hould be kept i n mi nd. Spine. Deformi t i es of t he spi ne (e.g., l ordosi s), t ubercul osi s (Pot t di sease), and met ast at i c or pri mary mal ignanci es of t he spi ne (e.g., myel oma) may pres ent as a pel vi c mass . Miscellaneous. A pel vi c ki dney may be felt . An i nfl amed

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segment of i l eum (regi onal il ei t i s) or t he appendi x shoul d be considered, as shoul d oment al cyst s and adhesi ons.

Approach to the Diagnosis
The associ at i on wi t h ot her sympt oms is t he key t o t he cli ni cal di agnosi s. A pai nl es s mas s is li kely t o be a neoplasm, whereas a t ender mass wit h fever sugges t s pel vi c infl ammat ory dis ease (PID) or a divert icul ar abscess . Obvi ously, an ect opi c pregnancy s houl d be ass oci at ed wi t h t ender breas t s, frequency of uri nat ion, and morni ng si ckness. The next l ogical st ep i s ul t ras onography and a gynecologi c consul t . Laboratory t est s i ncl ude uri nal ysi s and cul t ure, pregnancy t es t , st ool for bl ood and paras it es , and vaginal cul t ures. A proct oscopy and barium enema may be us eful . Colonoscopy, cul doscopy, perit oneos copy, and cys t os copy may all need t o be done before an explorat ory l aparot omy i s performed.

Other Useful Tests
Sediment at ion rat e (PID) Tuberculi n t es t (t ubercul os is of t he fall opian t ubes) Cathet eri zat i on for residual uri ne Culdocent esi s (rupt ured ect opi c pregnancy) Laparoscopy (ect opic pregnancy, neopl as m) CT scan of the pel vi s (neopl as m, st one, di vert i cul um, abscess ) Aortogram (aort i c aneurysm) Explorat ory l aparot omy Urology consul t Gynecology consul t

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> T able of Cont ent s > P > Pelvic Pain

Pelvic Pain

Vi sual iz ing t he anat omy of the pel vi c area i s t he key t o formi ng a li st of t he caus es of pelvi c pai n. St art i ng at t he ski n and worki ng inward, we have t he muscl es P.352 and fasci a, bl adder, peri t oneum, uterus, ovari es, fal l opian t ubes, int est i nes, rect um, and s pi ne. The ski n hel ps t o recall herpes zos ter, t he mus cl e and fasci a s uggest cont us i on and hernia, and t he peri t oneum would remi nd one of peri t onit i s and endomet rios i s. The ut erus, ovary, and tubes woul d prompt consi derat i on of PID, dysmenorrhea, pel vi c congest ion, and ect opi c pregnancy. Ovari an t umors can al so caus e pel vi c pain by t wis t ing on t hei r pedi cle. A peduncul at ed ut eri ne fi broi d can al so t wi st on i t s pedi cl e causi ng severe pain. If t he pel vi c pai n i s rel at ed t o t he mens t rual cycl e, one shoul d recall mi t t el schmerz. Consi deri ng the int est i nes, one shoul d recall appendi ci t i s and di vert i cul i t i s. Consi dering t he rect um shoul d prompt recall of hemorrhoids , fis sures, and rect al absces s. Fi nall y, t hi nking of t he spi ne shoul d sugges t rheumat oi d spondyli t i s, ost eomyel it i s, herni at ed di sk, and ot her condi t i ons.

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Approach to the Diagnosis
A good pel vi c and rect al exami nat ion i s es sent ial . These wi l l oft en di scl ose a mas s or ot her pat hol ogy t o expl ai n t he pai n. If t here i s a vaginal di scharge, a s mear and cul t ure for gonococcus and Chlamydi a need t o be done. A pregnancy tes t wil l help rul e out an ect opi c pregnancy, but ul t rasonography is most us eful. A gynecol ogy consul t shoul d be obtai ned when t here i s any doubt . In acut e cases, t he gynecol ogi st may proceed wi t h an explorat ory laparot omy i mmediat el y.

Pelvic pain

Other Useful Tests
CBC (PID, ruptured ect opic pregnancy) Chemi st ry panel Uri nalys i s (cyst i t i s, pyel onephrit i s) Uri ne cul t ure (cyst i t is , urinary t ract i nfect i on [UTI]) Pregnancy t es t (ect opic pregnancy) CT scan of abdomen and pelvi s (onl y i f pregnancy has been ruled out ) (neopl as m, abs ces s) Culdocent esi s (PID, neopl as m, ect opi c pregnancy) Laparoscopy (PID, neopl as m, ect opi c pregnancy)

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Perit oneal t ap (peri t oni t is , rupt ured ect opi c pregnancy)

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> T able of Cont ent s > P > Penile Pain

Penile Pain

Perhaps no other pai n wi l l bri ng a pati ent t o t he doct or more quickl y i n t hi s age of sexual candor. Mos t cases wil l be caused by inflammation, so a mnemoni c of et i ol ogi es i s, for t he most part , superfluous . Ut i l iz at i on of anatomy i s val uabl e, however. Let us begin, t hen, wit h t he head of the penis and proceed upward to t he prost at e, t he bl adder, and t he kidney. The head of the penis may be infl amed by a pai nful chancroi d ul cer or l ymphogranuloma venereum, but one mus t remember that a chancre (syphi l i t ic ul cer) i s not pai nful. Herpes progenit al i s, i n contras t , is ext remel y painful . Balanit i s i s us uall y caused by a nonspeci fic i nfect ion, but one shoul d caut i on the unci rcumci sed pati ent about proper cl eani ng of t he area and rule out Rei t er di sease. (Look for conjunct i vi t is and joint sympt oms.) Trauma t o t he head of t he penis s hould be obvi ous, but some pat i ents may be t oo shy t o ment i on it s ori gi n wi t hout careful quest i oning. Carcinoma of t he peni s rarel y causes pain, but l i ke all carci nomas, it wi ll oft en be pai nful when i t is secondaril y i nfect ed. Next , let us consi der t he urethra. Infl ammat i on here i s probably t he most common caus e of peni l e pai n. It is al most i nvariabl y ass oci at ed wi t h a di scharge, and t he smear wi l l usual ly di scl ose t he t ypical Gram-negat i ve i nt racell ul ar di pl ococci of gonorrhea. The cl ini ci an i s remi nded t hat nonspeci fic uret hri t i s i s more frequent ly encount ered each year and that Chl amydia and mima pol ymorpha are common caus es . Reit er di sease must al so be consi dered. Passage of a st one t hrough t he uret hra caus es pain i n t he peni s. The shaft of t he penis is one of t he few areas i n whi ch a vascul ar les i on may account for penil e pai n. Thrombos i s of t he corpus cavernosum i s oft en encount ered in bl ood dyscras i as (part i cul arl y leukemi a), and t he resul t i ng permanent erect i on may be enviabl e and even humorous t o t he obs erver but not to t he pat i ent. Peyroni e di sease wi ll cause a pai nful erecti on.

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Movi ng to t he prostate, one hardly needs t o be remi nded t hat both acute and chroni c prost at i t is are frequent causes of peni l e pain. In contras t , carci noma and hypert rophy of t he pros t at e are rarel y ass oci at ed wi t h pai n unl ess there i s as soci at ed infect ion. The bladder is anot her common s ource of peni le pai n, but becaus e t here is oft en an ass oci at ed uret hri t is , it i s uncert ai n whet her pure cyst i t i s causes penil e pai n by it s el f except on urinat i on. Bl adder st ones cause pai n i n t he peni s, especi al l y on uri nati on. Carci noma of t he bladder wi l l not us uall y cause peni l e pai n unl ess i t i s compli cat ed by i nfect i on. Hunner ulcer, i n cont ras t , causes great pain i n t he peni s at t i mes . Occasi onal ly, uret eral and renal st ones wil l cause peni le pai n, but pyel onephrit i s i s very unl i kely t o do so. Referred pai n from t he rect um caused by hemorrhoi ds and fi ssures is common.

Approach to the Diagnosis
Fi nding any l es i on of the peni s shoul d prompt a s mear and cult ure of t he exudat e or s crapings. A dark fi el d exami nati on wi l l oft en be indi cat ed by t he hi st ory of s exual P.353 contact . Any uret hral di scharge mus t al so be exami ned aft er a Gram st ai n and cult ured for gonococci and Chl amydi a. Prost at i c massage may be neces sary t o get adequat e uret hral mat eri al . Next , a uri nalys is is done and a fres h drop i s exami ned under high power for mot i le bact eri a si gnifyi ng cyst i t i s or pyel onephrit i s. A uri ne cul t ure and col ony count wil l be wi se i n any case. If the di agnos i s is st il l obscure, i t i s wis e t o consul t a urol ogis t before proceeding wit h an i nt ravenous pyel ogram (IVP) or ot her expens i ve t est s .

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Other Useful Tests
Cyst oscopy (st ri ct ure, t umor, st one) Retrograde pyel ography (t umor, st one, mal format ion) CBC (i nfecti on) Chemi st ry panel (hypercalcemi a, hyperuricemi a) St rai n uri ne for st one CT scan of the abdomen and pel vi s (t umors, st ones, mal format i on)

Penile pain

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Penile Sores

Penile Sores

To recal l t he pos si bl e causes of peni l e sores, t hi nk of the smal l es t micro-organi sm up t o t he largest . Virus. This bri ngs t o mi nd genit al herpes (herpes si mpl ex virus 2 [HSV2]). Geni t al wart s are i ncl uded here, but are rarel y di ffi cul t t o diagnos e. Bacteria. This shoul d faci li t at e t he recal l of chancroid (caused by Haemophil us ducreyi ; baci l lus ), lymphogranul oma venereum and granuloma i ngui nale (caused by calymmat obact eri um granulomat ous). Abscess and balani t is shoul d also be recal led here. Spirochete. Thi s sugges t s chancre, t he fi rst st age of syphi li s. The above clas si ficat i on would not hel p recal l an epi t hel ioma or lacerat i on and ot her l es i ons caused by t rauma.

Approach to the Diagnosis
Somet hi ng that i s oft en negl ect ed t oday i s t he t racking down of contact s whi ch can as si st i n t he di agnosi s. A pai nl es s les i on sugges t s chancre, whereas a pai nful l es ion i s t ypical of chancroi d, herpes si mpl ex, or bal ani t is . The presence of i ngui nal lymphadenopat hy s houl d alert t he cl ini ci an t o l ymphogranuloma venereum, chancre, and epit hel ioma. A smear and cul t ure s houl d be done i f bal anit i s or chancroi d i s t he cl ini cal di agnosi s. A dark fi el d exami nat ion i s done t o confi rm t he di agnosi s of chancre. The fi ndi ng of int racell ul ar Donovan bodi es wil l confirm t he diagnos i s of granul oma i ngui nale. A Tzanck t es t wil l assi st i n t he di agnos is of geni t al herpes but is not us uall y necessary. Serol ogi c t est s or a Giems a st ai n of scrapi ngs of t he pri mary l esi on may be exami ned for incl usi on bodies i n cases of lymphogranul oma venereum. A bi opsy i s necessary t o diagnos e an epit hel ioma.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Periorbit al and F ac ial Edema

Periorbital

and Facial Edema
The mechanism for peri orbi t al and faci al edema i s si mi l ar t o t hat for edema of t he ext remi t i es . Thus, increas ed backpres sure of t he veins wil l cause peri orbit al edema i n right heart fai l ure, const ri ct i ve pericardit i s, advanced pul monary emphys ema, and t hrombos i s or extri nsi c obst ruct ion of t he superi or vena cava (as in medi as t inal t umors). Hi gh blood pressure from acut e glomerul onephrit i s and mal ignant hypert ensi on wi l l cause peri orbit al and facial edema. Low serum albumi n wi ll l ead t o periorbi t al and faci al edema i n nephrosi s and cirrhos i s. Mucoprot ei n i n t he subcut aneous t is sue wi l l cause periorbit al edema i n hypot hyroi di sm. Other caus es for periorbit al edema are not ass oci at ed as frequent l y wit h edema in t he ext remi t i es. Al l ergic or i nfl ammat ory dil at at i on of t he capi l lari es around t he eyeli ds wi ll cause peri orbit al edema i n dermat omyosi t is and tri chi nosi s. A t hrombos ed cavernous si nus wil l al so cause peri orbit al edema, but t hi s is s imi l ar t o t hrombophlebi t i s of an ext remi t y. Local causes for periorbit al edema i ncl ude orbit al cel lul i t i s, urt i cari a, angi oneurot ic edema, contus i ons, and ot her orbi t al t rauma. The workup for peri orbit al edema i s si mi lar t o t hat for edema of t he ext remi t i es (see page 147).

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Phot ophobia

Photophobia

Sensi t ivi t y t o l ight may be due t o l ocal eye di sease or sys t emi c di sease, but in bot h cases i t is usual ly due t o i nfl ammat i on, wi t h t hree except i ons: al bi ni sm becaus e t here i s poor pi gment at i on of t he iri s and choroi d, al l owing more l i ght t o get in; mi grai ne, where t he explanat i on is s t il l not avai l able; and eye s t rai n from ast i gmat is m and, in part i cul ar, hyperopi a.

Local eye disease
Foll owi ng the pat h of l ight from t he conjunct i va t o t he ret ina, one may easi l y recall t he caus es of phot ophobi a. Conjunct i vi t is (chemical , al l ergic, and i nfect i ous), kerati t i s, forei gn bodies of t he cornea, i rit i s, ret i ni t i s, chori oret i ni t i s, and opt i c neuri t is may all be ass oci at ed wi t h phot ophobia.

Systemic disease
Al l the febri l e s t at es , especi al ly t hose ass oci at ed wi t h conjunct i val infect i on, cause phot ophobia. Measl es , meni ngit i s, encephal i t i s, hay fever, i nfl uenza, t he common col d, and t ri chi nosi s are just a few. Cert ai n t oxi ns can caus e phot ophobia, not ably i odi ne, bromi de, and at ropine deri vat i ves. Simpl y st aying i n t he dark wi ll cause phot ophobia. Hys t eri a and si mpl e fear or annoyance wi t h crowds wil l al so cause t hi s condi t ion.

Approach to the Diagnosis
The approach t o t he di agnosi s of phot ophobia i s t he same as t hat of bl urred vi si on (see page 67).

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Polyc yt hemia

Polycythemia

Pathophysi ol ogy wi ll help t o form a l i st of di agnos t ic poss ibi li t i es in a cas e of polycyt hemi a. Fi rst , it i s i mportant t o excl ude t hose cases of polycyt hemi a t hat are due t o a reduced plas ma volume such as dehydrat i on, diarrhea, P.355 and Gais böck syndrome i n whi ch t he act ual red cell mass is normal. Next , separat e t hose cases of polycyt hemia t hat are caus ed by an outs ide st i mul us t o t he bone marrow. This invol ves t wo groups: Those wi t h anoxi a as t he st i mul us and t hose wi t h t he hormone eryt hropoi et i n as t he st imul us . The anoxi c group i ncl udes pulmonary emphys ema, alveol ar hypovent il at ion, and cyanot i c congenit al heart di s ease. The group wit h eryt hropoi et in as t he st i mul us i ncl udes pheochromocytoma, Cus hi ng di sease, hydronephros i s, renal cel l carci noma, renal cyst , cerebel l ar hemangiobl ast oma, and hemat oma. Final l y, we are l eft wit h t he form of polycyt hemia t hat has no P.356 outs ide st i mul us for red cell product i on: pol ycyt hemia vera. Thi s i s most l i kely a neopl ast i c di sorder, and, i n fact, i t has been t ermed a “myel oprol iferat i ve†syndrome. In t hi s di sorder, t here i s al so leukocyt os is and t hrombocytos i s, whi ch are di st i nguis hi ng feat ures.

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Periorbital and facial edema

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Approach to the Diagnosis
Bl ood volume st udi es, serum and uri ne osmol al i t y st udi es, and el ect rol yt e ass essment wi ll help di fferent iat e rel at i ve or spurious forms of polycyt hemi a. Art eri al bl ood P.357 gas analys i s wil l di st i ngui sh t hose cases associ at ed wi t h anoxia such as pul monary emphys ema and cyanot i c heart di sease. Det ermi ni ng the bl ood eryt hropoi et i n wi ll help t o different iat e cases of eryt hropoi et i n as the st i mul us .

Polycythemia

Other Useful Tests
CBC (polycyt hemi a) Pl at el et count (polycyt hemia vera) Chemi st ry panel (renal di sease, heart di sease) IVP (hypernephroma) CT scan of the abdomen (hypernephroma) Chest x-ray (pul monary emphys ema) Pulmonary funct i on st udies (pulmonary fi brosis or emphysema) Cardiac cat het eri zat ion (congeni t al heart di sease) Pulmonary cons ul t Hemat ol ogy consul t Bone marrow examinat ion (myel oprol i ferat i ve di sorder)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Polydipsia

Polydipsia

Excessi ve t hi rst is best anal yz ed by t he appli cat ion of physiology. Increased des ire for wat er may be due t o a decreased intake, as in prol onged abs t inence, vomi t i ng of pyl ori c st enos is and int est i nal obst ruct i on, and diarrhea of any caus e. Poor transport of flui d i n hemorrhagic or vasomot or shock and CHF may be t he cause. Anyt hi ng that decreas es t he effect ive ci rcul at ory vol ume, s uch as hypoalbumi nemia, may caus e ret ent i on of sal t and consequent t hi rst t hrough the reni n–angi ot ensin–al dost erone mechanism. Increased output of wat er may be res pons i bl e for polydi psi a. The increas ed out put may resul t from a sol ut e diuresi s in di abet es mel li t us and hypercalcemi c s t at es (e.g., hyperparat hyroi di sm); an increas ed glomerul ar fi l t rat i on rat e i n hypert hyroi di sm; i nabil i t y of t he kidney t o res pond t o ant idi uret i c hormone (ADH) i n chroni c gl omerulonephri t i s, al dost eroni sm, and renal di abet es i nsi pi dus; or a l ack of ADH i n diabet es ins i pi dus. Increased output of sal t and wat er i n excessi ve s weat i ng of work or fever wi l l lead t o t hi rst . Thi s mechanism i s an addit i onal fact or i n hypert hyroidi s m and di abet es mel li t us where diaphoresi s i s common. A neurosis may be res ponsi bl e for pol ydips i a i n neurogenic di abet es ins i pi dus. Drugs such as li t hi um and demecl ocycl i ne hydrochl ori de (Declomyci n) can damage t he dis t al t ubul e and caus e renal di abet es i ns ipi dus. Drugs such as bel ladonna al kaloi ds , ami t ript yl ine hydrochl ori de, parasympat hol yt i c drugs, and gal l i c aci d may cause a dry mout h and an exces si ve t hi rst . Al cohol may cause excessi ve t hi rst by i nhibi t i ng ADH.

Approach to the Diagnosis
The approach t o t he di agnosi s of pol ydips i a i nvolves es t abli shi ng t he presence or abs ence of ot her s ymptoms such a polyuri a, polyphagi a, weakness , and weight l oss . Pol ydips ia wi t h pol yuri a and excessi ve appet i t e (polyphagi a) shoul d s uggest di abet es

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mel li t us or hypert hyroi di sm, whereas pol ydips ia wi t h pol yuri a alone shoul d sugges t a form of diabet es i nsi pi dus (pi t ui t ary, renal , or psychogeni c). The l aborat ory workup i nvol ves checki ng int ake and output , bl ood sugars, el ect rol yt es , and a t hyroid profi le.

Other Useful Tests
Uri nalys i s (renal or pi t ui t ary diabet es i nsi pi dus) Serum and urine os mol al i t y (di abet es ins i pi dus) Serum parathyroi d (PTH) l evel (hyperparat hyroi di sm) Serum ADH l evel (di abet es i ns ipi dus) 24-hour urine cal ci um (hyperparat hyroi di sm) Serum growt h hormone, lut ei ni zi ng hormone (LH), and fol li cl e-s t imul at i ng hormone (FSH) l evels (pi t ui t ary t umor) Hickey–Hare t est (di abet es i nsi pi dus) Pi t ressi n t es t (renal di abet es i ns ipi dus) CT scan or MRI of t he brai n (pit ui t ary t umor) Micros copic exami nat i on of the uri nary sediment (chroni c renal di s ease)

Case Presentation #73
A 44-year-ol d whi t e male Y MCA Summer Camp s upervi sor complai ned of a 1-week hi st ory of exces si ve t hi rst , pol yuri a, and wei ght l oss . He denied fever, chi ll s, or pal pi t at i ons. Question #1. Utilizing your knowledge of physiology, what would be on your list of possible causes? Further history reveals that he has a ravenous appetite. Physical examination was unremarkable, but he had a sweet odor to his breath. Urinalysis revealed 4+ glucose and was strongly positive for acetone. Vi ew Answer Hypert hyroi di sm Diabet es mel li t us Hyperparat hyroi di sm Diabet es ins i pi dus Chroni c renal di sease Psychogeni c pol ydips ia

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Question #2. What is your diagnosis now? Vi ew Answer Diabet i c aci dosi s Final Diagnosis: Di abet ic aci dosis

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Polyphagia

Polyphagia

The causes of i ncreased appet it e are si mi l ar t o t hose of obes it y and can be recall ed wi t h t he hel p of physiology. P.358 The appet i t e may be bas ed on a ps ychi c desi re for food, a lack of food or a parti cul ar vi t ami n, i mpaired i nt ake of food, an i ncreased met abol i sm of t he body (and cons equent ly an i ncreased need for food), increased upt ake of food by t he cel l , and inabi l i t y of t he cel l t o absorb food, caus i ng “cel l s t arvati on.â€

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Polydipsia Psychic desire for food. Thi s occurs in many chroni c

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anxiet y and depres s ed st at es and is frequent l y associ at ed wi t h obes i t y. Lack of food or a particular ingredient in food. St arvat i on and avi t ami nosis can cause pol yphagi a. P.359

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Polyphagia Impaired uptake of food. Rapi d mobi li t y of food i n gast ric hypers ecreti on and i nt es t inal bypass as wel l as preempt i ng of food by i nt es t inal worms may cause polyphagi a on thi s basis . Increased body metabolism. Hypert hyroi di sm, rapi d growt h of adol es cence, and gi gant i sm are i ncl uded i n t hi s cat egory. Increased uptake of food by the cell. Any condi t i on associ at ed wi t h hyperi ns ul i ni sm (funct i onal hypoglycemi a and insulinomas) is recall ed in t hi s cat egory. “ Cell starvation.†cannot absorb gl ucose. P.360 Here di abet es mel l i t us and acromegaly are ass oci at ed wi t h di abet es where t he cel l

Approach to the Diagnosis
Ass oci at i on wi t h ot her sympt oms is the key t o a defi ni t ive di agnosi s of pol yphagia. Thus , pol yphagi a and obes i t y sugges t an is let cel l adenoma. Polyphagia wi t h pol yuri a, pol ydips ia, weaknes s , and weight l oss sugges t hypert hyroidi s m or di abet es mel l i t us . The laborat ory workup s houl d i ncl ude t hyroi d funct i on st udi es , a skull x-ray for pi t ui t ary si ze, gl ucose t ol erance t es t s, and, pos si bl y, a 48-hour fast wit h frequent bl ood sugar det ermi nat ions. An MRI of t he pit ui t ary i s t he best way t o reveal microadenomas .

Case Presentation #74
A 28-year-ol d whi t e man complai ned of a ravenous appet i t e for several months . Question #1. Utilizing your knowledge of physiology, what would be your differential diagnosis? Further history reveals that the patient had experienced episodes of weakness, palpitations, and sweating during the same period of time. He had recently gained 25 pounds.

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Vi ew Answer Hypert hyroi di sm Cushi ng syndrome Isl et cel l adenoma Diabet i c mel l it us Pi t ui t ary adenoma Tapeworm i nfest at i on Chroni c anxi et y neuros is Question #2. What is your diagnosis now? Vi ew Answer Insul i noma Final Diagnosis: Ins ul i noma was confirmed by s igni ficant hypoglycemi a during a 72-hour fast and expl oratory s urgery.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Polyuria

Polyuria

Polyuri a i s an absol ut e i ncrease i n t he uri ne out put in a 24-hour period. The average i ndi vi dual excret es 1,500 mL of urine a day. Many physi ol ogi c condi t i ons increas e t he out put of uri ne (st ress, exercis e, and warm weat her associ at ed wi t h copi ous dri nking). From a pat hophysiol ogi c st andpoi nt , pol yuri a resul t s from one of four mechanisms: (a) i ncreas ed int ake of fl ui ds , (b) i ncreased gl omerular fi l t rat i on rat e, (c) i ncreased out put of sol ut es s uch as sodium chl ori de and gl ucose, and (d) i nabi li t y of t he ki dney t o reabsorb water i n t he dis t al t ubule. Increased intake of fluid. As al ready ment ioned, increas ed int ake can occur under s t res s and nervous t ension. It becomes pathol ogic i n psychogeni c di abet es ins i pi dus when 6 t o 10 L of flui d may be i ngest ed each day. Increased glomerular filtration rate. This i s a fact or in t he pol yuri a of hypert hyroidi s m and fever of any caus e. Increased output of solutes. Uncont rol l ed diabet es mel li t us (where t he sol ut e i s gl ucose) and hypert hyroidi sm (where t he sol ut e may be glucose or urea) are examples of t hi s t ype of polyuri a. Hyperparat hyroi di sm i s anot her i mport ant cause (increas ed cal cium out put ). Di uret i cs are a si gnifi cant cause of t hi s t ype of pol yuri a because t hey i ncrease t he amount of sol ut e arri vi ng at t he di st al t ubul e and hold onto t he water t hat woul d ot herwi se be absorbed. Decreased reabsorption of water in the distal tubule. This, t he most common caus e of pol yuri a, is di vi ded int o t wo groups: Condi t i ons i n whi ch t here i s i nadequate or bl ocked out put of ADH and condit i ons i n whi ch t he di st al t ubule and col l ect i ng duct s are unable t o respond t o t he ADH. Decreas ed out put of ADH occurs i n diabet es

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ins i pi dus from pi t ui t ary t umors, i nfarcts , Hand–Schüll er–Chri st i an dis ease, and sarcoidosi s among other caus es . It al s o resul t s from al cohol int oxicat ion and hypot hal amus les i ons. The inabi l i t y of t he dis t al t ubule t o respond t o ADH occurs in al dost eronis m, chronic gl omerul onephri t is , pol ycyst ic ki dneys, pyel onephrit i s, l it hi um and demecl ocycli ne (Declomyci n) t herapy, and i di opat hi c nephrogenic di abet es i ns ipi dus. Di ureti cs operat e somewhat i n t hi s manner. Cases of myxedema wi t h polyuri a have been reported, but the mechanism i s uncl ear.

Approach to the Diagnosis
The di agnosi s of pol yuri a depends l argely on t he associ at i on of ot her s ymptoms . Pol yuri a, pol yphagi a, and polydips i a sugges t di abet es mel l i t us and hypert hyroidi s m. Pol yuri a wi t h onl y polydi psi a sugges t s psychogeni c or i di opat hi c di abet es i ns ipi dus; t he Hickey–Hare t est wi l l di fferent i at e t he t wo. Polyuri a wit h polydips i a and weaknes s but wit h no si gnifi cant wei ght l os s sugges t s hypercalcemi a and pos si bl e hyperparat hyroi di sm. Chroni c nephri t is wil l be diagnos ed by exami nat ion of t he uri ne sedi ment and a speci fic gravi t y t hat remai ns at 1.010. Nephrogeni c di abet es ins i pi dus can be different i at ed from neurogeni c di abet es ins i pi dus by t he inabi l i t y of t he ki dney t o res pond t o a pi t ressi n i nject i on.

Other Useful Tests
Thyroi d profil e (hypert hyroi di sm) Glucose t ol erance t est (di abet es mel l i t us) 24-hour int ake and out put (di abet es i ns ipi dus) Addi s count (chroni c nephri t i s) Serum ADH as say (di abet es i ns ipi dus) Serum and urine os mol al i t y (pi t ui t ary di abet es i nsi pi dus, nephrogenic di abet es i nsi pi dus) Spot uri ne sodi um (diabet es i nsi pi dus) P.361

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Polyuria P.362

CT scan of the brai n (di abet es ins i pi dus) PTH ass ay (hyperparathyroi di sm) Endocri ne cons ul t

Case Presentation #75
A 38-year-ol d whi t e woman pres ents t o your office wi t h a hi st ory of weakness , fat igue, depres si on, and frequency of urinat i on over t he past year. She denies fever, dys uri a, or si gni ficant wei ght l os s. Question #1. Utilizing your knowledge of pathophysiology, what is your differential diagnosis? Further history reveals that she had an episode of right flank pain and hematuria 6 months ago. Vi ew Answer Hypert hyroi di sm Diabet es mel li t us Chroni c gl omerul onephrit i s Pyelonephri t i s Diabet es ins i pi dus Pri mary hyperparathyroi di sm Al dost eroni sm Endogenous depres si on Question #2. What is your diagnosis now? Vi ew Answer Pri mary hyperparathyroi di sm Final Diagnosis: Pri mary hyperparat hyroidi sm was confirmed by repeat edly el evat ed serum calci um and parat hyroi d hormone ass ays.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Poplit eal Swelling

Popliteal

Swelling
The key to recal l i ng the caus es of a popl it eal swel l ing i s anatomy. Each st ruct ure i n t he popli t eal space may be i nvolved by one or t wo condi t ions t hat cause a mass or s well i ng. In vi suali zi ng t he anat omy, one encount ers the ski n, s ubcut aneous t i ssues, muscl es , bursae, vei ns , art eri es , lymphat i cs , nerves, and bones . Skin. The s ki n may be i nvolved by urt i cari a, sebaceous cyst s, carbuncl es, l ipomas , hemangiomas, and vari ous ot her s ki n masses. Subcutaneous tissue. Li pomas , sarcomas, and cel l ul it i s are t he mai n l esi ons encount ered. Muscle. Cont usi ons of t he gas t rocnemi us and semi membranous mus cl es may caus e a mass i n t he popli t eal fossa. Bursae. Popl it eal cyst s (Baker cys t s ) may resul t from fil l ing of t he burs a bet ween the gas t rocnemi us and semi membranous mus cl es wi t h a gel at i nous or serous subst ance. Veins. The vei ns may enl arge from a varicocel e or t hrombophlebi t i s. Artery. An aneurys m of t he popli t eal art ery may res ul t from at heroscl erosi s or a guns hot wound. W hen t here i s a l oud bruit over t he artery and di st ent i on of the vei ns , an arteri ovenous fis t ul a shoul d be consi dered. Lymphatics. Enlarged popl i t eal nodes may resul t from infect i ons in t he dis t al port i on of t he ext remi t y, t ubercul ous adenopat hy, or met as t at i c mal i gnancy. Nerves. Traumat i c neuromas or neurofi bromas may invol ve t he nerves here. Bone. Exost osi s ari si ng from t he epi physeal cart i lage of

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t he femur is a wel l-defi ned t umor of chi ldren or young adult s . Medull ary giant cel l t umors, fibrosarcomas of t he perios t eum, and os t eomyel i t is may present as a mas s i n t hi s area al so. Fract ures and peri os t eal hemat omas shoul d present no probl em i n diagnos i s.

Approach to the Diagnosis
Ini t ial workup incl udes a CBC, sedi ment at i on rat e, and an x-ray of t he knee. If t hese have negat i ve fi ndings, i t may be wis e t o consul t an orthopedi c surgeon before any ot her t est s are done. If a Baker cyst i s sus pect ed, aspi rat i on wi l l help make t he di agnosi s. Before doing t hi s, i t is wi se t o rul e out a varicocel e by watchi ng for the di sappearance of t he mass on el evat i on of t he leg. Ul t rasonography can als o assi st in t hi s di fferent i at i on. Ul t rasonography wi l l al so be helpful i n rul i ng out an aort ic aneurysm. If t here is joi nt swel li ng or ot her s igns of joi nt invol vement , an MRI shoul d be performed. If t he mass seems fi xed t o t he bone, a bone s can or CT scan of t he bone and joint i s ordered.

Other Useful Tests
CBC Sediment at ion rat e (absces s) Tuberculi n t es t Art hri t i s profi l e (gout , l upus, rheumat oi d art hri t is ) Synovial fl ui d anal ysi s (sept i c art hri t i s, rheumat oi d art hri t i s, lupus ) Art hroscopy (t orn meni scus ) Lymphangi ogram (lymph node mas s) Explorat ory s urgery and bi opsy Art eri ogram (Baker cys t , aneurysm)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Priapism

Priapism

This unfort unat e condi t i on may be humorous t o everyone but t he one who i s “bl ess ed†wi t h i t . The common caus es are few, and t he mnemonic MINT i s an easy met hod for recall of t hese. M—Malformation sugges t s phimos i s and ot her deformit i es of t he penis. I—Inflammation and intoxication sugges t post eri or urethri t i s, pros t at i t i s, and cyst i t i s, as wel l as aphrodisi ac drugs such as si l denafi l cit rat e, al cohol , cannabis , indi ca, camphor, and dami ana. N—Neoplasms suggest t wo common caus es of pri apism—chroni c l ymphat i c or myeloi d l eukemi a P.363

and nasal polyps. The N al s o sugges t s neurologic di sorders such as neuros yphil i s, mul t i pl e scl erosi s, and di abet i c neuropat hy.

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Popliteal swelling T —T rauma recall s not only di rect t rauma to t he penis produci ng a local hemat oma but al s o t rauma t o t he spi nal cord wi t h fract ures or cont usi on.

Approach to the Diagnosis
The di agnosi s of pri api sm us uall y depends on t he associ at i on of ot her s ymptoms and si gns (e.g., boggy pros t at e), but a bl ood

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smear or bone marrow exami nati on may be neces s ary t o excl ude leukemi a. A careful hi st ory of t he pat i ent's sexual act ivi t i es t o rul e out t oo-frequent mast urbat i on or sexual excesses may be i ndicat ed.

Other Useful Tests
CBC (l eukemi a, si ckl e cel l anemi a) Coagulat ion st udi es (bl ood dyscras i as) Prost at i c massage and exami nat i on of the di scharge (prost at i t is ) P.364

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Priapism Uri ne cul t ure (cyst i t is , pyelonephri t is )

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Serum prot ei n el ect rophoresi s (macrogl obul inemi a) MRI of t he brai n (t umor, cerebrovas cul ar accident [CVA], mul t ipl e scl erosi s) MRI of spi nal cord (mult i pl e s cl erosi s, space-occupyi ng les i on) Spinal tap (mul t i pl e s clerosi s, neuros yphil i s) Neurology consul t Urology consul t

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Prost at ic Mass or Enlargement

Prostatic

Mass or Enlargement

Prostatic mass or enlargement Generall y, when t he physici an exami nes t he prost at e i n a rout i ne

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physi cal , t here are only t wo condi t ions t hat he or she is l ooki ng for—benign pros t at i c hypert rophy and pros t at e carcinoma. The former pres ents a di ffuse enl argement , soft i n consi st ency, and t he prost at e varies i n si ze from a pl um t o an orange. Pros t at e carci nomas, i n cont rast , pres ent as a s t ony, hard nodule i n t he lat eral superi or or i nferi or areas in t he earl y s t ages or as a di ffuse, hard, nodul ar enlargement i n t he more advanced s t ages. The approach is di fferent for t he pat ient pres ent ing wi t h a uret hral di scharge or di fficul t y voi di ng, becaus e t hen one mus t i ncl ude acute and chronic prostatitis and prostatic abscess in t he di fferenti al . In bri ef, t hat is t he di fferent i al di agnosi s of an enl arged pros t at e. The only t ri ck t hat might be useful in rememberi ng it is t o keep i n mind t he ages 20, 40, 60, and 80. In general , 20-year-old men usual ly have acut e prost at i t i s from gonorrhea or other bact eri a. The 40-year-old P.366 men usuall y have chroni c prost at it i s from previ ous gonorrhea or from nonspeci fic prost at i t i s. The 60-year-ol d men generall y have prost at i c hypert rophy, and t he 80-year-old men mos t li kely have prost at i c carci noma. However, i t is import ant t o remember t hat any one of t hese diseases may appear at t he ages of 40, 60, and 80.

Approach to the Diagnosis
The mai n consi derat i on in diagnos i ng a pros t at i c mass i s t o rul e out carci noma. It i s t herefore wi se t o draw bl ood for prost at e-speci fi c anti gen (PSA) before proceedi ng in anyone who i s sus pected of havi ng prost at e cancer. If t he mass i s l ocated i n t he post eri or lobes , t here is furt her s upport for the di agnos i s. Ult rasonography can be done for furt her l ocal i zat i on before proceeding wi t h a bi opsy. Obvi ousl y, i f the PSA t es t is posi t i ve, referral t o a urol ogist i s mandat ory, alt hough fal se-posi t i ves can occur in t hi s t est . A l arge, boggy pros t at e sugges t s a prost at i c abscess or prost at i t is . If t here i s no uret hral di s charge, one can el i cit a di scharge by pros t at i c mass age. However, t hi s shoul d not

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be done if t he pat i ent has fever and s igni ficant t enderness of t he prost at e. It i s bett er t o proceed wit h ant i bi ot i c t herapy and reexami ne the pat ient aft er t he fever has subsided. A s mear and cul t ure of the di scharge i s made. If upon examini ng t he di scharge under high-power mi cros copy, four or more whit e bl ood cel l s (W BCs) per high-power fi el d are found, t he di agnos is of prost at i t is can be made. If benign pros t at i c hypert rophy i s sus pect ed, cyst oscopy and ret rograde pyel ography can be done.

Other Useful Tests
CBC Sediment at ion rat e (i nfect i on) Chemi st ry panel (uremi a) Uri nalys i s (cyst i t i s, UTI) Cyst ogram (pros t at ic hypert rophy) Skelet al survey (met as t at i c carci noma) Bone scan (met as t at i c carci noma) Acid phos phat ase l evel (met as t at i c carci noma) CT scan of pelvi c l ymph nodes (met ast as i s) Lymphosci nt igraphy (node met ast as i s) Cyst oscopy (bl adder neck obs t ruct i on)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Prot einuria

Proteinuria

There are many caus es of prot ei nuria. The mnemonic VINDICAT E i s a helpful way of developi ng a li st of possi bi l i t i es. V—Vascular cat egory s hould cal l t o mi nd CHF, hypert ensi on, and renal vei n t hrombos i s. I—Inflammation. An import ant cause of prot ei nuria i s UTI. In addit i on t o t he common bact eri al infect i on, one shoul d not forget t ubercul osi s, schi s t osomi as i s, vi ral hepat i t i s, syphi li s, and mal ari a. N—Neoplasm cat egory i ncl udes W i l ms t umor, renal cel l carci noma, papil l oma of t he renal pelvi s and bl adder, and mul t i pl e myeloma. D—Degenerative di sorders are not a common caus e of protei nuri a. I—Intoxication cat egory i ncl udes t oxi c reacti ons t o gold, mercury, gent amycin, peni ci l l ami ne, capt opri l, and anti convul s ants . There are many other drugs t hat cause protei nuri a. Idiopathic prompt s t he recal l of ort host at i c protei nuri a. C—Congenital causes shoul d bri ng t o mi nd pol ycyst ic ki dneys, Al port syndrome, Fabry dis ease, horseshoe ki dney, and ot her congeni t al anomal ies . A—Allergic and autoimmune shoul d cal l t o mi nd acut e gl omerulonephri t i s, col l agen diseases , W egener granul omatos i s, Henoch–Schönl ei n purpura, amyloi dosi s, sarcoi dosis , and chronic i nt ers t it i al nephri t is . T —T rauma. The ki dneys are i nvol ved i n various forms of t rauma caus ing prot ei nuria, but us uall y t here is associ at ed hemat uri a. St ones shoul d also be i ncl uded i n t hi s cat egory becaus e t hey cause t rauma, induci ng protei nuri a and hemat uri a.

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E—Endocrine di s orders incl ude di abet i c nephrosi s, myxedema, and Graves di sease.

Approach to the Diagnosis
The first st ep i s t o det ermi ne whet her t he prot ei nuria i s caused by infect i on. A uri nalys is for W BCs and exami nati on of a fres h drop of unspun uri ne under the mi croscope for t he bact eri a are t he fast est ways of det ermi ni ng t hi s. The uri ne can als o be cul t ured. Next , determi ne i f there are red cel ls in t he uri ne. Thi s woul d i ndi cat e a more seri ous cause for t he prot ei nuria s uch as col l agen dis ease, st one, gl omerul onephrit i s, or neopl as m and prompt s t he need for an IVP, cyst os copy, and urol ogy consul t .

Other Useful Tests
CBC (pyel onephrit i s, i nfecti ous di sease) Sediment at ion rat e (i nfect i ous di sease) 24-hour urine prot ei n (nephros i s) Chemi st ry panel (uremi a, l i ver dis ease) Uri ne for Bence–Jones prot ei n (mult i pl e myel oma) Serum prot ei n el ect rophoresi s (mul t i pl e myeloma, col l agen disease) ANA analysi s (col lagen di sease) Addi s count (gl omerul onephrit i s) ASO t i t er (acut e glomerul onephrit i s) P.367

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Proteinuria CT scan of the abdomen and pel vi s (neopl as m, mal format i on) Retrograde pyel ography (neopl asm, hydronephros i s) Nephrology consul t Renal bi opsy (gl omerul onephrit i s) Renal angi ogram (renal art ery s t enosi s, renal vei n t hrombosi s)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Prurit us

Pruritus

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Pruritus The di fferenti al di agnos i s of pruri t us i s best devel oped by

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anatomy. Local condi t ions such as bi t es and paras i t i c i nfest at i ons (e.g., scabi es, hookworms , and schi st os omi as is ) usuall y reveal an obvious l es ion. General iz ed ski n condi t ions s uch as dermat it i s herpet i formi s, at opic dermat i t i s, and exfol iat ive dermat i t is are also more l i kely t o s how obvi ous ski n mani fest at i ons and severe i t chi ng. These condi t i ons are t o be di s t ingui shed from cut aneous syphi l is , where there i s no i t chi ng at al l, and ps ori asi s and pemphi gus, where the i t chi ng is mi ni mal . Numerous P.369 ot her s ki n condi t i ons cause prurit us , but we are more concerned wit h t he sys t emi c causes because t hey are more diffi cul t t o di agnose. Jaundi ce, part icul arl y obst ruct i ve jaundi ce, i s associ at ed wi t h marked prurit us . Primary bi l iary ci rrhosi s may begi n wi t h pruri t us wit hout jaundi ce because t he li ver must t urn more t han 30 g of bi le sal t s (t he caus e of t he i t chi ng) a day t o only 1 g of bi l i rubin. Thus, al t hough there may be enough funct i on left t o t urn over t he bi l irubi n, t here is not enough t o t urn over t he bil e s al t s. Diabet es mel li t us may cause pruri t us, part i cul arl y vulvar, where i t predis poses t o moni l ias i s. Renal di sease may al so caus e prurit us , presumabl y because of t he ret enti on of t oxic wast e product s. Fi nall y, l eukemi a and Hodgki n l ymphoma are s ys temi c causes of pruri t us. Of cours e, psychoneuros i s and mal i ngeri ng must be considered. In addi t ion t o s yst emi c condi t i ons ment ioned above, one s houl d search for l ocal condi t i ons in t he anus and rect um (prurit us ani), especi al l y hemorrhoids (int ernal ones may not be obvi ous), anal fis sure, anal absces s or fis t ul a, and anal monil i asi s or pi nworms . Condyloma acumi nat um may cont ribut e t o pruri t us. Any vaginal di scharge may caus e pruri t us vul vae. Thus, T ri chomonas and Candida organi sms shoul d be looked for. One shoul d also cons ider l ack of est rogen l eadi ng t o atrophi c vagi ni t is and dermat it i s.

Approach to the Diagnosis

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It shoul d be obvious t hat t he cli ni cal approach t o pruri t us wi t hout an obvious dermat ol ogic mani fest at i on is t o order appropriat e t est s. See bel ow t o rul e out t he above s ys t emi c di sorders.

Other Useful Tests
CBC (l eukemi a, polycyt hemi a) Chemi st ry panel (l iver di sease, uremi a) Thyroi d profil e (hypert hyroi di sm) Glucose t ol erance t est (di abet es mel l i t us) Protei n el ect rophoresi s (l ymphoma, myel oma) CT scan of abdomen (mal ignancy) Skin biopsy Dermat ol ogy consul t

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pt osis

Ptosis

A drooping eyeli d may resul t from di rect i nvolvement of t he levat or palpebrae superi ori s muscl e (end organ) or from i nvolvement of t he sympat het ic or ocul omot or nerve pat hways from t he muscl e t o t he central nervous sys t em. Consequent l y, vi sual i zi ng neuroanatomy is t he key t o a different i al di agnos i s. End organ (l evat or palpebrae superi ori s muscl e). The end organ can be invol ved in congeni t al pt osi s (defect ive devel opment of t he muscl e), i njury to t he t endon of the mus cl e, neoplas ms of t he eye or orbi t , or dermat omyosi t is . Sympathetic pathway. If the sympat het i c pathways are invol ved t here i s al most i nvari ably an as soci at ed mi osi s and enophthal mos (Horner syndrome). The l es ion may be al ong t he int racrani al pat hways of t he pos t gangl ioni c fibers around t he carot i d art ery i n i nt ernal carot i d aneurysms , thrombos i s, and mi graine. Orbi t al cel l ul i t i s or t umors may rarely affect t he sympat heti c nerve pathways here. The l esi on may be i n t he st el lat e gangl i on and it s connect i ons in cervi cal ri b, scal enus anti cus syndrome, Pancoas t tumors, cervi cal Hodgkin lymphoma, and brachi al pl exus i njuri es . The les ion may be in t he spi nal cord or nerve root s i n spi nal cord t umors, syri ngomyel i a, syphi li s, t horaci c spondyl osi s, met as t at i c carci noma, myel oma, or t ubercul os is of t he spi nal col umn. Final ly, t he l esi on may be i n t he brains t em i n gli omas, post eri or i nferi or cerebell ar art ery occlus ions, syri ngobul bi a, and encephal i t i s. Oculomotor nerve pathways. W hen t he pt osi s i s due t o invol vement i n t hi s pathway, t here are us uall y ot her extraocul ar mus cl e pals ies as well . The l evator mus cl e may be affected by myot oni c dyst rophy. The myoneural

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juncti on may be affect ed by myas t heni a gravi s. The oculomot or nerve may be i nvol ved by orbi t al tumors or cel l ul it i s by compres si on from herni at i on of the uncus i n cerebral t umors or s ubdural hemat omas, by cavernous si nus thrombos i s or carot i d aneurysms, and occas i onall y by syphi l i t ic or t ubercul ous meningi t is or pi t ui t ary and suprasel l ar t umors. Di abet i c neuropat hy may caus e pt os is due to ocul omot or nerve i nvol vement . In t he brains t em, t he nucl ei or supranucl ear connect i ons of t he oculomot or nerve may be i nvol ved by syphi l i s (e.g., general paresi s), gl i omas, pi neal omas, basi l ar art ery occlus ions, encephal i t i s, bot ul is m, and progres si ve muscul ar at rophy.

Approach to the Diagnosis
As al ways , t he diagnos i s i s us uall y es t abli shed by t he pres ence or absence of other neurol ogic s igns and sympt oms . Bi lat eral part ial pt os is suggest s myot oni c dyst rophy, a congeni t al origi n, or progressi ve muscul ar dyst rophy. Uni l at eral pt os is wi t hout mi osi s or extraocul ar mus cl e pals y sugges t s i njury to t he levat or palpebrae P.370 superi ori s muscl e or myast heni a gravi s. A Tens i lon t es t shoul d al ways be cons i dered. W hen al l t he component s of Horner s yndrome are present , x-rays of t he skul l, cervi cal and t horacic s pi ne, and chest shoul d be done. A s pi nal t ap and art eri ography shoul d be considered.

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Ptosis If oculomot or i nvolvement is cert ai n, a glucos e t ol erance t es t , skull x-rays, serologic t es t s for syphi l i s, spi nal tap (i f no contrai ndi cat i ons), CT s cans, and, pos si bl y, art eri ography are indi cat ed. The need for ot her t es t s depends on t he presence of ot her neurol ogic si gns. An opht halmol ogi st and neurol ogis t shoul d probably be consul t ed in al l cases of unil at eral pt os is .

Other Useful Tests
CBC (orbit al cel lul i t i s) ANA analysi s (col lagen di sease) Acet yl choli ne recept or ant ibody t it er (myast heni a gravi s)

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MRI of t he brai n (brain t umor or ot her space-occupyi ng les i on) Cerebral angi ogram (cerebral aneurys m) Response t o i nt ravenous t hi ami ne (W ernicke encephal opat hy) 24-hour urine creat ini ne and creat i ne (muscul ar dyst rophy) P.371

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Ptosis P.372

CT scan of medias t inum (medi as t i nal t umor, aneurys m) Chest x-ray (mal ignancy) Lymph node biopsy (l ymphoma)

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pt yalism

Ptyalism

The mnemoni c MINT wi ll faci l i t at e t he recal l of t he most i mport ant causes of pt yali sm. M—Malformation woul d prompt t he recal l of congenit al es ophageal at resi a. I—Inflammation ought t o s ugges t herpes si mpl ex, apht hous st omat i t is , and peri t onsi ll ar absces s. Syphi l is and t ubercul osi s rarel y cause ptyal i sm. N—Neurologic disorders that cause pt yali sm i ncl ude bulbar pal sy (as i n amyot rophi c lat eral scl erosi s and poli omyel it i s) and ps eudobul bar pal sy (as in mul t ipl e scl erosis and brai nst em gl i omas). They shoul d also sugges t myast heni a gravi s, Parki nsoni sm, and pt yali sm associ at ed wi t h dement i a. T —T oxic disorders t hat cause ptyal is m incl ude i odi ne medicat ions, mercury poi s oning, pi locarpi ne and ot her parasympat homimet ic drugs .

Approach to the Diagnosis
The most i mportant t hi ng t o do is look for ul cerat i ons or ot her abnormali t i es of t he mout h and oropharynx. Dental cares and gi ngivi t i s may caus e ptyal is m as may an i l l-fi t t ed dent al pl at e. If local condi t i ons can be excluded, a t horough neurol ogic exami nat i on shoul d be done t o rul e out bul bar and ps eudobul bar pal sy. A Tensi lon t es t or serum acet yl chol i ne receptor ant i body t i t er can be done t o excl ude myast henia gravi s . The busy phys ici an wi l l want t o consul t a neurol ogi st t o do t hi s. Al t hough a CT s can or MRI may be needed, a neurologic cons ul t is more cost -effecti ve. Do not hesi t at e t o consul t a dent i st or oral surgeon if t he di agnosi s i s i n doubt .

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pulsat ile Mass

Pulsatile Mass

Si mpl y by thi nking of t he locat i on of the pul sat i l e mass , one can ident i fy t he caus e or causes of a pul sat i l e mass. Orbit. This i s mos t li kely an art eri ovenous fist ul a rel at ed t o t rauma or t he spont aneous rupt ure of an aneurysm i nt o t he cavernous si nus. Neck. A carot i d, i nnomi nat e, or brachi al art ery aneurys m is the mos t li kely caus e here, but pul sat i ons may be fel t in t he neck from aort i c regurgi t at i on as wel l. Chest. An aneurys m of t he thoraci c aort a i s t he most li kely caus e here, but an enl arged heart or cardiac aneurysm may gi ve a not i ceabl e heave on i ns pect i on. Abdomen. Tri cuspi d regurgi t at i on may caus e pul sat i ons of t he li ver i n t he ri ght upper quadrant , but t he associ at ed asci t es and dependent edema shoul d make t he diagnos i s obvi ous. A puls at i ng abdomi nal aort a i s usual ly an at heroscl eroti c aneurysm, but i t may be an abnormal fi nding in ast heni c i ndivi dual s . It i s al so possi bl e t hat t he pul sat i ng mass is a t umor over a normal abdomi nal aort a. Extremities. A pul sat ing mas s in t he axi ll a, groi n, or popli t eal fossa i s usual ly an aneurys m, but ost eosarcoma can produce a pul s at i ng mass al ong wi t h eggshell cracki ng.

Approach to the Diagnosis
Ult rasonography wi ll us uall y confirm t he di agnos is of t hese l esi ons, but a CT scan or angi ography may be neces sary, part icul arl y when surgical i nt ervent ion i s pl anned. A cardi ovascul ar surgeon shoul d be consul t ed before ordering t hese expensi ve t es t s.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pulse Rhyt hm Abnormalit ies

Pulse

Rhythm Abnormalities
Vi sual iz ing t he conduct i on syst em of t he heart from i t s begi nning i n t he si nus node t o i t s ends i n t he ventri cul ar mus cl e, one can devel op a li st of t he caus es of pulse i rregul ari t i es. Sinus node. Pulse i rregul ari t i es as soci at ed wi t h t hi s node i ncl ude si nus arrhyt hmi a and si ck si nus syndrome. Atrium. Paroxys mal at ri al t achycardi a, at ri al premat ure contract i ons, at rial fl ut t er, and fi bri l lat i on are brought t o mi nd when we focus on t he at ri um. Arterioventricular (A-V) node. A-V nodal rhyt hm and nodal t achycardia are sugges t ed by t hi s anatomi c st ruct ure. Bundle of Hiss. This st ruct ure prompt s t he recal l of 1 s t , 2 n d , and 3 rd degree heart bl ock. Ventricular muscle. This t i ss ue facil i t at es t he recal l of vent ricul ar premat ure cont ract i ons (PVCs ), ventri cul ar t achycardia, and vent ri cul ar fi bri l lat i on. Si mpl y vi sual iz ing t he cardi ac conduct i on syst em wi l l not hel p t o recall t he slow pul se of vasovagal syncope or paras ympat homimet i c drugs. Furt hermore, a met hod of recall i ng the vari ous causes of t hese cardiac arrhyt hmi as i s st i l l needed. Thes e are consi dered on page 77 t hrough page 78. P.373

Approach to the Diagnosis
It is wi se t o get a cardi ol ogy consul t at t he out set . Rout i ne workup incl udes a CBC, s ediment at i on rat e, t hyroi d panel, chemis t ry panel , el ect rocardi ogram (EKG), and ches t x-rays. If rheumat i c fever is

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sus pected, an ASO t i t er or st rept ozyme t es t wil l be ordered. Echocardiography, Hi s s bundl e s t udies , and 24 hour Hol t er monit ori ng may be neces s ary. If a valvul ar les i on or coronary art ery di sease i s sus pect ed, cardi ac cat heteri z at i on and angiocardi ography wil l be necessary.

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Authors: Collins, R. Douglas T itle: Differential Diagnosis in Primary Care, 4th Edition Copyri ght ©2008 Li ppi ncot t W i ll i ams & W i l ki ns
> T able of Cont ent s > P > Pyuria

Pyuria

Pyuria i s i ncl uded here al t hough it i s not a sympt om or a defi ni t ive findi ng on phys i cal exami nat ion. Exami nati on of t he urine, however, is so frequent ly a part of every phys ical examinat i on that t he causes of pyuri a shoul d be avai l able for i mmedi at e recal l for al l pri mary care phys i cians. As i n ot her cases of purul ent di scharge, i nfl ammat i on is t he caus e of pyuria i n most cas es, t hus an et i ol ogic mnemoni c woul d seem unnecessary. However, t he mnemoni c MINT mus t be cons i dered at t he out set so t hat one recall s t he mal format i ons, neopl asms , and t raumat ic forei gn bodies t hat may caus e an obst ruct i on or provide a frui tful s oi l for bact eri al growt h. Unli ke a nonbl oody dis charge el sewhere, pyuria i s rarel y as soci at ed wi t h i nfl ammati on of a noninfect i ous nat ure; more t han t hat, i t is al most i nvariabl y due t o bacteri a. W hat is more, t he bact eri a are us uall y Gram-negat i ve bacil l i, part i cul arl y Es cherichi a col i , Ent erobac t er, Prot eus, or Pseudomonas organi sms . W i t h t hi s i n mi nd, l et us vi sual iz e t he anatomy of t he genit ouri nary t ree and develop a sys t em for ready recal l of t he di agnost i c possi bi l i t i es. The urethra bri ngs t o mi nd al l t he vari ous causes of uret hri t i s (see page 442). The prostate remi nds one of prost at i t is and prost at ic absces s. The bladder s uggest s cys t i t is , st ri ct ure, Hunner ulcers , cal cul i , and papil l omas that may i ni t i at e infect i on. Some urol ogist s may recal l fi nding a ves i covagi nal fi st ul a or rect ovesi cal fi st ul a i n pat i ent s who have had previ ous abdomi nal surgery; a fi st ul a may al so form i n regi onal il ei t i s. The uret ers sugges t the numerous congeni t al anomal i es (e.g., s t rict ure, congenit al band, and aberrant ves sel ) t hat may cause obs t ruct i on and infect i on. The renal pelvis and kidney recall pyel it i s and pyelonephri t i s, as wel l as renal carci noma, cal cul i , and congenit al anomal i es, al l of whi ch may contri but e t o i nfect i on. The rare caus es of pyuria must be cons i dered. Tuberculos i s of t he

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ki dney shoul d be ment ioned, becaus e when rout i ne cul t ures are negat i ve, t hi s is one of t he condi t i ons t o l ook for. Even act i nomycos is can cause pyuri a, t hus a cul t ure on Sabouraud media may be warranted. Al t hough Bi l harzia haemat obi um parasi t es usual ly caus e hemat uri a, pyuri a i s occasi onal l y t he ini t i al findi ng. An int ers t i t ial nephri t is of t oxic or aut oi mmune ori gi n may occasi onall y cause a “s hower†of eosinophi ls int o t he urine. Fi nall y, t here is probably not a surgeon al i ve who has not been fooled by t he pyuri a of an acut e appendi ci t i s, sal pi ngi t i s, or di vert i cul i t i s.

Approach to the Diagnosis
How does one track down t he cause of pyuri a? Fi rst , it mus t be determi ned t hat t he cloudy uri ne is real ly pyuri a. Amorphous phosphat es and ot her i nert mat eri al wi ll di sappear on t reat i ng the uri ne wi t h dil ut e acet i c aci d. Then, jus t as for ot her nonbl oody di scharges , one must do a smear and cul t ure for t he offendi ng organi sm; an exami nat i on of the uri ne, especi al l y t he unspun specimen, i s axi omat i c. If one fi nds cl umps of leukocyt es , renal gi t t er cell s, or W BC cas t s, t he infect i on almos t cert ai nl y comes from t he kidney. Mot i l e bact eri a i n an unspun speci men examined under high-power mi cros copy and a colony count of over 100,000 per mL si gni fy infect i on. A t hree-gl as s t est may be hel pful i n local i zi ng the si t e of origi n of t he pyuri a. Anaerobi c cul t ures and cul t ures for Chlamydi a may be needed. Look for eos i nophi l s on a W ri ght st ai n of t he urine i f t oxic nephri t i s i s sus pected. Vagi nal exami nati on and cul t ure may di scl os e a s ource for t he infect i on. In t he male, one epi sode of pyuri a shoul d be suffi ci ent indi cat i on for an IVP; a femal e shoul d have one aft er her second episode, es pecial ly i f no caus e can be found on phys i cal examinat i on. Cyst os copy and a voi di ng cyst ogram are often indi cat ed at t hi s ti me.

Other Useful Tests
CBC (pyel onephrit i s) Sediment at ion rat e (pyel onephri t is ) Chemi st ry panel (di abet es mel l it us , nephri t is )

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ANA analysi s (col lagen di sease) Retrograde pyel ography (t umor, malformat ion, obst ruct i ve uropat hy) Uri ne for aci d-fast bacil l us (AFB) smear and cul t ure and guinea pi g i nocul at ion (t ubercul os i s) Sonogram (di vert i cul um, pel vi c mass , cyst , abs cess ) CT scan of abdomen and pelvi s (t umor, mal format i on, obst ruct i ve uropat hy, ext rins i c mass) P.374

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Pyuria