ࡱ> FHABCDE#` bjbjmm -@(((8`|܋@2t ^^^^^ 0jt<$Qh-^^^^TTT^^TTT(^h 09cG(Z,0qq,(6qJT\lR@@@D@@@.<  HYPERLINK "http://www.mdtruth.com/" MDtruth.com Differential Diagnosis for Cardiac  HYPERLINK \l "dyspnea" Dyspnea  HYPERLINK \l "chestpain" Chest Pain  HYPERLINK \l "palpitations" Palpitations HYPERLINK \l "cardiacenlargement"Cardiac Enlargement  HYPERLINK \l "murmurs" Murmurs  HYPERLINK \l "orthostatichypotension" Orthostatic Hypotension  HYPERLINK \l "pulse" Pulse Pressure Abnormalities  HYPERLINK \l "jvp" Elevated JVP  HYPERLINK \l "splits2" Paradoxical Splitting  HYPERLINK \l "continuousmurmurs" Continuous Murmurs  HYPERLINK \l "hypertension" Hypertension Congestive Heart Failure (Acute) Lungs  HYPERLINK \l "cough" Cough  HYPERLINK \l "wheezing" Wheezing  HYPERLINK \l "hemoptysis" Hemoptysis  HYPERLINK \l "cavitary" Cavitary lesion of lungs  HYPERLINK \l "pleuraleffusion" Pleural Effusion  HYPERLINK \l "cyanosis" Cyanosis External Medicine Alopecia Acanthosis nigricans  HYPERLINK \l "clubbing" Clubbing  HYPERLINK \l "cyanosis" Cyanosis HYPERLINK \l "en"Erythema Nodosum Subcutaneous Nodules HYPERLINK "pathology.doc" \l "vesiculobullous"Vesicubullous lesions  HYPERLINK \l "nodulesarthritis" Nodules and Arthritis  HYPERLINK \l "exanthems" Exanthems Hand and Foot Rash Splinter hemorrhages Livedo reticularis  HYPERLINK \l "yellow" Yellow discoloration Endo  HYPERLINK \l "smalltestes" Small testes  HYPERLINK \l "delayedpuberty" Delayed puberty  HYPERLINK \l "hirsutism" Hirsutism OB/Gyn  HYPERLINK \l "Postmenopausalbleeding" Postmenopausal bleeding  HYPERLINK \l "amenorrhea" Amenorrhea Musculoskeletal Joint Pain (HYPERLINK "pathology.doc" \l "joint"see joint pathology) Muscle Weakness (HYPERLINK "pathology.doc" \l "myopathy"see myopathy)  HYPERLINK \l "backpain" Back Pain Hematological  HYPERLINK \l "abnormalhemostasis" Abnormal hemostasis HYPERLINK \l "hypercoagulability"Hypercoagulability  HYPERLINK \l "hemolyticanemia" Hemolytic Anemia  HYPERLINK \l "thrombocytopenia" Thrombocytopenia  HYPERLINK "path.doc" \l "thrombocytosis" Thrombocytosis  HYPERLINK \l "lymphocytosis" Lymphocytosis  HYPERLINK \l "rf" Rheumatoid Factor  HYPERLINK \l "hyperviscocity" Hyperviscocity Eosinophilia GI/Abdominal  HYPERLINK \l "abdominalpain" Abdominal Pain  HYPERLINK \l "distention" Abdominal distention  HYPERLINK \l "obstruction" Mechanical obstruction HYPERLINK \l "gibleed"GI bleed  HYPERLINK \l "vomiting" Vomiting  HYPERLINK \l "diarrhea" Diarrhea Liver  HYPERLINK \l "ascites" Ascites  HYPERLINK \l "splenomegaly" Splenomegaly  HYPERLINK \l "hepaticcysts" Cysts Renal  HYPERLINK "pathology.doc" \l "hematuria" HematuriaHead  HYPERLINK \l "delirium" Delirium  HYPERLINK \l "dementia" Dementia  HYPERLINK \l "ataxia" Ataxia  HYPERLINK \l "asterixis" Asterixis  HYPERLINK \l "amnesia" Amnesia  HYPERLINK \l "anisocoria" Anisocoria  HYPERLINK \l "epistaxis" Epistaxis  HYPERLINK \l "headaches" Headaches  HYPERLINK \l "seizures" Seizures  HYPERLINK \l "syncope" Syncope Vertigo Neck  HYPERLINK \l "cervical" Cervical lymphadenopathy  HYPERLINK \l "dysphagia" Dysphagia /  HYPERLINK \l "odynophagia" Odynophagia Neuro Mononeuritis Multiplex Electrolyte Abnormalities ( HYPERLINK "pathology.doc" \l "electrolytes" see other) Pediatrics  HYPERLINK \l "ftt" Failure to Thrive  HYPERLINK \l "mr" Mental Retardation  HYPERLINK \l "precocious" Precocious puberty /  HYPERLINK \l "latepuberty" Late Puberty Ddx for  HYPERLINK "micro.doc" \l "aidsddx" opportunistic pathogens in AIDS patients Causes of Dyspnea Heart disease Left ventricular failure Restrictive cardiomyopathy Constrictive pericarditis Pulmonary venous obstruction Mitral stenosis Cor triatriatum Left atrial myxoma Left atrial thrombus Tamponade Lung disease Obstructive airways disease Chronic obstructive pulmonary disease Asthma Restrictive lung disease Interstitial or diffuse alveolar lung disease Disorders of chest wall and bellows function Kyphoscoliosis Arthritis Neuromuscular disease Obesity Vascular disease Pulmonary embolism Primary pulmonary hypertension High altitude exposure Anemia Anxiety (hyperventilation syndrome) Causes of Chest Pain Heart disease Angina pectoris Atheromatous coronary artery disease Nonatheromatous coronary artery disease Aortic stenosis (HYPERLINK "pathology.doc" \l "as"AS) Aortic insufficiency (HYPERLINK "pathology.doc" \l "ar"AI) Idiopathic hypertrophic subaortic stenosis (HYPERLINK "pathology.doc" \l "hocm"HOCM, IHSS) Myocardial infarction Congestive cardiomyopathy Pulmonary hypertension Mitral valve prolapse (click-murmur) syndrome (HYPERLINK "pathology.doc" \l "mvp"MVP) Pericarditis Dissection of the aorta Pulmonary disease Pulmonary embolism Pleuritis Pneumothorax Pneumonia Tumor Collagen disease mechanism? Atelectasis mechanism? Musculoskeletal disease Arthritis Costochondritis (Tietze syndrome) Bursitis Intravertebral disc disease Thoracic outlet syndrome Muscle spasm Fracture Metastatic tumor or hematologic (leukemia) or plasma cell (myeloma) malignancy Neural disease Intercostal neuritis Herpes zoster Gastrointestinal disorders ("referred" chest pain) Hiatal hernia Cholecystitis Pancreatitis Ulcer disease Bowel disease Neoplasm Emotional duress or anxiety (e.g., neurocirculatory asthenia, Da Costa syndrome) Causes of Hemoptysis General: Massive Hemoptysis e" 600 ml in 24 hrs (place affected lung in dependent position, ?rigid bronchoscopy, ?intubation) Most common in US: bronchitis, lung cancer Hemoptysis + acute pleuritic pain ( PE Hemoptysis + chronic copious sputum ( bronchiectasis Cardiac Pulmonary venous hypertension Left ventricular failure Mitral stenosis Eisenmenger syndrome Pulmonary [see endobronchial Ddx] Infection Bronchitis (1st) Bronchiectasis Tb (2nd) Pneumonitis Abscess  HYPERLINK "path.doc" \l "lungca" Lung cancer (3rd) Trauma or foreign body Alveolar hemorrhage Vascular Rupture of AV fistula Thoracic aortic aneurysm Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) Primary pulmonary hypertension Pulmonary embolism Goodpastures syndrome Arthritides Polyarteritis nodosa (HYPERLINK "pathology.doc" \l "pan"PAN) Wegener's granulomatosis SLE Bleeding diathesis Endobronchial Lesions Endobronchial carcinoma Metastatic endobronchial tumor Melanoma Endometrial or ovarian carcinoma Thyroid carcinoma Renal cell carcinoma Kaposis sarcoma Calcified carcinoid tumor Endometrial endometriosis Benign tumor or pyogenic granuloma Granulation tissue Response to foreign body irritation Trauma Vasculitis, Wegeners Lymphomatoid granulomatosis Sarcoidosis Fungal infection aspergillosis, phaeohyphomycosis, sporotrichosis, blastomycosis, histoplasmosis, coccidioidomycosis Tuberculosis Broncholithiasis Causes of Palpitations Extra systoles Atrial premature beats AV junctional (nodal) premature beats Ventricular premature beats Tachyarrhythmias Supraventricular Regular Sinus tachycardia Paroxysmal supraventricular tachycardia AV junctional tachycardia Atrial flutter Irregular Atrial fibrillation Paroxysmal supraventricular tachycardia or atrial flutter with block Multifocal atrial tachycardia Ventricular tachycardia Bradycardia Sinus bradycardia Sinus arrest 2nd or 3rd degree AV block Conditions associated with increased force of cardiac contraction Thyrotoxicosis Anemia Fever Certain drugs, including catecholamines and cardiac glycosides Anxiety states Causes of Cardiac Enlargement Congestive heart failure Valvular heart disease Volume or pressure overload (e.g., L to R shunts, systemic arterial hypertension) Heart muscle disease (ischemia or cardiomyopathy) High-output failure Ventricular aneurysm Large stroke volume Athlete's heart Complete heart block Pericardial effusion Cardiac cysts and tumors Absence of the pericardium Common Causes of Murmurs Valvular heart disease Stenosis Insufficiency of congenital or acquired etiology Nonvalvular outflow obstruction Supravalvular and subvalvular outflow obstruction Idiopathic hypertrophic subaortic stenosis (HOCM, IHSS) Shunts (extracardiac and intracardiac) Complex congenital heart disease producing turbulence Physiologic murmurs Hyperdynamic states Anemia Fever Thyrotoxicosis Pregnancy AV fistula Excitement Flow across normal valves in high-volume states Diastolic rumble in mitral and tricuspid regurgitation, atrial and ventricular septal defect, patent ductus arteriosus Complete heart block Austin Flint murmur of aortic regurgitation Innocent murmurs of childhood Anatomic distortion producing turbulence Straight back syndrome Pectus excavatum Chest deformity High to low pressure communication Ruptured sinus of Valsalva aneurysm Coronary fistula Anomalous origin of left coronary artery from pulmonary artery AV fistula Arteriopulmonary connection Dilatation or stenosis of large or small vessels Aneurysm or dilatation of aorta or pulmonary artery Coarctation Peripheral pulmonary stenosis Atherosclerotic vascular narrowing Pulmonary embolism Alteration of arterial or venous flow in nonconstricted vessels Venous hum Mammary souffl High brachiocephalic flow in children High flow in collateral vessels Intercostal/bronchial collaterals in coarctation of aorta, pulmonic stenosis, or atresia Aortic regurgitation Sounds resembling murmurs Fusion of S3 and S4 gallops Prolonged gallop sounds Pericardial and pleural friction rubs Causes of Orthostatic Hypotension Idiopathic Hyponatremia Hypovolemia Drugs (e.g., tranquilizers, vasodilators) CNS disease (e.g., syringomyelia, tabes dorsalis) HYPERLINK "pathology.doc" \l "addisons"Addison's disease Pheochromocytoma  HYPERLINK "pathology.doc" \l "wernickes" Wernicke syndrome  HYPERLINK "pathology.doc" \l "amyloidosis" Amyloidosis Diabetes mellitus Primary autonomic insufficiency After sympathectomy Physical deconditioning Continuous Murmurs Location of MurmurDifferential Diagnosis First to second left intercostal spaces (and under left clavicle) Patent ductus arteriosusSecond to fourth left intercostal spaces Aorticopulmonary septal defectUsually best heard in the second to third left intercostal spaces; occasionally may be best heard at the right of the sternum in the same area Surgical shunts, such as aortopulmonary anastomosesUsually best heard along the lower left sternal border, although it may be audible over the entire precordiumRupture of sinus of Valsalva aneurysmAudible over the left precordium Coronary AV fistulaeMay be audible anywhere that they occur AV fistulae Pulse Pressure Abnormalities Increased Pulse Pressure Narrow Pulse PressureSinus bradycardia Severe heart failure (please understand how)Complete heart block ShockEmotion Aortic stenosis (usually occurs but is not always present)Exercise Hypovolemia Aortic regurgitationVasoconstrictive agents AV fistulaeFeverAnemia Hyperthyroidism Beri-beri Inelastic aorta (elderly patients)Abnormal connections between aorta and pulmonary artery (patent ductus arteriosus, aorticopulmonary window)Rupture of sinus of Valsalva aneurysm  Arterial Pulse Abnormalities Abnormality Description  Anacrotic pulse A small, slowly rising pulse with a notch on the ascending limb, such that there are two deflections on the upstroke of the carotidBisferiens pulseTwo palpable systolic peaks of almost equal height Dicrotic pulse A second peak during diastoleWaterhammer pulse Characterized by rapid and sudden systolic expansionIdiopathic hypertrophic subaortic stenosis pulseA carotid pulse with a very rapid upstroke. sometimes having a bisferiens quality Elevated Jugular Venous Pressure (JVP) Right ventricular failure Vascular pulmonic stenosis Infundibular pulmonary stenosis Pulmonary hypertension Tricuspid stenosis or insufficiency Hypervolemia Pericardial tamponade Constrictive pericarditis Superior vena caval obstruction Paradoxical Splitting of the Second Heart Sound Elevated PAP? Left bundle branch block Right ventricular ectopic beats Right ventricular pacing Angina pectoris Left ventricular failure Left ventricular outflow obstruction Severe systemic hypertension Note: Paradoxical splitting occurs in some but not all patients with these abnormalities Cough Pulmonary-related Cardiac-related MS may produce bouts of coughing (confused with bronchitis) Hemoptysis from heart disease (rare) sputum usually white, but can be blood streaked (high pulmonary pressure from chronic CHF, MS, Eisenmengers, impinging aortic aneurysm) Wheezing RAD (Asthma) cardiac wheezing - dont forget about this which responds to albuterol also Cavitary lesion of lungs [characteristic wall pattern] [ HYPERLINK "http://content.nejm.org/cgi/content/short/348/5/447?query=TOC" NEJM] Infectious Bacteria (thick): S. aureus, S pneumo (only type 3), Pseudomonas, klebsiella, legionella, H. influenza Tb (Gohn complex), M. avium, rhodococcus, actinomyces/nocardia, burkholderia, peptostreptococcus, prevotela, bacteroides, fusobacterium Parasites: entamoeba, toxoplasma, paragonimiasis,  HYPERLINK "micro.doc" \l "echinococcus" echinococcus (think lower lobe, R > L) Fungal: histoplasma (variable) blastomycosis, cryptococcus (thick) aspergillosis, coccidioides (thin) mucor, penicillum marneffei, PCP Developmental: sequestration (thick or thin), bronchial cyst (thin) Immunology: Wegeners (thick, irregular), Goodpasteurs (bilateral), rheumatoid, sarcoidosis (variable) Neoplasm: pulmonary (SCC) (thick, irregular), metastasis (adenoma or sarcoma) and Hodgkins lymphoma (thick or thin), adenoma, teratoma Vascular: septic thromboembolism (thick or thin, shaggy wall) Inhaled: silicosis, coal workers (thick, irregular) Other: Blebs or bullae (when infected) / cystic bronchiectasis, pulmonary laceration Pleural Effusion (HYPERLINK "pathology.doc" \l "pleuraleffusion"see lungs) PE: dullness to percussion, hyporesonance, decreased fremitus (increased with pneumonia), large effusion may shift trachea to opposite side / not generally associated with pain Exudate criteria: protein > 3 (0.5 ratio) / LDH > 200 (0.6 ratio) Clues: RF or glucose < 20 ( RA / leukoerythrogenic cells (so-called LE cells) ( SLE / 2x amylase ( pancreatitis/ruptured esophagus / Hct > 20% ( hemothorax / increased lymphocytes ( Tb or malignancy Heart CHF Left and right heart failure (if unilateral, usually right-sided) Pulmonary venous hypertension with right heart failure Autoimmune phenomena after heart injury Postpericardotomy syndrome / Dresslers syndrome (post-MI) Lungs Inflammation (pleura or lung) Infection Malignancy (can get pain with mesothelioma) PE Collagen disease with pulmonary involvement: SLE, RA Trauma: hemothorax, chylothorax (thoracic duct), esophagus Abdominal Pancreatitis (left sided effusion) Abscess Abdominal ascites  HYPERLINK "pathology.doc" \l "meigs" Meigs Hydronephrosis Systemic Hypothyroidism Hypoalbuminemia Nephrotic syndrome Drugs: nitrofurantoin, dantrolene, dopamine agonists, amiodarone, quinidine, IL-2 Erythema Nodosum (HYPERLINK "path.doc" \l "erythemanodosum"see derm) usually painful Infectious Post-Strep pharyngitis (HYPERLINK "pathology.doc" \l "rheumaticfever"ARF) HYPERLINK "micro.doc" \l "yersinia"Yersinia enteritis HYPERLINK "micro.doc" \l "chlamydia"Chlamydia HYPERLINK "micro.doc" \l "mycoplasma"Mycoplasma  HYPERLINK "micro.doc" \l "tb" TB Atypical mycobacterial infection (M. lepra) Immunodeficiency-related infection HYPERLINK "pathology.doc" \l "endocarditis"Endocarditis HYPERLINK "pathology.doc" \l "ebv"Infectious mononucleosis Autoimmune Sarcoidosis (HYPERLINK "pathology.doc" \l "lofgrens"Lofgrens) HYPERLINK "pathology.doc" \l "hsp"HSP HYPERLINK "pathology.doc" \l "sle"SLE HYPERLINK "pathology.doc" \l "ibd"IBD (ulcerative colitis) HYPERLINK "pathology.doc" \l "behcet"Behets (see below) Drug-related oral contraceptives / sulfonamides, bromides, gold Note: Female > male (5:1) mean age 31 yrs Acute phase reactant may be elevated without correlation to underlying disease Other (not exactly erythema nodosum) Behets, superficial thrombophlebitis, cutaneous vasculitides Subcutaneous nodules Infections: a jillion Neoplasms: neuroblastoma Onchocerciasis (parasite) Nodules and Arthritis RA, SLE, gout, sarcoid, sporotrichosis, MRH, type II hyperlipidemia, palmer fasciitis, CrEST Splinter hemorrhages Endocarditis / rheumatoid arthritis / vasculitis? Livedo Reticularis Atheroembolic syndrome PAN Type II cryoglobulinemia APS (Snedden syndrome) Exanthems  HYPERLINK "path.doc" \l "exanthems" See more on infectious exanthems  Petechial Rashes Serious infections: Neisseria meningitides, RMSF, atypical measles Other: endocarditis, DIC Desquamation Toxic shock syndrome, Kawasakis, scarlet fever, drug reactions Hand and Foot Rash Secondary syphilis Reiters RMSF Yellow Discoloration of Skin Carotenemia Hypothyroidism Liver disease Renal disease Diabetes (rarely) [ HYPERLINK "pics/diabetes-yellow.jpg" pic] Clubbing (rated as 0 to 4+) Pulmonary: Chronic pneumonia / pulmonary abscess / empyema Interstitial pneumonitis / CF or other bronchiectasis Interstitial fibrosis / pulmonary alveolar proteinosis Cardio: cyanotic congenital heart disease / subacute bacterial endocarditis GI: UC or Crohns / polyposis / biliary cirrhosis/atresia Neoplasms, familial, thyrotoxicosis Precocious Puberty Central hamartomas producing LHRH disinhibition (radiation therapy, etc.) upregulation of LH receptors (only affects boys since girls require LH and FSH) HCG tumor applies to boys (modest testicular enlargement) McCune-Albright deficient GS-alpha (failure to hydrolyze GTP to GDP) produces hyperfunction of several endocrine secretors more in girls than boys CAH precocity in boys, ambiguity in girls Peripheral ovarian tumor functional ovarian cysts adrenal tumor oral contraceptives Cyanosis Peripheral cyanosis Decreased blood flow in vasoconstricted states with high oxygen extraction Reduced cardiac output Shock Congestive heart failure Cold exposure Peripheral arterial and/or venous disease Central cyanosis Arterial unsaturation due to impaired gas exchange in lungs Hypoxia due to general hypoventilation with increased PCO, and decreased PaO2 Regional hypoventilation with respect to perfusion Perfusion of unventilated regions of lung Impaired diffusion Low inspired oxygen tension Right-to-left shunts Intracardiac Extracardiac Hemoglobinopathy False cyanosis Argyria Musculoskeletal Back Pain Trauma: injury to bone, joint, ligament Mechanical: pregnancy, obesity, fatigue, scoliosis Degenerative: osteoarthritis Infectious: osteomyelitis, subarachnoid or spinal abscess, Tb, meningitis, basilar pneumonia Metabolic: osteoporosis, osteomalacia Vascular: leaking aortic aneurysm, subarachnoid or spinal hemorrhage/infarction Neoplastic: myeloma, Hodgkins, pancreatic CA, mets from breast, prostate, lung GI: penetrating ulcer, pancreatitis, cholelithiasis, IBD Renal: hydronephrosis, stones, neoplasm, renal infarction, pyelonephritis Heme:  HYPERLINK "pathology.doc" \l "sicklecell" sickle cell crisis, acute hemolysis GYN: uterine tumors, ovarian tumors, dysmenorrhea, salpingitis, uterine prolapse Inflammatory: ankylosing spondylitis, psoriatic arthritis, Reiters Lumbosacral strain Psychogenic: malingering, hysteria, anxiety Endocrine: adrenal hemorrhage or infarction Breast Mass Fibrocystic breasts Benign tumors (fibroadenoma, papilloma) Mastitis (acute bacterial mastitis, chronic mastitis) Malignant neoplasm Fat necrosis Hematoma Duct ectasia Mammary adenosis Ascites HYPERLINK "pathology.doc" \l "portalvenous"Portal hypertension/cirrhosis Hypoalbuminemia: nephrotic syndrome, protein losing gastroenteropathy, starvation Hepatic congestions: CHF, constrictive pericarditis, tricuspid insufficiency, hepatic vein obstruction (Budd-Chiari syndrome), IVC or portal vein obstruction Peritoneal infection: Tb and other bacteria, fungal, parasite Neoplasm: primary vs. mets, lymphoma, leukemia, myeloid metaplasia Lymphatic obstruction: mediastinal tumors, trauma to thoracic duct, filariasis Ovarian disease: Meigs syndrome, struma ovarii Chronic pancreatitis or pseudocyst Urinary, biliary or chylous extravasation Hypothyroidism (myxedema) Splenomegaly Hematologic: Hodgkin and Non-Hodgkin lymphoma, CML, CLL, hairy cell leukemia, PRV, myelofibrosis, POEMS, WM Infectious:  HYPERLINK "micro.doc" \l "psittacosis" psittacosis, histoplasmosis, schistosomiasis, SBE, EBV, AIDS, malaria, leischmaniasis, splenic abscess Others: Feltys, malignant mastocytosis,  HYPERLINK "pathology.doc" \l "spherocytosis" spherocytosis, thalassemia, sarcoidosis, berylliosis, portal hypertension, Gauchers, Niemann-Pick Hepatic Cysts Neoplasm Cystadenoma Cystadenocarcinoma Squamous cell carcinoma colon, ovary, pancreas, neuroendocrine Non-Neoplasm Simple cyst, ciliated foregut cyst, APKD, biloma, Carolis disease Infection Echinococcus, pyogenic abscess, actinomyces, Entamoeba histolytica Delayed puberty incomplete list Central hypogonadism 25% have Kallmans syndrome (central hypogonadism and anosmia) Pseudo-something Autoimmune Turners Small testes Exogenous steroids (mild shrinkage) Klinefelters (small) Kallmans (very small) Certain pituitary tumors (takes years to secondarily shrink testes a lot) Myotonic dystrophy and non-dystonic myotonias Hirsutism  HYPERLINK "pathology.doc" \l "pcos" PCOS exogenous Drugs: minoxidil, phenytoin, diazoxide, cyclosporin Free testosterone increase (altered SHBG) HYPERLINK "pathology.doc" \l "cah"CAH (21, 11, 3) prolactinemia ovarian tumor: sertoli-leydig, granulosa-theca, hilar (Leydig), luteoma of pregnancy, cystadenoma, Krukenbergs Cushings or other adrenal tumors theca lutein cysts, stromal hyperplasia and hyperthecosis Alopecia Non-scarring Telogen effluvium Androgenetic alopecia Alopecia areata Tinea capitis Traumatic alopecia Drugs (usu. reversible): heparin, PTU, vitamin A, colchicines, amphetamines Scarring Lichen planus Cutaneous lupus Linear scleroderma Chemotherapy agents: daunorubicin, others Acanthosis nigricans [in progress;  HYPERLINK "path.doc" \l "acanthosis" see path] Insulin resistance Gastric carcinoma Failure To Thrive (FTT) Neglect (1st) Congenital heart disease GI malformations pyloric stenosis, atresia?, Hirschprungs Malabsorption: celiac sprue Late presenting MSUD / familial dysautonomia FAS Metabolic: abetalipoproteinemia, methylmalonic aciduria, Congenital nephrogenic diabetes Neoplasms: neuroblastoma, Mental Retardation (very incomplete) Fetal Alcohol Syndrome (FAS) Trisomy 21 (Downs), Fragile X, Other Congenital: Retts, DMD, NF (40-50%), tuberous sclerosis, Prader-Willi, Angelman, Velo-Cardio-Facial, Williams, Chediak-Higashi, Metabolic: Hurlers, maple syrup urine, homocystinuria (variable), methylmalonic aciduria, galactosemia, Lesch-Nyhan, mother with PKU (uncontrolled), Infections: congenital rubella Teratogens: HYPERLINK "pharm.doc" \l "phenytoin"phenytoin, CNS Trauma: stroke, Deafness (very incomplete) HYPERLINK "pathology.doc" \l "deafness"Congenital disorders Congenital infections (rubella, CMV, Drug toxicity: aminoglycosides, Delirium CNS lesion Head injury: CVA, ICH Infection Mass lesion: hematoma, tumor Seizure, postictal No lesion Metabolic encephalopathy Anoxia (hypoxemia, underperfusion, PE, sleep apnea, etc.) Hepatic encephalopathy Uremic encephalopathy Hypo or hyperglycemia Hypo or hyperthyroid Hyponatremia Hypercalcemia Toxic encephalopathy Drug withdrawal (alcohol, benzodiazepines, narcotics, others) Drug toxicity (Dilantin, others) Substance abuse Infections causing systemic/CNS effect (usually in elderly) Dementia (most common ( Alzheimers, multi-infarct, depression) Degenerative: Alzheimers, Huntingtons, Parkinsons Endocrine: thyroid, parathyroid, pituitary, adrenal Metabolic: alcohol, electrolytes, B12, glucose, liver, renal, Wilsons Exogenous: heavy metals, CO, drugs Neoplasia Trauma: subdural hematoma Infection: meningitis, encephalitis, abscess, endocarditis, HIV, syphilis, prion, lyme Affective: depression Stroke/Structure: multi-infarct dementia, ischemia, vasculitis, normal pressure hydrocephalus Coma Metabolic CVA ( bilateral hemispheric or basilar to RAS Headaches Acute: SAH, hemorrhagic stroke, meningitis, seizure, acutely elevated IC, hypertensive encephalopathy, post-LP, ocular disease (glaucoma, iritis), new migraine Subacute: HYPERLINK "pathology.doc" \l "gca"temporal arteritis, PRV, intracranial tumor, subdural hematoma, pseudotumor cerebri, trigeminal/glossopharyngeal neuralgia, postherpetic neuralgia, hypertension Chronic: migraine, cluster, tension, sinusitis, dental disease, neck pain (including cervical radiculopathy) Seizures (incomplete) Infection Meningitis, Toxins - Shigella, ETEC Febrile roseola Sturge-Weber Metabolic: porphyria (Swedish), neuronal ceroid lipofuscinosis Electrolyte congenital syndromes - Retts, Melas, FAS, tuberous sclerosis, Sturge-Weber, metabolic - neuronal ceroid lipofuscinosis chronic pancreatitis (late) Ataxia Vertebral-basilar ischemia / lateral medullary syndrome of Wallenberg Diabetic neuropathy Tabes dorsalis Nurtritional: Wernickes ataxia, B12 deficiency MS and other demyelinating Meningomyelopathy (e.g. s/p meningitis) Cerebellar neoplasm (neuroblastomas), hemorrhage, abscess, infarct Paraneoplastic Parainfectious: Guillain-Barr syndrome, acute ataxia of childhood and young adults Toxins: phenytoin, alcohol, sedatives, organophosphates, lead Wilsons disease (hepatolenticular degeneration) Hypothyroidism Myopathy Cerebellar and spinocerebellar degeneration Congenital: spinocerebellar ataxia type 1, acute cerebellar ataxia, ataxia-telangiectasia, Friedreichs ataxia Metabolic: Abetalipoproteinemia, Hartnups Frontal lobe lesions: tumors, thrombosis of anterior cerebral artery, hydrocephalus (and NPH) Labyrinthine destruction: neoplasm, injury, inflammation, compression Hysteria AIDS Asterixis Liver and/or Kidney dysfunction Drugs: tegretol Amnesia Degenerative (e.g. Alzheimers, Hungtingtons) CVA (esp. thalamus, basal forebrain, hippocampus) Trauma, post-surgical Infection (HSV, meningitis) Wernicke-Korsakoff syndrome Brain anoxia Hypoglycemia CNS neoplasm Creutzfeldt-Jakob disease Medications (midazolam and other BZs) Psychosis Malingering Anisocoria Mydriatic or miotic drugs Prosthetic eye Inflammation (keratitis, iridocyclitis) Infection (HSV, meningitis, encephalitis, Tb, diptheria, botulism) Subdural hemorrhage Cavernous sinus thrombosis Intracranial neoplasm Cerebral aneurysm Glaucoma CNS degenerative Internal carotid ischemia Toxic polyneuritis (alcohol, lead) Adies syndrome Horners syndrome DM Trauma, congenital Mononeuritis Multiplex Diabetes mellitus Infectious: HIV, lyme, leprosy Vasculitis: SLE, Sjogrens Paraneoplastic: leukemia, lymphoma (rare), Castlemans disease, angioimmunoblastic lymphadenopathy with dysproteinemia, plasma-cell dyscrasia, monoclonal gammopathy of undetermined significance Amyloidosis Sarcoidosis Cryoglobulinemia (HCV) Hereditary susceptibility to pressure palsies Epistaxis Trauma Nose-picking Foreign body URI Nasal Polyps Antihistamine Xs Telangiectasia Blood dyscrasias Pertussis Congestive Heart Failure (Acute) Myocardial infarction Pulmonary embolism Infection Anemia Thyrotoxicosis / pregnancy Arrhythmias / rheumatic, other myocarditis Infective endocarditis Physical, dietary, fluid, environmental and emotional Systemic hypertension Syncope [ HYPERLINK "http://content.nejm.org/cgi/content/full/343/25/1856" NEJM] Yield of H&P (45%) Causes: vasovagal (20%), arrhythmias (15%), neurologic disease (10%), unknown (30%) Focus on cardiac abnormalities / get BP in both arms! Get ECG 1st (5% yield, but very important) / if positive, echo/stress may follow / a random echo detects unsuspected abnormalities in 5-10% / Holter monitor sensitivity is 20% @24 hrs, some say 40% @48 hrs / continuous-loop event monitoring (will catch ~10% of undiagnosed recurrent syncope / EP studies are okay for tachycardias but are low S/S for bradycardias Chemistries et al are very low yield (2%) unless indicated (can suggest seizures) CT head (4% yield), EEG (2% yield), transcranial dopplers only if suggested Hospitalization ( anything suggesting cardiac causes, severe orthostasis, drug-reaction Treatment( B-blockers?, pacemakers?, other specific treatments Cardiac output Neurocardiogenic may have clonic jerks of face, limbs appearing seizure-like usu. have prodrome allowing patient to sit down rather than suddenly drop Vasovagal or (true cardiac response) (18%) parasympathetic response to undue cardiac distension or strenuous contractions Situational (5%) young people ( stress, fear, pain elderly ( postprandial, often follows meals with alcohol Carotid sinus hypersensitivity (1%) leads to bradycardia and hypotension, diagnosis of exclusion (unless you can induce it with carotid massage, which has a 0.3% risk of inducing CVA) Cough/Micturition syncope valsalva or straining (that promotes parasympathetic tone and decreases venous return via pressurizing SVC/IVC; thus decreasing cardiac output) Arrhythmias: VT/SVT, prolonged QT interval, heart block/conduction defect Left ventricular outflow obstruction Valvular aortic stenosis Supravalvular aortic stenosis Discrete subvalvular aortic stenosis Obstructive cardiomyopathy ( HYPERLINK "pathology.doc" \l "hocm" HOCM) Tetralogy of Fallot (HYPERLINK "pathology.doc" \l "tof"TOF) Other cardiac: atrial myxoma, massive MI, restrictive/constrictive myocardial (amyloid), or pericardial disease (tamponade) Orthostatic hypotension (see  HYPERLINK \l "hypotension" hypotension) (8% overall; 30% in elderly population) Drug (medication-induced, peripheral neuropathy (DM, alcohol, nutritional, amyloid, idiopathic, Shy-Drager, deconditioning, sympathectomy, Guillain-Barr), hypovolemia (adrenal insufficiency, blood loss, etc) Test ( patient sits for 5 minutes, then stands for 3 minutes / Chemical Tilt Tests approach 90% specificity Metabolic Hypoglycemia Hypoxia (including PE, pulmonary HTN) Hyperventilation Neurologic (10%) Seizures atonic seizures or ictal bradycardic (rare) Note: some spasms may occur resulting from CNS hypoperfusion (so hypotension appears like a true seizure) CVA/TIA: focal cerebral ischemia to RAS / random carotid U/S is very low yield Subarachnoid hemorrhage Basilar artery migraine rare but true Arnold-Chiari malformation Narcolepsy Glossopharyngeal neuralgia Tumor Colloid cyst of 3rd ventricle Other Vascular HYPERLINK "pathology.doc" \l "subclaviansteal"Subclavian steal syndrome Aortic Dissection - always check BP in both arms!! Vasculitis Psychiatric, factitious (uncommon) (2%) Vertigo [HYPERLINK "pathology.doc" \l "vertigo"see neuro] Lasting ( > 24 hrs): vestibular neuritis, brainstem stroke, multiple sclerosis Hours or minutes: Menieres, TIA, migraine, seizures (rarely), perilymph fistula Seconds: BPPV Hypotension Nonneurogenic causes Cardiac pump failure: MI, constrictive pericarditis, aortic stenosis, tachy/bradyarrhythmias Hypovolemia: straining on urination/defecation, dehydration, diarrhea, hemorrhage, burns, salt-losing nephropathy (hyponatremia), HYPERLINK "pathology.doc" \l "addisons"Addison's (cortisol and aldosterone), diabetes insipidus Venous pooling: alcohol, postprandiol dilation of splanchnic vessels (morphine?), vigorous exercise with dilation of skeletal vessel beds, heat, fever, prolonged recumbency of standing, sepsis Drugs: antihypertensives, diuretics, vasodilators (nitrates/hydralazine), alpha/beta blockers, CNS sedatives (barbiturates, opiates), TCAs, phenothiazines Physical deconditioning Pheochromocytoma? Idiopathic Neurogenic causes Primary ANS Multisystem atrophy (?Bradbury-Eggelston, Shy-Drager syndrome) Pure ANS failure Subacute dysautonomia Secondary ANS Brain and brainstem: tumor, stroke, multiple sclerosis, post-sympathectomy Spinal cord: transverse myelitis, syringomyelia, tumor, tabes dorsalis Peripheral nervous system diabetes, Guillain-Barr, alcoholic polyneuropathy (HYPERLINK "pathology.doc" \l "wernickes"Wernicke), HIV, HYPERLINK "pathology.doc" \l "amyloidosis"Amyloidosis, porphyria Hypertension Essential Pre-eclampsia Pheochromocytoma Renal artery stenosis (aldosteronemia) Rheumatoid Factor RA (80%) Sjogrens (5080%) SLE (50%) PSS (15-20%) Polymyositis (15-20%) Arteritis (15-20%) Endocarditis, TB, other chronic infections (fungal) Chronic liver disease and/or cryoglobulins Drug abuse (IV) Aging Hyperviscocity PRV (very common) POEMS syndrome WM (50%) MM (< 5%, even with cryoglobulinemia) Hyperviscocity absent: CML, AMMM, CML, Hodgkins, Heavy-chain diseases, amyloidosis Lymphocytosis Pertussis infectious lymphocytosis CMV HYPERLINK "micro.doc" \l "ebv"EBV Tuberculosis Toxoplasmosis chronic inflammatory disorders autoimmune syndromes Abnormal Hemostasis  HYPERLINK \l "thrombocytopenia" Thrombocytopenia Malignancy Decreased clotting factors DIC autoimmune (anti-VIII) congenital (hereditary hemorrhagic telangiectasia,  HYPERLINK "path.doc" \l "vwd" vWD) Uremia Medications: coumadin, ASA, plavix Hypercoagulability Risk Factors: sedentary, post-operative, OCP/estrogens, pregnancy Acquired: malignancy (Trousseaus) mostly venous myeloproliferative arterial/venous HYPERLINK "pathology.doc" \l "pnh"PNH connective (HYPERLINK "pathology.doc" \l "sle"SLE) HYPERLINK "pathology.doc" \l "behcets"Behets  HYPERLINK "pathology.doc" \l "buergers" Buergers Vasculitis arterial/venous HYPERLINK "pathology.doc" \l "prv"Polycythemia Vera HYPERLINK "pathology.doc" \l "thrombocythemia"Primary Thrombocythemia HYPERLINK "pathology.doc" \l "ttp"TTP arterial and venous HYPERLINK "pathology.doc" \l "dic"DIC HYPERLINK "pathology.doc" \l "dm"DM (nephrotic syndrome) CHF (stasis?) Congenital APA syndrome arterial/venous APC resistance (Factor V Leiden) Protein C deficiency / Protein S deficiency Antithrombin deficiency Dysfibrinogenemia Hyperhomocystinuria - arterial Prothrombin G20210A Anemia (HYPERLINK "pathology.doc" \l "anemiaworkup"see work-up) Drugs: AZT, quinidine, chloramphenicol, methyldopa, benzene, cancer drugs Blood loss: menstruation, GI/GU bleeds HYPERLINK "pathology.doc" \l "hemolyticanemia"Hemolytic anemia Deficiency: Iron, Folic acid Infection: sepsis, AIDS, malaria Chronic: cancer, ESRD, endocrine Genetic: Thalassemia, sickle cell, many others Hemolytic anemia (HYPERLINK "path.doc" \l "hemolyticanemia"see other) mechanical artificial valves, DIC, TTP autoimmune warm drug-induced cold agglutinin syndrome -  HYPERLINK "micro.doc" \l "mycoplasma" Mycoplasma pneumoniae and (rarely) EBV paroxysmal cold hemoglobinuria - anti-P antigen alloimmune - erythroblastosis fetalis / transfusion rxn Thrombocytopenia (see  HYPERLINK "path.doc" \l "thrombocytosis" thrombocytosis) For just bleeding, consider other causes of  HYPERLINK \l "abnormalhemostasis" abnormal hemostasis Inpatient = * Pregnancy Decreased production Myelodysplasia (myelofibrosis, malignancy) Chemicals, alcohol, drugs, radiation, viruses Decreased survival Hypersplenism  HYPERLINK "path.doc" \l "itp" ITP APS/SLE* Lymphoma Infection: HIV Cavernous hemangioma  HYPERLINK "path.doc" \l "dic" DIC/Sepsis*  HYPERLINK "path.doc" \l "ttp" TTP*  HYPERLINK "path.doc" \l "hus" HUS Post-transfusion purpura* (rare, 5-10 days after, multigravida women) Drug-induced thrombocytopenia Alcohol (shortens lifespan) Medications: quinidine, quinine, sulfonamide, B-lactams, thiazides, gold, heparin ( HYPERLINK "path.doc" \l "hit" HIT) Cardiac disease HIT Use of IIb/IIIa antagonists Adenosine diphosphate antagonists CABG Intra-aortic balloon pump Eosinophilia AEC > 500-750 Neoplasm Allergy Adrenal insufficiency Connective tissue disease Parasite infection or Pancreatitis Other: atheroembolic vasculitis, IBD, sarcoidosis, TB, parasitic infection Cervical lymphadenopathy cat Scratch, Cyclic Neutropenia HIV Many others Dysphagia Solids carcinoma, esophageal web or ring, dysphagia lusoria (anomalous blood vessel) Liquids/solids scleroderma, achalasia, diffuse esophageal spasm Transfer dysphagia neuromuscular disorder (many including polymyositis) Odynophagia Motor disorders (achalasia, spasm) Mucosal disruption Chemical ingestion Peptic esophagitis Infectious esophagitis (HIV, candida, HSV, CMV, MAI) Drug-induced esophagitis KCl, tetracycline, clindamycin, quinidine, Fe supplements, ascorbic acid) Radiation esophagitis Postmenopausal bleeding Exogenous estrogens (30%) Atrophic vaginitis/endometritis (30%) Endometrial cancer (15%) Endometrial or cervical polyps (10%) Endometrial hyperplasia (5%) Other: cervical CA, uterine sarcoma, urethral carbuncle, trauma (10%) Amenorrhea (HYPERLINK "pathology.doc" \l "amenorrhea"see other) Primary: Turners, gonadal dysgenesis, 17-alpha-hydroxylase deficiency Ovarian: pregnancy, PCO, ovarian failure gonadal stromal tumors Pituitary/Central Axis hyper/hypothyroid, stress, anorexia, neoplasm, post-partum hemorrhage, surgery, XRT prolactinemia: idiopathic, drugs (D2 blockers), Uterovaginal: congential (imperforate hymen, imperforate cervix, imperforate or absent vagina, mullerian agenesis), acquired (destruction of endometrium with curettage (Aschermans), trauma, hysterectomy Other: metabolic (liver, kidney), malnutrition, rapid weight loss, obesity, endocrine (Cushings, Graves, hypothyroidism) Work-up: UPT / prolactin, TSH / Progestin challenge then Estrogen/Progestin challenge / FSH / MRI Note: no such thing as post-pill amenorrhea (you must work it up, you cant blow it off) Primary Amenorrhea Gonadal causes Gonadal dysgenesis (Turner's syndrome) Testicular feminization syndrome Resistant ovary syndrome Extragonadal causes Hypopituitarism Hypogonadotropic hypogonadism Delayed menarche Congenital adrenal hyperplasia Abnormalities of the uterus or vagina Secondary Amenorrhea Pregnancy Menopause Uterine causes Intrauterine synechiae (Aschermans syndrome) Hysterectomy Hypothalamic-pituitary causes (45%) Hypopituitarism Hypothalamic (psychogenic) amenorrhea Exercise, stress, nutrition/malnutrition, chronic illness Discontinuation of oral contraceptives Infiltrative: craniopharyngioma, sarcoidosis, histiocytosis Empty sella syndrome, Sheehan syndrome Ovarian causes Primary ovarian failure (premature menopause) Oophorectomy Radiotherapy, chemotherapy Estrogen excess Ovarian tumors Prolactin excess HYPERLINK "pathology.doc" \l "pituitaryadenoma"Pituitary tumors (18%) Thyroid disease (hypothyroid) Androgen excess Polycystic ovary syndrome ( HYPERLINK "pathology.doc" \l "pcos" PCOS) (30%) Overproduction of adrenal androgen (adrenal hyperplasia) Ovarian tumors Oligomenorrhea Definition: menses at infrequent intervals > 40 days or < 9/yr Many of same as above Hypoglycemia Diabetes Pancreatitis Hemolysis Cold agglutinins PRV Hypertension Renal Glomerulonephritis Pyelonephritis Parenchymal (cystic, etc.) Obstructive uropathy Nephrotic syndrome Renal tumor Renal failure Renal trauma Neurologic Increased ICP Hemorrhage Brain injury Familial dysautonomia Drugs and toxins Oral contraceptives Corticosteroids Cyclosporin Cocaine Endocrine Congenital adrenal hyperplasia Cushing syndrome Hyperthyroidism Pheochromocytoma HYPERLINK "pathology.doc" \l "hyperpth"Hyperparathyroidism (how?) Hyperaldosteronism  HYPERLINK "path.doc" \l "siadh" SIADH Vascular Coarctation of the aorta Renal vein thrombosis Renal artery stenosis Large AV fistula Infective endocarditis Vasculitis Other Chronic upper airway obstruction Preeclampsia Neurofibromatosis Hypercalcemia Malignant hyperthermia Hypernatremia HYPERLINK "pathology.doc" \l "porphyria"Acute intermittent porphyria Drugs Both medical and illicit (cocaine, etc.) Pain, anxiety Essential hypertension Abdominal Pain Differential (HYPERLINK "pathology.doc" \l "abdominalworkup"work-up) Diffuse or Any Quadrant Early appendicitis Aortic aneurysm Gastroenteritis Diverticulitis Peritonitis Adhesions Small bowel obstruction Large bowel obstruction (intussusception, volvulus, tumor) Mesenteric insufficiency or infarction Pancreatitis IBD Irritable bowel Mesenteric adenitis Metabolic: toxins, lead poisoning, uremia, drug overdose, DKA, heavy metal poisoning Sickle cell crisis Pneumonia (rare) Trauma UTI, PID Other: acute intermittent porphyria, tabes dorsalis, periarteritis nodosa, HSP, adrenal insufficiency, MI (can present w/ abdominal pain) Epigastric Gastric: PUD, gastric outlet obstruction, gastric ulcer Duodenal: PUD, duodenitis Biliary: cholecystitis, cholangitis Hepatitis Pancreatitis SBO, early appendicitis Cardiovascular: angina, MI, pericarditis, aortic dissection Pneumonia, pleurisy, pneumothorax Supraphrenic abscess Suprapubic Colon: obstruction or gangrene, diverticulitis, appendicitis Reproductive: ectopic pregnancy, Mettelschmerz, torsion of ovary or ovarian cyst, PID, salpingitis, endometriosis, rupture of endometrioma Cystitis, rupture of bladder Periumbilical Intestinal: SBO, gangrene, early appendicitis Mesenteric thrombosis, aortic dissection Pancreatitis Uremia, DKA RUQ Gastric: PUD/DUD, alcoholic gastritis, neoplasm, pyloric stenosis, hiatal hernia Biliary: gall stones, cholecystitis, cholangitis, neoplasm Hepatic: hepatitis, abscess, hepatic congestion, neoplasm (e.g. HCC), trauma Intestine: diverticulosis, retrocecal appendicitis, intestinal obstruction, high fecal impaction, perforation HELLP (via capsular distention) Pancreas: pancreatitis, neoplasm, stone in ampulla Renal: stones, infection, inflammation (e.g. pyelonephritis), neoplasm, rupture of kidney Pulmonary: pneumonia, pulmonary infarction, pleurisy Cardiac: inferior MI, pericarditis Other: cutaneous herpes zoster, trauma, Fitz-Hugh-Curtis syndrome (perihepatitis) LUQ Same as RUQ plus: Splenic: splenomegaly, splenic infarction, ruptured spleen, splenic abscess RLQ Intestinal: acute appendicitis, regional enteritis, incarcerated hernia, diverticulitis, small or large bowel obstruction, perforation of ulcer/intestine, Meckels diverticulitis Reproductive: ectopic pregnancy, Mettelschmerz, torsion of ovary or ovarian cyst, ovarian tumor, PID, TOA, salpingitis, endometriosis, rupture of endometrioma, seminal vasculitis Renal (as above), aortic dissection, biliary/hepatic (can be lower quadrant) Psoas abscess LLQ Same as RLQ (including appendicitis if appendix on wrong side) Abdominal Distention Excessive gas Intraabdominal infection Extraabdominal infection (sepsis, pneumonia, empyema, osteomyelitis of spine) Trauma Retroperitoneal irritation (renal colic, neoplasm, infection) Vascular insufficiency (thrombosis, embolism) Metabolic/toxic (hypokalemia, uremia, lead poisoning) Chemical irritation (perforated ulcer, bile, pancreatitis) Peritoneal inflammation Severe pain, pain medication Mechanical Obstruction Neoplasm (intraluminal, extraluminal) Adhesions Endometriosis Infection (intraabdominal abscess, diverticulitis) Gallstones Foreign body, bezoar Pregnancy Hernia Volvulus Stenosis at surgical anastomosis, radiation stenosis Fecaliths IBD Hematoma Other: parasite, SMA syndrome, pneumatosis intestinalis, annular pancreas, Hirschprungs, intussusception, meconium GI Bleeding [ HYPERLINK "http://www.nejm.org/content/1999/0341/0001/0038.asp" NEJM] Upper GI Bleeding PUD/DUD HYPERLINK "pathology.doc" \l "givarices"Gastroesophageal varices Lower GI Bleeding HYPERLINK "pathology.doc" \l "diverticulosis"Diverticulosis HYPERLINK "pathology.doc" \l "avcolon"AV Malformation Work-up Rectal brisk upper GI bleed is cathartic, should see melena, hematochezia NG lavage Barium swallow? EGD tagged RBC scan (requires 0.1 cc/min) SMA angiogram (requires 1 cc/min) colonoscopy Treatment for Variceal ( HYPERLINK "pathology.doc" \l "givarices" see other) Treatment for Non-Variceal [ HYPERLINK "http://www.annals.org/cgi/content/full/139/10/843" 2003 consensus] 2 large bore IVs aggressive fluid and blood products consider NG lavage consider early (< 24 hrs endoscopy) IV pantoprazole 80 mg bolus then 8 mg/hr No proven benefit of octreotide or somatostatin in non-variceal bleeds although may consider for persistent bleeding if endoscopy unavailable consider testing and treatment for H. pylori after resolution of acute illness Vomiting Gastroenteritis Gastritis/gastric ulcer Motion sickness Gastroparesis (see below) Gastric outlet obstruction Small bowel obstruction (usually above mid-jejunum) Systemic illness (high fever/severe pain) Peritonitis pregnancy (including hyperemesis gravidarum or acute fatty liver of pregnancy) Drugs or toxins (including chemotherapy) Increased intracranial pressure CVA (cerebellar) Psychogenic vomiting/eating disorder Delayed Gastric Emptying Post-vagotomy, DM, viral, GERD, brainstem lesions, anorexia, tachygastria Rapid Gastric Emptying Dumping syndrome, pancreatic insufficiency, celiac sprue, ZES, duodenal ulcer Diarrhea Viral: Rotavirus, Norwalk, Adenovirus, Astrovirus, Coronavirus, Coxsackievirus, Hepatitis A, CMV, Primary HIV Bacterial: SSYC, HYPERLINK "micro.doc" \l "etec"E.coli, C. difficile, Whipples, Legionella, Mycoplasma, Neisseria, Cryptosporidium, Isosporidium, MAI, primary intestinal Tb Toxins:  HYPERLINK "micro.doc" \l "vibrio" Vibrio, E. coli, Campylobacter, Yersinia, Klebsiella, C. difficile, C. perfringens, C. botulinum, B. cereus, TSST Fungal: histoplasmosis Parasites: all of them. Bastards! (e.g. Giardia, Entamoeba) Food poisoning: S. aureus, B. Cereus, Listeria, etc. Ciguatoxin (dinoflagellates eaten by fish ( CNS + GI toxin) Scomboid (histamines in overripe fish) Exogenous: laxatives, drugs, toxic chemicals Other: IBD, celiac, bacterial overgrowth, mesenteric ischemia, allergy, anaphylaxis, Behets, Churg-Strauss, idiopathic inflammation, chronic radiation enterocolitis, short bowel syndrome (fatty acid and/or bile salt malabsorption), carbohydrate malabsorption (sorbitol, fructose), GVHD (dermatitis, hepatic cholestasis, enteritis), alcoholic diarrhea (acute/chronic) Secretory Laxatives (many different kinds) Meds/drugs Diuretics, caffeine, theophylline, cholinergic drugs (eye drops, bladder stimulants), cholinesterase inhibitors, quinidine/quinine, colchicine, ACE inhibitors, H2 blockers, SSRIs, prostaglandins, others Toxins (see bacteria) Metals, mushrooms, organophosphates, seafood toxins, MSG Hormone-producing tumors Vipoma and ganlioneuromas Medullary carcinoma of thyroid (calcitonin and prostaglandins) Mastocytosis (histamine) Villous adenoma (prostaglandins) Increased or uncoordinated motility Irritable bowel syndrome, infectious, hyperthyroidism, carcinoid, scleroderma (early), too many carbs, DM, Shy-Drager syndrome*, mass lesion of brain stem*, carcinoma-associated visceral neuropathy, amyloidosis (local neuropathy), idiopathic primary visceral neuropathy / *may respond to clonidine Hospital Acquired Diarrhea C. diff (20% of nosocomial infections overall), EHEC Meds: colchicine, cholestyramine, antibiotics Chemotherapy or XRT / Rx: loperamide and NSAIDs Immunosuppressed (more susceptible to nosocomial viral diarrhea) Fecal impaction Liquid formulations (of any med) (typical patient on NG meds may get 20 g sorbitol/day) Enteral feeding (unclear reasons) Physiology Points that people forget Cortisol has pressor effects on vasculature too! 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