a LANGE medical book SYMPTOM TO DIAGNOSIS An Evidence-Based Guide Second Edition Scott D C Stern, MD, FACP Professor of Medicine Co-Director, Junior Clerkship in Medicine Clinical Director of Clinical Pathophysiology and Therapeutics University of Chicago Pritzker School of Medicine Chicago, Illinois Adam S Cifu, MD, FACP Associate Professor of Medicine Co-Director, Junior Clerkship in Medicine University of Chicago Pritzker School of Medicine Chicago, Illinois Diane Altkorn, MD, FACP Associate Professor of Medicine Director, Senior Student Clerkships in Medicine University of Chicago Pritzker School of Medicine Chicago, Illinois New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2010 by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-178131-2 MHID: 0-07-178131-5 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-149613-1, MHID: 0-07-149613-0 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgraw-hill.com Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been 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AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise In memory of Kim Michele Stern Scott Stern In memory of my father, Dr Robert Cifu Adam Cifu In memory of my father, Robert Seidman Diane Altkorn This page intentionally left blank Contents Contributing Authors vii Preface ix Acknowledgments xi The Diagnostic Process Screening & Health Maintenance 10 Abdominal Pain 26 Acid-Base Abnormalities 49 AIDS/HIV Infection 67 Anemia 100 Back Pain 114 Chest Pain 130 Cough, Fever, and Respiratory Infections 149 10 Delirium and Dementia 169 11 Diabetes 181 12 Diarrhea, Acute 199 13 Dizziness 212 14 Dyspnea 229 15 Edema 248 16 Fatigue 266 17 Gastrointestinal Bleeding 275 18 Headache 287 19 Hypercalcemia 305 20 Hypertension 314 21 Hyponatremia and Hypernatremia 327 22 Jaundice and Abnormal Liver Enzymes 347 23 Joint Pain 365 24 Rashes 386 25 Renal Failure, Acute 405 26 Syncope 420 27 Weight Loss, Involuntary 442 28 Wheezing and Stridor 467 Index 485 Color Insert appears between pages 404 and 405 v This page intentionally left blank Contributing Authors John Luc Benoit, MD Section of Infectious Diseases and Global Health Assistant Professor of Medicine Director, Infectious Diseases Fellowship Program Director, Travel Clinic AIDS/HIV Infection (Coauthored with Scott Stern) Sarah Stein, MD Section of Dermatology Associate Professor of Medicine Rashes (Coauthored with Adam Cifu) vii This page intentionally left blank Preface Our goal in creating Symptom to Diagnosis was to develop an interesting, practical, and informative approach to teaching the diagnostic process in internal medicine Interesting, because real patient cases are integrated within each chapter, complementing what can otherwise be dry and soporific Informative, because Symptom to Diagnosis articulates the most difficult process in becoming a physician: making an accurate diagnosis Many other textbooks describe diseases, but fail to characterize the process that leads from patient presentation to diagnosis Although students can, and often do, learn this process through intuition and experience without direct instruction, we believe that diagnostic reasoning is a difficult task that can be deciphered and made easier for students Furthermore, in many books the description of the disease is oversimplified, and the available evidence on the predictive value of symptoms, signs, and diagnostic test results is not included Teaching based on the classic presentation often fails to help less experienced physicians recognize the common, but atypical presentation This oversight, combined with a lack of knowledge of test characteristics, often leads to prematurely dismissing diagnoses Symptom to Diagnosis aims to help students and residents learn internal medicine and focuses on the challenging task of diagnosis Using the framework and terminology presented in Chapter 1, each chapter addresses one common complaint, such as chest pain The chapter begins with a case and an explanation of a way to frame, or organize, the differential diagnosis As the case progresses, clinical reasoning is clearly articulated The differential diagnosis for that particular case is summarized in tables that delineate the clinical clues and important tests for the leading diagnostic hypothesis and important alternative diagnostic hypotheses As the chapter progresses, the pertinent diseases are reviewed Just as in real life, the case unfolds in a stepwise fashion as tests are performed and diagnoses are confirmed or refuted Readers are continually engaged by a series of questions that direct the evaluation Each chapter contains several cases and concludes with a diagnostic algorithm Symptom to Diagnosis can be used in three ways First, it is designed to be read in its entirety to guide the reader through a third-year medicine clerkship We used the Core Medicine Clerkship Curriculum Guide of the Society of General Internal Medicine/Clerkship Directors in Internal Medicine to select the symptoms and diseases we included, and we are confident that the text does an excellent job teaching the basics of internal medicine Second, it is perfect for learning about a particular problem by studying an individual chapter Focusing on one chapter will provide the reader with a comprehensive approach to the problem being addressed: a framework for the differential diagnosis, an opportunity to work through several interesting cases, and a review of pertinent diseases Third, Symptom to Diagnosis is well suited to reviewing specific diseases through the use of the index to identify information on a particular disorder of immediate interest Our approach to the discussion of a particular disease is different than most other texts Not only is the information bulleted to make it concise and readable, but the discussion of each disease is divided into sections The Textbook Presentation, which serves as a concise statement of the common, or classic, presentation of that particular disease, is the first part The next section, Disease Highlights, reviews the most pertinent epidemiologic and pathophysiologic information The third part, Evidence-Based Diagnosis, reviews the accuracy of the history, physical exam, laboratory and radiologic tests for that specific disease Whenever possible, we have listed the sensitivities, specificities, and likelihood ratios for these findings and test results This section allows us to point out the findings that help to “rule in” or “rule out” the various diseases We often suggest a test of choice It is this part of the book in particular that separates this text from many others In the final section, Treatment, we review the basics of therapy for the disease being considered Recognizing that treatment evolves at a rapid pace, we have chosen to limit our discussion to the fundamentals of therapy rather than details that would become quickly out of date The second edition differs from the previous edition in several ways First, there are five new chapters—Hypertension, Diabetes, Rashes, HIV/AIDS, and Screening and Health Maintenance—as well as pages of full-color images of rashes Second, there is more emphasis on highlighting the pivotal points for each symptom that help to focus a broad differential diagnosis into one tailored to the individual patient Third, history and physical exam findings so highly specific that they point directly to a particular diagnosis are indicated with the following “fingerprint” icon: FP = fingerprint Fourth, the diagnostic algorithms at the end of each chapter are more uniform Finally, all chapters have been updated to reflect new information on diagnostic testing For generations the approach to diagnosis has been learned through apprenticeship and intuition Diseases have been described in detail, but the approach to diagnosis has not been formalized In Symptom to Diagnosis we feel we have succeeded in articulating this science and art and, at the same time, made it interesting to read Scott D C Stern, MD Adam S Cifu, MD Diane Altkorn, MD ix WHEEZING OR STRIDOR / 477 significantly less common in children since the use of the Haemophilus influenzae B vaccine Table 28–7 Prevalence of the signs and symptoms of epiglottitis Disease Highlights Symptoms and Signs A Epiglottitis is an infectious disease, classically caused by H influenzae, that causes swelling of the epiglottis and supraglottic structures B Can rapidly cause airway compromise so the diagnosis is always considered an airway emergency C Classic presentation is a patient with sore throat, muffled “hot potato” voice, drooling, and stridor D H influenzae is cultured in only a small percentage of adult patients; respiratory viruses are the likely cause of most cases of epiglottitis E Epiglottitis is a difficult diagnosis because initial presentation is often identical to pharyngitis Sore throat 95% Odynophagia 94% Muffled voice 54% Pharyngitis 44% Fever 42% Cervical adenopathy 41% Dyspnea 37% Drooling 30% Sitting erect 16% Stridor 12% Evidence-Based Diagnosis A The gold standard for diagnosis is visual identification of swelling of the epiglottis Otolaryngology consultation is thus mandatory in any patient with a high suspicion for the disease Visualization can be achieved with direct or indirect laryngoscopy In patients with signs of severe disease (eg, muffled voice, drooling, and stridor), an experienced physician should perform direct laryngoscopy and be prepared to intubate the patient or perform a tracheostomy (if airway control cannot be obtained) B The classic symptoms of muffled voice, drooling, and stridor are seen very rarely and signify imminent airway obstruction Sitting erect and stridor are independent predictors of subsequent airway intervention (RRs of 4.8 and 6.2, respectively) In study of patients with epiglottitis, the test characteristics of sitting erect at presentation and stridor were as follows: a Sitting erect at presentation: Sensitivity, 47%; specificity, 90%; LR+, 4.7; LR− 0.59 b Stridor: Sensitivity, 42%; specificity, 94%; LR+, 7; LR−, 0.61 C Common symptoms and signs of patients with epiglottitis are shown in Table 28–7 D Lateral neck films, a commonly used diagnostic tool, have a sensitivity of about 90% The classic finding is the “thumb sign” of a swollen epiglottis A normal lateral neck film does not rule out epiglottitis Laryngoscopy should be performed in a patient with a high clinical suspicion of epiglottitis, even if the neck film is normal Frequency Reproduced from Frantz TD, Rasgon BM, Quesenberry CP Jr Acute epiglottitis in adults Analysis of 129 cases JAMA 1994;272:1358–1360 Copyright © 1994 American Medical Association All rights reserved Elective intubation is preferred because intubation in a patient with epiglottitis can be very difficult Some advocate prophylactic intubation of all patients Epiglottitis is an airway emergency Patients need to be monitored extremely closely and not left alone until the airway is stable Otolaryngology consultation is mandatory B Antibiotics Necessary to cover H influenzae Second- or third-generation cephalosporins are usually recommended MAKING A DIAGNOSIS Mr S’s history is very concerning His upright posture, voice changes, and stridor are not only indicative of epiglottitis but also of imminent airway closure None of these findings would be seen with pharyngitis Foreign-body aspiration does not fit the history Retropharyngeal abscess remains a possibility Given the concern for epiglottitis, lateral neck films were obtained, and an otolaryngologist was called to examine the patient’s upper airway Treatment A Airway control All patients should be admitted to the ICU for close monitoring Patients with signs or symptoms of airway obstruction should be intubated electively Have you crossed a diagnostic threshold for the leading hypothesis, epiglottitis? Have you ruled out the active alternatives? Do other tests need to be done to exclude the alternative diagnoses? 478 / CHAPTER 28 Alternative Diagnosis: Retropharyngeal Abscess Textbook Presentation Retropharyngeal abscess can be seen in either children or adults Patients usually have symptoms similar to those seen in epiglottitis but commonly have a history of a recent upper respiratory infection or trauma from recently ingested materials (bones), or procedures (pulmonary or GI endoscopy) Disease Highlights A Symptoms that suggest retropharyngeal abscess rather than epiglottitis are: Patients with retropharyngeal abscesses often will sense a lump in their throat Patients are often most comfortable supine with neck extended (very different from epiglottitis) Evidence-Based Diagnosis A The diagnosis of retropharyngeal abscess is made when a thickening of the retropharyngeal tissues is seen on lateral neck radiographs B Radiographs are probably not 100% sensitive, so when radiographs are normal and clinical suspicion is high, CT scanning should be done to verify the diagnosis CHIEF COMPLAINT PATIENT Mrs A is 52-year-old woman who comes to your office with shortness of breath and wheezing She reports that her symptoms have been present for about years She reports almost constant, mild dyspnea that is worst with exercise or when she has a cold Only rarely does she feel “nearly normal.” She also complains of a mild cough productive of clear sputum She does not feel that her cough is much of a problem as it is significantly better since she stopped smoking years ago At this point, what is the leading hypothesis, and what are the active alternatives? What other tests should be ordered? PRIORITIZING THE DIFFERENTIAL DIAGNOSIS The pivotal points in this case are the patient’s chronic dyspnea wheezing, and smoking history COPD and asthma should be high in the differential diagnosis HF is also a possibility The patient’s smoking history is a risk factor for coronary disease, the most common cause of HF, and she suffers from nearly constant dyspnea that is worse with exertion As noted in Chapter 14, Dyspnea, HF frequently complicates COPD or is misdiagnosed as the pulmonary disease Bronchiectasis could cause symptoms of Treatment A Retropharyngeal abscesses are usually polymicrobial B Treatment is both medical and surgical Surgical drainage should be accomplished as soon as possible Many antibiotics have been suggested Coverage of grampositive organisms and anaerobes make clindamycin a common choice CASE RESOLUTION The patient’s lateral neck radiograph showed probable acute epiglottitis with a thumb sign An otolaryngologist visualized the epiglottis and, given the patient’s symptoms and severity of the visualized airway obstruction, placed an endotracheal tube Mr S was admitted to the ICU and treated with a second-generation cephalosporin Cultures of the blood and epiglottis were negative The patient’s infection was diagnosed on the lateral neck radiographs Intubation was necessary because the patient had signs and symptoms of airway obstruction and the actual obstruction was visualized on laryngoscopy dyspnea, cough, and sputum production, but the patient’s sputum production seems to be a minor symptom, unlike what is usually seen in bronchiectasis Tuberculosis (TB) should probably be considered in the differential, since it can cause chronic cough and dyspnea Given the chronic nature of the symptoms, if TB were the cause, we would expect to hear about weight loss and other constitutional signs Table 28–8 lists the differential diagnosis Mrs A reports a 60 pack-year history of smoking She stopped years ago, after smoking packs a day for 30 years, when her chronic cough began to worry her She reports that she still coughs but only rarely brings up sputum She has not experienced fever, chills, weight loss, or peripheral edema She does say that when her breathing is bad it is worse when lying down She has never had symptoms consistent with paroxysmal nocturnal dyspnea Orthopnea is a very nonspecific symptom It is found in many types of cardiopulmonary disease Is the clinical information sufficient to make a diagnosis? If not, what other information you need? WHEEZING OR STRIDOR / 479 Table 28–8 Diagnostic hypotheses for Mrs A Diagnostic Hypotheses Clinical Clues Important Tests Leading Hypothesis COPD Chronic irreversible airway obstruction with a smoking history Spirometry and sometimes imaging Active Alternative—Most Common Asthma Episodic and reversible airflow obstruction Peak flow PFTs Methacholine challenge Response to treatment Active Alternative—Must Not Miss HF Presence of risk factors and consistent physical exam findings Echocardiography Chronic, heavy, purulent sputum production CT scan of the chest Other Alternative Bronchiectasis E Diagnosis of early, minimally symptomatic COPD is important because it may allow for more appropriate treatment of mild symptoms (cough) and may provide extra incentive for smoking cessation F Emphysema and chronic bronchitis are currently being used less as descriptors of types of COPD Emphysema is a pathologic term not accurately correlating with its general clinical usage Chronic bronchitis is the presence of mucus production for most days of the month, months of a year, for successive years This symptom does not relate to the airflow obstruction that causes the morbidity in COPD Due to the overlap and lack of specificity of these terms, COPD should be used as the diagnostic term G Two staging systems provide a way of categorizing patients by symptoms and prognosis The WHO/NHLBI outlines stages of COPD (Table 28–9) that are useful for both diagnosis and management of patients They are based mainly on spirometry and are thus very easy to use Other indices, such as the BODE index, take into account other patient features, such as body mass index, degree of dyspnea, and exercise tolerance, and are very useful prognostically Evidence-Based Diagnosis Leading Hypothesis: COPD Textbook Presentation Presenting symptoms of COPD include progressive dyspnea, decreased exercise tolerance, cough, and sputum production The onset is usually slow and progressive with occasional acute exacerbations A long smoking history is present in almost all patients with COPD who live in industrialized countries A The diagnosis of COPD is based on history, physical exam, and ancillary tests (primarily PFTs) B Important aspects of the history are: Smoker’s cough Lingering colds Table 28–9 WHO/NHLBI stages of COPD Disease Highlights A COPD is defined in the WHO/NHLBI Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease as a “disease state characterized by airflow limitation that is not fully reversible The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.” B COPD should be considered in any patient with a smoking history who has pulmonary complaints These complaints can be: Mild (smokers’ cough or lingering colds) Moderate (chronic cough, sputum production, and dyspnea) Severe (activity-limiting dyspnea with life-threatening exacerbations) C COPD can also be seen in patients without a smoking history but with significant exposure to secondhand smoke, occupational dust and chemicals and, especially in less developed countries, indoor air pollution from cooking stoves D Because of the wide variation in disease course, it is impossible to give an average amount of exposure necessary to cause disease Pulmonary symptoms usually develop after about 10 years of exposure Airflow obstruction may develop later Stage Spirometry Symptoms At Risk Normal Chronic cough and sputum production Mild COPD FEV1/FVC < 70% FEV1 > 80% Chronic cough and sputum production often without dyspnea 2A Moderate COPD FEV1 = 50–80% Chronic dyspnea possibly with intermittent exacerbations 2B Moderate COPD FEV1 = 30–50% Chronic dyspnea probably with intermittent exacerbations Severe COPD FEV1 < 30% Also may be diagnosed with PaO2 < 60 mm Hg, PaCO2 > 50 mm Hg or cor pulmonale COPD, chronic obstructive pulmonary disease; FEV1/FVC, forced expiratory volume in second/forced vital capacity Pauwels RA, Buist AS, Calverley PM, Hurd SS Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease NHLBI/WHO Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) Workshop Summary Am J Respir Crit Care Med 2001 163: 1256–1276 480 / CHAPTER 28 Chronic cough Sputum production Dyspnea Decreased exercise tolerance C Physical exam The physical exam is useful mainly in patients with more advanced disease No findings are sensitive enough to exclude a diagnosis of COPD The test characteristics for some of the physical exam findFP ings are listed in Table 28–10 The absence of wheezing does not rule out, or even significantly decrease the likelihood of, COPD D Spirometry Because the results of spirometry are part of the information required to make a diagnosis of COPD, test characteristics cannot be calculated For the diagnosis of COPD, the most important spirometric values are postbronchodilator, since COPD is defined by irreversible airway obstruction Typically PFTs in COPD reveal: a Increased total lung capacity secondary to decreased elastic recoil b Increased functional residual capacity and residual volume secondary to air trapping c Decreased FEV1 and FVC due to airflow obstruction d Decreased DLCO secondary to destruction of the oxygen/Hgb interface E Other tests Spirometry with bronchodilator response is recommended to rule out asthma Patients with completely reversible airflow obstruction likely have asthma Chest radiograph is generally not useful in diagnosing COPD Table 28–10 Test characteristics for physical exam findings in COPD Criteria Sensitivity Specificity LR+ LR− 4–27% 97–99% ≈8 ≈1 Absent cardiac dullness LLSB 15% 99% 15 ≈1 Diaphragmatic excursion < cm 13% 98% 6.5 ≈1 Early inspiratory crackles 25–77% 97–98% 8–38.5 ≈1 Any unforced wheeze 13–56% 86–99% 1–56 ≈1 Subxiphoid cardiac impulse COPD, chronic obstructive pulmonary disease; LLSB, left lower sternal border Modified from McGee SR Evidence-based physical diagnosis Philadelphia, PA: Saunders, 2001:382 With permission from Elsevier a Some findings are suggestive (1) Upper lobe bullous disease (uncommon but nearly diagnostic) (2) Flattened diaphragm on the lateral chest radiograph (3) Large retrosternal air space (4) Hyperlucency of the lungs (5) Diminished distal vascular markings b Chest radiography is always recommended to rule out other causes of symptoms ABG measurement is recommended in patients with FEV1 < 40% predicted or with right-sided heart failure Testing for α1-antitrypsin deficiency (a rare cause of COPD) is recommended in patients: a In whom COPD develops before age 45 years b Who not have a smoking history or suspicious exposure In general, any patient with a smoking history who complains of chronic cough, sputum production, or dyspnea should be considered to have COPD if no other diagnosis can be made Additional testing can help establish the diagnosis and assess severity Treatment A Management of stable disease Nonpharmacologic and preventive therapy a Smoking cessation or removal of other inhaled toxic agents b Exercise programs if allowable from a cardiovascular standpoint c Vaccination against influenza and pneumococcal pneumonia Pharmacologic a Anticholinergic inhalers ipratropium or tiotropium (1) Mainstay of therapy (2) Initial therapy for symptomatic patients (3) Also recommended for patients with FEV1 < 50% of predicted regardless of symptoms (4) Recent data suggest that these medications increase the risk of cardiovascular events b β-Agonists (1) Short-acting medications are useful if the patient’s response to anticholinergic inhalers is insufficient (a) Can be used as-needed or on a scheduled basis (b) Combinations with anticholinergic inhalers are useful (2) Long-acting medications are especially useful for treatment of nocturnal symptoms c Theophylline (1) May be used in patients with inadequate response to long-acting β-agonists and anticholinergic inhalers (2) Narrow therapeutic window limits usefulness d Inhaled corticosteroids (1) Use remains somewhat controversial (2) There is some evidence that inhaled corticosteroids decrease symptoms and reduce the frequency of exacerbations WHEEZING OR STRIDOR / 481 (3) They not seem to effect the rate of decline in pulmonary function and may increase rates of pneumonia e Home oxygen is recommended for persons with chronic hypoxia or cor pulmonale B Management of exacerbations Evaluation a Patients who are likely to have the worst outcomes have low baseline FEV1, PaO2, pH, and high PCO2 Discharge of such patients from an emergency department should be done with great care b Exacerbating factors (1) Factors that likely led to the COPD exacerbation should be sought and addressed during treatment (2) Historical evidence of infection or exposure (air pollution, ozone) should be sought (3) All patients should have a chest radiograph to look for pneumonia (4) As discussed in Chapter 14, Dyspnea, if a cause of the exacerbation is not found, consideration should be given to pulmonary embolism c Unlike in the assessment of asthma exacerbations, spirometry is of little value in making admission decisions Therapy a Anticholinergic inhalers should be given to all patients with addition of β-agonists if necessary b Systemic corticosteroids are effective when given for up to weeks There is no evidence that inhaled corticosteroids are effective Antibiotics are effective for more severe exacerbations It is unclear which the most effective antibiotic is Oxygen therapy is beneficial a Oxygen does carry a risk of hypercapnia and respiratory failure b The development of respiratory failure is somewhat predictable c The following equation identifies patients who are at high risk for CO2 retention and for requiring mechanical ventilation: pH = 7.66 − 0.00919 × PaO2 If the calculated pH is greater than the patients true pH, he is at high risk for being intubated Sensitivity is ≈ 80% If a patient with a COPD exacerbation requires oxygen, it should be provided and not withheld for fear of causing CO2 retention If respiratory failure does ensue, it is caused by COPD and not by the physician who administered the oxygen Noninvasive positive pressure ventilation (eg, bilevel positive airway pressure) decreases rates of intubation, length of stay, and in-hospital mortality in patients with severe exacerbation Mucolytics, theophylline, and chest physiotherapy have no role in the treatment of COPD exacerbations MAKING A DIAGNOSIS On the physical exam, Mrs A appears well Her vital signs are normal The only findings on lung exam are decreased breath sounds and a prolonged expiratory phase Her chest radiograph is normal Some of the results of her PFTs are shown in Table 28–11 Have you crossed a diagnostic threshold for the leading hypothesis, COPD? Have you ruled out the active alternatives? Do other tests need to be done to exclude the alternative diagnoses? The patient’s history and physical exam is certainly consistent with the diagnosis of COPD She has a smoking history, persistent cough, and dyspnea Her physical exam reveals findings of decreased breath sounds The chest radiograph does not argue for another diagnosis Her PFTs are also supportive of the diagnosis Most importantly, there is an irreversible decrease in airflow The severity of disease is surprising given the patient’s mild symptoms The low DLCO (carbon monoxide diffusing capacity), suggests loss of a portion of the Hgb/air interface Asthma and HF, the alternative diagnoses, are very unlikely The irreversibility of the airway disease excludes asthma as a potential cause The lack of purulent sputum excludes bronchiectasis HF remains a much less likely possibility not supported by the PFTs Table 28–11 Pulmonary function test results for Mrs A Prebronchodilator Postbronchodilator Test Result Total lung capacity (L) 6.92 128 Forced vital capacity (L) 3.03 FEV1 (L) 1.03 FEV1/FVC (%) 34 DLCO (mL/min/mm Hg) % of Predicted Result % Change 91 2.90 −4.0 43 1.00 −4.0 34 NA 50 DLCO, carbon monoxide diffusing capacity of the lungs; FEV1/FVC, forced expiratory volume in second/forced vital capacity 482 / CHAPTER 28 Alternative Diagnosis: Bronchiectasis Treatment Textbook Presentation A Antibiotics are used both to treat flares of disease and to suppress chronic infection B Pulmonary hygiene Chest physiotherapy There may be a role for bronchodilators, mucolytics, and antiinflammatory medication C Surgery is mainly used to treat airway obstruction, to remove destroyed and chronically infected lung tissue, and to treat life-threatening hemoptysis Dyspnea and chronic, purulent sputum production are usually present in patients with bronchiectasis There is usually a history of a chronic infection that has led to airway destruction Disease Highlights A Chronic sputum production is the hallmark of the clinical presentation of bronchiectasis B The disease is caused by the combination of an airway infection and an inability to clear this infection because of impaired immunity or anatomic abnormality (congenital or acquired) Bronchiectasis can be the result of common (viral infection) or rare (Kartagener syndrome) diseases Pertussis and TB were the classic causes of bronchiectasis Some of the common causes now are: a Postviral, often with lymphadenopathy causing airway obstruction b Aspergillus fumigatus, mainly in association with allergic bronchopulmonary aspergillosis c Mycobacterium avium complex infection, usually causing middle lobe disease d Cystic fibrosis e HIV C The most common bacteria isolated from the sputum of people with bronchiectasis are H influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae D Complications of the disease include hemoptysis and rarely amyloidosis, given the chronic levels of inflammation Evidence-Based Diagnosis A The diagnosis of bronchiectasis depends on recognizing the clinical symptoms (chronic sputum production) and demonstrating airway destruction, usually by high-resolution CT scanning B Symptoms and their prevalence Dyspnea and wheezing, 75% Pleuritic chest pain, 50% C Signs and their prevalence Crackles, 70% Wheezing, 34% D Differentiation of bronchiectasis from COPD can sometimes be difficult because both may present with cough, sputum production, dyspnea, and airflow limitation Important points in the differentiation are as follows: Sputum production is heavy and chronic in bronchiectasis, while it is only truly purulent in COPD during exacerbations There is usually a smoking history associated with COPD Spirometry is not helpful since bronchiectasis can cause both airflow limitation and airway hyperreactivity Imaging (CT scan) will show diagnostic airway changes in bronchiectasis In COPD, imaging may or may not demonstrate parenchymal destruction CASE RESOLUTION Given the minor role that sputum production plays in Mrs A’s disease, the diagnosis of COPD is nearly definite Mrs A is given a tiotropium inhaler, and she reports mild improvement in her symptoms A month later, a longacting β-agonist inhaler was added This regimen produced better control of her symptoms Four months later, she arrives at the emergency department with acute worsening of her symptoms at the time of an upper respiratory tract infection She is admitted with an exacerbation of COPD REFERENCES Aaron SD, Vandemheen KL, Fergusson D et al Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial Ann Intern Med 2007;146(8):545–55 Bach PB, Brown C, Gelfand SE, McCrory DC Management of acute exacerbations of chronic obstructive pulmonary disease: a summary and appraisal of published evidence Ann Intern Med 2001;134:600–20 Barker AF Bronchiectasis N Engl J Med 2002;346:1383–93 Bingham CO An Overview of Angioedema UpToDate, accessed 4/2008 Bone RC, Pierce AK, Johnson RL Jr Controlled oxygen administration in acute respiratory failure in chronic obstructive pulmonary disease: a reappraisal Am J Med 1978;65:896–902 Calverley PM, Anderson JA, Celli B et al Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease N Engl J Med 2007;356(8):775–89 Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF Vocal-cord dysfunction presenting as asthma N Engl J Med 1983;308:1566–70 Corren J, Newman KB Vocal cord dysfunction mimicking bronchial asthma Postgrad Med 1992;92:153–6 Mahler DA, Harver A, Lentine T, Scott JA, Beck K, Schwartzstein RM Descriptors of breathlessness in cardiorespiratory diseases Am J Respir Crit Care Med 1996;154:1357–63 NIH/NHLBI Guidelines for the Diagnosis and Management of Asthma Bethesda, 1997:146 Turcotte H, Langdeau JB, Bowie DM, Boulet LP Are questionnaires on respiratory symptoms reliable predictors of airway hyperresponsiveness in athletes and sedentary subjects? J Asthma 2003;40:71–80 WHO/NHLBI Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2001 WHEEZING OR STRIDOR / 483 Are the symptoms of wheezing or stridor acute or chronic? Chronic Acute Are the symptoms persistent or episodic? Episodic Consider asthma, paradoxical vocal cord movement, CHF Are the symptoms accompanied by signs of infection? Persistent Consider COPD, CHF, bronchiectasis, tracheal disease, goiter, benign or malignant laryngeal disease, vocal cord pathology No Consider foreign body aspiration, anaphylaxis, angioedema CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease Diagnostic Approach: Wheezing and Stridor Yes Consider bronchitis, epiglottitis, retropharyngeal abscess, pharyngitis This page intentionally left blank Index Page numbers followed by italic f or t denote figures or tables, respectively A Abdominal aortic aneurysm (AAA): abdominal pain, 44–45 screening for, 18 Abdominal pain, 26–48 abdominal aortic aneurysm (AAA), 44–45 acute cholecystitis, 37 acute pancreatitis, 38–40 appendicitis, 27–29, 28t ascending cholangitis, 36–37 biliary colic, 30–31, 31f choledocholithiasis, 36–37, 36t chronic pancreatitis, 459–461 differential diagnosis, 26, 27f, 28t, 30t, 35f, 40t, 41f, 44t, 48t diverticulitis, 46–47 hepatitis A, 353, 353f hepatitis B, 354, 354f hepatitis C, 355–357, 357f, 362f irritable bowel syndrome (IBS), 31–32 ischemic bowel, 32–34, 34t, 35t large bowel obstruction (LBO), 41–42, 41t by location, 27f, 48t nephrolithiasis, 45–46 peptic ulcer disease (PUD), 452–454, 452t, 453t, 454f small bowel obstruction (SBO), 42–43 Acid-base abnormality: alcoholic ketoacidosis, 65 compensation in, 50t delta-delta gap, 66 diabetic ketoacidosis (DKA), 53–56, 55t differential diagnosis, 49–53, 51f, 53t, 57t, 61t D-lactic acidosis, 64 lactic acidosis, 50t, 63–64, 64t lactic acidosis secondary to sepsis, 57–60, 58t, 59f, 59t metabolic alkalosis, 65, 65f mixed disorders, 66 renal tubular acidosis (RTA), 64 respiratory acidosis, 62–63 respiratory alkalosis, 65–66 starvation ketosis, 64 uremic acidosis, 56 Acne vulgaris, 388–389 Active alternative hypotheses, Acute blood loss, 100 Acute bronchitis, 153 Acute cholecystitis, 37 Acute diarrhea, 199–211 antibiotic-associated diarrhea, 204–205 Campylobacter infection, 207–208, 207t differential diagnosis, 199, 200, 200t, 204t, 206t, 211f Acute diarrhea (Cont.): E coli infection, 207t, 209t gastroenteritis caused by Salmonella species, 202–203, 207t Giardia lamblia, 205–206 lactose intolerance, 203–204 norovirus, 200–201 Shiga toxin-producing E coli (0157:H7) infection, 207t, 209 Shigella infection, 207t, 208 toxin-mediated gastroenteritis, 201–202, 202t travelers’ diarrhea, 209–210 Acute glomerulonephritis, 415, 416t Acute mesenteric ischemia, 33, 34t Acute myocardial infarction (MI), 136–140, 137t–139t Acute pancreatitis, 38–40 Acute pericarditis, 146–147 Acute renal failure (ARF), 405–417 acute glomerulonephritis, 415, 416t acute tubular necrosis (ATN), 407–410, 408t, 409t acute urinary retention, 412 atheroembolism, 416–417 benign prostatic hyperplasia (BPH), 412–413, 413t chronic kidney disease (CKD), 417 differential diagnosis, 405–406, 407t, 410t, 414t, 419f interstitial nephritis, 414–415 measuring kidney function, 406, 406f NSAID-induced renal hypoperfusion, 414 renal artery thrombosis, 415, 416 thromboembolism of the renal arteries, 416 urinary tract obstruction, 411–412 vascular causes of, 415–417 Acute respiratory complaints, 149–168 acute bronchitis, 153 aspiration pneumonia, 154–155 community-acquired pneumonia (CAP), 150–152, 150t, 152t differential diagnosis, 149, 150t, 154t, 167f, 168f influenza, 162–166, 163f, 164t, 165t Pneumocystis jiroveci pneumonia (PCP), 156–157 tuberculosis (TB), 157–162, 159t, 160t, 161f Acute tubular necrosis (ATN), 407–410, 408t, 409t Acute urinary retention, 412 Acute vestibular neuritis, 216, 218 485 AD (see Alzheimer disease) Adrenal insufficiency, 337–340, 339f AF (see Atrial fibrillation) AIDS-related complaints, 67–98 chronic diarrhea (see Chronic diarrhea [in HIV-positive patients]) CNS disorders, 84t cough and fever (see Cough and fever [in HIV-positive patients]) differential diagnosis, 67 headache (see Headache [in HIV-positive patients]) HIV encephalopathy (HIV-associated dementia), 82 HIV infection, 67–73, 68f–71f, 68t, 69t, 72t, 73t Kaposi sarcoma, 98, 98f neurosyphilis in HIV-positive patients, 82–83 Alcohol withdrawal, 173–174, 173f Alcoholic ketoacidosis, 65 Alcoholic liver disease: alcoholic steatohepatitis, 350 cirrhosis, 350 jaundice, 350–351 jaundice (hyperbilirubinemia), 350–351 steatosis, 350 Alcoholic steatohepatitis, 350 Alcoholism, involuntary weight loss from, 456–459, 457t Alkaline phosphatase (AP), 364f Alzheimer disease (AD), 175–178, 176t American Academy of Family Physicians guidelines, for hyperlipidemia, 17 American Cancer Society guidelines: for colorectal cancer, 15 for mammography, 22 for Pap smears, 20 for prostate cancer, 13 American College of Chest Physicians guidelines, for chest radiograph, 17 American College of Obstetrics and Gynecology guidelines: for mammography, 23 for Pap smears, 20–21 American Gastroenterological Association guidelines, for colorectal cancer, 15 American Heart Association guidelines, for carotid artery stenosis (CAS), 19 American Society of Neuroimaging guidelines, for carotid artery stenosis, 19 American Urological Association guidelines, for prostate cancer, 13 Anal fissures, 285 Anatomic frameworks for diagnosis, 486 / INDEX Anemia, 100–113 anemia of inflammation, 108–109 B12 deficiency, 105–106, 106f differential diagnosis, 100–102, 101f, 103t, 105t, 108t, 110t folate deficiency, 106–107 hemolysis, 110–111 iron deficiency anemia, 103–105 α-thalassemia, 113 β-thalassemia, 113 sickle cell anemia, 111–113, 112t Anemia of inflammation, 108–109 Angiodysplasia, 279 Angioedema, 475–476, 475f Anion gap acidosis, 49, 50 Antibiotic-associated diarrhea, 204–205 Anxiety, fatigue and, 267 Aortic dissection, 141–143, 142t Aortic stenosis, 435–437, 436f AP (alkaline phosphatase), 364f Appendicitis, 27–29, 28t AR (see Chronic aortic regurgitation) ARF (see Acute renal failure) Arthritis: osteoarthritis (OA), 381–382 psoriatic, 374 reactive, 379, 379t rheumatoid (RA), 372–374, 373t septic, 369–370 Ascending cholangitis, 36–37 Ascites, 252–254, 253f, 254t Aspiration pneumonia, 154–155 Asthma: classification of severity, 469t initial evaluation/treatment of, 472f pharmacotherapy of, 471t pulsus paradox in, 62t test for symptoms of, 469t wheezing or stridor, 468–473, 469t, 470f, 471t, 472f Atheroembolism, 416–417 Atherosclerotic renal artery stenosis, 319–321, 320t ATN (see Acute tubular necrosis) Atrial fibrillation (AF), 238–240, 238f, 239t Atrioventricular (AV) heart block, bradycardia due to, 429, 429t, 430f B B12 deficiency, 105–106, 106f Back pain (see Low back pain) Bacteremia, predictors of, 59t Bacterial overgrowth, involuntary weight loss and, 461 Bacterial pneumonia, 87–89, 88t, 93t Basal cell carcinoma, 400, 400f Benign paroxysmal positional vertigo (BPPV), 215–216, 217f Benign prostatic hyperplasia (BPH), 412–413, 413t Benign thunderclap headache, 298 Biliary colic, 30–31, 31f Bilirubin, 347 Blood loss, acute, 100 Blood pressure, measuring guidelines for, 315t BPH (see Benign prostatic hyperplasia) BPPV (see Benign paroxysmal positional vertigo) Bradycardia: due to atrioventricular (AV) heart block, 429, 429t, 430f from sick sinus syndrome (SSS), 428–429 Breast cancer, screening for, 21–23 Bronchiectasis, 482 Bronchitis, acute, 153 Bullous arthropod bites, 392–393, 392f Bullous impetigo, 392, 392f Bullous pemphigoid, 393, 393f C CAD (coronary artery disease), 240 (See also Chest pain) Calcium pyrophosphate dihydrate deposition disease (CPPD), 368–369 Campylobacter infection, 207–208, 207t Canadian Task Force on Preventive Health Care guidelines, 11 Cancer cachexia, 446 CAP (see Community-acquired pneumonia) Cardiac syncope, 425–427, 426t Cardiogenic shock, 63, 64t Carotid artery stenosis (CAS), 18–19 Carotid sinus syndrome, 437 CAS (carotid artery stenosis), 18–19 CDR (see Clinical decision rule) Celiac disease, 464–465, 465f Cellulitis, 261–264, 262t, 263f Cerebellar hemorrhage, 219–220 Cerebellum, lacunar infarction of, 225–227 Cerebrovascular disease, 224–227, 225t dizziness, 224–227, 225t lacunar infarction of the pons or cerebellum, 225–227, 226t and syncope, 438 vertebrobasilar insufficiency (VBI), 224–225 Cervical cancer, screening for, 19–21 Chest pain, 130–147 acute myocardial infarction (MI), 136–140, 137t–139t acute pericarditis, 146–147 aortic dissection, 141–143, 142t differential diagnosis, 130, 131, 131t, 137t, 143t gastroesophageal reflux disease (GERD), 134–136, 135t pleural effusion, 143–146, 144t stable angina, 131–134, 132t, 133t unstable angina, 140–141, 140t Chest radiograph, 17 Chief complaint, Cholecystitis: acute, 37 Choledocholithiasis, 36–37, 36t Chronic aortic regurgitation (AR), 236–238, 237t, 238t Chronic blood loss, 100 Chronic diarrhea (in HIV-positive patients), 93–98 Cryptosporidium parvum, 96 cytomegalovirus (CMV) colitis, 97 differential diagnosis, 93–94, 95f, 96t Giardia lamblia, 97 microsporidia, 96–97 Mycobacterium avium complex (MAC) infection, 97 Chronic hepatitis B, 354–355, 355t Chronic kidney disease (CKD), 417 Chronic mesenteric ischemia, 32–33 Chronic obstructive pulmonary disease (COPD), 479–481, 479t, 480t Chronic pancreatitis, 459–461 Cirrhosis: alcoholic liver disease, 350 ascites, 252–254, 253f, 254t edema, 251–256 encephalopathy, 254–255, 255t hypersplenism, 255–256 hyponatremia, 331–332, 332t jaundice, 350 variceal bleeding, 281–282, 281t CKD (chronic kidney disease), 417 Clinical decision rule (CDR), 4, Clinical problems, CMV colitis, 97 CMV encephalitis, 78 CNS aneurysm, unruptured, headache due to, 291–292 CNS disorders, in AID patients, 84t Colon cancer, 279–280 Colonoscopy, 14 Colorectal cancer: high risk for, 13t, 14t screening for, 13–15 Community-acquired pneumonia (CAP), 150–152, 150t, 152t Congestion, acute (see Acute respiratory complaints) Conjugated bilirubin, 347 Context of problems, COPD (see Chronic obstructive pulmonary disease) Coronary artery disease (CAD), 240 (See also Chest pain) Cough, acute (see Acute respiratory complaints) Cough and fever (in HIV-positive patients), 84–93 bacterial pneumonia, 87–89, 88t, 93t differential diagnosis, 84–85, 85t, 86f, 87, 87t Mycobacterium avium complex (MAC), 92–93 pulmonary TB in AIDS patients, 89–92, 89t, 91f, 93t CPPD (calcium pyrophosphate dihydrate deposition disease), 368–369 Crohn disease, 462, 463, 463f Cryptococcal meningoencephalitis, 74, 76–77 Cryptosporidium parvum, 96 CT colonography (CTC), 14 INDEX / 487 Cytomegalovirus (CMV) colitis, 97 Cytomegalovirus (CMV) encephalitis, 78, 78t D DASH diet, 317t Data acquisition, 1, D-dimer, Deep vein thrombosis (DVT): dyspnea, 241–246, 245t, 246f, 246t upper extremity DVT (UEDVT), 264–265, 264t Delirium and dementia, 169–180 alcohol withdrawal, 173–174, 173f Alzheimer disease (AD), 175–178, 176t delirium, 170–173, 171t dementia with Lewy bodies (DLB), 172t, 180 differential diagnosis, 169–170, 170t, 175t mild cognitive impairment (MCI), 179 multi-infarct dementia (vasculardementia, VaD), 178–179 Dementia with Lewy bodies (DLB), 172t, 180 Depression: fatigue, 267 involuntary weight loss, 446–448 Diabetes, 181–198 diabetic complications (see Diabetic complications) differential diagnosis, 181, 182t, 184t, 195f, 196t hyperglycemia, 191–194, 192t hyperosmolar hyperglycemic state, 196–198, 196t, 197f insulin, types of, 194t testing and monitoring for, 191t Type diabetes mellitus (DM), 181 Type diabetes mellitus (DM), 182–184, 182t, 183t, 195f Diabetic complications: diabetic foot ulcers, 189–198, 190t nephropathy, 188–189 neuropathy, 185–188, 187t retinopathy, 184–185 Diabetic foot ulcers, 189–198, 190t Diabetic ketoacidosis (DKA), 53–56, 55t Diagnostic process (see Differential diagnosis) Diagnostic testing, 4–9, 5f–7f, 6t, 8t (See also Screening tests) Diarrhea: acute (see Acute diarrhea) diagnostic approach, 460f infectious, 199 by mechanism, 457t noninfectious, 199 Differential diagnosis: data acquisition in, 1, developing a framework, 1, prioritizing, 1, 3, 4t problem representation in, 1, reviewing/reprioritizing, role of diagnostic testing in, 4–9, 5f–7f, 6t, 8t (See also Screening tests) steps in, 1, 2f testing hypotheses, 1, 4–9 Digital rectal exam (DRE), 12 Disseminated gonorrhea, 370, 370t Diuretic-induced hyponatremia, 336–337 Diverticular bleed, 277–278 Diverticulitis, 46–47 Dizziness, 212–228 acute vestibular neuritis, 216, 218 benign paroxysmal positional vertigo (BPPV), 215–216, 217f central vs peripheral vertigo, 215t cerebellar hemorrhage, 219–220 cerebrovascular disease, 224–227, 225t differential diagnosis, 212, 213f–215f, 213t, 221t, 223f, 224t Meniere disease, 218 migraine & vertigo, 219 multiple sclerosis (MS), 221–222 multiple sensory deficits, 223–224 nonspecific, 227–228 vertebral artery dissection (VAD), 220 DKA (see Diabetic ketoacidosis) D-lactic acidosis, 64 DLB (see Dementia with Lewy bodies) Double-contrast barium enema, 14 DRE (digital rectal exam), 12 Duplex ultrasonography, 6t DVT (see Deep vein thrombosis) Dysequilibrium, 212, 213f, 213t (See also Dizziness) Dyspnea, 229–247 atrial fibrillation (AF), 238–240, 238f, 239t chronic aortic regurgitation (AR), 236–238, 237t, 238t coronary artery disease (CAD), 240 (See also Chest pain) deep vein thrombosis (DVT), 241–246, 245t, 246f, 246t differential diagnosis, 229–230, 230t–232t, 241t heart failure (HF), 231–235, 233f, 233t, 234t history and physical exam, 231f mitral regurgitation (MR), 235–236, 236t, 237t pulmonary embolism (PE), 241–246, 242t, 243t, 244f E E coli infection, 207t, 209, 209t Ecstasy (MDMA) intoxication, 342 Edema, 248–265 cellulitis, 261–264, 262t, 263f cirrhosis, 251–256 differential diagnosis, 248–249, 249f, 250f, 251t, 258t, 261t erysipelas, 261–264 nephrotic syndrome, 256–257 pulmonary hypertension, 257–259 upper extremity DVT (UEDVT), 264–265, 264t venous insufficiency, 259–261, 259f Encephalitis: cryptococcal meningoencephalitis, 74, 76–77 cytomegalovirus (CMV) encephalitis, 78, 78t toxoplasmosis encephalitis, 78–80, 80f Encephalopathy: cirrhosis, 254–255, 255t HIV encephalopathy, 82 progressive multifocal leukoencephalopathy, 80–81 Epiglottitis, 476–477, 477t Erysipelas, 261–264 Esophageal variceal hemorrhage, 281–282, 281t Essential hypertension, 315–317, 316t, 318t Exercise-associated hyponatremia, 341 F Familial hypocalciuric hypercalcemia (FHH), 307–308 Fatigue, 266–274 depression & anxiety, 267 differential diagnosis, 266, 267t, 268f, 269t hypothyroidism, 273–274 insomnia, 270–271, 271t obstructive sleep apnea (OSA), 272 periodic limb movement disorder (PLMD), 273 Fecal occult blood testing (FOBT), 13–15 Femoral stress fractures, 382, 384 Fever (in HIV-positive patients) (see Cough and fever [in HIV-positive patients]) FHH (familial hypocalciuric hypercalcemia), 307–308 Fingerprints of diseases, Flexible sigmoidoscopy, 14 FOBT (fecal occult blood testing), 13–15 Folate deficiency, 106–107 Frameworks for diagnosis, 1, G Gastroenteritis: caused by Salmonella species, 202–203, 207t toxin-mediated, 201–202, 202t Gastroesophageal reflux disease (GERD), 134–136, 135t GI bleeding, 275–286 anal fissures, 285 angiodysplasia, 279 colon cancer, 279–280 differential diagnosis, 275–276, 276t, 277t, 280t, 283t diverticular bleed, 277–278 esophageal variceal hemorrhage, 281–282, 281t hemorrhoidal bleeding, 284 Mallory-Weiss tear, 282–283 obscure GI bleeding, 286 occult GI bleeding, 285–286 peptic ulcer disease, 282, 282t Giardia lamblia: acute diarrhea, 205–206 chronic diarrhea (in HIV-positive patients), 97–98 Glomerulonephritis, acute, 415, 416t Gout, 366–368, 367t, 368t Guttate psoriasis, 395–396 488 / INDEX H Haptoglobin, 110 Head trauma, 303 Headache, 287–304 associated with head trauma, 303 associated with sexual activity, 297–298 associated with substances or their withdrawal, 294–295 benign thunderclap headache, 298 differential diagnosis, 287, 288t, 293t, 296t, 299t, 304f due to unruptured CNS aneurysm, 291–292 in HIV-positive patients (see Headache [in HIV-positive patients]) intracerebral hemorrhage, 298–299 intracranial neoplasms, 293–294 medical morning headaches, 294 meningitis, 302–303, 302t migraine headaches, 288–290, 289t, 290t primary cough headache, 297–298 primary exertional headache, 297–298 primary vs secondary, 287 subarachnoid hemorrhage (SAH), 296–297 subdural hematoma, 301 temporal arteritis, 299–300, 300t tension headaches, 290–291 Headache (in HIV-positive patient), 73–82 cryptococcal meningoencephalitis, 74, 76–77 cytomegalovirus (CMV) encephalitis, 78, 78t differential diagnosis, 73–74, 75f, 76f, 76t HIV encephalopathy (HIV-associated dementia), 82 neurosyphilis in HIV-positive patients, 82–83 primary CNS lymphoma, 81 progressive multifocal leukoencephalopathy, 80–81 toxoplasmosis encephalitis, 78–80, 80f Heart attack, risk assessment for, 16f Heart failure (HF): dyspnea, 231–235, 233f, 233t, 234t and hyponatremia, 332–333 Hemolysis, 100, 110–111 Hemorrhoidal bleeding, 284 Hepatitis A, 353, 353f Hepatitis B, 354–355, 354f, 355t Hepatitis C, 355–357, 357f, 362f Hereditary hemochromatosis, 359–360 Herniated disk, 119–121, 120t HF (see Heart failure) HIV encephalopathy (HIV-associated dementia), 82 HIV infection: chronic diarrhea with (see Chronic diarrhea [in HIV-positive patients]) cough and fever with (see Cough and fever [in HIV-positive patients]) headache with (see Headache [in HIV-positive patients]) opportunistic infections with, 73t rates of, 68f HIV infection (Cont.): stages of, 68–69 testing for, 69–71 treatment of, 71–72 Humoral hypercalcemia of malignancy, 310 Hyperbilirubinemia (see Jaundice) Hypercalcemia, 305–313 differential diagnosis, 305, 306t, 309t, 313f familial hypocalciuric hypercalcemia (FHH), 307–308 humoral hypercalcemia of malignancy, 310 local osteolytic hypercalcemia of malignancy, 310–311 milk-alkali syndrome, 311–312 primary hyperparathyroidism, 306–307 secondary & tertiary hyperparathyroidism, 312 thiazide-induced hypercalcemia, 308 Hypercholesterolemia, 318t Hyperglycemia, 191–194, 192t Hyperlipidemia: risk assessment for, 16f screening for, 15–17 Hypernatremia, 343–346 differential diagnosis, 343, 344t, 346f secondary to inadequate water intake, 344–345 Hyperosmolar hyperglycemic state, 196–198, 196t, 197f Hyperparathyroidism: primary, 306–307 secondary & tertiary, 312 Hypersplenism, 255–256 Hypertension, 314–326 atherosclerotic renal artery stenosis, 319–321, 320t differential diagnosis, 314, 315t, 316t, 319t, 322t, 326f essential hypertension, 315–317, 316t, 318t hypertensive emergencies, 323–324, 324t hypertensive urgency, 322–323 nonpharmacologic approaches to managing, 316t, 317t pheochromocytoma, 325–326, 325t primary hyperaldosteronism, 321 Hypertensive emergencies, 323–324, 324t Hypertensive urgency, 322–323 Hyperthyroidism, 448–450, 449t, 450f Hypertrophic cardiomyopathy, 423–424 Hypervolemia, 333–334 Hyponatremia, 327–343 adrenal insufficiency, 337–340, 339f associated with hypervolemia, 333–334 cirrhosis, 331–332, 332t differential diagnosis, 327–330, 328f–330f, 330t, 331t, 335t diuretic-induced, 336–337 Ecstasy (MDMA) intoxication, 342 exercise-associated, 341 heart failure (HF) and hyponatremia, 332–333 hypovolemic hyponatremic syndromes, 340–341 Hyponatremia (Cont.): nephrotic syndrome, 333 pseudohyponatremia, 342–343 psychogenic polydipsia, 341–342 symptoms, 328–331 syndrome of inappropriate antidiuretic hormone (SIADH), 335–336 Hypothyroidism, 273–274 Hypovolemia, 65f Hypovolemic hyponatremic syndromes, 340–341 Hypovolemic shock, 63, 64t I IBS (see Irritable bowel syndrome) Immunosuppression (HIV), 75 Influenza, 162–166, 163f, 164t, 165t Insomnia, 270–271, 271t Interstitial nephritis, 414–415 Intracerebral hemorrhage, 298–299 Intracranial neoplasms, 293–294 Involuntary weight loss, 443–465 alcoholism, 456–459, 457t bacterial overgrowth, 461 cancer cachexia, 446 celiac disease, 464–465, 465f chronic pancreatitis, 459–461 depression, 446–448 differential diagnosis, 443–445, 444f, 445t, 451t, 455t hyperthyroidism, 448–450, 449t, 450f irritable bowel syndrome (IBD), 461–464, 462t peptic ulcer disease (PUD), 452–454, 452t, 453t, 454f Iron deficiency anemia, 103–105 Irritable bowel syndrome (IBS), 461–464 abdominal pain, 31–32 Crohn disease, 462, 463, 463f involuntary weight loss, 461–464, 462t markers for diagnosis of, 462t ulcerative colitis, 463–464 Ischemic bowel, 32–34, 34t, 35t abdominal pain, 32–34, 34t, 35t acute mesenteric ischemia, 33, 34t chronic mesenteric ischemia, 32–33 ischemic colitis, 33–34, 34t Ischemic colitis, 33–34, 34t J Jaundice (hyperbilirubinemia), 347–360 alcoholic liver disease, 350–351 chronic hepatitis B, 354–355, 355t cirrhosis, 350 differential diagnosis, 347–348, 348t, 349t, 352t, 358t elevated alkaline phosphatase (AP), 364f elevated serum bilirubin, 363f hepatitis A, 353, 353f hepatitis B, 354, 354f hepatitis C, 355–357, 357f, 362f hereditary hemochromatosis, 359–360 nonalcoholic fatty liver disease (NAFLD), 358–359 pancreatic cancer, 351–352 INDEX / 489 Joint pain, 365–384 calcium pyrophosphate dihydrate deposition disease (CPPD), 368–369 differential diagnosis, 365, 366t, 372t, 377t, 381t, 385f disseminated gonorrhea, 370, 370t femoral stress fractures, 382, 384 gout, 366–368, 367t, 368t Lyme disease, 370–371 osteoarthritis (OA), 381–382, 382t parvovirus, 378 periarticular syndromes, 383t, 384 psoriatic arthritis, 374 reactive arthritis, 379, 379t rheumatic fever, 379–380, 380t rheumatoid arthritis (RA), 372–374, 373t septic arthritis, 369–370 systemic lupus erythematosus (SLE), 374–376, 375t, 376t viral causes of arthritis, 378t K Kaposi sarcoma, 98, 98f Ketoacidosis: alcoholic, 65 diabetic (DKA), 53–56 Kidney function, measuring, 406, 406f L Lactic acidosis: acid-base abnormality, 50t, 63–64, 64t secondary to sepsis, 57–60, 58t, 59f, 59t Lactose intolerance, 203–204 Lacunar infarction of the pons or cerebellum, 225–227, 226t Large bowel obstruction (LBO), 41–42, 41t Latent tuberculosis (TB) infection, 157 LBO (see Large bowel obstruction) Leading hypothesis, Likelihood ratio (LR), 6, negative, 6, positive, 6, Lipid panel, 15–17 Liver disease: alcoholic, 350–351 nonalcoholic fatty liver disease (NAFLD), 358–359 Local osteolytic hypercalcemia of malignancy, 310–311 Low back pain, 114–129 differential diagnosis, 114, 115, 115f–117f, 118t, 119t, 122t, 124t due to metastatic cancer, 122–123, 122t herniated disk, 119–121, 120t mechanical low back pain, 118–119 osteoporotic compression fracture, 123–124 peripheral arterial disease (PAD), 126–128, 126t, 127f spinal epidural abcess, 128 spinal stenosis, 125–126, 125t vertebral osteomyelitis, 128–129 LR (see Likelihood ratio) Lyme disease, 370–371 M MAC (see Mycobacterium avium complex) Malabsorption: diagnostic approach, 460f with folate deficiency, 107 Mallory-Weiss tear, 282–283 Mammograms, 21–23, 22t Mass lesions (HIV), 75 MCI (mild cognitive impairment), 179 MDMA (Ecstasy) intoxication, 342 Mechanical low back pain, 118–119 Medical morning headaches, 294 Melanoma, 401–403, 402f Meniere disease, 218 Meningitis, 302–303, 302t Mesenteric ischemia, acute, 33, 34t Metabolic alkalosis, 65, 65f Metastatic cancer, low back pain due to, 122–123, 122t MI (see Acute myocardial infarction) Microsporidia, 96–97 Migraine: dizziness, 219 headache, 288–290, 289t, 290t Mild cognitive impairment (MCI), 179 Milk-alkali syndrome, 311–312 Mitral regurgitation (MR), 235–236, 236t, 237t Mixed disorders (acid-base abnormality), 66 Mnemonics, MR (see Mitral regurgitation) MS (multiple sclerosis), 221–222 Multi-infarct dementia (vasculardementia, VaD), 178–179 Multiple sclerosis (MS), 221–222 Multiple sensory deficits, 223–224 Musculoskeletal disorders, back pain due to, 114 Must not miss hypothesis, Mycobacterium avium complex (MAC): chronic diarrhea, 97 cough and fever, 92–93 Myocardial infarction (MI), 136–140, 137t–139t N NAFLD (nonalcoholic fatty liver disease), 358–359 National Cholesterol Education Program guidelines, for hyperlipidemia, 17 National Guideline Clearinghouse (NGC) guidelines, 11 National Osteoporosis Foundation (NOF) guidelines, for osteoporosis, 23 Near syncope, 212, 213f, 213t (See also Dizziness) Negative LR, 6, Nephrolithiasis, 45–46 Nephropathy, 188–189 Nephrotic syndrome: edema, 256–257 hyponatremia, 333 Neurocardiogenic (vasovagal) syncope, 421–422, 422f Neuropathy, 185–188, 187t Neurosyphilis in HIV-positive patients, 82–83 NGC (National Guideline Clearinghouse) guidelines, 11 NOF (National Osteoporosis Foundation) guidelines, for osteoporosis, 23 Nonalcoholic fatty liver disease (NAFLD), 358–359 Non-anion gap acidosis, 49, 50 Nonspecific dizziness, 212, 213f, 213t, 227–228 Norovirus, 200–201 NSAID-induced renal hypoperfusion, 414 Nummular dermatitis, 397, 397f O OA (see Osteoarthritis) Obscure GI bleeding, 286 Obstructive sleep apnea (OSA), 272 Occult GI bleeding, 285–286 Organ/system frameworks for diagnosis, Orthostatic hypotension, 434–435, 434t OSA (obstructive sleep apnea), 272 Osteoarthritis (OA), 381–382, 382t Osteoporosis, screening for, 23, 25 Osteoporotic compression fracture, 123–124 P PAD (see Peripheral arterial disease) Pancreatic cancer, 351–352 Pancreatitis: acute, 38–40 chronic, 459–461 Pap smear, 19–21 abnormal, management of, 21t test characteristics of, 20t Paradoxical vocal cord movement (PVCM), 474 Parvovirus, 378 Pathophysiologic frameworks for diagnosis, PCP (Pneumocystis jiroveci pneumonia), 156–157 PE (see Pulmonary embolism) Peptic ulcer disease (PUD): GI bleeding, 282, 282t involuntary weight loss, 452–454, 452t, 453t, 454f Periarticular syndromes, 383t, 384 Pericarditis, acute, 146–147 Periodic limb movement disorder (PLMD), 273 Peripheral arterial disease (PAD), 126–128, 126t, 127f Petechiae, 399 Pheochromocytoma, 325–326, 325t Pityriasis rosea, 396, 396f Pivotal points, Pleural effusion, 143–146, 144t PLMD (periodic limb movement disorder), 273 Pneumocystis jiroveci pneumonia (PCP), 156–157 Pneumocystis pneumonia, 93t Pons, lacunar infarction of, 225–227 Positive LR, 6, Possibilistic approach to diagnosis, Posttest probability, 5, 8, 8t 490 / INDEX Potential harms of missed diagnosis/treatments, Pragmatic approach to diagnosis, Prediabetes, 182 Pretest probability, 3, and actual test results, validated CDR for, Primary CNS lymphoma, 81 Primary cough headache, 297–298 Primary exertional headache, 297–298 Primary hyperaldosteronism, 321 Primary hyperparathyroidism, 306–307 Prioritizing a diagnosis, 1, 3, 4t Probabilistic approach to diagnosis, 3–5, 5f, 6f Problem representation (in diagnosis), 1, Professional societies’ screening guidelines, 11 Prognostic approach to diagnosis, Progressive multifocal leukoencephalopathy, 80–81 Prostate cancer, screening for, 12–13 Prostate specific antigen (PSA), 12–13 PSA (prostate specific antigen), 12–13 Pseudohyponatremia, 342–343 Psoriatic arthritis, 374 Psychogenic polydipsia, 341–342 PUD (see Peptic ulcer disease) Pulmonary embolism (PE): dyspnea, 241–246, 242t, 243t, 244f syncope, 429–430 Pulmonary hypertension, 257–259 Pulmonary TB in AIDS patients, 89–92, 89t, 91f, 93t Purpura, 399, 399f PVCM (paradoxical vocal cord movement), 474 R RA (see Rheumatoid arthritis) Rash, 386–404 acne vulgaris, 388–389 basal cell carcinoma, 400 bullous arthropod bites, 392–393, 392f bullous impetigo, 392, 392f bullous pemphigoid, 393, 393f differential diagnosis, 386–387, 387t, 390t, 395t, 404t guttate psoriasis, 395–396 melanoma, 401–403 nummular dermatitis, 397, 397f petechiae, 399 pityriasis rosea, 396, 396f purpura, 399, 399f rosacea, 389, 389f secondary syphilis, 397–398 skin cancer, 400–403, 400f–402f squamous cell carcinoma, 400–401 Stevens-Johnson syndrome, 393–394, 394f, 394t tinea corporis, 397, 397f urticaria, 398–399, 398f varicella zoster virus (herpes zoster/shingles), 390–391 Reactivation tuberculosis (TB), 157 Reactive arthritis, 379, 379t Red blood cells, underproduction/destruction of, 100 Renal artery thrombosis, 415, 416 Renal failure, acute (see Acute renal failure) Renal tubular acidosis (RTA), 64 Respiratory acidosis, 62–63 Respiratory alkalosis, 65–66 Respiratory complaints, acute (see Acute respiratory complaints) Reticulocyte production index (RPI), 102 Retinopathy, as diabetic complication, 184–185 Retropharyngeal abscess, 478 Rheumatic fever, 379–380, 380t Rheumatoid arthritis (RA), 372–374, 373t Rosacea, 389, 389f RPI (reticulocyte production index), 102 RTA (renal tubular acidosis), 64 S SAH (subarachnoid hemorrhage), 296–297 SBO (small bowel obstruction), 42–43 Screening tests, 10–25 for abdominal aortic aneurysm (AAA), 18 for breast cancer, 21–23 for carotid artery stenosis (CAS), 18–19 for cervical cancer, 19–21 chest radiograph, 17 for colorectal cancer, 13–15 guidelines for, 10–12, 24t for hyperlipidemia, 15–17 numbers needed to screen, 24t for osteoporosis, 23, 25 for prostate cancer, 12–13 reasoning behind, 10 Secondary & tertiary hyperparathyroidism, 312 Secondary syphilis, 397–398 Seizures, 431–432, 431t, 432t Sensitivity, Sepsis: MEDS score, 59f stages of, 58t Septic arthritis, 369–370 Septic shock, 63, 64t Serum bilirubin, 363f Sexual activity, headache associated with, 297–298 Shiga toxin-producing E coli (0157:H7) infection, 207t, 209 Shigella infection, 207t, 208 Shock: hemodynamic features of, 64t types of, 63 Sick sinus syndrome (SSS), bradycardia from, 428–429 Sickle cell anemia, 111–113, 112t Situational syncope, 437 Skin cancer: basal cell carcinoma, 400, 400f melanoma, 401–403, 402f rash, 400–403, 400f–402f squamous cell carcinoma, 400–401, 401f SLE (see Systemic lupus erythematosus) Small bowel obstruction (SBO), 42–43 Society of Vascular Surgery guidelines: for abdominal aortic aneurysm (AAA), 18 for carotid artery stenosis (CAS), 19 Specialty societies’ guidelines, 11 Spinal epidural abcess, 128 Spinal stenosis, 125–126, 125t Squamous cell carcinoma, 400–401, 401f SSS (sick sinus syndrome), bradycardia from, 428–429 Stable angina, 131–134, 132t, 133t Starvation ketosis, 64 Steatosis, 350 Stevens-Johnson syndrome, 393–394, 394f, 394t Stridor, 467 (See also Wheezing or stridor) Subarachnoid hemorrhage (SAH), 296–297 Subdural hematoma, 301 Substances or their withdrawal, headache associated with, 294–295 Syncope, 420–442 aortic stenosis, 435–437, 436f bradycardia due to atrioventricular (AV) heart block, 429, 429t, 430f bradycardia from sick sinus syndrome (SSS), 428–429 cardiac syncope, 425–427, 426t carotid sinus syndrome, 437 cerebrovascular disease and, 438 differential diagnosis, 420, 421t, 425t, 431t, 433t, 441f, 442f hypertrophic cardiomyopathy, 423–424 neurocardiogenic (vasovagal) syncope, 421–422, 422f orthostatic hypotension, 434–435, 434t pulmonary embolism, 429–430 seizures, 431–432, 431t, 432t situational syncope, 437 ventricular tachycardia (VT), 427–428, 427f Wolff-Parkinson-White (WPW) syndrome, 437–438, 438f, 439f Syndrome of inappropriate antidiuretic hormone: hyponatremia, 335–336 Systemic diseases, back pain due to, 114, 115 Systemic lupus erythematosus (SLE), 374–376, 375t, 376t T TB (see Tuberculosis) Temporal arteritis, 299–300, 300t Tension headaches, 290–291 Test characteristics, 6, 6f Test threshold, Tests (see Screening tests) Thiazide-induced hypercalcemia, 308 Threshold model, 5, 5f, 6f Thromboembolism of the renal arteries, 416 INDEX / 491 Tinea corporis, 397, 397f Toxin-mediated gastroenteritis, 201–202, 202t Toxoplasmosis encephalitis, 78–80, 80f Travelers’ diarrhea, 209–210 Tuberculosis (TB), 157–162, 159t, 160t, 161f pulmonary TB in AIDS patients, 89–92, 89t, 91f, 93t Type diabetes mellitus (DM), 181 Type diabetes mellitus (DM), 182–184, 182t, 183t, 195f U UEDVT (see Upper extremity DVT) Ulcerative colitis, 463–464 Ultrasonography, for abdominal aortic aneurysm (AAA), 18 for carotid artery stenosis (CAS), 18–19 Unconjugated bilirubin, 347 Unstable angina, 140–141, 140t Upper extremity DVT (UEDVT), 264–265, 264t Uremic acidosis, 56 Urinary tract obstruction, 411–412 Urobilinogen, 347 Urticaria, 398–399, 398f US Preventive Services Task Force (USPSTF) screening guidelines, 11, 12, 24t for abdominal aortic aneurysm (AAA), 18 for carotid artery stenosis (CAS), 19 for chest radiograph, 17 for colorectal cancer, 14, 15 for hyperlipidemia, 17 for mammography, 22 for osteoporosis, 23 for Pap smears, 20 for prostate cancer, 13 V VaD (vascular dementia), 178–179 VAD (vertebral artery dissection), 220 Varicella zoster virus (herpes zoster/shingles), 390–391 Vascular dementia (VaD), 178–179 VBI (vertebrobasilar insufficiency), 224–225 Venous insufficiency, 259–261, 259f Ventricular tachycardia (VT), 427–428, 427f Vertebral artery dissection (VAD), 220 Vertebral osteomyelitis, 128–129 Vertebrobasilar insufficiency (VBI), 224–225 Vertigo, 212, 213f, 213t, 219 (See also Dizziness) Virtual colonoscopy, 14 Visceral disease, back pain due to, 114 VT (see Ventricular tachycardia) W Water intake, inadequate, hypernatremia secondary to, 344–345 Weight loss, involuntary (see Involuntary weight loss) Wheezing or stridor, 467–483 angioedema, 475–476, 475f asthma, 468–473, 469t, 470f, 471t, 472f bronchiectasis, 483 chronic obstructive pulmonary disease (COPD), 479–481, 479t, 480t differential diagnosis, 467, 468t, 474t, 476t, 479t, 483f epiglottitis, 476–477, 477t paradoxical vocal cord movement (PVCM), 474 retropharyngeal abscess, 478 Wolff-Parkinson-White (WPW) syndrome, 437–438, 438f, 439f UPLOADED BY [STORMRG] ... inability to pass stool and flatus, melena, hematochezia, fever, chills, weight loss, altered bowel habits, orthostatic symptoms, or urinary symptoms) Pulmonary symptoms or a cardiac history can... each symptom that help to focus a broad differential diagnosis into one tailored to the individual patient Third, history and physical exam findings so highly specific that they point directly to. .. 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