ေရာဂါလကၡဏာမ်ား

Differential Diagnosis: Symptoms, Signs, and Conditions: Introduction
This chapter is a general guide to commonly encountered symptoms and conditions and their frequent causes primarily in adults unless specified. Remember: “There are more uncommon presentations of common diseases than common presentations of uncommon diseases.”
Abdominal Distention
Ascites, intestinal obstruction, cysts (ovarian or renal), tumors, hepatosplenomegaly, aortic aneurysm, uterine enlargement (pregnancy), bladder distention, inflammatory mass



Abdominal Pain
Diffuse:
Intestinal angina, early appendicitis, colitis, diabetic ketoacidosis, hereditary angioedema, gastroenteritis, mesenteric thrombosis, mesenteric lymphadenitis, peritonitis, porphyria, sickle cell crisis, uremia, renal colic, renal infarct, pancreatitis
Right Upper Quadrant:
Dissecting aneurysm, gallbladder disease (cholecystitis, cholangitis, choledocholithiasis), hepatitis, hepatomegaly, pancreatitis, PUD, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarct, appendicitis (retroperitoneal)
Left Upper Quadrant:
Dissecting aneurysm, esophagitis, hiatal hernia, esophageal rupture, gastritis, pancreatitis, PUD, myocardial infarction, pericarditis, pneumonia, pulmonary embolus, pyelonephritis, renal colic, renal infarction, splenic abscess, splenic rupture, splenic infarction
Lower Abdomen:
Aortic aneurysm, colitis including inflammatory bowel disease, diverticulitis including Meckel diverticulum, intestinal obstruction, hernia, perforated viscus, pregnancy, ectopic pregnancy, dysmenorrhea, endometriosis, mittelschmerz (ovulation), ovarian cyst or tumor (especially with torsion), PID, renal colic, UTI, rectal hematoma, bladder distention
Right Lower Quadrant:
Appendicitis, ectopic pregnancy, ovarian cyst or tumor, salpingitis, mittelschmerz, cholecystitis, perforated duodenal ulcer, Crohn disease
Adrenal Mass
Adrenal adenoma, adrenal hyperplasia (unilateral or bilateral), adrenal metastasis (solid tumors, lymphoma, leukemia), adrenocortical carcinoma, pheochromocytoma, adrenal myelolipoma, adrenal cyst, adrenal varices, hemorrhage, congenital adrenal hyperplasia, ganglioneuroma, micronodular adrenal disease
Alopecia
Male pattern baldness (alopecia, androgenic type in both men and women), trauma and hair pulling, congenital, tinea capitis, bacterial folliculitis, telogen arrest, anagen arrest (chemotherapy, radiation therapy), alopecia areata, discoid lupus
Amenorrhea
Pregnancy, menopause (physiologic or premature), severe illness, weight loss, stress, excessive athletic training, physiologically delayed puberty, anatomic anomaly (eg, imperforate hymen, uterine agenesis, etc), gonadal dysgenesis (eg, Turner syndrome), hypothalamic and pituitary tumors, virilizing syndromes (eg, polycystic ovaries, idiopathic hirsutism). Amenorrhea is categorized as primary (never had menses) or secondary (cessation of menses).
Anorexia
Hepatitis, carcinoma (most types, especially advanced), anorexia nervosa, generalized debilitating diseases, digitalis toxicity, uremia, depression, CHF, pulmonary failure, radiation exposure, chemotherapy
Anuria
(See Oliguria and Anuria).
Arthritis
Osteoarthritis, bursitis, tendonitis, connective tissue disease (rheumatoid arthritis, SLE, rheumatic fever, scleroderma, gout, pseudogout, rheumatoid variants [ankylosing spondylitis, psoriatic arthritis, Reiter syndrome]), infection (bacterial, viral, TB, fungal Lyme disease), trauma, sarcoidosis, sickle cell anemia, hemochromatosis, amyloidosis, coagulopathy
Ascites
(See Chapter 13, Peritoneal [Abdominal] Paracentesis for more details.) Use the serum albumin to ascitic albumin difference (serum albumin minus ascites albumin) to help differentiate the cause of ascites. If the difference is > 1.1, portal hypertension is present. If the difference is 50–100 mL
Hematemesis:
Vomiting blood
Melenemesis:
Vomiting of material that looks like coffee grounds
Note: These three conditions suggest a bleeding site in the upper GI tract (ie, proximal to the ligament of Treitz) but can be as distal as the right colon with reflux of blood through the pylorus. Swallowed blood (eg, from epistaxis), esophageal varices, esophagitis, Mallory–Weiss syndrome, hiatal hernia, gastritis, duodenal or gastric ulcer, duodenitis, gastric carcinoma, tumors (small and large bowel), ischemic colitis, and aortoenteric fistula. Bleeding diathesis and anticoagulation can unmask GI tract abnormality. Medications, eg, bismuth-containing mediations and iron supplements can darken stool.
Hematochezia
Grossly bloody stool. Massive upper GI bleeding (rapid GI transit), hemorrhoids, anal fissure, diverticular disease, angiodysplasia, polyps, carcinoma, inflammatory bowel disease, ischemic colitis
Hematuria
(See also Blood [Hematuria].)
First rule out false-positives: myoglobinuria, hemoglobinuria, porphyria. GU neoplasms (malignant and benign), polycystic kidneys, trauma, infection (urethra, bladder, prostate, etc), stones, glomerulonephritis (primary and secondary such as Wegener granulomatosis, SLE, and polyarteritis nodosa), renal infarction, renal vein thrombosis, enterovesical fistula, sickle cell anemia, vigorous exercise (runner’s hematuria), accelerated hypertension, factitious and vaginal and rectal bleeding. Bleeding diathesis and anticoagulation can unmask GU tract abnormalities.
Hemoptysis
Infection (pneumonia, bronchitis, fungal, TB), bronchiectasis, cancer (bronchogenic or metastatic), bronchial adenoma, pulmonary embolus, A–V malformations, Wegener granulomatosis, Goodpasture syndrome, SLE, pulmonary hemosiderosis, foreign body, trauma, bleeding diatheses, excessive anticoagulation (can unmask respiratory tract abnormalities), cardiogenic pulmonary edema, mitral stenosis
Hepatomegaly
Right-sided CHF, tricuspid stenosis, hepatitis (viral, alcoholic, drug-induced, autoimmune), fatty liver, tumors (primary and metastatic, lymphoma, chronic myelocytic leukemia, lymphocytic leukemia), amyloid, biliary obstruction, hemochromatosis, chronic granulomatous disease, amyloidosis, infection (schistosomiasis, liver abscess, hydatid cysts), hepatic vein thrombosis, Wolman disease. Riedel lobe is a normal variant, elongated right lobe of the liver with normal total liver volume
Hiccups (Singultus)
Uremia, electrolyte disorders, diabetes, medications (benzodiazepines, barbiturates, others), emotionally induced (excitement, fright), gastric distention, CNS disorders, psychogenic, thoracic and diaphragmatic disorders (pneumonia, MI, diaphragmatic irritation), alcohol ingestion
Hirsutism
Idiopathic, familial, adrenal causes (Cushing disease, congenital adrenal hyperplasia, virilizing adenoma or carcinoma), polycystic ovaries, medications (minoxidil, androgens)
Impotence (Erectile Dysfunction)
Psychogenic, vascular, neurologic (spinal cord injury, radical prostatectomy, rectal surgery, aortic bypass), pelvic radiation, medications (common drugs: antihypertensives, especially thiazide diuretics, beta-blockers and methyldopa; antidepressants especially the SSRIs, anticholinergics; addictive medications: alcohol, narcotics; antipsychotics; antiandrogens: histamine H2 blockers, finasteride, LHRH analogues, spironolactone, others); history of priapism, Peyronie disease, testicular failure, hyperprolactinemia
Incontinence (Urinary)
Cystitis, dementia and delirium, stroke, prostatic hypertrophy, fecal impaction, peripheral or autonomic neuropathy, medications (diuretics, sedatives, alpha-blockers), diabetes, spinal cord trauma or lesions, MS, childbirth, surgery (prostate, rectal), aging, acute and chronic medical conditions, estrogen deficiency
Jaundice
Hepatitis (alcoholic, viral, drug-induced, autoimmune), Gilbert disease, Crigler–Najjar syndrome, Dubin–Johnson syndrome, Wilson disease, drug-induced cholestasis (phenothiazines and estrogen), gallbladder and biliary tract disease (including inflammation, infection, obstruction, and primary and metastatic hepatic tumors), hemolysis, neonatal jaundice, cholestatic jaundice of pregnancy, TPN
Lymphadenopathy and Splenomegaly
Infection (bacterial, fungal, viral, parasitic, rickettsial), benign neoplasm (histiocytosis), malignant neoplasm (primary lymphoma, metastatic), sarcoid, connective tissue disease (eg, rheumatoid arthritis, SLE, Sjögren syndrome), lipid storage diseases, drugs (eg, phenytoin), HIV and AIDS, splenomegaly without lymphadenopathy (cirrhosis, hereditary spherocytosis, hemoglobinopathies, hairy cell leukemia, histiocytosis X, amyloidosis, Wolman disease)
Melena
(See Hematemesis, Melenemesis, and Melena.)
Nausea and Vomiting
Appendicitis, acute cholecystitis, chronic gallbladder disease, PUD, gastritis (especially alcoholic), pancreatitis, gastric distention (diabetic atony, pyloric obstruction), intestinal ischemia, intestinal obstruction, peritonitis, food intolerance, intestinal infection (bacterial, viral, parasitic), acute systemic infections (especially in children), hepatitis, toxins (food poisoning), CNS disorders (tumor, hemorrhagic stroke, hydrocephalus, meningitis; increased intracranial pressure often causes vomiting without nausea), labyrinthitis, Ménière disease, migraine headache, acute coronary syndrome, CHF, endocrine disorders (DKA, adrenal crisis), hypercalcemia, hyperkalemia, hypokalemia, pyelonephritis, nephrolithiasis, uremia, hepatic failure, pregnancy, PID, drugs (opiates, digitalis, chemotherapeutic agents, levodopa, NSAIDs), psychogenic vomiting, porphyria, radiation therapy
Nystagmus
Congenital, vision loss early in life, MS, neoplasms, ocular infarction, toxic or metabolic encephalopathy, alcohol intoxication, thiamine (B1) deficiency, cerebellar degeneration, medications (anticonvulsants, barbiturates, phenothiazines, lithium, others), encephalitis, vascular brainstem lesions, Arnold–Chiari malformation, nonpathologic (extreme lateral gaze), opticokinetic nystagmus (attempt to fix gaze on a rapidly moving object, eg, a train)
Oliguria and Anuria
(See also Urinary Indices.)
Oliguria is < 500 mL urine/24 h; anuria is < 100 mL urine/24 h in adults.
Prerenal:
Volume depletion, shock, heart failure, fluids in the third space, renal artery compromise
Renal:
Glomerular disease, acute tubular necrosis, bilateral cortical necrosis, interstitial disease (acute and chronic interstitial nephritis, urate or hypercalcemic nephropathy), transfusion reaction, myoglobulinuria, radiographic contrast media (especially in diabetic, dehydrated, and elderly patients and those with multiple myeloma), ESRD, drugs (aminoglycosides, amphotericin B, vancomycin, NSAIDs, cephalosporins, penicillins, and sulfonamides), malignant hypertension, ischemia, emboli, thrombosis, TTP, HUS, and DIC
Postrenal:
Bilateral ureteral obstruction, prostatic obstruction, neurogenic bladder
Pleural Effusion
(See Chapter 13, Thoracentesis, for more details.)
Transudate:
(Pleural to serum protein ratio < 0.5, pleural to serum LDH ratio < 0.6, and pleural LDH 0.5, pleural to serum LDH ratio > 0.6, or pleural LDH > 2/3 the upper limit of normal for serum LDH), bacterial or viral pneumonia, pulmonary infarction, TB, rheumatoid arthritis, SLE, malignancy (most common, breast, lung lymphoma, leukemia, ovarian, unknown primary, GI, mesothelioma), pancreatitis, pneumothorax, chest trauma, uremia, peritoneal dialysis
Chylothorax:
Traumatic or postoperative complication
Empyema:
Bacteria, fungi, TB, trauma, surgery
Hydrothorax:
Usually iatrogenic (central venous catheter complication)
Pruritus
Skin lesions (papulosquamous, vesicobullous, eczematous, contact dermatitis, urticaria, folliculitis, neurotic excoriations, fiberglass dermatitis, infestation [eg, scabies], infection), xerosis (dry skin), especially in winter, liver disease, uremia, diabetes, gout, iron deficiency anemia, multiple myeloma, Hodgkin disease, leukemia, polycythemia vera, systemic mastocytosis, intestinal parasites, drug reactions with or without rash (without rash consider allopurinol, birth control pills, captopril, cephalosporins, cimetidine, clonidine, diuretics, HMG-CoA reductase inhibitors, narcotics, penicillin, phenothiazines, phenytoin), pregnancy, psychosomatic factors, neurologic or circulatory disturbances
Seizures
Generalized:
Grand mal and petit mal (absence), febrile
Partial Seizures:
Partial motor, partial sensory, partial complex (psychomotor or temporal lobe, déjà vu, automatisms)
Causes:
Primary or metastatic CNS tumors, trauma, metabolic disorders (eg, hypoglycemia, hypocalcemia, hypomagnesemia, hypophosphatemia, hyponatremia, hypernatremia, acidosis, alkalosis, porphyria, uremia), fever (especially in children), infection (meningitis, encephalitis, abscess), anoxia (arrhythmia, stroke, carbon monoxide poisoning), drugs (alcohol or barbiturate withdrawal, cocaine, amphetamines, ethylene glycol, methanol), lead, collagen–vascular disease (SLE), chronic renal failure, trauma, hypertensive encephalopathy, toxemia of pregnancy, neurodegenerative disorders (eg, Alzheimer disease, Down syndrome, neurofibromatosis, tuberous sclerosis, glycogen or lipid storage diseases), Whipple disease, sickle cell disease, psychogenic factors
Splenomegaly
(See Lymphadenopathy and Splenomegaly.)
Syncope
Vasovagal (simple faint). Orthostatic: volume depletion, sympathectomy (either functional or surgical), diabetes, Shy–Drager syndrome (idiopathic), drugs (eg, TCAs and diuretics). Postprandial in the elderly. Psychiatric: anxiety (hyperventilation), depression, or conversion disorder. Situational: micturition, cough, Valsalva maneuver, or swallowing. Cardiac: arrhythmia (PAT, AF, VT, sinoatrial or atrioventricular block), pacemaker malfunction, aortic stenosis, hypertrophic cardiomyopathy, primary pulmonary hypertension, atrial myxoma, cardiac tamponade, aortic dissection, subclavian steal syndrome, acute coronary syndrome, pregnancy, hypoglycemia, hypoxia, seizure disorder, migraines, subarachnoid hemorrhage, TIA (vertebrobasilar or, rarely, anterior circulation with simultaneous events or 100% stenosis of the carotid artery with a TIA involving the other side). Idiopathic
Tremors
Resting (Decrease with Movement):
Parkinson disease, Wilson disease, brain tumors (rare), medications (SSRI antidepressants, metoclopramide, phenothiazines [tardive dyskinesia])
Action (Present with Movement):
Benign essential tremor (familial and senile), cerebellar diseases, withdrawal syndromes (alcohol, benzodiazepines, opiates), normal or physiologic (induced by anxiety, fatigue)
Ataxic (Worse at End of Voluntary Movement):
MS, cerebellar diseases
Other:
Medication-induced (caffeine [coffee, tea], steroids, valproic acid, bronchodilators), febrile, hypoglycemic, hyperthyroidism, pheochromocytoma
Vaginal Bleeding
Normal menstrual period, dysfunctional uterine bleeding (premenopausal bleeding, oral contraceptives, luteal phase defect), anovulatory abnormal uterine bleeding (hypothalamic and pituitary disorders, stress, thyroid and adrenal disease, endometriosis), pregnancy-related (ectopic pregnancy, threatened or spontaneous abortion, retained products of gestation), neoplasia (uterine fibroids; cervical polyps; endometrial, cervical, ovarian, and vulvar carcinoma)
Vaginal Discharge
Vaginitis due to Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, herpesvirus, chronic cervicitis, tumors, irritants, foreign bodies, estrogen deficiency
Vertigo
Ménière disease (recurrent vertigo, deafness, tinnitus), labyrinthitis, aminoglycoside toxicity, benign positional vertigo, vestibular neuronitis, brainstem ischemia and infarction, basilar artery migraine, cerebellar infarction, acoustic neuroma, motion sickness, excess of ethanol, quinine, or salicylic acid
Vomiting
(See Nausea and Vomiting.)
Weight Loss
Normal or Increased Appetite:
Diabetes, hyperthyroidism, anxiety, drugs (thyroid), carcinoid, malabsorption (sprue, pancreatic deficiency), parasites
Decreased Appetite:
Depression, anorexia nervosa, GI obstruction, carcinoma, liver disease, severe infection, severe cardiopulmonary disease including end-stage COPD, uremia, adrenal insufficiency, hypercalcemia, hypokalemia, intoxication (alcohol, lead), old age, drugs (amphetamines, digitalis), HIV and AIDS
Wheezing
Large airway difficulty (laryngeal stridor, tracheal stenosis, foreign body, epiglottitis, vocal cord dysfunction), endobronchial tumor, asthma, bronchitis, emphysema, aspiration, pulmonary embolus, anaphylactic reactions, myocardial ischemia with pulmonary edema