ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.

html

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)
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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 .)
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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)
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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 rine
ory m ive n e
Allergi
c
Perip Causal gi a Pel l a Al coh Porph Infecti Trau Tetany
heral Raynaud disease gra ol i c yri a ous ma of
Nerv Buerger dis ease Beri b neuro neuron Hem hypop
e Art eri os clerosi s eri pat hy it i s at om arathy
Ischemic neuri t i s Nut ri t Isoni a Periart a roi di s
i onal zi d eri t is Lacer m
neuro t oxici nodos at ion Al dost
pat hy t y a Neur eronis
Lead oma m
and Fros t
ars eni bi t e
Nerv Leri che Pancoast Scal e Infecti Cont Diabet
c
e syndrome t umor nus ous us i on ic
neuro
Plex ant i cu neuron Lacer neurop
pat hy
us s it i s at ion at hy
Cervi c Fract
al ri b ure
Nerve Tabes Met a Herni Spondyl ol i st Fract ure
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Root dorsa st at i at ed hesi s Herni at ed

lis c and di s c di s c
Tuber pri m Cervi
cul os i ary cal
s t umo and
rs of l umb
t he ar
cord s pon
and dyl os
spi ne i s
(mul t
i pl e
myel
oma)
Spin Anter Pol io Met a Spon Trans Spi na Guil l ai Fract ure
al ior myel i st at i dyl os vers e bi fi da n–B Herni at ed
Cord spi na t i s c and i s myeli t Myel o arré di s c
l Epi du pri m Di sc is cel e syndro Hemat oma
art er ral ary di s ea from Syri ng me
y absce t umo s e radiat omyel Mult i pl
occlu ss rs of Perni i on ia e
si on Tuber t he ci ous scl ero
Aorti cul os i cord anem si s
c s and ia
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 syphi l t umo e ol i sm ent ri c cerebri es se ry
embo i s r deme Bromi ul ar t is d t umor
lus , Encep nt ia sm anom Mult i pl fract Acrom
t hro hal it i Prese Encep al i es e ure egaly
mbus s ni l e hal op Aneur scl ero Subd
, Brai n deme at hy ys m si s ural
hemo absce nt ia Opi at Epi l ep hema
rrhag ss es , sy t oma
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

e barbi t Cereb
Carot urat e ral
id or s, pal sy
basil et c.
ar
art er
y
ins uff
ici enc
y
Migra
ine

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

TABLE 50. Pelvic Mass

M I N T
Malforma Inflammat
Anatomy tion ion Neoplasms T rauma
Bladder Obst ruct io Hunner Carcinoma Rupt ure
n wi t h ul cer Polyp of t he
di vert icul bl adder
um
Cal cul i
Urethra Uret hrocel e
Ureters Papil l oma
Cyst ocel e
Double uret er
Cal cul us
Uret erocel e
Vagina Prolapsed Bart holi ni t Carcinoma Forei gn
cervix i s fis t ul a body
Rect ocel e wit h Tear
rect um or
bl adder
Cervix Cervi ci t is Carcinoma
(rarel y) Polyp
Uterus Bi cornuat Endomet rit Endometri al Rupt ure
e ut erus is carci noma during
Ret roversi Choriocarci no pregnan
on ma cy
Fi broid
Fallopian Ect opi c Salpi ngit i s Carcinoma
T ubes pregnancy (rarel y)
Endomet ri
os is
Ovary Beni gn Oophori t i s Cyst adenoma
congeni t al Cyst adenocar
ovari an cinoma
cys t (e.g., Foll icul ar and
Morgagni ) granul osa
cel l cyst
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Rectum Prolapse Infl amed Rect al

Rect ocel e hemorrhoi carci noma
d
Rect al
absces s
Fi st ul a
Sigmoid Divert i cul Divert i cul i Carcinoma of Forei gn
um tis polyp body
Granuloma
t ous
col i t i s
Ulcerat i ve
col i t i s
Arteries Aneurysm
Spine Lordosi s Rheumat oi Met ast at ic Fract ure
Scol ios i s d art hri t i s carci noma Rupt ure
Spondyl osi Myel oma d dis c
s Hodgkin
Tubercul os lymphoma
is
Miscellane Pelvi c Appendi ci t Pelvi c Bl ood
ous ki dney is met as t asi s cl ot i n
Oment al Regi onal from cul -de-s
cys t and i lei t is st omach, ac
adhes ions e.g. Surgi cal
absces s

P.351

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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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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 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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Pelvic pain
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.

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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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 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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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 .
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

Penile pain
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)
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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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Polycythemia
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 .

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

Question #2. What is your diagnosis now?

Vi ew Answer
Diabet i c aci dosi s
Final Diagnosis: Di abet ic aci dosis
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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€
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

Polydipsia
Psychic desire for food. Thi s occurs in many chroni c
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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.†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
cannot absorb gl ucose.
P.360

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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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)
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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.
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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
ABC Amber CHM Conv erter Trial version, http://www.processtext.com/abcchm.html

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